Every finding on record at Ansted Center

Based on observation, record review and staff interview, the facility failed to ensure the menu was followed as posted in the facility and as printed on resident tray cards. This failed practice had the potential to affect more than a limited number of residents. Resident Identifiers: #15, #21, #25, #30, #37, and #54. Facility Census: 59. Findings included: a) The Lunch Menu posted for 03/23/2026 included: -Salisbury Steaks w/Gravy-Scalloped Potatoes-California Blend Vegetables-Dinner Roll-Brown Sugar Glazed Angel Food Cakeor-Kielbasa-Scalloped Potatoes-California Blend Vegetables-Dinner Roll On 03/23/26 at 12:00 PM, the posted menu, tray cards, and food service errors were reviewed with the Administrator and Director of Nursing (DON) viewed posted menu, tray card and food errors and the DON stated, I understand. Resident #37 received California Blend Vegetables, but the tray card stated [NAME] Peas - 1/2 Cup. Resident # 37 stated, They're never right. Nursing Assistant #31 confirmed resident #37's tray and stated, Let me go see about that. No further information was provided. Resident #54, #21, #30, #25 all received [NAME] Peas and the posted menu stated California Blend Vegetables. Resident #15 received sauerkraut which she wanted removed from her tray because the smell made her sick. Sauerkraut was not on the menu. Another state surveyor reported incident to this State Surveyor and the Director of Nursing. On 03/24/2026 at 11:20 AM, the state surveyor asked to temp the garnish (lettuce and tomato per the menu) and Account Manager #69 stated she was using parsley but would fix the lettuce and tomato per the menu. Lettuce and tomato were served with the fish sandwich this date per the menu following state surveyor intervention.

Based on observation, record review and staff interview, the facility failed to ensure food was stored in accordance with professional standards for food service safety and in a manner that prevents foodborne illness to the residents. This failed practice has the potential to affect more than a limited number of residents. FACILITY:FACILITY. Facility Census: 59. Findings included: a) On 03/23/2026 at 10:30 AM, an initial kitchen investigation was initiated with Account Manager #69. The following items were identified: Dry Storage -Yellow Cake Mix leaking out of a bag onto the shelf.-Hotdog and hamburger buns - no use by date.-Imperial pumpkin - dented can.-Gehls Mild Cheddar Cheese - dented can.-Lasagna Noodles - not labeled in a plastic zipper bag Freezer - -Bakers' Source Southern Style Biscuits - opened in the delivery, brown box, not sealed and no use by date.-Two (2) Angel Food Cakes - no use by date. b) On 03/24/2026 at 8:50 AM, the nourishment center in the main dining room was investigated. The following items were identified: - Sterile Water -opened and dated 1/22 - water was yellowish in the bottle.- Apples for Resident #64 with use by date of 03/04/2026. Account Manager #69 confirmed the items and stated the policy for food brought in by family to discard after seven (7) days. - Bread - open with use by date 03/23/2026- [NAME] crackers -in a zipper bag with a use by date of 03/20/26 Account Manager #69 confirmed the items at 9:01 AM. c) The facility's policy and procedures for Food Brought in for Patients/Residents stated, Food will be held in refrigerator for three (3) days following date on label and will be discarded by staff upon notification to resident. The facility's policy and procedure for Food Storage: Dry Goods stated, Storage areas will be neat, arranged for easy identification, and date marked as appropriate. The facility's policy and procedure for Food Storage: Cold Foods stated, All foods will be stored wrapped or in covered containers, labeled and dated, and arranged in a manner to prevent cross contamination.

Based on observation and staff interview the facility failed to dispose of garbage and refuse properly. The facility failed to maintain a clean and sanitary environment, creating potential health and safety risks for all residents of the facility. Facility census #59. Findings included: a) 03/24/26 at 1:20 PM during the tour of the exterior garbage dumpster area, loose trash was observed scattered around the dumpster. Items included multiple gloves, plastic spoons, plastic lids, plastic bags, Styrofoam bowls, a Pringles container, soda bottles, and loose tissue. This was confirmed with DON at 1:30 PM. 03/24/26.

Based on observation, interview and policy review the facility failed to provide nail care to dependent residents to ensure nails were short, and smooth to avoid injury. Resident identifiers: #53. Facility census: 59.a) Resident #2 On 03/24/26 at 9:53 AM observation revealed Resident #2 had long, jagged unkept fingernails. The resident said she would like to have the nails shorter. On 03/24/26 at 2:00 PM Registered Nurse #4 was told what the residen [NAME] said regarding her fingernails. b) Resident #39 On 03/25/26 at 12:49 PM an observation of Resident #39 revealed this residen [NAME] long, jagged unkept fingernails. He said he would like to have them trimmed but was not sure who would do it. c) Resident #42 On 03/24/26 during the lunch meal observation revealed Resident #42 had long, jagged unkept fingernails. He said he would like to have them shorter. d) Resident #57 On 03/25/26 at 9:00 AM observation revealed this resident had long, jagged unkept fingernails. He said he would like to have them trimmed. He said he had clippers in his drawer but would need help trimming his nails. A policy review titled NSG222 Nail Care dated 05/01/25 stated Patient nails will be kept short and smooth to avoid skin injury. Routine cleaning and inspection of nails will be provided during activities of daily living (ADL) care on an ongoing basis. On 03/26/26 at 11:45 AM during an interview with the Director of Nursing the above findings were relayed to her. No futher comments were provided regarding the lack of nail care for these residents. e) Resident #53 During the survey conducted on 3/25/26 in the afternoon different surveyors observed an offensive odor permeating into the hallway from Resident #53's room. Interview with the Director of Nursing (DON) on 03/25/26 at approximatley 3:15 PM revealed the odor was most likley associated with Resident #53 and challenges related to a yeast infection. Record review indicated the resident had received a shower on 03/25/26 after the surveyor brought the issue up to the nursing staff. The care plan review did not reflect a history of shower refusals. A review of the resident's physiciain's orders revealed orders for Diflucan Oral Tablet 150 MG (Fluconazole) which was prescribed on 03/25/26 at 5:59 PM. Nystatin External Powder 100000 UNIT/GM (Nystatin (Topical) apply to abdominal fold typically three (3) times a day for Yeast for 30 days. This order was dated 02/06/25 Apply to Abdominal Fold topically three times a day for Yeast for 30 Days Another order dated 01/05/26 was for Nystop External Powder 100000 Unit/GM (Nystatin (Topical) apply to under breast topically every day and night shift for yeast infection for 14 days.

Based on record review and staff interview the facility failed to ensure three (3) of six (6) residents received a written notification whenever their account reached within $200 of the asset level allowed for Medicaid. Resident identifiers: #55, #27, and #10. Facility census: 59. Findings included:a) A record review conducted on 03/25/26 identified the following balances in resident accounts: - Resident #55: $2,795.17- Resident #27: $2,835.00- Resident #10: $1,990.00 On 03/25/26 at 1:00 PM, Business Office Advisor (BOA) #82 stated that the required notices regarding assets being over or within $200 of the $2,000 Medicaid limit had not been sent. Admissions Director #52 confirmed this information on 03/26/26 at 1:30 PM.

Based on observation and staff interview the facility failed to ensure a homelike environment for the residents. There were issues with caulking around the base of the toilets, and with base moulding as well as an issue with a bug zapper in the hallway. Room identifiers: #212, #215, Facility census: 59. a) room [ROOM NUMBER]Observation revealed missing or disrepaired caulking around the base of toilets in room [ROOM NUMBER].b) room [ROOM NUMBER]The floor molding near the sink was torn and in disrepair.The surveyor reviewed and confirmed these findings with the facility Administrator at approximately 3:20 PM.Further observation during the facility walkthrough revealed that insect control devices (bug lights) in the 100 and 200 hallways contained multiple dead insects adhered to visible sticky paper, indicating a lack of routine maintenance. The condition of these devices was inconsistent with a clean and homelike environment. The surveyor observed this on 3/24/26 at approximately 12:45 PM and confirmed it with the facility Administrator at 1:05 PM.

Based on record review and staff interview, the facility failed to notify the resident or the resident's representative(s) of the transfer or discharge and the reasons for the move in writing; send a copy of the notice to a representative of the Office of the State Long-Term Care Ombudsman; and provide the resident and the resident representative written notice which specified the duration of the bed-hold policy. This was found to be true for two (2) of four (4) residents reviewed during the long term care survey process. Resident identifiers: #64, #10. Facility census: 59. Findings included:a) Resident #64 Resident #64 had the capacity to make their own medical decisions. Resident #64 had an emergency transfer to an acute care facility on 03/13/26, following a fall at the facility. The resident returned to the facility on [DATE] following surgery for a left femur fracture resulting from the fall. The facility provided an electronic eInteract Communication Form with resident medical information to the hospital. However, the facility failed to issue a transfer/discharge notice to the resident or to the Office of the State Long Term Care Ombudsman. A Bed Hold Notice was located in the electronic medical record. The facility had obtained verbal consent from the resident's next of kin due to the emergency situation. However, the facility failed to obtain a written signature or have a second person witness the verbal consent. When the forms were reviewed with the Director of Nursing (DON) on 03/24/2026 at 4:01 PM, she acknowledged the errors and the lack of a transfer notice. b) Resident #10 Resident #10 did not have the capacity to make their own medical decisions. Resident #10 was transferred to an acute care facility on 10/11/25. The resident returned to the facility on [DATE].The facility provided an electronic eInteract Communication Form with resident medical information to the hospital. However, the facility failed to issue a transfer/discharge notice to the resident's representative or to the Office of the State Long Term Care Ombudsman. A Bed Hold Notice was located in the electronic medical record. The facility had initiated a Bed Hold Notice of Policy and Authorization, however, it was not signed by the facility or by the resident's representative. When the forms were reviewed with the Director of Nursing (DON) on 03/24/2026 at 4:01 PM, she acknowledged the errors and the lack of a transfer notice.

Based on a review of Centers for Disease Control and Prevention (CDC) guidance, medical records, and staff interviews, the facility failed to follow established disease control and prevention protocols. The following issues were identified: A staff member was observed carrying linens against their clothing. A staff member failed to wear a gown while providing incontinence care to a resident on enhanced barrier precautions.Signage on a resident's door failed to identify which specific bed required enhanced barrier precautions. Resident identifier: #4. Facility census: 59. b) Resident #4 On 03/24/26 at approximately 9:45 AM, it was observed that Nurse Aide (NA) #46 was providing incontinence care to Resident #4 behind a closed divider curtain. NA #46 was subsequently seen exiting the curtained area with bagged linens and incontinence products while not wearing a gown. According to the Centers for Disease Control and Prevention (CDC) staff members providing care to residents should gown and glove during during high contact tasks. A review of Resident #4's records indicates a history of carbapenem-resistant Enterobacteriaceae (CRE), requiring enhanced barrier precautions. The precautions sign posted on the resident's door explicitly states that a gown must be worn when performing high-contact care. The Director of Nursing was informed of these findings during interviews conducted on 03/24/26 and on 03/26/26 at 11:45 AM. c) On 03/23/2026 3:49 PM, during the initial survey interview process on the 100 Hall, Central Supply Staff #51 was observed by the state surveyor carrying a stack of clean linen (towels and sheets) down the hallway to the linen closet against his shirt. Central Supply Staff #51 confirmed the linen was not being carried away from his clothes and it was not in a bag and stated, Oh, okay. The staff member later asked, Has it always been like that? On 03/25/2026at 9:45 AM, another state surveyor observed Account Manager #64 carrying a blanket against his clothing on the 200 Hall. d) On 03/23/2026 at 11:30 AM, an enhanced barrier precautions (EBP) sign outside the door of room [ROOM NUMBER] was observed to have no bed marked or labeled to identify the residents(s) on precautions for staff. Corporate Registered Nurse #81 confirmed a bed(s) was not identified on the signage for EBP. The Director of Nursing confirmed neither resident in the room were on EBP. According to the Centers for Disease Control and Prevention (CDC) staff members providing care to residents should gown and glove during during high contact tasks. e) Resident #30 On 03/26/2026 at 9:55 AM, an observation of wound care for Resident #30 was completed. The wound care was provided by Registered Nurse (RN) #24 and RN #39. The resident is noted with an unstageable (UN) wound to the coccyx and moisture-associated skin damage (MASD) to the left and right buttock. There was no signage at the door of Resident #30's room to indicate the resident was on enhanced-barrier precautions. Neither RN #24 nor RN #39 donned personal protective equipment (PPE) upon entering the resident's room and providing wound care. An interview was held with RN #39 regarding the enhanced-barrier precautions and the PPE. RN #39 stated, there was no sign hanging at her door. On 03/26/2026 at 11:10 AM, the Director of Nursing (DON) confirmed the resident does have a chronic wound and should be on enhanced-barrier precautions and the nurses should have worn PPE. Facility Policy On 03/26/26 at 11:00 AM, the DON provided the facility policy entitled, Enhanced Barrier Precautions. Under the heading of definitions, Chronic wounds were listed and states, refers to a wound that is not healing as expected or that has been present for more than 30 days.

Based upon record review and staff interviews, the facility failed to ensure the accuracy of the Pre-admission Screening and Resident Review (PASARR) of residents upon admission to the facility. This was found to be true for three (3) of seven (7) residents reviewed during the long term care survey process. Resident identifiers: #18, #8, and #64. Facility census: 59. Findings included: a) Resident #8 On 03/23/2026 at 12:43 PM, record review for Resident #8 included a review of the resident's diagnoses. The resident was admitted on [DATE] with a diagnosis of schizophrenia. Upon further review, the Pre-admission Screening (PAS) dated 02/20/26 did not include the diagnosis of schizophrenia. On 03/25/2026 at 2:30 PM, the Director of Nursing (DON) confirmed the PAS dated 02/20/26 was incorrect. Also, the DON stated, We are aware of the issues with the PASARR. b) Resident #18 On 3/23/2026 at 2:32 PM a review of the latest Pre-admission Screening and Resident Review (PASSR) for Resident #18 (dated 2/1/24), provided by the facility states under Section 30, Current Diagnosis a) None. However the medical diagnosis and medication indications reflect differently. A Review of Resident #18's Medical Diagnosis show the following: a. BiPolar Disorder Mild or Moderate Severity b) Anxiety Disorder Resident #18 has the following current medication orders by the Physician 1) Buspirone HCL Oral Tablet 10 milligrams (MG). Give 2 tablets by mouth three times a day for targeted behaviors: cursing, yelling and combativeness for anxiety. 2) Cymbalta Oral Capsule Delayed Release Particles 60 MG. Give 1 capsule by mouth once a day for Targeted behaviors of cursing, yelling for depression. 3) Lamictal Oral Tablet 100 MG. Give 1 tablet by mouth one time a day for Bi Polar disorder. Document behaviors: agitation, restlessness. 4) Latuda Oral Tablet 80 MG. Give 80 MG by mouth one time a day for Bi Polar disorder. Targeted behaviors: cursing, yelling, combative towards others. 5) Trazodone HCL Oral Tablet. Give 200 MG by mouth at bedtime for depression. Document behaviors: Restlessness, wandering, NPI: offer food/drink, redirect. Document side effects such as headache, hallucinations. Resident #18 was admitted to the facility on [DATE] According to an interview with Unit Manager #10 and the Administrator on 3/26/26 at 10:49 AM Resident #18 had the previously mentioned medical diagnoses upon admission to the facility. They also agreed the PASSR should reflect the following medical diagnoses: Bipolar, Depression, and Anxiety c) Resident #64 Resident #64 was initially admitted to the facility on [DATE], with a re-admission on [DATE]. At admission, the resident had the following diagnoses related to mental/intellectual diabilities: -Depression -Mental disorder, not otherwise specified A Pre-admission Screening and Resident Review (PASARR) was completed on 01/21/26 at another facility. Under Section III Question 30 of the PASARR for current diagnosis, mood disorder - stable, managed with medications was the only diagnosis marked. The PASARR did not contain a diagnosis of depression or mental disorder, unspecified. A review of the resident's Minimum Data Set (MDS) dated [DATE] includes the following diagnoses : -Depression -Mental disorder, not otherwise specified. Therefore, the PASARR was incorrect for the resident upon admission to the facility. This was reviewed with the Director of Nursing (DON) on 03/24/26 mid afternoon. She stated she identified PASARRs as an issue on 03/21/26 and had put a plan in place to get these corrected.

Based on record review and staff interview, the facility failed to ensure medical records were accurate and complete. This was true for three (3) of five (5) residents reviewed under the care area of unnecessary medications. One relating to a Physicians Order for Scope of Treatment (POST) form, one for a vaccination witness and one for medical diagnoses. Resident Identifiers: #8, #18 and #64. Facility Census: #59.Findings included: a) Resident #8 On 03/23/2026 at 3:59 PM, a record review was completed for Resident #8. The review found the informed consents for the COVID-19 vaccination and for the chicken pox, shingles, respiratory syncytial virus, measles, mumps, rubella, varicella, tetanus, diptheria and pertussis vaccinations were signed by the resident. However, there were no witness signatures by staff on the document. On 03/23/26 at 4:10 PM, the Director of Nursing (DON) was notified and confirmed both consents did not have witness signatures. b) Resident #64 Upon initial review of the resident's medical record on 03/23/26 at approximately 1:10 PM, the resident's WV Post Form dated 01/23/26, was marked with the selection for full code. The resident has capacity to make own medical decisions. Conversely, the electronic health record and the resident's care plan showed the resident to be DNR (Do Not Resusitate). This surveyor asked another member on the survey team to review the discrepancy with me. We agreed there was a discrepancy in the medical record. The surveyor submitted a request to the facility on [DATE] at approximately 2:00 PM to see any Post forms for residents which were not yet uploaded into the medical record. At 4:45 PM, when surveyor asked again about the Post forms, the Director of Nursing responded that all post forms had already been uploaded. Upon arrival to the facility the next morning on 03/24/26 at aproximately 9:00 AM, an additional review of the resident's medical record was conducted. The electronic medical record included a new Post form dated 03/20/26. The resident had on 03/20/26 elected to be DNR. An interview was held with the Social Services staff #50 on 03/24/26 at 2:25 PM with the medical record pulled up. Surveyor pointed out the change in the Post form from Full Code to DNR. Surveyor asked about their process for when a change like this occurs, how do they void the older version of the Post form in the medical record. The medical record had two entries Post form 01/23/26, and Post form 03/20/26. Social Service staff #50 stated the new Post is uploaded and staff know to go by the most recent date. When asked what about new staff? #50 did not answer. When asked if a new Post form is sent to the WV Registry, she stated if the resident requests it. The guidance provided on the WV Post Form states: .voiding a POST form:If a patient or MPOA representative/surrogate (for patients lacking capacity) wants to void the form: destroy paper form and contact patient's health care provider and the WV e-Directive Registry to void orders in patient's medical record and the Registry.For health care providers: destroy copy (if possible), note in patient record form is voided and notify the WV e-Directive Registry When asked if the facility had a policy addressing voiding of Post forms, staff member #50 stated no. By failing to adhere to the guidelines surrounding voiding the previous WV Post form, it could create the potential for confusion of the desires of the resident in regards to life saving measures. New staff coming into the facility may not know to look for the most recent date of the form. c) Resident #18 On 3/23/2026 at 2:32 PM a review of Resident #18's medical diagnoses reflects Bi Polar and Anxiety disorder. However Resident #18 has the following current medication orders by the Physician 1) Buspirone HCL Oral Tablet 10 milligrams (MG) Give 2 tablets by mouth three times a day for Targeted behaviors, cursing, yelling and combativeness for anxiety. 2) Cymbalta Oral Capsule Delayed Release Particles 60 MG. Give 1 capsule by mouth one times a day for Targeted behaviors of cursing, yelling for depression. 3) Lamictal Oral Tablet 100 MG Give 1 tablet by mouth one time a day for Bi Polar disorder. Document Behaviors, agitation, restlessness. 4) Latuda Oral Tablet 80 MG Give 80 MG by mouth one time a day for Bi Polar disorder. Targeted Behaviors of cursing, yelling, combative towards others. 5) Trazodone HCL oral Tablet Give 200 MG by mouth at bedtime for depression. Document behaviors of Restlessness, wandering, NPI: offer food/drink, redirect. Document side effects such as headache, hallucinations. Resident #18 was admitted to the facility on [DATE] and according to an interview with the Unit Manager #10 and the Administrator on 3/26/26 at 10:49 AM Resident #18 had the previous mentioned medical diagnoses upon admission to the facility. They also agreed the following medical diagnoses should be reflected on the Diagnosis Report which should list all diagnoses: Bi Polar, Depression, and Anxiety

Based on resident interview and staff interview the facility failed to provide reasonable accommodations of needs for Resident #39. This was found true for one (1) of 29 residents reviewed. Resident identifier: #39. Facility census: 59. Findings included:a) Resident #39. During an interview with Resident #39 on 03/27/26 at 10:45 AM, the resident reported that his reclining chair, in which he slept, did not function properly. Observation and interview revealed the leg/foot rest of the recliner did not deploy. The resident stated he elevates his legs in a wheelchair at night due to the malfunctioning recliner.This concern was brought to the attention of the Director of Nursing (DON). Documentation provided by the on 03/23/26 at 3:55 PM. DON confirmed that a new reclining chair was ordered for the resident following surveyor intervention.

Based on record review and staff interview the facility failed to ensure two (2) of two (2) residents were provided quarterly statements. Resident identifiers: #41, and #24. Facility census: 59.Findings included: a) Resident #41 On 03/23/26 at 2:00 PM during an interview with Resident #41 and the resident's daughter they mentioned they had not received a quarterly statement to show the amount in the resident's account. During an interview with Business Office Advisor (BOA) #82 on 03/25/26 at 11:00 AM the BOA said the former business office manager had left the job and she did not think she could verify the quarterly statements had been provided. On 03/26/26 at 1:00 PM a letter dated 07/23/25 was provided to the surveyor by Admissions Director (AD) #52. The letter verified that a quarterly statement was provided for the quarter ending June 2025. No additional statements could be provided. b) Resident #24 During an interview with Resident #24 on 03/23/26 at 11:15 AM the resident stated she had not received a quarterly statement to show the amount of money in her account. During an interview on 03/24/26 at 11:00 AM with the BOA she said she could not provide any quarterly statement verifications and that the facility's BOM had recently left the position. On 03/26/26 at 1:00 PM AD #52 provided a letter dated 07/23/25 which reflected that Resident #24 had received a letter indicating what her account balance was for the quarter ending June 2025. No additional statement verifications were able to be provided before the end of the survey on 03/26/26 at 2:15 PM. No additional statemeent verifications were able to be provided before the end of the survey on 03/26/26 at 2:15 PM.

Based upon record review and staff interview, the facility failed to ensure a new Pre admission Screening and Resident Review (PASARR) was completed when three (3) of seven (7) residents developed a new mental disorder. Resident identifiers: #7, #22, #53. Facility census: 59.Findings included: a) Resident #53 The most recent PASARR was completed at an acute care facility on 12/17/24. Under Section III, Question 30, Current Diagnosis (Check all that apply). (a) none was checked, and (n) Other related conditions (Specify below) bipolar disorder was typed in. Question 37 is Diagnosis - Other medical conditions requiring services. Included in the typed list are altered mental status, visual hallucinations, bipolar illness, Dementia with behavioral problem. Question 47: The individual has a primary diagnosis of: Dementia was checked. Resident #53 was admiitted to the facility on [DATE]. The resident does not have capacity to make own medical decisions. The resident had the following diagnoses related to mental illnesses: Depression - Primary Diagnosis 01/16/2025 Bipoloar Disorder, - 12/20/2024 Admission/readmission Anxiety Disorder - 01/16/2025 Adjustment Disorder with mixed anxiety and depressed mood - 09/26/25 For these conditions, the resident had the following physician orders: SEROquel XR Oral Tablet Extended Release 24 Hour 300 Milligram (Quetiapine Fumarate)Give 1 tablet by mouth at bedtime for Target Behaviors: agitation, halluccinations, delusions dx: Bipolar DisorderPharmacy Active 03/06/2026 busPIRone HCl Oral Tablet 10 MG (Buspirone HCl)Give 10 mg by mouth two times a day for Targeted behaviors: AgitationPharmacy Active 12/7/2025 Depakote Oral Tablet Delayed Release 250 MG (Divalproex Sodium)Give 2 tablet by mouth two times a day for Targeted behaviors Delusions, hallucinations.Pharmacy Active 12/7/2025 The medical record also included a completed Provider Attestation for Schizophrenia, Schizoaffective or Schizophreniform Diagnosis form. This form was dated on 01/16/26 and has comments patient exhibits signs and symptoms of schizoaffective disorder. The form was signed by the physician/practitioner with an acknowledgement that this resident meets the diagnostic criteria as set by the American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) as outlines in the reference table below for the current psychiatric listed above. The PASARR was reviewed with the Director of Nursing (DON) on 03/24/26 mid afternoon. The DON stated they were already in the process of identiying incorrect PASARRs and showed me the facility plan she had put together just a few days prior. b) Resident #22 Resident #22 was admitted into the facility on [DATE]. This resident did not have capacity to make their own medical decisions. Upon admission, the resident had the following diagnosis related to mental illness: - Bipoloar Disorder During the stay at the facility, the resident subsequently was diagnosed with the following mental illness: -Depression Date of Diagnosis- 3/17/2025 For the above conditions, the resident had the following orders: -Lamictal Oral Tablet 100 MG (Lamotrigine)Give 1 tablet by mouth one time a day for depressionPharmacy Active 02/17/2026 -Cymbalta Oral Capsule Delayed Release Particles 60 MG (Duloxetine HCl)Give 1 capsule by mouth one time a day for Bipolar Disorder document behaviors: yelling out, restlessness. Non-Pharmalogic Intervention (NPI): re-direct, re-approach.Monitor for side effects: nausea, dry mouthPharmacy Active 01/01/2026 -Buspirone HCl Oral Tablet 7.5 MG (Buspirone HCl)Give 1 tablet by mouth two times a day for Bipolar disorderPharmacy Active 05/08/2025 The Preadmission Screening and Resident Review (PASARR) was completed on 06/20/24 by the facility. Section III, Question 30 Current Diagnosis (Check all that Apply): only (n) was checked for Other related conditions, where bipolar disorder was inserted. A review of the most recent Minimum Data Set (MDS) completed on 03/10/26, contained the following diagnoses related to mental illness: - Bipolar Disorder- Depresssion The facility's policy entitled Pre-admission Screening for Mental Disorders andor Intellectual Disability Patients, was effective on 06/01/01, and most recently revised on 02/16/24. Under the Practice Standards revealed the following: Social Services will coordinate and/or inform the appropriate agency to conduct the evaluation and obtain results if it is learned after admission that the Pre-admission screening and Resident Review (PASARR) was not completed or is incorrect; or there is a significant change in status that results in new evidence of possible mental disorder, intellectual disability or a related condition. Social Services will review PASARR to determine appropriate care needs and incorporate recommendations into the patient's assessment, care planning, and transition of care. The discrepancy in the PASARR and the MDS was reviewed with the Director of Nursing (DON) on 03/24/26 mid afternoon. The DON stated the facility had already identified PASARRs as an issue and she just put a plan in place to correct these on Friday. c) Resident #7 On 03/23/26 at 11:00 AM, a record review was completed for Resident #7. The review found the Pre-admission Screening and Record Review (PASARR) dated 06/27/25 did not include the diagnosis of Post-Traumatic Stress Disorder (PTSD). On 03/23/2026 at 2:50 PM, the Director of Nursing (DON) confirmed the PAS dated 06/27/25 was incorrect. For Resident #7 a record review indicated PTSD had an active diagnosis with the date of 07/09/25.

Based on observation, staff interview, resident interview and record review, the facility failed to ensure oxygen therapy was provided at the correct setting per the physician's order and the resident's care plan. This failed practice had the potential to affect a limited number of residents. Resident Identifier: #37. Facility Census: 59. Findings include: a) Resident #37On 03/23/2026, during the initial interview process, Resident #37's oxygen concentrator setting was on two (2) liters. The resident reported she was on four (4) liters of oxygen. Resident #37 reported difficulty breathing. At 11:27 AM, Corporate Registered Nurse #81 reported the oxygen concentrator was set between two (2) and three (3) liters. Corporate Registered Nurse #81 reported the resident's order stated three (3) liters, confirmed the oxygen setting was between two (2) to three (3) liters, and stated they were giving the unit to maintenance to fix. At 11:27 AM, Unit Manager #10 reported the concentrator would not go above two and a half liters so they were replacing it and giving the unit to maintenance to fix. Resident #37's orders stated, Oxygen at 3 L/min via Nasal Cannula, continuously. The resident's care plan stated, Administer Oxygen via n/c as ordered/indicated. A progress note dated 03/23/2026 at 12:02 PM stated: Nursing observations, evaluation, and recommendations: Resident reports feeling SOB. Upon checking to ensure the oxygen concentrator was working, it was noted that it was malfunctioning. The concentrator was replaced, and the resident was assessed. She states she is no longer SOB. Pulse ox is 93% via Nasal Cannula.

Based on observation, record review and staff interview the facility failed to follow the Bed Safety Evaluation and Bed Safety Evaluation Follow-up for bed rails in order to avoid risks including entrapment due to the use of bed rails. This was true for one (1) of two (2) assessments for bed rails. Resident Identifier: #44. Facility Census: #59a) Resident #44 On 03/23/26 at 3:11 PM, Resident #44 was observed with bilateral bed rails in use. A subsequent review of the bed safety evaluation dated 01/25/26 indicated that bed rails should not be used for this resident. According to the evaluation's Step 2 guidance, if a No was recorded for any of the eight mobility questions, staff were instructed to attempt alternatives. The assessment dated [DATE] recorded No for all seven mobility questions. The Bed Safety Evaluation Follow-up dated 01/26/26 noted that alternatives, including elevating the head of the bed and a PT/OT screen, were attempted. The results confirmed these alternatives were successful, concluding that bed rails should not be used for this resident. During an interview on 03/24/26 at 11:25 AM, the Director of Nursing reviewed these evaluations and confirmed that Resident #44 should not have bed rails.

Based on record review, hospital staff and facility staff interviews, the facility failed to ensure Resident #63 was permitted to return to the facility following a hospitalization for behavioral evaluation. The facility's refusal to readmit the resident was based on behaviors that occurred prior to the hospitalization. Resident Identifier: #63. Facility Census: 60.a) Resident #63 Record review revealed Resident #63 was transferred to the local emergency room on [DATE] due to aggressive behavior. Progress notes from [DATE] documented the resident exhibited increased agitation and verbal aggression and was sent to the local emergency room for further evaluation per physician order.Interview with Hospital Care Manager (HCM) (#75) on [DATE] revealed the facility refused to take the resident back. HCM #75 was told the resident could not return to the building or to any facility owned/operated by the same company. HCM #75 further stated the facility did not inform the hospital at the time of transfer that the resident would not be accepted back.There was no documentation to show that the facility:Completed a discharge notice Involved the resident and representative in the discharge planning process;Documented that the resident's needs could not be met in the facility; orMade efforts to determine reasonable accommodations or interventions to support the resident's return.Review of available bed census confirmed that the facility had an available bed on and after the date the resident's hospital bed-hold expired.During an interview with the Administrator on [DATE] he confirmed the clinical administrative team for the corporation declined to readmit Resident #63 due to behavioral issues exhibited and acknowledged that no discharge notice was issued.

Based on record review and interviews, the facility failed to provide required written notice to the resident, resident representative, and the long-term care ombudsman prior to discharging Resident #63 and refusing readmission following hospitalization. The facility's failure to issue appropriate notice deprived the resident and representative of their right to appeal and participate in discharge planning. Resident Identifier: #63 Facility Census: 60Findings included:a) Resident #63Record review showed Resident #63 was transferred to the on 09/04/25 and remained hospitalized beyond the bed-hold period. Despite hospital documentation showing the resident was ready for return, the facility declined readmission.Interview with the Hospital Care Manager confirmed the resident and representative were not notified in writing of the facility's decision to refuse the resident's return. There was no evidence that:A written discharge notice was provided to the resident and representative;The notice contained the reason for discharge, effective date, and appeal rights;The state long-term care ombudsman received a copy of the notice; orDischarge planning was coordinated with the hospital and community services.During an interview with the Administrator and Director of Nursing (DON) acknowledged that a written notice of discharge was not issued prior to refusing the resident's readmission.

Based on record review, staff interview and resident interview the facility failed to ensure they served food at palatable temperatures. This failed practice was a random opportunity for discovery and had the potential to affect more than a limited number of residents during the complaint survey process. Resident identifiers #2, #44, and #3. Facility census: 59. Findings include: a) A review on 05/27/25 at 1:00 PM, of the recorded food temperatures before meal service from 01/25 to present revealed the following dates with missing food temperatures: -01/18/25: No temperatures taken on the chicken, rice, or mashed potatoes at the lunch meal. -01/24/25: No temperatures taken on the lunch meal. -01/31/25: No temperatures taken on the fish at the supper meal. -02/08/25: No temperatures taken on the chicken, potatoes, or green beans at the lunch meal. -02/27/25: No temperatures taken on the supper meal. -03/02/25: No temperatures taken on the supper meal. -03/09/25: No temperatures taken on the supper meal. -04/23/25: No temperatures taken on the western omelet, and eggs at the breakfast meal. -04/28/25: No temperatures taken on the breakfast or lunch meals. -05/16/25: No temperatures taken on the lunch meal. -05/24/25: No temperatures taken on the breakfast or lunch meals. -05/25/25: No temperatures taken on the pork, meatballs, baked potatoes, mashed potatoes, or green beans at the lunch meal. During an interview on 05/27/25 at 1:30 PM, The Certified Dietary Manager (CDM) stated I know there are a lot of holes on the temperature logs. I have my two that have been here for a while but have had several new ones to leave because they said it was just too much. During an interview on 05/27/25 at 2:00 PM, Resident #2, who had a Brief Interview for Mental Status (BIMS) of 15, stated, Sometimes the food is okay, but most of the time it is cold. That makes it nasty, sometimes it is just barely warm. The biscuits and gravy yesterday were not hot at all. Now, we do have a good variety, and they come around and ask what we want. During an interview, on 05/27/25 at 2:15 PM, Resident #44, who had a BIMS of (9) nine, stated, This food here is not very good. It is cold all the time when you get it. How would they like to eat cold food? During an interview on 05/27/25 at 2:40 PM, Resident #3, who had a BIMS score of 15, stated, I have not been here very long, but what I have eaten has not been hot, except for my cheeseburger. During an interview, on 05/27/25 at 3:07 PM, the Administrator stated, We are just going to have to do better. The Administrator confirmed the temperatures on the above dates had not been taken.

Based on record review and staff interview, the facility failed to provide the residents with an environment free from abuse from other residents. Resident #9 was physically abused by Resident#159. Resident #159 slapped Resident #9in the face. This was determined as Past Non-Compliance immediate jeopardy. Immediate jeopardy was determined to begin on 06/22/24 and was abated on 07/11/24. Resident identifiers: #159, #9. Facility census: 60. Findings included: a) Resident #159 During a medical record review on 09/30/24 at approximately 10:30 AM, it was found that Resident #159 was admitted on [DATE]. Admitting diagnoses included encephalopathy, altered mental status, cognitive communication deficit, and Unspecified dementia, unspecified severity with other behavioral disturbance, and anxiety disorder. It was further identified that the resident did not have the capacity to make medical decisions and had a score of six (6) for a Brief Interview for Mental Status (BIMS). 05/22/247:34 PM a behavioral status evaluation revealed the resident had physical aggression and was a danger to self or others. The resident took the lever off the mechanical lift and hit the emergency exit door and cracked the window in the door. Resident became combative with staff when attempting to remove resident from the situation and was placed 1:1. 05/28/24 at7:05 PM a progress note revealed a nurse heard banging at the end of unit 2hallway. Resident was noted to be banging on a window. Staff attempted to redirect residents. Resident started to swing a bar at the staff that he had. Staff were able to intercept and get the bar away from the resident. But resident showed continual aggression by cussing and punching staff. No injuries. Upon inspection of the window a hole through the glass was noted. 05/28/24 at 7:22 PM progress note revealed the resident was sent to a local hospital for psychiatric evaluation. 05/30/245:00 PM progress note revealed the resident returned to the facility from the psychiatric evaluation. 06/22/24 at 8:21 PM a note revealed nursing staff tried to give resident Buspar and behavior was observed. The resident was aggressive with a female resident when she tried to wheel past him. He cursed at her and stated, I will knock the hell out of you. He was immediately moved away from the resident. 06/27/24 at11:11 PM the resident was by FNP (Family Nurse Practitioner) for medication review. - The note by the FNP stated, Resident is refusing medications and having increased behaviors. History of present illness: Resident has had behaviors where he has busted out windows at the nursing and was sent to the ER at BARH. Sent back with no new orders or medication changes. The resident continues to have increased behaviors, to where he swings his fists at other residents when he passes them, refuses medication, very difficult to redirect. Assessment and plan: Medications reviewed, nursing manager will call Dr. (name) concerning resident's increased behaviors and medication refusal and ask for medication adjustments. 06/30/24 at 8:48 PM a nursing note stated, Resident attempting to go out door. Several attempts to finally get him to calm down. He states he wants to go home, and he had been trying to call his girlfriend but did not get an answer, which upset him. Refused to take meds. 07/04/24 at 9:20 AM a nursing note stated, Resident kicking exit door in dining room. Being combative towards staff. Grabbed the arm of CNA (certified nursing assistant) when she attempted to redirect and move him away from door. Upon intervention, he stated I stated I hate this f-ing place, and I will beat the hell out of all of you. Attempted to contact girlfriend, left voicemail. Resident sitting in front of office door at this time, no signs or symptoms of distress at this time. Offered snacks and drinks, he declined. 07/04/24 at10:41 a nursing note stated the resident had hit another resident who was trying to push the telehealth device away. The power of attorney was unable to be contacted by phone and nursing was unable to do 1:1 supervision. The resident was sent out for treatment. A note on 07/11/24 at 4:56 PM revealed Resident #159 slapped Resident #9 in the face and Resident #9 was noted to have redness to the left side of face. It was identified in the medical record for Resident #9 that was a long-term resident of the facility and does not have capacity. Resident #9 is severely impaired cognitively for daily decision making. Resident #9 mobility was with a wheelchair and is constantly traveling throughout the facility. During an interview with NA #20 at 3:15 PM on 09/30/24. NA #20 stated that on 07/11/214 Resident#159 was yelling and screaming but that was the first time she had seen him hit someone. NA #20 said she had seen the resident pushing Resident#9's wheelchair trying to aggravate her. NA #20 further stated Resident #159 would yell at the victim (Resident #9) at this time. NA #20stated, I think there are times he has hit other people, but I have not seen that. NA #20 states she witnessed Resident #159 tell the Resident #9 prior to Resident #9 being slapped in the face and saying, I'll knock the hell out of you. The incident of verbal abuse where Resident #159 told Resident #9 he would knock the hell out of her was not identified, reported or investigated as allegations of verbal abuse. During an interview with Nurse Aide (NA) #74 at 6:20 PM on 09/30/24 NA #74 stated she had witnessed, multiple times prior to the 07/11/24 incident where Resident #159 would say to Resident #9, Don't fxxxxxx bump into me and I'll beat the sxxx out of you. This incident of verbal abuse of Resident #159 towards Resident #9 was not identified to have been identified, reported or investigated. A medical record review on 09/30/24 at 5:30 PM identified Licensed Practical Nurse (LPN)#75 documented on 06/02/24 at 8:21 PM note text stating that LPN #75 tried to give resident Buspar, and behavior was observed, resident was aggressive with female resident when she tried to wheel past him. He cursed at her and stated, I will knock the hell out of you. He was immediately moved away from the resident and no other behaviors were noted since then. Continue to monitor. Further medical review, prior to this incident on 06/02/24, identified two (2)incidents dated 5/22/24 and 5/28/24 that Resident #159 was identified to remove the bar from the mechanical lift and as he brandished the weapon, he began beating the emergency exit doors and windows and busting the windows each time. It is identified that Resident #159's girlfriend and Medical Power of Attorney attempted to be reached numerous times during episodes but was unsuccessful. On 07/04/24at 9:20 AM the resident was trying to kick the door in the dining room. At10:41 AM the facility tried to reach the MPOA to send residents to hospital but was unable to reach MPOA. 07/15/24 at4:11 PM - a note revealed, Resident placed on 1:1. Resident#159 was transferred to a local hospital on 08/27/24 and passed away at a local hospice on 09/14/24. During an interview with the Administrator on 10/01/24 at approximately 1:00 PM the Administrator stated the facility had self-identified concerns with implementing their policy with regards to identifying, reporting and investigating allegations of abuse. An immediate jeopardy (IJ) template was provided to the administration on 10/01/24 at1:07 PM. The Administrator stated that after the event on 07/11/24 the facility self-identified concerns with the activities not being effective with person centered interventions to implement and concerns with the need of psych service training for the nursing staff in the event it was to be needed again. The Administrator stated the facility had completed the following Plan of correction on 07/11/24. The Administrator further stated that the verbal abuse incident would be reported immediately, and the staff involved would be addressed. Upon receiving the Plan of Corrections documentation on 10/02/24 at approximately 2:30 PM an audit of the plan of correction began. A review of the staff education signatures of completion were verified via the staff roster. Facility Plan of Correction- 07/11/24 1. Implemented Policy and Procedure on abuse prohibition 2. Education completed on 07/11/24 with all staff for reporting abuse and neglect. 3.Telehealth training for psych services in the event the situation happened again and services were needed.4. Audit of getting to know me tools with activities and implementing them with person centered care. The IJ began on 06/22/24 and ended on 07/11/24.

Based on record review and staff interview the facility failed to ensure residents were assessed to identify risk factors and provide care and services that are resident centered to prevent falls with injury and to ensure medications were administered as ordered. This was true for 3 (three) of 6 (six) residents reviewed for the Long Term Care Survey Process. Facility census: 60. Resident identifiers: Resident #162, Findings include: a) Resident #162 On 10/01/24 at approximately 03:30 PM, a record review was started for Resident #162 which reveal that Resident #162 was an [AGE] year-old female admitted on [DATE] status post hospitalization for an unwitnessed fall that occurred at home. Resident #162 was admitted with the following past medical history: A further review of Resident #162 admitting orders revealed that an order for non-skid footwear for safety was entered upon admission with an active date of 12/11/23. Resident #162 was deemed incapacitated with long term duration due to a dx of Alzheimer's Disease on 12/13/24. Furthermore, Resident #162 scored an 8 on the Brief Interview For Mental Status (BIMS) Evaluation which indicates moderate cognitive impairment. A review of the Policy and Procedure entitled, Falls Management revealed that all patients will be assessed for risk of falls upon admission, with reassessments routinely, which includes post fall, to determine ongoing needs for fall prevention precautions. The Center will implement and document patient-centered interventions according to the individual risk factors to the patient plan of care. The Center, to the extent possible, will provide the patient and/or patient representative with opportunities to participate in the care planning process for risk reduction and fall reduction strategies. In addition, the policy states for Post-Fall Management the circumstances of the fall will be documented as well as the post fall assessment. In addition, Resident #162 progress notes were reviewed which revealed the following documented notes (typed as written): 12/11/23 at 11:30 PM Nursing Documentation Note: Patient was admitted /readmitted for the following reason(s): admission Additional details about this note: Resident resting in bed at this time. admitted from (name of hospital) due to resident having a fall. Resident alert with some confusion at this time. System Review: Neurological system reviewed Mental Status: Alert. Oriented to Person Severely impaired in decision making skills for daily routine Vision Reviewed Hearing and Speech reviewed Highly impaired hearing. 12/16/23 at 11:30 PM eINTERACT SBAR Summary for Providers: CNA called me to residents room. Resident in floor on right side facing door. Bed in lowest position, resident has regular white ankle socks on. Resident awake and able to answer questions, states she was trying to get up to go home No new pain complaints, resident has multiple bruises in various stages of healing from previous falls. ROM wnl. neuro's initiated. mpoa notified as well as NP. vitals obtained. 12/18/23 T 4:05 PM General Fall huddle meeting held. New intervention for fall mat to right side of bed 12/20/23 at 3:56 PM eINTERACT SBAR Summary for Providers Called to room by social worker, resident noted to be lying on the floor on her right side, fall mat was in place at the time of fall, resident alert, Neuro assessment complete with no issues noted, skin assessment completed, lacerated noted to right side of forehead, first aide administered, resident sent to ER for further evaluation. Relevant medical history is: Dementia 12/21/23 at 00:42 AM General Spoke with nursing staff at PMC ER, Resident transferred to CAMC General division for Subdural Hematoma 12/21/24 at 9:09 AM General Fall huddle meeting held. New intervention to place signage in room to remind resident to call for assistance for transfers On 10/02/24 at approximately 08:30 AM, Resident #162 care plan was reviewed which revealed the following fall care plan: Focus: Resident is at risk for falls: cognitive loss, lack of safety awareness. Date initiated: 12/12/23 Goal: Resident will have no falls with injury throughout the next review period. Date initiated: 12/12/23 Interventions: Place glasses within reach in a consistent place and encourage use. Date initiated: 12/12/23 Bed in low position. Date initiated: 12/12/23 Fall mat to right side of bed. Date initiated: 12/18/23 Signage in room to remind resident to call for assistance with transfers. Date initiated: 12/21/24 Provide resident/caregiver education for safe techniques of when to use call light for assistance. Date initiated: 12/21/23 Assist resident/caregiver to organize belongings for a clutter-free environment in the resident's room and consistent furniture arrangement. Date initiated: 12/12/23. In addition, Resident #162 Standard Assessments were reviewed which revealed no Fall Risk Evaluation performed on admission or for post fall for 12/16/23 and for post fall 12/20/23. The eINTERACT Change in Condition Evaluation assessment for the dates of 12/16/23 and 12/20/23 were also reviewed and revealed the following information: 12/16/23 Section 2 Functional Status Evaluation in which the resident's supine, sitting and standing blood pressures are to be entered are blank. 12/20/23 Section 2 Functional Status Evaluation in which the resident's supine, sitting and standing blood pressures are to be entered are blank. On 10/02/24 at 09:00 AM, the Policy and Procedure entitled, Accidents/Incidents was completed which revealed that when conducting an investigation, the Administrator, DON or designee will make every effort to ascertain the cause of the accident/incident and document the root cause and initiate actions to prevent or reduce recurrence of further accident/incident. On 10/02/24 at 09:55 AM, an interview was conducted with the DON. At that time the DON acknowledged the following: 1. Fall Risk Evaluation is to be completed on admission 2. Fall Risk Evaluation is to be completed post fall 3. Nursing should be documenting circumstances surrounding fall and aren't. Such as incontinence and assistive devices. 4. Nursing assessments should be completed in their entirety and that orthostatic blood pressure readings should be obtained. 5. No admission fall risk evaluation was completed for Resident #162, as per policy. 6. No post-fall fall risk evaluation for the dates of 12/16/23 and 12/20/23 was completed, as per policy. At this time, this Surveyor reviewed Resident #162 incident forms, dated 12/16/23 and 12/20/23, which has sections to be completed for predisposing physiological factors and predisposing situation factors with the DON. At this time, the DON acknowledged that both forms lacked required documentation such as, Resident # 162 was receiving and antidepressant, antihypertensive, antiparkinsonian, laxative and wore glasses. In addition, the DON acknowledged, the incident form dated, 12/16/2,3 lacked the required documentation that Resident #162 was newly admitted within the last 7 (seven) days and that Resident #162 was wearing unsafe footwear and not the ordered non-skid sole footwear on admission. The DON then stated, the IDT team relies heavily on the nurses note and look at trends to know which fall interventions to put in place. At that time, this Surveyor asked the DON if you don't have the circumstances of the fall documented, how do you do that? The DON then states, You have a point. On 10/02/24 at approximately 12:00 PM, this Surveyor completed a review of the emergency room documentation for Resident #162 fall which occurred on 12/20/23. Resident #162 was sent from the Center to [NAME] Area Medical Center (CAMC) Plateau Medical Center (PMC) following the fall that occurred on 12/20/23, which revealed the following: CAMC PMC 12/20/23: Resident #162 was transferred to CAMC General for neurosurgery, higher level of care with diagnoses: 1. Traumatic Subdural Hemorrhage 2. Laceration without foreign body of scalp 3. History of falling Review of the documentation from CAMC General revealed the following: Resident #162 was admitted to the hospital to the Intensive Care Unit (ICU) with hourly neuro-checks. Resident #162 underwent a repeat Cat Scan (CT) of her head which initially slightly increased, but was then subsequently stable, at which point Resident #162 was transferred from the ICU to the floor. Resident #162 subsequently developed decreased mental status and underwent repeat CT imaging which showed increased subdural with a midline shift. Resident #162 was transferred back to the ICU after which a discussion with family was held who believed that in light of the patient's recent decision to be a Do No Resuscitate (DNR), Resident #162 would not want any invasive procedures or prolonged hospital course. The decision was made to proceed with comfort care with transition to hospice care. Resident #162 was noted to expire on 12/27/23 On 10/02/24 at 1:04 PM, an interview was conducted with the Director of Nursing (DON). At this time, the DON acknowledged that the Center had knowledge Resident #162 had a history of falls at home prior to admission. When this Surveyor reviewed the 12/15/23 72 hour post admission meeting documentation with the DON, she stated when she spoke with Resident #162 daughter, the daughter stated to her, We can't keep her off the floor, that's why she is here. At this time, this Surveyor asked the DON if she asked Resident #162 daughter about circumstances surrounding Resident #162 falls at home in order to implement resident centered relevant interventions to prevent further falls, the DON stated, I am sure I did. When asked the DON to provide documentation of this, the DON acknowledged that she was unable to provide it. This Surveyor then asked the DON if root causes were performed on Resident #162 falls. The DON stated, Yes. When asked the DON to provide documentation, the DON acknowledged she was unable to provide it. This Surveyor then asked the DON what the root causes where for Resident #162 falls, to which the DON acknowledged she could not provide them. This Surveyor then asked how interventions to prevent falls were determined to be resident centered based on the resident's individual risk factors, relevant and appropriate for Resident #162 to which the DON acknowledged she was unable to provide that. This Surveyor then reviewed the Policy and Procedure, Falls Management and Accidents/Incidents and asked the DON to review these policies. Then DON then said, I am aware of what they say. On 10/03/24, shortly after arrival to the facility at approximately 08:25 AM, the Senior Executive Director stated to this Surveyor, We found that a risk evaluation is built into the admission assessment last night. On 10/03/24 at approximately 08:30 AM, an interview was conducted with the DON. At this time, the DON stated that Point Click Care has since been updated and changed, however, the previous admission assessments had a fall risk evaluation embedded in it. At this time, the DON pulled an admission assessment up on her computer and clicked on a number by the admission assessment which was a hyperlink. The DON clicked on this link, which pulled up an addendum which gave a numeric value for different risks factors based on the answers from the admission assessment. The DON stated, We accidentally found this last night. At that time, this Surveyor asked the DON if facility staff were unaware of this tool, how was it utilized to develop the plan of care based on the resident's individualized risk factors. The DON stated, We didn't utilize it. In addition, this Surveyor asked the DON to review said resident's fall care plan and interventions, which were done. This Surveyor then asked the DON, based off said resident's risk factors, how does the care planned interventions address and mitigate this resident's individual risk factors? The DON stated, They don't. 49650 b) Resident #10 During a medical record 10/01/24 at 2:46 PM, Resident #10's physician order identified an order for Sinemet Tablet 25-100 MG (Carbidopa-Levodopa) and to give 2 tablet by mouth five times a day for Parkinson disease active date of 01/09/23. During further review of the Residents Medication Administration Record (MAR) it is identifeid that the following doses were not documented to have been administered per the physicians order. * 06/29/24, the 1800 hour dose is missing * 08/29/24 the 1800 hour dose is missing * 09/15/24 the 1800 hour dose is missing During an interview with the Director of Nursing on 10/01/24 at approximately 10:40 AM the DON acknowledged the doses were not documented as being administered per the physicians order. 50552 Based on record review and staff interview the facility failed to ensure residents were assessed to identify risk factors and provide care and services that are resident centered to prevent falls with injury and to ensure medications were administered as ordered. This was true for 2 (two) of 6 (six) residents reviewed for the Long Term Care Survey Process. Resident identifiers: #162, #10. Facility census: 60. Findings include: a) Resident #162 On 10/01/24 at approximately 03:30 PM, a record review was started for Resident #162 which reveal that Resident #162 was an [AGE] year-old female admitted on [DATE] status post hospitalization for an unwitnessed fall that occurred at home. Resident #162 was admitted with the following past medical history: -Alzheimer's Disease -Hypothyroidism -Essential Hypertension -Repeated Falls -Cognitive Communication Deficit -Parkinson's Disease -Insomnia -Depression -Tremors Resident #162 was receiving the following medications upon admission: -Carbidopa-Levodopa- diagnosis (dx): Parkinson's -Cympbalta- dx: Depression -Metoprolol Succinate Extended Release- dx: Hypertension -Rozeram- dx: Insomnia -Miralax- dx: Constipation A further review of Resident #162 admitting orders revealed an order for non-skid footwear for safety was entered upon the resident's admission with an active date of 12/11/23. Resident #162 was deemed incapacitated with long term duration due to a dx of Alzheimer's Disease on 12/13/24. Furthermore, Resident #162 scored an 8 on the Brief Interview For Mental Status (BIMS) Evaluation which indicates moderate cognitive impairment. A review of the Policy and Procedure entitled, Falls Management revealed that all patients will be assessed for risk of falls upon admission, with reassessments routinely, including post fall, to determine ongoing needs for fall prevention precautions. The policy stated, The Center will implement and document patient-centered interventions according to the individual risk factors to the patient plan of care. The Center, to the extent possible, will provide the patient and/or patient representative with opportunities to participate in the care planning process for risk reduction and fall reduction strategies. In addition, the policy states for Post-Fall Management the circumstances of the fall will be documented as well as the post fall assessment. Resident #162 progress notes were reviewed which revealed the following documented notes (typed as written): 12/11/23 at 11:30 PM Nursing Documentation Note: Patient was admitted /readmitted for the following reason(s): admission Additional details about this note: Resident resting in bed at this time. admitted from (name of hospital) due to resident having a fall. Resident alert with some confusion at this time. Pt. has a history of falls. Neurological system reviewed Mental Status: Alert. Severely impaired in decision making skills for daily routine. Highly impaired hearing. A physiatry progress note dated 12/13/24 revealed the resident had mobility and activities of daily living (ADL) deficits secondary to a fall. The note stated the resident would be getting skilled therapy services with the goal of increasing strength, endurance and self care abilities as well as working on neuromotor training, stair climbing and functional moblity trainng. On 12/16/23 at 11:30 PM a note revealed the resident was found in the floor on her right side facing the door. She was found by a nurse aide (NA). She was awake and able to answer questions and stated she was trying to get up to go home. The note revealed the resident had no regular white ankle socks and the bed was in the lowest position. On 12/18/24 a progress note revealed the fall huddle meeting was held and a new intervention was put into place for a fall mat to the right side of the bed. On 12/20/23 a progress note stated, Called to room by social worker with the resident noted lying on the floor on right side with fall mat in place. The note reflected that the resident had a laceration to the right side of the forehead. The resident was sent to the emergency department for further evalution. A note dated 12/21/23 stated the resident had been transferred to a larger area hospital due to subdural hematoma. On 12/21/24 a fall huddle meeting was held a a new intervention was placed in the room. A sign was placed to remind resident to call for assistance with transfers. On 10/02/24 at approximately 08:30 AM, Resident #162 care plan was reviewed which revealed the following: Focus: Resident is at risk for falls: cognitive loss, lack of safety awareness. Date initiated: 12/12/23 Goal: Resident will have no falls with injury throughout the next review period. Date initiated: 12/12/23 Interventions: Place glasses within reach in a consistent place and encourage use. Date initiated: 12/12/23 Bed in low position. Date initiated: 12/12/23 Fall mat to right side of bed. Date initiated: 12/18/23 Signage in room to remind resident to call for assistance with transfers. Date initiated: 12/21/23 Provide resident/caregiver education for safe techniques of when to use call light for assistance. Date initiated: 12/21/23 Assist resident/caregiver to organize belongings for a clutter-free environment in the resident's room and consistent furniture arrangement. Date initiated: 12/12/23. In addition, Resident #162 Standard Assessments were reviewed which revealed no Fall Risk Evaluation performed on admission or for post fall for 12/16/23 and for post fall 12/20/23. The Change in Condition Evaluation assessment for the dates of 12/16/23 and 12/20/23 were also reviewed and revealed the following information: A review of functional status evaluations dated 12/16/23 and 12/20/23 revealed in Section 2 that the resident's supine, sitting and standing blood pressures were to be entered were blank. On 10/02/24 at 09:00 AM, the Policy and Procedure entitled, Accidents/Incidents was completed which revealed that when conducting an investigation, the Administrator, DON or designee will make every effort to ascertain the cause of the accident/incident and document the root cause and initiate actions to prevent or reduce recurrence of further accident/incident. On 10/02/24 at 9:55 AM, an interview was conducted with the Director of Nursing (DON). At that time the DON acknowledged the following: 1. Fall Risk Evaluation were to be completed on admission 2. Fall Risk Evaluation were to be completed post fall 3. Nursing should document circumstances surrounding falls and were not. These circumstances include things such as incontinence and assistive devices. 4. Nursing assessments should be completed in their entirety andorthostatic blood pressure readings should be obtained. 5. No admission fall risk evaluation was completed for Resident #162, as per policy. 6. No post-fall fall risk evaluation for the dates of 12/16/23 and 12/20/23 were completed, as per policy. At this time, this Surveyor reviewed Resident #162 incident forms, dated 12/16/23 and 12/20/23, which had sections to be completed for predisposing physiological factors and predisposing situation factors with the DON. The DON acknowledged that both forms lacked required documentation such as, Resident # 162 received and antidepressant, antihypertensive, antiparkinsonian, laxative and wore glasses. In addition, the DON acknowledged, the incident form dated, 12/16/23 lacked the required documentation that Resident #162 was newly admitted within the last 7 (seven) days and that Resident #162 was wearing unsafe footwear and not the non-skid sole footwear ordered on admission. The DON then stated, the IDT team relies heavily on the nurses note and looks at trends to know which fall interventions to put in place. At that time, this Surveyor asked the DON, If you don't have the circumstances of the fall documented, how do you do that? The DON then states, You have a point. Resident #162 was noted to expire on 12/27/23 On 10/02/24 at 1:04 PM, an interview was conducted with the Director of Nursing (DON). At this time, the DON acknowledged the Center had knowledge Resident #162's history of falls at home prior to admission. When this Surveyor reviewed the 12/15/23 72 hour post admission meeting documentation with the DON, she stated when she spoke with Resident #162 daughter, the daughter stated to her, We can't keep her off the floor, that's why she is here. At this time, this Surveyor asked the DON if she asked Resident #162 daughter about circumstances surrounding Resident #162 falls at home in order to implement resident centered relevant interventions to prevent further falls, the DON stated, I am sure I did. When asked the DON to provide documentation of this, the DON acknowledged that she was unable to provide it. This Surveyor asked the DON if root causes were performed on Resident #162 falls. The DON stated, Yes. The DON acknowledged was unable to provide these root cause analysis. This Surveyor then asked the DON what the root causes where for Resident #162 falls, to which the DON acknowledged she could not provide them. This Surveyor asked how interventions to prevent falls were determined to be resident centered based on the resident's individual risk factors, relevant and appropriate for Resident #162 to which the DON acknowledged she was unable to provide that. This Surveyor then reviewed the Policy and Procedure, Falls Management and Accidents/Incidents and asked the DON to review these policies. Then DON then said, I am aware of what they say. On 10/03/24, shortly after arrival to the facility at approximately 08:25 AM, the Senior Executive Director stated to this Surveyor, We found that a risk evaluation is built into the admission assessment last night. On 10/03/24 at approximately 08:30 AM, an interview was conducted with the DON. At this time, the DON stated that Point Click Care has since been updated and changed, however, the previous admission assessments had a fall risk evaluation embedded in it. At this time, the DON pulled an admission assessment up on her computer and clicked on a number by the admission assessment which was a hyperlink. The DON clicked on this link, which pulled up an addendum which gave a numeric value for different risks factors based on the answers from the admission assessment. The DON stated, We accidentally found this last night. At that time, this Surveyor asked the DON if facility staff were aware of this tool and how was it utilized to develop the plan of care based on the resident's individualized risk factors. The DON stated, We didn't utilize it. In addition, this Surveyor asked the DON to review the resident's fall care plan and interventions, which were done. This Surveyor then asked the DON, based off said resident's risk factors, how did the care planned interventions address and mitigate this resident's individual risk factors. The DON stated, They don't. b) Resident #10 During a medical record review on, 10/01/24 at 2:46 PM, it was revealed that Resident #10's physician order identified an order for Sinemet Tablet 25-100 MG (Carbidopa-Levodopa) and to give 2 two tablet by mouth 5 times a day for Parkinson disease active date of 01/09/23. During further review of the Residents Medication Administration Record (MAR) it is identifeid that the following doses were not documented to have been administered per the physicians order. * 06/29/24, the 1800 hour dose is missing * 08/29/24 the 1800 hour dose is missing * 09/15/24 the 1800 hour dose is missing During an interview, with the Director of Nursing on 10/01/24 at approximately 10:40 AM, the DON acknowledged the doses were not documented as being administered per the physicians order.

Based on observation, policy review, family interview, staff interview and medical record review the facility failed to ensure a resident who received nutrition through a Gastrostomy tube (G-tube) received sufficient caloric intake daily to prevent weight loss. Harm occurred when the resident experienced a significant weight loss and G-tube feedings were held. The G-tube feedings were held to encourage the resident to eat by mouth, but the facility failed to have a plan in place to ensure caloric intake would be maintained if the resident did not eat by mouth. This was true for one (1) of three (3) residents reviewed who receive nutrition via a G-tube. Resident #55. Facility Census: 57. Findings included: a) Resident #55 Resident #55 was admitted to the facility from the hospital on 05/02/23. The resident had suffered a recent stroke and was admitted to the with a Gastrostomy tube (g-tube). The g-tube allowed the resident to receive nutrition directly through the stomach. b) Facility policy Facility policy titled, Procedure Weight and Heights effective date 06/01/01, with a revision date of 02/01/23 read as follows: 2. Significant weight Change Management: 2.1 Significant weight changes will be reviewed by the licensed nurse for assessment. 2.1.1.1 - 5% in one month 2.1.1.2 - 10% in six month 2.2 The licensed nurse will: 2.2.1 Notify the physician/APP and the Dietitian of significant weight changes: 2.2.2 Document notification of physician/APP and the Dietitian in the PCC (point click care) weight Change Progress Note. 2.3 The licensed nurse will notify the: 2.3.1 Physician/APP of the Dietitian recommendations: 2.3.2 Patient representative of the weight change and the Dietitian recommendations. During an interview, on 07/10/23 at 12:58 PM, Resident #55 wife/Medical Power of Attorney (MPOA) stated she was aware her husband had lost weight. She said the staff were trying to get him to eat by mouth so he could do without the feeding tube and go home. Record review on 07/10/23 at 2:15 PM, revealed the following weights: -07/09/23 - 162.2 Pounds (Lbs.) Mechanical Lift -07/02/23 - 168.4 Lbs. Mechanical Lift -06/25/23 -167.4 Lbs. Mechanical Lift -06/18/23 - 170.6 Lbs. Mechanical Lift -06/11/23 - 171.8 Lbs. Mechanical Lift -06/04/23 - 173.2 Lbs. Mechanical Lift -05/28/23 - 167.6 Lbs. Mechanical Lift -05/21/23 -171.4 Lbs. Mechanical Lift -05/14/23 - 170.2 Lbs. Mechanical Lift -05/07/23 - 177.2 Lbs. Mechanical Lift -05/02/23 - 178.0 Lbs. Standing On 06/04/23, the resident weighed 173.2 lbs. On 07/09/2023, the resident weighed 162.2 pounds which is a -6.35 % significant weight loss in one (1) month. On 05/02/23, the resident weighed 178 lbs. On 07/09/2023, the resident weighed 162.2 pounds which is a -8.88 % significant weight loss in two (2) months. Review of the Speech therapists (ST)' notes found the ST recommended holding the resident's feedings to attempt to get the resident to eat by mouth. Further record review revealed a physician order dated 07/06/23, to hold the feedings to help stimulate PO (by mouth) appetite. Further record review revealed a Medication Administration Record (MAR) for the month of July (typed as written) Enteral Feed Order, one time a day Jevity 1.5 CAL (calorie) Administer continuous via Pump 88 ML(milliliters) per hour. Until total nutrient delivered of 968 ml. (milliliters) Start at rate of 50 ml/hr (milliliters per hour) titrating up to 25mls/hr every 4 hours until goal of 88ml/hr is reached. Start Date 06/06/23. This order was placed on hold from 07/06/23 through 07/09/23. A second order directed: Enteral Feed Order, two times a day Jevity 1.5 CAL administer bolus via gravity 237 ml 2 times a day per day Start Date 06/03/23. This order was placed on hold from 7/06/23 through 07/08/23. Further Record Review revealed Resident #55 PO (by mouth) meal consummation percentage for the days the feedings were held is as follows: -07/06/23 1:19 PM 0 percent (%) -07/06/23 6:37 PM 25% -07/07/23 was void of any documentation -07/08/23 8:18 AM void of any documentation -07/08/23 12:28 PM 0% -07/08/23 5:54 PM 0% -07/09/23 10:52 AM 0% -07/09/23 12:00 PM 0% -07/09/23 6:06 PM 0% In a three (3) day time period the resident only received 25% of a meal via oral intake on 07/06/23 at 6:37. The resident was not weighed directly before and after the feedings were held. The weights indicate the resident was weighed on 07/02/23 and his weight was 168.4 lbs. On 07/09/23 the Residents weight was 162.2 lbs., which was a 6.2 pound weight loss in 7 (seven) days. During an interview on 07/12/23 at 11:18 AM, the Director of Nursing (DoN) stated, We notify the physician when residents looses 5% in a month. This surveyor asked, What if they are weight weekly and have a six (6) pound weight loss in a week?. The DoN stated, It depends if they are requesting to lose weight, have Congestive heart failure, or take diuretics. This surveyor asked, What if a resident has a G-tube and loses weight? The DoN stated,Yes definitely the physician needs to be notified of a weight loss like that. The issue of Resident #55's weight loss was discussed with the DoN. The DoN said it was the speech therapist's idea to stop the feedings for three (3) days to attempt to get the resident to eat by mouth. The DON was asked to provide information as to how the facility addressed the situation when the resident only consumed 25% of one oral meal in a three-day time period and provide documentation of notification to the physician and the registered dietician when the Resident ate only 25% of one of the nine meals that should have been served. She was asked what the plan was if the resident did not eat by mouth? On 07/12/23 at 1:05 PM, the DoN provided a weight change progress note written by LPN #19, dated 07/11/23. The note documented the Interdisciplinary care plan (IDCP) team, dietician and provider monitoring weekly weights related to residents transitioning from tube feeding to PO (by mouth) intake. Current weight was 162.2 lbs. and last week weight was 168.4. Resident weight decreased 6.2 lbs. The resident's tube feeding was placed on hold from 07/06/23 to 07/09/23. Resident bolus and nightly feeding resumed on 07/09/23. Resident trial of holding feeding to stimulate appetite was not successful. Resident PO (by mouth) appetite was poor on 07/06/23, 07/07/23 and 07/08/23. Resident continued to consume 25% or less of meals. Resident declined for staff to assist him with meals. Resident was able to feed self with left upper extremity (LUE) without difficulty. Wife aware of resident weight loss and poor PO (by mouth) appetite. Appetite stimulant discussed with wife (wife's name) requested to think about it and call her tomorrow. Name of family nurse practioner (FNP) and dietician aware. Will follow up with (wife's name) on 07/12/23. The note dated 7/12/23, was the first note written in the resident's medical record after the facility held the g-tube feedings. The DON was unable to provide any documentation the facility addressed the fact the resident only consumed 25% of one meal on 07/06/23, and nothing was eaten by mouth on 07/07/23 or 07/08/23. The DoN was unable to reach the speech therapist for comment due to a family emergency. The DON was unable to provide documentation the speech therapist (ST) addressed the situation in the ST notes. During an interview on 07/12/23 at 2:06 PM, Registered Dietitian (RD) #81 stated he worked with Speech, and they wanted Resident #55 PO (by mouth) intake to increase. Resident #55 was on Argiment AT powder, but the facility could no longer get it, so the RD switched him to Juven. The RD said, I do a nutritional assessment weekly on him, but I have been out for two weeks due to an illness. It looks like (Name of Resident #55's) weight loss was from the feeding being on hold and not eating anything PO (by mouth.) Because last time I was here and completed a nutritional assessment his weight had plateaued, and I adjusted it to accommodate his caloric and protein intake. The Surveyor asked the RD # 81 Should someone have made you aware of the significant weight loss and no nutritional intake? LPN #19 was present during this interview with the RD and LPN #19 stated, The nursing staff should have notified RD #81. LPN #19 also stated, We offer Resident #55 trays, and he keeps refusing them every time. The Surveyor asked the RD #81, how many calories should Resident #55 should consume daily. The RD #81 stated Resident #81 received his calories and protein from the Jevity from G tube feedings and bolus feedings, he also receives Juven for calories and protein. RD #81 said, The orders to hold the feedings should have been written that if he accepted nothing or little by mouth then the feeding should have been altered and the physician notified. The RD was unable to provide documentation to validate this happened. The order directed to only hold the feedings. This surveyor asked the RD #81 When were you notified of Resident #55 significant weight loss from 07/09/23? The RD #81 stated, I did not know anything until I arrived in the facility today, I have been off for two weeks with Shingles. This surveyor referenced the weight change progress note mentioned above to LPN # 19 and asked, When did you write this note dated 07/11/23?. LPN #19 stated, I did put the note in today (07/12/23) I did not notify the RD, the note is wrong, I should not have written that note until I notified the RD and the medical director, I falsified the medical records. During an interview on 07/12/23 at 3:30 PM, the DON was made aware of LPN #19 not contacting the RD or the medical director when Resident #55's significant weight loss occurred and the fact that LPN #19's said she falsified the medical record. A further review of medical records on 07/12/23 at 4:30 PM revealed nutritional assessment by the Registered Dietician, dated 07/12/23, Section B titled Diet Order, Nutrients provided by enteral feeding: Calories 2163 Protein 92 Intake observation (typed as written) Working with ST (speech therapist). per nursing doc. (documentation) ST (speech therapist) requested for feeding to be held from 07/06-07/09 with goal of stimulating appetite. Per nursing notes FNP (family nurse practioner) aware and approved. Meal intakes 0-25% of meals with multiple refusal per activities of daily living (adls) on 14 day review (typed as written) 07/12/23 body weight of 163.6 lbs (pounds) (74.4kgs kilograms) used to calculate needs 25-30 kcals (kilocalories) /kg (kilogram). 1860-2232 kcals (kilocalories) /day 1.3-1.5 gms (grams)/pro (protein) /kg (kilogram) r/t (related to) wound healing 97-112 gms (grams) /pr (per) /day 1mL (milliliter) fluid kcal (kilocalorie) consumed or 30 ml (milliliter) /fluid/kg. (kilogram). 2232 ml (Milliliters) fluid/day (typed as written) Bolus feeding providing 711 kcals (kilocalories), 30 gms (grams) /pro per 360 mL(milliliter) /free water per day Continue feed providing 1452 kcals (kilocalories), 62 gms (grams) /pro 736 mL (milliliters) /free water Juven bid 160 kcals (kilocalories), 5 gms. (grams) /pro per day. Total intake feedings/supps (supplements) 2323 kcal (kilocalories), 97 gms. (grams) /pro.,1096 mL (milliliters) /free water per day. A further record review revealed a nutritional assessment by the RD, dated 06/13/23 reads as follows: Section B titled Diet Order, Nutrients provided by enteral feeding: Calories 2163 Protein 92 (typed as written) 06/13/23 body weight of 173 lbs (pounds) (78.6kgs -kilograms) used to calculate needs 25-30 kcals (kilocalories)/kg. (kilograms) 1965-2358 kcals (kilocalories/day 1.3-1.5gms (grams) /pro/kg (kilogram) r/t (related to) wound healing 102-118 gms (grams) /pr/day 1mL (milliliter) fluid kcal (kilocalories) consumed or 30 ml (milliliter) /fluid/kg. (kilogram) 2358 ml (milliliters) fluid/day (typed as written) Tube feed providing 2160 kcals 92 gms/pro per day + Argiment AT bid (twice a day) providing 240 and 20 gms./pro=2400 kcals (kilocalories) and 112 gms. (grams) /pro per day. Resident meeting estimated needs with supplementation and tube feed alone not including varied po (by mouth) meal intakes. During an interview on 7/12/23 at 5:30 PM the Administrator stated the speech therapist assisted Resident #55 with his meals and the speech therapist tells the Nurse Aides what percentage of meal consumption to document in the Residents medical records. Neither the Administrator nor the DoN was able to contact the Speech Therapist for an interview or to provide more information before the close of the survey.

Based on record review and staff interview, the facility failed to monitor / assess and obtain timely medical intervention for one (1) of twelve (12) residents of the sample selection with an infected pressure sore. Resident #40 exhibited sign and symptoms of an infected pressure sore and did not receive physician intervention; the resident was taken to a [MEDICAL TREATMENT] center for treatment and was immediately transferred by the [MEDICAL TREATMENT] center to the hospital [MEDICAL CONDITION]. Facility census: 55. Findings include: a) Resident #40 A review of Resident #40's medical record revealed a skin integrity report, dated 07/02/09, which indicated the resident's Stage IV pressure ulcer had purulent drainage. There was no corresponding entry in the nursing notes to reflect the resident's physician was notified of this finding. Nursing notes, dated 07/03/09 at 7:15 p.m., recorded, "New order noted for Tylenol 650 mg every 4 hours for elevated temp. Temperature 100.8 F." At 10:30 p.m., the resident's temperature was 99 F. On 07/06/09 at 6:30 a.m., a nursing note indicated, "Temperature 99.2 F and 99.4 F. ... Ambulance to take resident to [MEDICAL TREATMENT] treatment per family's request. Family wants resident to have an extra treatment." Later on 07/06/09 (no time given), a nursing note recorded, "[MEDICAL TREATMENT] center called to inform me resident's temp was 102 F and the resident is septic and unresponsive and was sent to the hospital." A discharge summary from the hospital, dated 07/08/09, revealed a [DIAGNOSES REDACTED]. The resident's pressure ulcer was necrotic and was debrided at the hospital. A wound VAC was placed, and resident was given [MEDICATION NAME] (an antibiotic) after [MEDICAL TREATMENT] and received two (2) units of blood. In an interview on 07/28/09 at 2:00 p.m., the director of nursing related that the nurses had called the physician on 07/02/09, when the resident was exhibiting purulent drainage and an elevated temperature. A review of the nursing notes for 07/02/09 found no evidence to reflect the physician was notified of purulent drainage in the pressure sore. .