Every finding on record at Arc at Chillicothe

Based on observation, interview, and record review, the facility failed to ensure a resident with a risk for skin breakdown received accurate skin assessments to identify a newly acquired pressure injury, provide a pressure injury treatment and physician notification promptly and ensure interventions were implemented timely and followed to prevent further injury to an unstageable pressure ulcer for one of four residents (R28) reviewed for pressure ulcers in the sample of 35. This failure resulted in R28 returning from the hospital with an unstageable pressure injury and going five days without a wound treatment order, physician notification, or any wound assessments. Findings include:R28's Census sheet documents R28 is an [AGE] year-old female who admitted to the facility on [DATE].R28's Medical Diagnosis List documents Acute Respiratory Failure, Morbid Obesity, Heart Failure, Anxiety and Depression, Difficulty in Walking, Localized Edema, Acute Kidney Failure, and Osteoarthritis in both feet.R28's Minimum Data Set (MDS) assessment dated [DATE] documents R28 is cognitively intact and is dependent on staff for toileting, showers and bathing, upper and lower body dressing and transfers. This same MDS documents R28 is cognitively intact.R28's admission care plan did not include any interventions to prevent pressure ulcers.R28's Treatment Assessment Record (TAR) dated an order with a start date of 2/26/26 and discontinued 4/3/26 to apply a liquid film-forming wipe (Skin Prep) to R28's Right Heel three times a day and as needed.R28's Medical Record does not include any skin assessment for R28's right heel area, when a treatment was obtained on 2/26/26 through when R28 was transferred to the hospital on 3/28/26.R28's hospital records contained a physician progress note dated 3/30/2026 that documented R28 had an unstageable pressure ulcer to the right heel present on admission (to the hospital), with corresponding wound care orders to cleanse with normal saline and apply moisture wicking dressing and cover with a foam dressing every 48 hours.R28's Hospital Discharge Orders, dated 4/1/26, documents a Physician order for R28 to receive treatment to R28's right heel as follows: Cleanse with normal saline and apply moisture wicking dressing and cover with a foam dressing every 48 hours.R28s admission Skin assessment dated [DATE] documents R28 does not have any skin concerns or pressure ulcers identified. R28's care plan initiated on 4/3/2026 documents a pressure blister to R28's right heel but was not revised to reflect the unstageable pressure ulcer and did not contain appropriate interventions for pressure relief and wound management.R28's Treatment Administration Record dated 4/1/26 through 4/5/26 (5 days after being admitted back to the facility from the hospital) does not contain treatment to R28's right heel to cleanse with normal saline and apply moisture wicking dressing and cover with a foam dressing every 48 hours as ordered from the hospital discharge orders.R28's Medical Record dated 4/1/26 through 4/5/26 does not include any documentation or skin assessment of R28's unstageable right heel pressure ulcer.R28's Wound Note dated 4/6/26 documents that V21 (Wound Doctor) was notified by the facility Medical Director that R28 had a wound on her right foot that needed evaluation by V21. This wound note further documents R28 has an unstageable pressure ulcer to her right heel with dead skin. This note documents the pressure ulcer measures 2.9 centimeters (cm) x 2.6 cm and the depth is unmeasurable due to presence of nonviable tissue and necrosis. V21 documents to use a pressure-reliving boot to the right foot and keep R28's heels offloaded. This note contains a new order for R28's right heel to apply foam dressing every two days and as needed: if saturated, soiled, or dislodged for 30 days.On 4/21/2026 at 9:30 AM, R28 was lying in her bed with both heels resting directly on the bed. R28 stated she has a wound on her right heel and does not remember how long she has had it.On 4/22/2026 at 9:00 AM, observation of R28's right heel revealed a dime-sized pressure ulcer with surrounding redness, yellow dead tissue at the edges, and a darkened brown area approximately the size of a pencil eraser in the center of the pressure ulcer.On 4/22/2026 between 9:00 AM and 10:00 AM, intermittent observations revealed the R28 did not have a low air loss mattress in place, R28's heel boot was not in use, and R28's heels were resting directly on the bed without offloading. R28's call light was on from 9:20 AM and still on at 10:00 AM.On 4/22/26 at 9:20 AM, V17 stated that prior to R28 going to the hospital on 3/28/26 R28 had a fluid filled blister on her right heel. V17 stated she could not find documentation of a blister on R28's heel or any assessment including a skin assessment or measurements of the blister. V17 stated there should have been a skin assessment in R28s chart regarding R28's right heel area prior to R28 going to the hospital on 3/28/26. V17 verified R28 does not have a low air loss mattress on her bed because R28 refused one. V17 stated R28's heels should not be laying directly on the bed to prevent further deuteriation of wound or additional wounds. V17 stated the facility received an order from the hospital on 4/1/16 for R28s right heel and nobody caught it until an audit was performed of the readmission by V17 on 4/7/26.R28s current Care Plan does not include documented interventions for R28 to receive a right heel boot to offload right heel at all times or an intervention of a low air loss mattress.R28's electronic medical record does not contain documentation that R28 refused a low air loss mattress or a right heel boot. On 4/22/2026 at 12:15 PM, V21 (Wound Physician) stated he was not notified of the wound until 4/6/2026 and confirmed that failure to implement pressure-relieving interventions and assess and identify timely could result in worsening of the pressure ulcer.The facility's Pressure Injury and Skin Assessment Policy, revised 1/2018, documents the purpose of the policy is to establish guidelines for assessing, monitoring, and documenting skin breakdown and pressure injuries, and to ensure appropriate interventions are implemented. The policy requires that a skin condition assessment and a pressure ulcer risk assessment (Braden Scale) be completed upon admission and readmission. It further requires that residents identified as at risk receive ongoing monitoring, including weekly skin assessments by a licensed nurse. The policy states that when a pressure injury or skin breakdown is identified, a wound assessment must be initiated and documented in the clinical record, including measurements and characteristics of the wound. The policy also requires that, at the earliest sign of skin impairment, the resident, the attending physician, and the resident's representative be notified. Additionally, the initial observation must be documented in the nursing progress notes, and the resident's care plan must be revised to reflect the change in condition, including appropriate goals and interventions. The policy further states that wound assessments are to be completed at least weekly and documented in the medical record.

Based on observation, record review and interview, the facility failed to provide readily available grievance forms and failed to post grievance/complaint procedures in a prominent location throughout the facility. This has the potential to affect all 89 residents residing in the facility. The facility's CMS (Centers for Medicare and Medicaid Services) Form 671 dated 4/20/26 and signed by V1 (Administrator), documents 89 residents reside within the facility.On 4/21/2026 at 10:37 AM R15, R27, R37, R84, and R87 all stated they have never been shown how to fill out a grievance, where the grievance forms are located, how to fill one out anonymously, or who the grievance official is to turn the forms into.On 4/21/26 at 11:00 AM a tour was conducted with V1/Administrator asking V1 to show where the grievance forms are located for the residents and where prominent locations(s) are for the grievance procedure in the building. V1 could not locate the grievance forms herself and thought they may be located at each nurse's desk but was unable to locate them at this time. V1 stated, I am not aware of the grievance procedure posted anywhere. (V10) would be our Grievance Official. The residents should know they can ask anyone to fill out a grievance for them and that the staff member filling it out would turn it in for them. I think the residents are just used to telling us issues instead of filling out a grievance form.On 4/21/26 at 11:04 AM V10/Social Service Director verified she is the grievance official. V25 stated, Grievance forms are located at the nurse's station behind the desk in a binder. Residents would have to ask for a grievance form. I do not have anything located around the facility how to fill out a grievance or who to turn the grievance paper into. There is no grievance forms located where a resident can grab one anonymously.The facility's Grievance Policy, dated 9/17/26, documents Purpose: To ensure prompt resolution of all grievances with respect to care and treatment which has been furnished as well as that which has not been furnished, the behavior of staff and of other residents, and other concerns regarding their stay at this campus. Guidelines: Grievances may be filed orally (meaning spoken), in writing, or anonymously. This same Grievance Policy documents, An appointed Grievance Official (usually Social Service Director) is responsible for overseeing the grievance process, receiving and tracking grievances through to their conclusion, leading any necessary investigations and maintaining the confidentiality of all information associated with grievances.

Based on Record Review and Interview, the facility failed to ensure residents and/or resident families are provided with a written notice of transfer when being transferred to the hospital. This failure has the potential to affect all 89 residents residing in the facility.Findings include:On 4/20/26 at 11:00 AM, R13 stated she has been sent back and forth to the hospital multiple times for numerous reasons, while in the facility.R13's current electronic medical record documents, R13, was most recently transferred out of the facility to the hospital on 1/4/26 and again on 2/28/26. This same medical record does not document that written notice of transfer was provided to the resident at the time of transfer.On 4/22/26 at 10:58 AM, V2 (Director of Nursing) confirmed that R13 does not have any written notices of transfer, with a reason for why R13 was being sent to the hospital. V2 stated, We (facility) do not have a formal transfer form that is provided to the residents or their families. We notify the resident's family via telephone, but we do not have a form with the reason for transfer that we provided to (R13) or any resident or family members of residents sent to the hospital. It has not been practiced due to us (facility staff) being unaware it's required.The facility's CMS (Centers for Medicare and Medicaid Services) Form 671 dated 4/20/26 and signed by V1 (Administrator), documents 89 residents reside within the facility.

Based on interview and record review, the facility failed to offer bedtime snacks to six of six residents (R15, R27, R37, R84, and R87) reviewed for bedtime snacks in the sample of 35.Findings include:R15, R27, R37, R84, and R87 electronic health records do not contain documentation of R17, R18, R27, R30, R38, and R52 being offered or receiving bedtime snacks.On 4/21/26 at 10:45 AM R15, R27, R37, R84, and R87 were in the resident council meeting. R15, R27, R37, R84, and R87 all stated they are not offered bedtime snacks and would like them to have offered them.On 4/21/26 at 2:05 PM V12/Certified Nursing Assistant stated, I have worked at the facility since October 2025. I do not go around and offer snacks at bedtime to all residents who can have them. They can ask for one and we would get them for them, but we don't go around and offer them.On 4/22/26 at 10:58 AM V2/Director of Nursing stated Dietary staff provide a drawer of snacks located at each nurse's station where a resident can ask for a snack.On 4/22/26 at V3/Dietary Manager stated that a dietary aide is scheduled to distribute ice cream to the Medicare hallway nightly at 6:15 PM. Following this, the aide leaves snacks at both nurses' stations. Regarding the North/South hallway, the manager noted that snacks and ice cream are not actively offered or distributed by dietary staff; however, these items are available to those residents upon request.The facility's Snacks and House Supplements Policy, dated 2022, documents House Snacks provide additional calories and meet a resident's individualized nutritional and care plan needs. Any type of food may be served as a snack as long as it is not contraindicated to the physician's diet order and the food item is handled employing all proper safe food handling practices. HS (bedtime) Snack Suggestions: HS Snacks should provide a minimum of a starch or bread serving and fruit drink.The facility's Bedtime Care Policy, dated 1/2018, documents Purpose: To promote comfort and relaxation before sleep. Guidelines: Provide bedtime snack and/or fluids as appropriate.

Based on observation, interview, and record review the facility failed to ensure a resident's fingernails were kept clean and trimmed for one of one resident (R60) reviewed for ADLs (Activities of Daily Living) in the sample of 35.Findings include:R60's admission Record documents R60 is a [AGE] year-old female who admitted to the facility on [DATE], with the following but not limited to, diagnoses: Senile Degeneration of Brain, Age-Related Osteoporosis, Frontotemporal Neurocognitive Disorder, Hypertension, Chronic Kidney Disease, Dementia, and Major Depressive Disorder.R60's MDS (Minimum Data Set) Assessment, dated 2/25/26, documents R60 is severely cognitively impaired and receives hospice services.R60's current Care Plan documents R60 requires assistance of one staff assistance with personal hygiene.On 4/20/26 at 11:32 AM R60 was sitting in the dining room in her wheelchair at a table. All R31's fingernails were long (past fingertips), jagged, and had brown debris underneath. On 4/20/26 at 11:35 AM V4/CNA (Certified Nursing Assistant) verified R60's were long past fingertips, jagged, with brown debris underneath and stated R60's nails needed trimmed and cleaned. On 4/22/26 at 10:58 AM V2/Director of Nursing stated resident's fingernails should be cleaned and trimmed with every shower or as needed.The facility's Nail Care Policy, dated 12/2025, documents Equipment: Nail Clippers. 1. Observe condition of resident nails during each time of bathing. Note cleanliness, length, uneven edges, and hypertrophied nails. 3. Perform hand hygiene.

Based on observation, interview and record review the facility failed to implement a range of motion program for two of two residents (R7 and R14), with known functional limitations, in a sample of 35. 1. R7's facility admission record documents that R7 was admitted to the facility on [DATE] with the following diagnoses: Relapsing-Remitting Multiple Sclerosis, Paraplegia, Muscle Wasting and Atrophy. R7's current Physician Order Sheet, dated April 2026 includes the following physician orders: No Weight Bearing to the right lower extremity; Ankle brace to the right ankle. R7's current Restorative Assessment, dated 2/9/26 documents R7 requires staff assistance for all activities of daily living, would benefit from a range of motion program, has a functional limitation in the bilateral upper and lower extremities and has paralysis in the bilateral upper and lower extremities. R7's current Minimum Data Set Assessment, dated 2/9/26 documents R7 is alert and oriented with a brief interview for mental status as a 13 out of 15. On 4/20/2026 at 11:05 A.M., R7 was up in a wheelchair in his room, watching television. R7 was alert and oriented and able to answer questions appropriately. R7 stated he has multiple sclerosis. An ankle/foot brace was present to R7's right leg. R7 stated staff do not perform range of motion exercises for him. 2. R14's facility admission record documents R14 was admitted to the facility on [DATE] with the following diagnoses: Cerebral Infarction, and Hemiplegia and Hemiparesis Affecting Right Dominant Side. R14's current Physician Order Sheet, dated April 2026, includes the following physician orders: Evaluate and treat for new brace to the right forearm and right leg due to weakness from stroke. R14's current Restorative Assessment, dated 2/20/26 documents that R14 requires staff assistance for all activities of daily living, would benefit from a range of motion program, has a functional limitation in the right upper and lower extremities and has paralysis in the right upper and lower extremities. R14's current Minimum Data Set Assessment, dated 2/11/26 documents R14 is alert and oriented with a brief interview for mental status as a 13 out of 15. On 4/20/2026 at 11:02 A.M., R14 was lying in bed, in her room, watching television. R14 was alert and oriented and able to answer questions appropriately. R14 stated she had a stroke. A black splint was present to R14's right wrist and to R14's right leg. R14 stated staff do not perform range of motion exercises for her. On 4/21/26 at 1:46 P.M., V15/Corporate MDS/Restorative Nurse stated that she oversees the restorative programs for the facility. V15 stated she recalled R7 and R14 and stated she is unsure why they did not have a passive range of motion program. At that time, V15 stated that both R7 and R14 could benefit from a passive range of motion program, due to contractures. On 4/21/26 at 2:30 P.M., V16/Certified Occupational Therapy Assistant stated in her opinion R7 and R14 would benefit from a range of motion program. The facility policy, Restorative Nursing Program, dated (approved) 12/2025 directs staff that the purpose of a restorative program is to promote each resident's ability to maintain or regain the highest degree of independence as safely as possible. To determine a restorative need for a resident during their stay, review range of motion assessments, looking for an improvement or decline in range of motion. Range of motion programs may include Active Assisted Range of Motion, Active Rage of Motion or Passive Range of Motion.

Based on observation, interview, and record review, the facility failed to check gastric tube feeding residual prior to administering an enteral feeding for two of two residents (R9 and R34) reviewed for gastric tube feedings in a sample of 35.Findings include:1. R9's current Physician Order Sheet, dated April 2026, includes the following diagnoses: Dysphagia Following Cerebral Infarction; Gastrostomy Status and the following physician orders: Check tube placement before feeding, flush(ng) and meds (medications). R9's current care plan includes the following interventions: Check for tube placement and gastric contents/residual volume per facility protocol and record. On 4/21/2026 at 8:42 A.M., V8/Registered Nurse (RN) prepared to administer medications for R9. V8/RN applied a gown and gloves and entered R9's room. V8/RN connected a 60 CC (Cubic centimeter) syringe to R9's gastronomy tube, and without checking tube placement, flushed R9's gastrostomy tube with 30 cc's of water, added pre- mixed medications and administered 325 cc's of a prescribed formula, followed by 50 cc's of water. At that time, V8 removed the syringe, reapplied the cap and left R9's room. V8/RN verified she did not check placement of R9's gastrostomy tube by checking for gastric contents, prior to administering medications, flushes and a feeding. 2. R34's current Physician Order Sheet documents to check residuals before beginning a feeding and before medication administration. This form documents if residual greater than 100ml hold feedings and recheck in one hour. If not resolved, call the MD (medical doctor). On 4/20/26 at 10:00am, V13, Licensed Practical Nurse, washed her hands and applied gloves. V13 opened the cap on the gastrotomy tube and flushed it with 30ml (Milliliter) of water. V13 then poured 60ml at a time of ordered enteral feeding to equal 240ml. V13 flushed the gastrostomy tube with 30ml of water after the enteral feeding was administered. V13 did not check for placement prior to feeding R34. On 4/22/26 at 8:50am, V13 verified that she did not check the placement of R34's gastrostomy tube prior to administering his enteral feeding. The facility policy, Gastrostomy Tube- Feeding and Care, dated (last) 01/2026 directs staff, Checking for Tube Placement: Aspirate to visually verify stomach contents. Gastric fluid normally appears clear or yellow with mucus or may appear milky if residual remains from previous feeding. Aspirated contents must be returned to the stomach to maintain pH, fluid and electrolyte balance.

Based on observation, interview, and record review, the facility failed to don the required personal protective equipment during high-contact care for two of five residents (R11 and R34) reviewed for infection control in a sample of 35.Findings include: 1.R34's current Physician Order Sheet documents EBP, enhanced barrier precautions. On 4/20/26 at 10:00am, V13, Licensed Practical Nurse, washed her hands and applied gloves. V13 opened the cap on the gastrotomy tube and flushed it with 30ml (Milliliter) of water. V13 then poured 60ml at a time of ordered enteral feeding to equal 240ml. V13 did not apply personal protective equipment before administering R34's enteral feeding. On 4/22/26 at 8:50am, V13 verified that R34 is on enhanced barrier precautions because of his gastrostomy tube. V13 stated that she did not put on a gown prior to administering R34's enteral feeding. On 4/22/26 at 11:30am, V17, Infection Preventionist, stated that the appropriate personal protective equipment is to be donned before any high-contact care. 2. R11's current Care Plan, dated 8/6/25, documents, (R11) has an actual skin impairment of pressure to coccyx. This same care plan documents Enhanced barrier precautions related to wounds. Educate staff/resident/family on enhanced barrier precautions as needed. Gown and glove during high contact resident care activities (such as dressing, bathing, showering, changing briefs, assisting with toileting, or wound care). On 4/22/26 at 8:55 AM R11 was in his room being cared for by V19 and V20 (Certified Nursing Assistants, CNA). V20 came to the door upon opening stated, We are just getting (R11) up right now. V19 and V20 were not wearing gowns while dressing R11 and providing a mechanical lift transfer. On 4/22/26 at 9:00 AM, V19 confirmed that R11 has a wound, is in Enhanced Barrier Precautions (EBP) and that V20 and V19 did not wear gowns when getting R11 out of bed. V19 stated We only have to wear the EBP gown during the (wound) dressing change, I believe. It is not required for just dressing with clothing and getting him transferred out of bed. On 4/22/26 at 12:25 PM, V17 (Registered Nurse/ Infection Preventionist) confirmed that facility staff should be wearing a gown and gloves during transfers for residents in EBP precautions. The facility's Enhanced Barrier Precautions policy, reviewed 12/2025, documents that enhanced barrier precautions (EHP) recommendations now include the use of EBP for residents with chronic wounds or indwelling medical devices during high-contact resident care activities, regardless of their multidrug-resistant organism status. EBP may be considered and implemented for wounds and/or indwelling medical devices (central line, feeding tube, tracheostomy, drains, AV fistulas, etc.) This form also documents that standard precautions must be followed with all care. Additionally, gown and gloves must be worn when providing the following cares: Dressing, bathing/showering, providing hygiene, changing linens, incontinence care, medical device care, and wound care.

Based on Observation, Interview and Record review, the facility failed to report allegations of staff to resident mental abuse and neglect to the facility's abuse coordinator and the state agency for three of four residents (R13, R39, R72) reviewed for abuse in the sample of 35.Findings include: 1. R13's current Care Plan, dated 3/26/26, document R13 has a self-care deficit and requires assistance of one staff member for bed mobility and two staff members for transfers. This same care plan documents a plan initiated on 12/19/24 (R13) is at a high risk for abuse/neglect as noted from abuse screening related to depression. On 4/20/26 at 11:00 AM, R13 was sitting in her wheelchair in common area of the facility. R13 stated about three weeks ago she had an incident with a CNA (Certified Nursing Assistant) being mean to her and she felt like after she complained that the whole crew of staff was upset with her. R13 stated she cannot remember the CNA's name, but she knows it was in the afternoon time. R13 stated I asked her to help me get up and she refused to help. She said No. It hurt my feelings, and I didn't know how long I was going to be left there. I was crying and I felt upset about that for a couple weeks. I think she refused to help me because she doesn't like me. The main lady (V1, Administrator) came and talked to me. I don't know if the employee still works here but she is not allowed to take care of me anymore. On 4/20/26 at 1:30 PM, V1 provided the facility's reported abuse allegations and investigations for the past six months which did not include any reported allegations or investigations for R13. On 4/21/26 at 1:12 PM, V2 (Director of Nursing) confirmed that V9 (CNA) is no longer being assigned to R13's hall when working. V2 confirmed she was notified by V4 (CNA) of some conflict that R13 expressed. V2 stated (R13) feels like (V9) rushes when she is in there and complained that she felt like the CNA rushed her roommate (R39). We didn't prohibit (V9) from caring for (R13) we just have her off of (R13's) hall for preference and to avoid conflict. On 4/21/26 at 1:30 PM, V1 (Administrator) confirmed that V9 does not get assigned to R13's hallway to work anymore. V1 stated, (R13) doesn't overly like (V9) for whatever reasons. V1 confirmed she was informed of a complaint from R13 at the end of March 2026. V1 stated, There was a complaint relayed to us around 3/31/26 and the allegation was that (R13) didn't want to come back to the facility from the hospital, and she had made a statement that the CNA (V9) had possibly caused harm to her roommate (R39). V1 confirmed there is no documentation in the resident's record to explain the encounter and that she did not initiate an abuse investigation. V1 stated I did not report anything to the state. 2. On 4/20/2026 at 12:00 PM, R72 reported concerns regarding alleged verbal abuse by a night shift nurse identified as (V7, Registered Nurse). R72 stated that V7 was disrespectful and aggressive during an interaction that occurred on third shift on 04/17/2026. R72 reported that she has taken Meclizine for years to manage hand tremors and following a recent hospitalization, the medication order was changed from scheduled to as needed (PRN). R72 stated that on the night of the incident, she requested Meclizine due to significant shaking. R72 stated, V7 responded in an aggressive manner, questioning the need for the medication and stating, Why do you need this? what is this about? This drug makes you shake not take it away. R72 reported that despite explaining her history with the medication, V7 did not acknowledge her input, left the room, and returned with printed material disputing her claims. R72 stated the interaction escalated into a yelling exchange, during which she felt humiliated and dismissed. R72's Nurse Progress Note dated 4/17/26 at 4:42 AM, V7 (Registered Nurse) documents Resident (R72) asked for cough syrup approx. 15 minutes ago from. This nurse was in another room with G-tube meds, etc. When I (V7) got out, I (V7) pulled her (R72) am meds along with her cough syrup. When I (V7) got in her (R72) room, she (R72) said I asked for that 1-1/2 hour ago. I (V7) told her maybe 15 minutes or at the longest 30 minutes. I (V7) was in another room when your light went off. It was 4:25 AM because I looked at the clock. Then when I (V7) was done, I pulled your morning meds and got you cough syrup. I (V7) am sorry, but I was busy with another resident and he takes a few minutes when I go in there. She (R72) said well you are wrong it was over 1-1/2 hours ago. I just left the room. On 4/20/2026 at 2:10 PM, V22 (Certified Nursing Assistant/CNA) stated R72 has declined functionally since admission and now requires total assistance. V22 stated that R72 reported that third shift staff were mean and verbally rude the other night, but the V22 did not report the concern at that time because V22 didn't want to involve herself in the drama. On 4/20/2026 at 2:00 PM, V2 stated she had received prior communication from a nurse expressing concern about R72's use of Meclizine and requested the nurse practitioner to change the order to PRN every 12 hours. V2 acknowledged she had not spoken directly with R72 prior to the change. Upon review of a nurse progress note dated 04/17/2026 by V7, V2 stated the documentation was inappropriate and confirmed she was unaware of the note. On 4/20/22 at 2:15 PM, V1 (Administrator/abuse Coordinator) stated that she had not been made aware of the verbal abuse allegations. The facility's Abuse Prevention and Reporting policy, dated 3/2026, documents This facility affirms the right of our residents to be free from abuse, neglect, exploitation, misappropriation of property, deprivation of goods and services by staff or mistreatment. This facility therefore prohibits abuse, neglect, exploitation, misappropriation of property, and mistreatment of residents. In order to do so, the facility has attempted to establish a resident sensitive and resident secure environment. The purpose of this policy is to assure that the facility is doing all that is within its control to prevent occurrences of abuse, neglect, exploitation, misappropriation of property, deprivation of goods and services by staff and mistreatment of residents. This will be done by: identifying occurrences and patterns or potential mistreatment; identifying concerns of residents' allegations of deprivation of goods and services by staff; immediately protecting residents involved in identified reports of possible abuse, neglect, exploitation, mistreatment, and misappropriation of property; implementing systems to promptly and aggressively investigate all reports and allegations of abuse, neglect, exploitation, mistreatment, and misappropriation of property and mistreatment, and making the necessary changes to prevent further occurrences; filing accurate and timely investigative reports. This policy also documents Verbal Abuse is the use of oral, written, or gestured language that willfully includes disparaging and derogatory terms to residents or families, or within their hearing distance, regardless of an individual's age, ability to comprehend, or disability. Mental Abuse includes but is not limited to, humiliation, harassment, threats of punishment or deprivation. Retaliation means when there is a hinderance of a resident's involvement in one or more of the protected activities and that interferes with a resident's quality of life at the facility or results in either the imposition of selective restrictions or the resident's neglect or reduced access to services. Neglect means the failure to provide goods and services to a resident that are necessary to avoid physical harm, pain, or mental anguish. Neglect means a facility's failure to provide, or willful withholding of, adequate medical care, mental health treatment, psychiatric rehabilitation, personal care, or assistance with activities of daily living that is necessary to avoid physical harm, mental anguish or mental illness of a resident, including deprivation of goods and services by staff. This policy further documents Employees are required to report any incident, allegation or suspicion of potential abuse, neglect, retaliation, exploitation, mistreatment or misappropriation of resident property they observe, hear about, or suspect to the administrator immediately, or to an immediate supervisor who must then immediately report it to the administrator. In absence of the administrator, reporting can be made to an individual who has been designated to act as administrator's absence. Reports should be documented and a record kept of the documentation. Upon learning of the report, the administrator or a designee shall initiate an incident investigation. Any allegation of abuse, retaliation, or any incident that results in serious bodily injury will be reported to the (state agency) immediately, but not more than two hours after the allegation of abuse. Any incident that does not involve abuse and does not result in serious bodily injury shall be reported within 24 hours.

Based on Observation, Interview and Record review, the facility failed to ensure an abuse investigation was conducted and residents were protected from alleged perpetrators of mental abuse and neglect for three of four residents (R13, R39, R72) reviewed for abuse in the sample of 35.Findings include:1. R13's current Care Plan, dated 3/26/26, document R13 has a self-care deficit and requires assistance of one staff member for bed mobility and two staff members for transfers. This same care plan documents a plan last updated on 6/12/25: (R13) is at a high risk for abuse/neglect as noted from abuse screening related to depression. On 4/20/26 at 11:00 AM, R13 was sitting in her wheelchair in common area of the facility. R13 stated about three weeks ago she had an incident with a CNA (Certified Nursing Assistant) being mean to her and she felt like after she complained that the whole crew of staff was upset with her. R13 stated she cannot remember the CNA's name, but she knows it was in the afternoon time. R13 stated, I asked her to help me get up and she refused to help. She said, No. It hurt my feelings, and I didn't know how long I was going to be left there. I was crying and I felt upset about that for a couple weeks. I think she refused to help me because she doesn't like me. The main lady (V1, Administrator) came and talked to me. I don't know if the employee still works here but she is not allowed to take care of me anymore. R13's electronic medical record does not document any investigations or progress notes related to staff and resident conflicts, refusal to get R13 transferred or updates to R13's care plan related to the alleged incident. On 4/20/26 at 1:30 PM, V1 provided the facility's reported abuse allegations and investigations for the past six months which did not include any reported allegations or investigations for R13. On 4/20/26 at 2:10 PM, V4 (CNA) confirmed she has known in the past that there have been issues with staff on the evening shift and R13 not meshing well. V4 stated, (R13) has told me this without much specifics, but that the staff member was moved to a different floor and no longer cares for (R13). I believe it was a third shift CNA, and this was about 2 weeks ago. When I came the next morning, she told me and had already told (V2, Director of Nursing) and (V1) that she does not want that staff in her room anymore. On 4/21/26 at 1:12 PM, V2 confirmed that V9 (CNA) is no longer being assigned to R13's hall when working. V2 confirmed she was notified by V4 of some conflict that R13 expressed. V2 stated, (R13) feels like (V9) rushes when she is in there and complained that she felt like the CNA rushed her roommate (R39). We didn't prohibit (V9) from caring for (R13) we just have her off (R13's) hall for preference and to avoid conflict. V2 confirmed that V1 is the facility's abuse coordinator and stated she does not have any documentation from this incident. V2 stated, When we meet with someone with stuff like that, I leave the documentation to (V1). We did not talk with any other residents besides (R39), in that situation that I can recall, and I do not have any staff members written statements. On 4/21/26 at 2:05 PM (V2) provided a report that documents verbal warning was given to V9 on 4/13/26 for customer service issues. V2 then stated she does not have a written statement from V9 and stated the conversation took place over the phone. On 4/21/26 at 1:30 PM, V1 (Administrator) confirmed that V9 does not get assigned to R13's hallway to work anymore. V1 stated, (R13) doesn't overly like (V9) for whatever reasons. V1 confirmed she was informed of a complaint from R13 at the end of March 2026. V1 stated, There was a complaint relayed to us around 3/31/26 and the allegation was that (R13) didn't want to come back to the facility (from the hospital) and made a statement that the CNA (V9) had possibly caused harm to the roommate (R39). (R13) does not like (V9), I don't know why. So, we moved (V9) to a different hall since there is an issue there. V1 confirmed there is no documentation in the resident's record to explain the encounter and that she did not initiate an abuse investigation, suspend the employee while investigating or keep a file with statements and interviews conducted. V1 stated, I don't see anything. I may have just had paper notes. (V2) and I both met with (R39). I may have got rid of them (notes), because it didn't amount to anything. I didn't get a statement from (V9). I did not talk to any other residents. 2. On 4/20/2026 at 12:00 PM, R72 reported concerns regarding alleged verbal abuse by a night shift nurse identified as (V7, Registered Nurse). R72 stated that V7 was disrespectful and aggressive during an interaction that occurred on third shift on 04/17/2026. R72 reported that she has taken Meclizine for years to manage hand tremors and following a recent hospitalization, the medication order was changed from scheduled to as needed (PRN). R72 stated that on the night of the incident, she requested Meclizine due to significant shaking. R72 stated, V7 responded in an aggressive manner, questioning the need for the medication and stating, Why do you need this? What is this about? This drug makes you shake not take it away. R72 reported that despite explaining her history with the medication, V7 did not acknowledge her input, left the room, and returned with printed material disputing her claims. R72 stated the interaction escalated into a yelling exchange, during which she felt humiliated and dismissed. On 4/20/2026 at 2:00 PM, V2 (Director of Nursing) stated she had prior knowledge of concerns related to R72's use of Meclizine and had requested a medication change; however, she acknowledged she had not spoken directly with R72 regarding the concern. V2 further stated she was unaware of the nurse progress note dated 04/17/2026, authored by V7(Registered Nurse), which documented an argumentative interaction with the resident. Upon review, V2 identified the documentation as inappropriate. On 4/20/2026 at 2:10 PM, V22 (Certified Nursing Assistant/CNA) stated R72 had expressed concerns the other day that third shift staff were mean and verbally rude; V22 stated that she did not report to V1 (Administrator/Abuse Coordinator) because V22 didn't want involved in the drama. V22 confirmed she did not investigate or question any further with other residents or staff. On 4/20/2026 at 2:15 PM, V1 (Administrator/Abuse Coordinator) V1 confirmed there was no evidence that the facility had initiated an investigation at the time the allegation was reported to V22 and stated she does not know how often V7 has provided care to R72 since the new incident. The facility's Abuse Prevention and Reporting policy, dated 3/2026, documents This facility affirms the right of our residents to be free from abuse, neglect, exploitation, misappropriation of property, deprivation of goods and services by staff or mistreatment. This facility therefore prohibits abuse, neglect, exploitation, misappropriation of property, and mistreatment of residents. In order to do so, the facility has attempted to establish a resident sensitive and resident secure environment. The purpose of this policy is to assure that the facility is doing all that is within its control to prevent occurrences of abuse, neglect, exploitation, misappropriation of property, deprivation of goods and services by staff and mistreatment of residents. This will be done by: identifying occurrences and patterns or potential mistreatment; identifying concerns of residents' allegations of deprivation of goods and services by staff; immediately protecting residents involved in identified reports of possible abuse, neglect, exploitation, mistreatment, and misappropriation of property; implementing systems to promptly and aggressively investigate all reports and allegations of abuse, neglect, exploitation, mistreatment, and misappropriation of property and mistreatment, and making the necessary changes to prevent further occurrences; filing accurate and timely investigative reports. This policy also documents Verbal Abuse is the use of oral, written, or gestured language that willfully includes disparaging and derogatory terms to residents or families, or within their hearing distance, regardless of an individual's age, ability to comprehend, or disability. Mental Abuse includes but is not limited to, humiliation, harassment, threats of punishment or deprivation. Retaliation means when there is a hinderance of a resident's involvement in one or more of the protected activities and that interferes with a resident's quality of life at the facility or results in either the imposition of selective restrictions or the resident's neglect or reduced access to services. This same policy also documents The facility will take steps to prevent potential abuse while the investigation is underway. Employees of this facility who have been accused of abuse, neglect, retaliation, exploitation, mistreatment or misappropriation of resident property will be removed from resident contact immediately. The employee shall not be permitted to return to work until the results of the investigation have been reviewed by the administrator and it is determined that any allegation of abuse, neglect, exploitation, mistreatment or misappropriation of resident property is unsubstantiated. All incidents will be documented, whether or not abuse, neglect, retaliation, exploitation, mistreatment or misappropriation of resident property occurred, was alleged or suspected. Any incident or allegation involving abuse, neglect, exploitation, retaliation, exploitation, mistreatment or misappropriation of resident property will result in an investigation. Investigation procedures; the appointed investigator will, at a minimum, attempt to interview the person who reported the incident, anyone likely to have direct knowledge of the incident and the resident, if interviewable. Any written statements that have been submitted will be reviewed, along with any pertinent medical records or other documents. Residents to whom the accused has regularly provided care, and employees with whom the accused has regularly worked, will be interviewed to determine whether any one has witnessed any prior abuse, neglect, exploitation, mistreatment or misappropriation of resident property by the accused individual.

Based on Observation, Interview and Record review, the facility failed to ensure a residents Minnimum Data Set (MDS) assessments were completed accurately to reflect insulin usage for one of 24 residents (R2) reviewed for MDS accuracy in the sample of 35.Findings include:On 4/20/26 at 1:55 PM, R2 was sitting in her room watching television. R2 stated she does have a diagnosis of Diabetes, but she is able to control it with oral medication. R2 stated she does not have to take insulin injections.R2's Physician Order sheet, dated 12/26/25 through 4/22/26 and includes current and discontinued medications, does not document R2 is prescribed an insulin category medication.R2's MDS assessments dated 1/2/26, 1/22/26 and 3/16/26 all document that R2 received one insulin administration in the last seven days.On 4/22/26 at 11:10 AM, V18 (Licensed Practical Nurse/ MDS coordinator) confirmed that R2's MDS assessments have been coded for insulin, and that R2 does not receive insulin. V18 stated, It was marked due to her order for Trulicity (injectable glucagon-like peptide-1 (GLP-1)) which is a GLP-1, and not an insulin. (R2's) assessments will need corrected.

Based on interview, and record review, the facility failed to prevent abuse for two (R7 and R8) of three residents reviewed for abuse in a sample of eight.Findings include:Facility Initial abuse investigation, dated 2/11/26, for R7 and R8 documents the following: On 2/11/2026 at approximately 2:40pm notified of alleged Resident to Resident Contact: Residents separated immediately.Facility Final abuse investigation, dated 2/12/26, documents the following: (R7) stated, I did not like the conversation (R8) was having with another resident; (R8) gave me the finger and said mind your own business. (R8) then used his open hand and made physical contact on her stomach area and (R7) made physical contact with (R7) on his chest area with her left hand. Two staff members overheard the argument in dining room and immediately separated the two of them.Facility interviews dated 2/11/26 documents the following: V11/visitor stated V11 saw R7 trying to hit R8. Both were yelling back and forth. R8 tried hitting/hit R7, and R7 started hitting R8 again. R7 kept leaning forward trying to reach for R8; and V10 HR/Human Resources was walking by the north/south dining room and saw R7 hit R8 with her fist in the chest area, and then R8 started swinging back at R7.On 3/3/26 at 11:30am, V1 Administrator stated, We have had resident (R7) to resident abuse (R8) that was reported to the state.On 3/4/26 at 12:00pm, R7 stated she had a verbal issue with R8, and R8 hit her in the stomach after he gave her the middle finger. Facility Abuse Prevention and Reporting, last reviewed 10/2022, documents This facility affirms the right of our residents to be free from abuse. Abuse means any physical injury inflicted upon a resident other than by accidental means. Abuse is the willful infliction of injury.

Based on record review and interview the facility failed to ensure the resident's environment was free of hazards to prevent falls for one of three residents (R1) reviewed for accidents in the sample of five.Findings include:R1's Progress Notes dated 8/16/25 at 12:29 PM and signed by V5 (RN/Registered Nurse) documents, Per (V6/CNA/Certified Nursing Assistant), (V6) tripped in (R1's) room on the air mattress cord and fell, tipping (R1's) wheelchair over. (R1) fell out of her (high back padded wheelchair) and hit her head on the (mechanical lift) machine. (R1) noted to have a small amount of blood present to the right side of (R1's) head. Area cleansed (and) bleeding stopped. PRN (as needed) Dilaudid and Xanax administered. (V3/R1's Power of Attorney/POA) left voicemail to call facility. On call nurse and hospice notified. (V4/R1's Physician) notified. Neuro (Neurological) checks initiated.R1's IDT (Inter-Disciplinary Team) Fall Follow-Up Progress Note dated 8/18/25 at 3:06 PM documents, IDT met regarding recent fall (8/16/25). (R1) was tipped out of wheelchair by (CNA/V6). Root cause: (V6) got wheelchair caught on cord from air mattress and tripped and accidentally tipped wheelchair. Intervention: Rearrange room for better ease of equipment.On 10/9/25 at 10:02 AM V6 (CNA) stated, On 8/16/5 sometime around noon I was getting (R1) ready. I took (R1) into her room and turned (R1's) chair around. The cords at the end of the bed were pulled out from under the bed and lying on the floor in front of (R1's) wheelchair. I was just trying to lift the back of (R1's) wheelchair up to get the wheelchair over the cord. I went to push (R1) forward to try to unravel the cord that was wrapped around R1's wheelchair wheel and picked up the back of (R1's) wheelchair. When I tipped (R1's) wheelchair up, (R1) fell out forward onto the floor. (R1) was sitting up straight and I should have put the back of the wheelchair back to keep (R1) from falling out. (R1) landed on the floor in front of her wheelchair. The side of (R1's) head was bleeding.On 10/14/25 at 11:00 AM V2 (Director of Nursing) stated V6 should have moved R1's cord out of the way before trying to push R1's wheelchair over the cord to prevent R1 from falling out of the wheelchair. V2 stated V6 should not have lifted the back of R1's wheelchair.The facility's Fall Prevention Program policy dated 10/2024 documents, Purpose: To assure the safety of all residents in the facility, when possible. The program will include measures which determine the individual needs of each resident by assessing the risk of falls and implementation of appropriate interventions to provide necessary supervision and assistive devices are utilized as necessary. Programs will monitor the program to assure ongoing effectiveness. Standards: Fall/safety interventions may include but are not limited to: The resident's environment will be kept of clutter which would affect ambulation and remove hazards.

Based on interview and record review the facility failed to ensure diagnostic testing results were reported and reviewed in a timely manner for 1 of 1 residents reviewed for medical testing in the sample of 5. The findings include: R1's admission record documents he was admitted to the facility on [DATE] with a primary diagnosis of acute respiratory failure with hypoxia (low levels of oxygen). The 1/17/25 resident care and screening assessment documents R1 to have moderate cognitive impairment. On 1/13/25, V12 (Nurse Practitioner-NP) ordered R1 to have a repeat chest x-ray with a diagnosis of history of bilateral pleural effusions (fluid in the lung tissues). The order was noted by nursing two days later 1/15/25. The x-ray results of the 1/15/25 chest x-ray show right basilar opacity. Correlate clinically for atelectasis (collapse of a lung or section of a lung), chronic scarring, edema, and/or pneumonia. The 1/15/25 x-ray report shows it was reported on 1/15/25 at 9:24 AM, however, the report with orders shows on 1/21/25, V12 ordered an antibiotic due to a diagnosis of pneumonia. On 2/11/25 at 9:53 AM, V3 (R1's daughter) said when R1 was admitted he had been complaining of a cough and sore throat. She said the symptoms were reported to nursing, and nothing seemed to get done. The nurses were checking R1's lungs, and reporting they were clear. She said eventually a nurse ordered breathing treatments and some cold medication. It was not until she attended the care team meeting with the staff, she learned R1 had a chest x-ray on 1/15/25 that showed pneumonia, but she was not advised of an antibiotic starting until 1/21/25. She said R1 went 6 days without getting any medication. On 2/11/25 at 10:45 AM, V5 LPN (Licensed Practical Nurse) said when an x-ray is ordered, the order is placed in the computer, and it will go to the x-ray company, and they will do the exam and fax the results to the facility. She said the nurse is responsible to getting results and reporting them to the provider. She said if a resident had a result of pneumonia, she would just fax it to the NP. On 2/11/25 at 11:14 AM, V7 RN (Registered Nurse) said when an x-ray is ordered, the order is placed in the computer, and the nurse must call to schedule a time for the exam. When the exam is complete, results are reported right away. Those results are faxed to the NP, and we await orders. On 2/11/25, V2 DON (Director of Nursing) said all x-ray orders are called in and scheduled. Results are faxed typically within a couple of hours. It can be hit or miss as to what number the results are sent; we have educated the staff to forward results to the correct nursing station. When the faxed results are in, they are forwarded to the medical group for review, and they will give direction. They send back the same test results with orders pasted to the bottom of the page. V2 said the original x-ray order should have been processed and completed on 1/13/25 when it was written. V2 said if the x-ray and results were done and reviewed on 1/15/25, R1 could have started the antibiotic earlier. The facility's 10/2024 policy for physician notification of laboratory/radiology/diagnostic results documents its purpose is to assure physician ordered diagnostic test are performed, and to assure test results are reported to the physician so that prompt, appropriate action may be taken if indicated for the resident's care. A nurse is responsible for monitoring the receipt of test results. Test results should be reported to the physician or other practitioner who ordered them.

Based on observation, interview and record review the facility failed to ensure laboratory testing was completed as ordered for 1 of 1 residents reviewed for medical testing in the sample of 5. The findings include: R1's admission record documents he was admitted to the facility on [DATE] with a primary diagnosis of acute respiratory failure with hypoxia (low levels of oxygen). The 1/23/25 follow up visit by V12 (Nurse Practitioner), shows R1 was to have stat lab work, and continue the antibiotic for pneumonia. The order summary sheet shows the lab order was placed in the computer to be completed on 1/24/25. R1 had no labs on record. Progress notes were reviewed and show no documented labs being drawn. On 2/11/25 at 9:53 AM, V3 (R1's daughter) said when R1 was admitted he had been complaining of a cough and sore throat. She said the symptoms were reported to nursing, and obtained an x-ray and he was diagnosed with pneumonia. V3 said she was advised R1 was to have labs done on 1/24/25. When she asked the nurse for his results, the nurse told her the labs were never done. V3 said the nurse offered to change the date of the labs. On 2/11/25 at 10:45 AM, V5 LPN (Licensed Practical Nurse) said when blood work is ordered, a paper form (carbon copy) is filled out and placed in the accordion file, and when lab arrives the day of the lab, they take a copy of the order, and another copy is left at the facility. V5 said the nurse is responsible to getting results and reporting them to the provider. On 2/11/25, at each nurses station, an accordion file was observed to have carbon copy lab slips filed by the date to be drawn. On 2/11/25, V2 DON (Director of Nursing) said the lab work ordered does not appear to be done, and it should have been drawn on 1/24/25. The facility's 10/2024 policy for physician notification of laboratory/radiology/diagnostic results documents its purpose is to assure physician ordered diagnostic test are performed, and to assure test results are reported to the physician so that prompt, appropriate action may be taken if indicated for the resident's care. A licensed nurse is responsible for assuring the laboratory is notified of physicians order for testing. A requisition is to be completed and lab to be drawn on the next scheduled lab draw day unless stat or same day order is received. A nurse is responsible for monitoring the receipt of test results.

Based on observation, interview, and record review, the facility failed to ensure the staff completely covered hair in a sanitary manner while in the kitchen; and failed to ensure a chemical product was not stored in an unlocked lower cabinet in the dining room. These failures have the potential to affect 89 of the 90 residents who consume food in the facility (R75 was nothing by mouth/NPO). Findings include: The facility's Dietary-Staff Hygiene/Hair Nets Policy dated 9/2023 documents: Guidelines: 2.D. Hairnets or coverings shall be worn at all times in the Dietary Department and applied appropriately to keep hair from contacting exposed food, clean utensils and single-service/use items if unwrapped. The facility's Housekeeping Chemical Use Procedures Policy dated 11/1/12 documents: A. Chemical Use Rules 1. All chemicals must be in users line of sight at all times or stored in a locked cabinet or room. On 1/28/25 at 9:15am, V12 Dietary Manager was noted in the facility kitchen with dietary staff. V12's bangs at the front of her head were not covered. V12 stated, My hair slipped out; and I don't usually go into the kitchen but I am being the cook today. At this same time, V13 Dietary Aide wore a cap that did not cover her hair on the sides and back of her head. V14 Dietary Aide was doing dishes and had uncovered hair at the back and sides of her head. V14 stated that she did not realize all of her hair was not covered. V12, V13 and V14 stated that kitchen staff were supposed to have all their hair covered while in the kitchen. On 1/28/25 at 9:30 am, a full container of All Purpose Cleaner was located in an unlocked lower cabinet near the sink in the dining room. V12 Dietary Manager stated that the chemical was not supposed to be in the lower cabinet and was not sure who placed it there. V12 stated, The cabinet should have been locked to keep the product away from residents. The facility's Long-Term Care Facility Application for Medicare and Medicaid (Centers for Medicare and Medicaid Services/CMS 671) Form, dated 1/28/25, documents 90 residents reside in the facility.

Based on record review, observation and interview the facility failed to secure a controlled substance medication in a double-locked location for one of one resident (R74) reviewed for medication storage. Findings include: The facility's Medication Storage policy dated 10/2024 documents, Controlled Substances Storage: 2. After receiving controlled substances and adding to inventory, Facility should ensure Schedule II-V substances are immediately placed into a secured storage area (i.e., a safe, self-locked cabinet, or locked room, .and double-locked inside a medication cart or locked box in locked medication room). On 1/30/25 at 11:55am, a plastic bag containing medications labeled with R74's name, included a medication bottle labeled Lorazepam 0.5mg/milligrams tablets, was in an unlocked cabinet in the facility's South Hall Medication Room. Lorazepam is a Schedule IV, controlled substance prescribed for anxiety. V2 DON/Director of Nursing stated the medication bottles in the bag were (R74's) medications from home. V2 stated, They should have been sent home with family when the resident was admitted . V2 stated the Lorazepam should have been counted by two Nurses, documented on the facility's Controlled Drug Record/Disposition Form and placed in the medication cart's double locked, controlled substance drawer or in the Medication Room, secured in a second locked location.

Based on observation, interview and record review, the facility failed to ensure the facility's annual State Survey Results were readily and easily accessible to residents for review. This failure has the potential to affect all 90 residents residing at the facility. Findings include: The facility's Resident Rights Policy, dated 1/30/24 documents: Policy Statement: Staff shall treat all residents with kindness, respect, and dignity. 1. Federal and state laws guarantee certain basic rights to all residents of the (facility) community. These rights include the resident's right to: H. Be supported by the (facility) community in exercising their rights; M. Exercise rights not delegated to a legal representative; and W. Examine survey results. The facility's State Survey Results Binder was located in a cabinet drawer in the front foyer. The access to the front foyer was through double glass doors that were not wheelchair accessible; an electronic code was used by staff to open the glass doors to enter into the front foyer, which led to another set of glass doors to exit. Staff stated that residents did not have access to the electronic code. On 1/29/2025 at 1:00pm, Residents R8 and R21 attended the Resident Council Meeting. Both R8 and R21 indicated that V9 Activities Director informed them that the State Survey Results Binder was located at the East Wing Nursing Station. On 1/29/25 at 1:30pm, R8 asked V9 Activities Director to show (R8) the Binder at the East Wing Nursing Station. The Binder was not at that location. On 1/29/25 at 1:40pm, V9 Activities Director confirmed that she had informed the residents that the Binder was at the East Wing Nursing Station; stated that the Binder used to be at the East Wing Nursing Station prior to facility remodel in 2017 and that it (the Binder) probably was moved to the front foyer with the remodel. At this same time, V9 stated, None of the residents had asked to see the Survey Binder; they (residents) would have to ask to see it. On 1/29/25 at 1:30pm, V15 Licensed Practical Nurse/LPN stated: The Binder is in the front foyer; it has never been at the East Wing Nursing Station since the time I have worked here, five years. Residents cannot get out there (into foyer) unless someone gets them there. On 1/29/25 at 1:35pm, V1 Administrator stated they have always kept the Survey Results Binder in the drawer in the front foyer at the entrance. The facility's Long-Term Care Facility Application for Medicare and Medicaid (Centers for Medicare and Medicaid Services/CMS 671) Form, dated 1/28/25, documents 90 residents reside in the facility.

Based on interview and record review the facility failed to obtain a urinalysis in a timely manner for one of three residents (R1) reviewed for urinary tract infections in the sample of seven. Findings Include: R1's Medical Diagnoses list dated 6/18/2024 documents Acute Kidney Failure, Type 2 Diabetes Mellitus with Hyperglycemia, Difficulty in Walking, and Lack of Coordination. R1's Physician Order written by V13 (R1's physician) dated 6/28/24 documents an order for a urinalysis. R1's Lab Services Urine Microbiology Results dated 7/5/24 document R1's urine was collected on 7/2/23 at 6:45 PM and was sent to the lab on 7/3/24 at 11:24 AM. R1's urine's microbiology results detected Escherichia coli Extended Spectrum Beta-Lactamase (ESBL) 50-100,000 colonies per milliliter. On 8/21/24 at 2:00 PM, V2 Director of Nursing confirmed R1 had received a physician order for a urinalysis. V2 stated V13 ordered a urinalysis to be completed on 6/28/24 at 7:24 AM and staff should have collected and sent the urine sample to the lab the same day or next day at the latest. V2 stated staff should not have waited more than 24 hours to collect the urine sample and if they were unable to collect the urine sample V13 should have been notified. V2 stated this delay subsequently delayed the urinalysis results and treatment for R1's urinary tract infection.

Based on observation, interview, and record review the facility failed to apply the correct treatment to a wound for one (R6) of three residents reviewed for wounds in a sample list of seven. Findings include: R6's Care Plan initiated 5/6/2024 includes the following diagnoses: Wedge Compression Fracture of Unspecified Lumbar Vertebra, Alzheimer's Disease, Difficulty In Walking, Symptoms And Signs Involving The Musculoskeletal System, and Protein-Calorie Malnutrition. R6's Pressure Ulcer Risk assessment dated [DATE] documents R6 is at moderate risk for skin breakdown. R6's Wound assessment dated [DATE] documents R6 has a facility acquired stage 4 pressure ulcer to the left buttock. R6's physician's order dated 8/12/24 written by V13 (R6's Physician) documents to cleanse the wound to the left buttock, pat dry, apply calcium alginate, and cover with an abdominal (ABD) pad every day and as needed. The Facility's Medication Administration Policy effective 03/2024 states in section II bullet one: Medications must be administered in accordance with the physician's order. On 8/20/24 at 8:18 AM, there was a hydrocolloid dressing on R6's left buttock. V5 (LPN) removed the hydrocolloid dressing from R6's left buttock. V5 then cleansed the wound, applied calcium alginate to the wound bed and covered with an ABD pad. On 8/20/24 at 8:52 AM, V5 confirmed R6's treatment order for the wound on the left buttocks is to cleanse the wound to the left buttock, pat dry, apply calcium alginate, and cover with an ABD pad every day and as needed. V5 stated that sometimes the ABD pad becomes soiled, and the other nurses often use the hydrocolloid to cover the wound. On 8/21/24 at 12:28 PM, V2 Director of Nursing stated all nurses are expected to follow the physician's orders.

Based on interview and record review, the facility failed to clarify an admission Physician order, perform diabetic monitoring and ensure necessary equipment and medication were available for one (R1) of three residents reviewed for diabetic care in the sample of three. These failures resulted in R1's blood sugar not being monitored, R1 not having an insulin pump for insulin medication and R1 not receiving medically necessary insulin by other means subsequently resulting R1's blood sugar level becoming elevated, and R1 becoming unresponsive without a pulse or respirations, CPR (cardiopulmonary resuscitation) being initiated, R1 being transferred to the local hospital and R1 expiring due to Diabetic Ketoacidosis. These failures resulted in an Immediate Jeopardy. While the immediacy was removed on [DATE], the facility remains out of compliance at Severity Level 2 while the facility is in the process of educating new and/or agency licensed nurses, auditing, and monitoring diabetic management and new admission process. The facility is also in the process monitoring physician notification for change in condition three times a week for four weeks and performing audit tools which will be reviewed in the QA (Quality Assurance) meeting. Findings include: The Facility Assessment, dated ,d+[DATE] through ,d+[DATE], documents, Part 2: Services and Care We Offer Based on our Residents' Needs includes: Administration of medications that residents need by route: oral, nasal, [MEDICATION(S)], sublingual, topical, subcutaneous, rectal, intravenous (peripheral or central lines), intramuscular, inhaled (nebulizer), vaginal, ophthalmic, etc. Management of medical conditions includes Assessment, early identification of problems/deterioration, management of medical and psychiatric symptoms and conditions such as diabetes. Competencies for new direct care staff are completed during their orientation phase, verified annually and as needed thereafter. (The facility) has a core group of competencies for nursing staff that include: 1. Licensed Nurses a. Injections, b. Blood Glucose Monitoring. Additional References to the Facility Assessment: Nursing Services 483.35 - The facility must have sufficient nursing staff with the appropriate competencies and skills sets to provide nursing and related services to assure resident safety and attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident, as determined by resident assessments and individual plans of care and considering the number, acuity and diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The facility Admission Policy, dated [DATE], documents, 4. Each resident shall be required to undergo a physical examination by the Physician of his/her choice either prior (within five days) to his/her admission to the home, or within 72 hours of such admission. The report of such examination, together with the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The facility Admission Check List - Nurse form, dated ,d+[DATE], documents on admission the Nurse is to Verify orders and complete the resident's Physician Orders, Fax orders to or call pharmacy and Make out medication sheet. The facility Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . All such orders shall be written on the medical record and shall be given as prescribed by the Physician and at the designated times. g) If for any reason, a Physician's medication or treatment cannot be followed, the Physician shall be notified as soon as is reasonable, depending upon the situation, a notation of this will be made into the medical record. The CDC (Centers for Disease Control and Prevention) documents, Diabetic ketoacidosis (DKA) is a serious complication of diabetes that can be life-threatening. DKA is most common among people with Type I Diabetes. People with Type II diabetes can also develop DKA. DKA develops when your body doesn't have enough insulin to allow blood sugar into your cells for use as energy. Instead, your liver breaks down fat for fuel, a process that produces acids called ketones. When too many ketones are produced too fast, they can build up to dangerous levels in your body. DKA usually develops slowly. Early symptoms include: Being very thirsty, urinating a lot more than usual. If untreated, more severe symptoms can appear quickly such as: Fast, deep breathing. Dry skin and mouth. Flushed face. Fruity-smelling breath. Headache. Muscle stiffness or aches. Being very tired. Nausea and vomiting. Stomach pain. The facility Blood Glucose Testing and Monitoring policy and procedure, Revised ,d+[DATE], documents, Blood glucose levels will be monitored and obtained per licensed health care practitioner's orders. If a resident exhibits signs or symptoms of [CONDITION(S)] or [CONDITION(S)], licensed nurse may obtain a blood glucose level. The facility provided a [CONDITION(S)] policy and procedure, however, was unable to provide a policy and procedure for [CONDITION(S)]. On [DATE] at 12:15 pm, V3, Regional Director of Operations, stated the facility does not have a policy for [CONDITION(S)], only [CONDITION(S)]. V3 was uncertain why the facility did not have a policy on [CONDITION(S)]. The RN (Registered Nurse) Job Description, effective [DATE], documents some of the RNs essential job functions are, Responsible for nursing care of assigned residents. Consult with supervisor and Director of Nursing when necessary. Administer [MEDICATION(S)], intramuscular, and sub-cutaneous injections. Transcribe physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Order medications. Possesses skills for handling, fingering and feeling required for palpation, operating, and maintaining equipment, and providing medical treatments for abnormal conditions, i.e.: Wound care, resident care and medication administration. The Restorative Nurse Job Description, effective [DATE], documents some of the Restorative Nurse's Knowledge, skills, and abilities include, Ability to follow set rules and protocol; provide direction to team members. Possesses skills for continuous handling, fingering, and feeling required for palpation, operating and maintaining equipment, and providing medical treatments for abnormal conditions, i.e.: Wound care, resident care and medication administration. The DON (Director of Nursing) Job Description, effective [DATE], documents some of the essential job functions of the DON are to, Coordinate admissions. Be accountable for nursing compliance, excellence, and delivery of resident-care services in adherence with federal, state, and local regulations. Ensure that adequate and proper equipment and supplies are available to staff. The History and Physical for R1, dated [DATE], documents R1 with the following Diagnoses: [MEDICAL RECORD OR PHYSICIAN ORDER] . Past medical history includes: Arrhythmia, [CONDITION(S)], [CONDITION(S)], Closed bimalleolar fracture, Complication of anesthesia, Diabetes mellitus, Exercise tolerance finding, Gallstones, GERD, [CONDITION(S)], Hypertension, [CONDITION(S)], [CONDITION(S)] arthritis, [CONDITION(S)], Pneumonia, PONV (postoperative nausea and vomiting), sleep apnea, status post [MEDICAL RECORD OR PHYSICIAN ORDER] The Hospital medical record for R1, dated [DATE] through [DATE] documents R1 was receiving the following insulin orders during her hospital stay: Insulin [MEDICATION(S)] ([MEDICATION(S)]) injection - vial, 18 units nightly, Insulin [MEDICATION(S)] ([MEDICATION(S)]) - vial, ,d+[DATE] units, TID (three times daily) PC (after meals), Insulin [MEDICATION(S)] ([MEDICATION(S)]) injection - vial, ,d+[DATE] units, nightly, Insulin [MEDICATION(S)] ([MEDICATION(S)]) injection - vial, 7 units, TID PC. The Hospital Discharge paperwork and Discharge Summary for R1, dated [DATE], documents a follow up appointment with R1's Endocrinologist for Diabetes on [DATE] and includes an Insulin order for R1 as: Insulin [MEDICATION(S)] 100 unit/ml (milliliters) injection - vial, Commonly known as: [MEDICATION(S)]. Use per Insulin pump est (estimated): 100 units per day as directed. The Discharge Summary includes further diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R1's Medical Record documents R1 was admitted to the facility on [DATE] at 12:49 PM. On [DATE] at 1:47 pm, V4 LPN (Licensed Practical Nurse) stated she admitted R1 to the facility on the afternoon of [DATE]. V4 stated the hospital sent admission MEDICATION ORDERS FOR [MEDICAL RECORD OR PHYSICIAN ORDER] . V4 stated she had never had a patient with an insulin pump before and called the local hospital for more information. V4 stated the hospital informed her they were not using the insulin pump but were giving insulin as sliding scale. V4 stated she talked with V5 LPN/Restorative Nurse who told her she would take care of it. V4 stated she did not call R1's Physician for clarification orders but did report off to V7 Agency RN (Registered Nurse) that R1's admission paperwork was done, and she was just waiting for clarification of R1's insulin pump order. On [DATE] at 2:49 pm, V7 Agency RN stated she worked on [DATE] from 6:00 pm to [DATE] at 6:00 am. V7 stated she does not recall V4 LPN telling her in report that R1 was diabetic, had an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . V7 stated she did not perform blood glucose monitoring or give R1 any insulin during her shift because she was unaware R1 was diabetic. On [DATE] at 12:32 pm, V5 LPN/Restorative Nurse stated V4 LPN called (V5's) attention to R1's insulin pump order. V5 stated, We do not use insulin pumps in the facility. I was going to get a MD (Medical Doctor) order for sliding scale. V5 stated she put the order on her desk because she got pulled away to do something else and stated, Out of sight out of mind. V5 stated she forgot about it, did not speak to anyone about R1's insulin pump or clarify the order with a Physician. The facility admission POS (Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . On [DATE] at 9:15 am V15 CNA (Certified Nursing Assistant) stated she worked [DATE] and [DATE] and provided cares for R1. V15 stated R1 would use the bedpan and wore a brief because she was incontinent at times. V15 stated R1 would use her call light and ask for water a lot. V15 stated she didn't know R1 was diabetic and does not recall seeing the Nurses do any Accuchecks (blood glucose monitoring) or giving R1 insulin. On [DATE] at 10:26 am, V22 Agency CNA stated she worked on [DATE] from 6:00 pm to [DATE] 6:00 am and does not recall anything that was concerning to her that would need reported to the Nurse. V22 stated she did vital signs and filled R1's water pitcher a few times on her shift but does not remember how many times. V22 stated R1 was continent on her shift, and she did not have to change her and R1 denied having to go to the bathroom. V22 stated she did not know R1 was diabetic. On [DATE] at 1:35 pm, V19 CNA stated she worked [DATE] from 6:00 pm to [DATE] at 6:00 am and was told there was a new admission. V19 stated she provided incontinence care and gave R1 ice water that night but does not recall R1 being on her call light or anything unusual. V19 stated she also worked on [DATE] at 6:00 pm to [DATE] at 6:00 am and provided care to R1. V19 stated she noticed a change in R1 with R1 being a bit confused from the previous night. R1 would say she was dry and when (V19) checked R1 she would be wet (incontinent). V19 stated around 7:00 or 8:00 pm, R1 put the call light on and asked for ice water. V19 stated she changed R1's wet brief and got R1 more ice water. Around 10:00 pm, R1 put the call light on and asked for ice water again and an emesis basin. V19 stated R1 had the trash can next to her and had thrown up for the first time. V19 stated R1 vomited all over herself and into the trash can. V19 stated she cleaned R1 up, got R1 an emesis basin, another pitcher of ice water told V17 Former RN that R1 had thrown up and was drinking a lot of water. V19 stated when she returned from her break, she saw another CNA getting R1 more ice water. V19 stated she again told V17 Former RN that this was third pitcher of ice water R1 had requested. V19 stated that V17 Former RN told her to, reduce the amount of water, to give more ice and less water. V19 stated at 4:30 am, she asked R1 about getting cleaned up and dressed but R1 didn't have any of her clothes at the facility yet and R1 was fine with the gown. V19 stated she peaked in on R1 before she left at the end of V19's shift at 6:00 am and R1 was fine then. V19 stated she did not know R1 was diabetic and that no one reported that to V19. On [DATE] at 12:57 pm, V20 CNA stated on [DATE] at the end of her 6:00 am to 2:00 pm shift, R1 was admitted to the facility. V20 stated she helped get R1's weight, vital signs, and got R1 settled prior to leaving for the day. V20 stated on [DATE] there was nothing concerning reported to V20 when she came into work. V20 stated she took R1 to the bathroom and filled her pitcher of water that day but that's all. V20 stated on [DATE] when she came into work the third shift CNA reported R1 had thrown up during the night. V20 stated that V13 RN also told V20 that R1 had thrown up a few times during the night and had been drinking lots of water and to let (V13) know if R1 threw up any more. V20 stated she was not aware that R1 had diabetes, it was not reported to her and neither R1 nor V10 (R1's) Family Member ever said anything about it to V20. V20 stated shortly after 7:00 am a Housekeeper asked (V20) where the crash cart was and took it to (R1's) room. V20 stated when she walked into R1's room she saw a Nurse from the other side of the facility doing compressions and (V20) stepped in to help with the respirations. V20 stated, We continued until the EMTs (emergency medical transport) got here and took over. On [DATE] at 11:40 am, V9 R1's FNP (Family Nurse Practitioner) stated she did a video telehealth visit with R1 on [DATE] due to her being a New Admission. V9 stated that generally she reviews the electronic health record for diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . V9 stated that R1 was admitted the previous day and her orders would have already been verified by the admitting Nurse. V9 stated she was not notified or called and does not have any clarification order requests for R1. V9 stated they (facility nursing staff) should be clarifying these orders upon admission and checking all medications and reaching out for clarification if they need it. V9 stated that she does not have any clarification requests regarding an insulin pump, insulin or blood glucose monitoring for R1. V9 stated usually the DON initiates the telehealth visits, meets with (V9) and lets (V9) know if there are any concerns or resident needs that need addressed. The DON, a Nurse or CNA will round with (V9) and then (V9) circles back to the Nurse or DON if (V9) needs to for orders, clarifications or for whatever is needed. V9 stated that V6 Former DON initiated the telehealth visit on [DATE] and never mentioned anything about an insulin pump, insulin, or glucose monitoring for R1. V9 stated R1 did not mention anything about it either and had no concerns for (V9) other than constipation. On [DATE] at 6:24 pm, V10, (R1's) Family Member, stated that R1 has been a Type I Diabetic since (R1) was [AGE] years old and admitted to the facility on [DATE] after a hospital stay. V10 stated the hospital did not use R1's insulin pump while she was there but was checking her blood sugars manually and giving R1 insulin injections based off the blood sugar result. V10 stated that R1 would not initiate a conversation with anyone and would usually only answer yes or no to questions when asked and does not believe R1 would have been able to communicate her needs to the facility staff if she was not feeling well or something was wrong. V10 stated that when (R1) was discharged to the facility, they were supposed to be using her Insulin pump and stated, I would think that was in her orders. I had no idea they weren't (using the insulin pump). No one asked me about it. I assumed they knew what they were doing and expected them to know what to do. V10 stated that he was at home on [DATE] when the facility called him reporting that R1 was not doing well. V10 stated he immediately got dressed and went to the facility and, by the time I got there, they already had her on the floor and had the thumper thing on her doing CPR. V10 stated that he heard one of the staff say they didn't know (R1) had an insulin pump and that was very concerning to V10 that no one knew, but at the moment V10 was too concerned with R1's condition. V10 stated that R1 was taken to the local hospital and kept alive until family could get to the hospital and when the Doctor removed the tube, (R1) didn't even take a breath, she just died . V10 stated, The Doctor told us that her blood sugar was so high that she was in ketoacidosis, which stopped her heart. We were married for [AGE] years, and this was a senseless and careless death that didn't have to happen. On [DATE] at 10:45 am, V6 Former DON stated she generally checks new resident admission orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The Progress Notes for R1, dated [DATE] at 12:49 pm document R1 was admitted to the facility (on [DATE]) and on [DATE] at 7:20 am, approximately 31.5 hours after R1 was admitted to the facility, CPR (cardiopulmonary resuscitation) was initiated for R1 due to being found unresponsive, without a pulse and without respirations. R1's Progress Notes, do not document R1's Physician was notified for clarification of R1's insulin pump orders. R1's Progress Notes also do not document any insulin orders, diabetic monitoring orders or notification of any changes in R1's condition. The hospital Emergency Department Notes, dated [DATE], documents: (R1) female with history of diabetes who presents to the ED (Emergency Department) for [CONDITION(S)] and was intubated and a central line was placed. The laboratory results for R1's CMP (comprehensive metabolic profile) blood draw showed abnormal laboratory values including a Glucose level of 864 and, large amount of ketones. The ED report documents, Concern for DKA (Diabetic ketoacidosis) and severe acidosis precipitating [CONDITION(S)]. This note documents after multiple medications were administered to R1, The patient never had a shockable rhythm. Total of about 1.5 hours of resuscitation before ROSC (return of spontaneous circulation). Clinical Impression: 1. [CONDITION(S)], 2. DKA, 3. Metabolic acidosis, 4. [CONDITION(S)]. On [DATE] at 1:20 pm, V8, R1's PCP (Primary Care Physician), stated he had not met the resident yet and was unaware of any concerns with her and did not receive any calls from the facility requesting clarification of admission orders [MEDICAL RECORD OR PHYSICIAN ORDER] . V8 stated that it was probably a Nurse who was unfamiliar with an Insulin Pump and was a poor order from the hospital. V8 stated he would have expected the Nurse to get clarification orders, usually managed by their Endocrinologist. V8 stated that the Nurse should have at least been doing blood glucose checks, R1 should have been on a sliding scale and maybe a long-[MEDICATION(S)] insulin. V8 stated, Of course when asked if R1 was not receiving insulin for a few days could it have contributed to R1's death. On [DATE] at 3:03 pm, V14 County Coroner, stated Immediate cause of death was DKA (Diabetic Ketoacidosis) for days and the second was absent Insulin pump and missed insulin injections for days. V14 stated (R1) had multiple comorbidities but the DKA and missed insulin was the cause of (R1's) death. The Death Certificate for R1, dated [DATE], documents R1's death on [DATE] with immediate cause of death as, Diabetic Ketoacidosis due to Absent Insulin Pump/Missed Insulin Injections. The Immediate Jeopardy was identified on [DATE] at 1:23pm. The Immediate Jeopardy began on [DATE] at 12:49 pm when the facility failed to clarify R1's admission medication for Insulin. V1 (Administrator) and V3 (Regional Director of Operations) were notified of the Immediate Jeopardy on [DATE] at 3:17 pm. The surveyor confirmed through interview and record review that the facility took the following action to remove the Immediate Jeopardy: 1. On [DATE], Inservice held for licensed nurses regarding diabetic care, signs and symptoms, and complications by V6 Former DON and again on [DATE] by V24 Regional Clinical Educator and V25 Regional Nurse Consultant. 2. On [DATE], Inservice held for licensed nurses regarding Physician notification by V24 Regional Clinical Educator and V25 Regional Nurse Consultant. 3. On [DATE], Inservice held for licensed nurses regarding clarification of resident admission orders [MEDICAL RECORD OR PHYSICIAN ORDER] . 4. On [DATE], Inservice held for licensed nurses regarding process to ensure necessary equipment is available by V24 Regional Clinical Educator and V25 Regional Nurse Consultant. 5. On [DATE], Inservice held for licensed nurses on [CONDITION(S)] policy and procedure by V24 Regional Clinical Educator and V25 Regional Nurse Consultant. 6. Agency nurses have been included in the above education and new agency nurses will be educated in all areas above prior to working the first shift in the facility by V2 DON or V24 Regional Clinical Educator. 7. All new hired nurses will be educated in all areas above during orientation, prior to their first shift in the facility by V2 DON or V24 Regional Clinical Educator. 8. The facility has developed a [CONDITION(S)] policy. 9. The facility updated the Admission Checklist to include Diabetic Management and equipment needs. 10. Audits were conducted on all residents with a Diabetes Mellitus diagnosis, including orally managed and insulin dependent. Assured Accuchecks were in place and reviewed ranges, ensured hypoglycemic medications were ordered, and audits were conducted to ensure medications were in the facility. 11. Physicians were contacted for parameters and orders updated with the parameters. 12. Care plans were audited and updated to assure appropriate Diabetes Management interventions were in place. 13. V8 Medical Director was notified.

Based on interview and record review, the facility failed to ensure new admission Physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . These failures resulted in R1 not receiving diabetic monitoring or medically necessary insulin which resulted in R1 vomiting, becoming unresponsive with absence of pulse and respirations, requiring CPR (cardiopulmonary resuscitation) initiation, transferring to the local hospital, and subsequently expiring. These failures resulted in an Immediate Jeopardy. While the immediacy was removed on [DATE], the facility remains out of compliance at Severity Level 2 while the facility is in the process of educating, auditing and monitoring all new admissions for clarification of all admission orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The facility is also in the process of reviewing the auditing tools in the ongoing QA (Quality Assurance) meeting. Findings include: The facility Admission policy and procedure, dated [DATE], does not include the procedures used for the admission process. The facility Admission check List - Nurse, dated ,d+[DATE], documents the following for the Nurse: 2. Fill out admission order sheet. a. Lab work ordered pertaining to diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Verify orders. POS (Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . 4. Fax orders to or call pharmacy. Make out medication sheet. The facility Admission Record Review - New Admission policy and procedure, dated [DATE], documents the new admission, Should be completed within 24 hours of admission This review includes, Medication ordered (including dx (diagnosis), route, stop dates). Checked against MAR (Medication Administration Record) for sites, pulses, etc. The local Hospital Discharge Summary, dated [DATE], documents the following discharge diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The hospital Medical Record for R1, dated [DATE], documents R1's diabetes is controlled, (R1) on insulin pump at home, and Hospital administering [MEDICATION(S)] (insulin) 18 units at bedtime, 7 units (insulin), three times daily with meals and SSI (sliding scale insulin), adjust as needed. The local Hospital Discharge Summary, printed [DATE], includes Insulin as a discharge medication for R1 and further documents: Continue taking these medications: [MEDICAL RECORD OR PHYSICIAN ORDER] . Use per Insulin pump est (estimated): 100 units per day. R1's Medical Record documents R1 was admitted to the facility on [DATE] at 12:49 pm. The facility Order Summary Report for R1, dated [DATE] through [DATE] does not include a Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . The facility MAR (Medication Administration Record) for R1, dated [DATE] through [DATE] does not include the Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . There are no insulin orders on R1's MAR. The facility Progress Notes for R1, dated [DATE] through [DATE], do not document any Physician notification requesting clarification orders were obtained for R1's insulin pump or for insulin orders. On [DATE] at 1:47 pm, V4 LPN (Licensed Practical Nurse) stated she was the admitting nurse on [DATE] for R1. V4 stated upon assessment she did notice that R1 had a glucose monitoring device on her abdomen, but she had never had a resident with one and wasn't sure what to do. V4 stated R1's hospital discharge paperwork listed a Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . V4 stated V6 Former DON (Director of Nursing) was already gone for the day so she asked V5 LPN/Restorative Nurse about the insulin pump order and (V5) said she would take care of it. V4 stated she reported off to V7 RN (Registered Nurse) during shift change that R1's admission was complete except for the Insulin pump clarification and (V4) left at 6:00 pm at the end of her shift. V4 stated R1 did not have any Accuchecks (blood glucose checks) or insulin orders at that time she left and (V4) didn't call the doctor because V5 LPN/Restorative Nurse was going to follow up with it. On [DATE] at 12:32 pm V5 Former LPN/Restorative Nurse stated V4 LPN informed her of R1's orders for an insulin pump and wasn't sure what to do. V5 stated that she told V4 she would take care of it. V5 stated she put R1's order for the insulin pump on her desk and got pulled away to do something else. V5 stated that she was going to call R1's doctor to get a sliding scale order for insulin but V5 did not call R1's doctor and no insulin order were obtained. V5 stated, Out of sight, out of mind and she forgot. I feel so terrible about it. On [DATE] at 2:49 pm, V7 RN stated she worked on [DATE] from 6:00 pm to [DATE] at 6:00 am and does not recall V4 LPN telling her in report that R1 was diabetic, had an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . V4 stated she did not perform blood glucose monitoring or give R1 any insulin during her twelve hour shift. On [DATE] at 9:50 am, V3 Regional Director of Operations stated she suspended then terminated V5 Former Restorative Nurse for not following up on R1's insulin pump orders and terminated V6 Former DON because she is supposed to review all the new admission orders [MEDICAL RECORD OR PHYSICIAN ORDER] . On [DATE] at 11:40 am, V9 R1's FNP (Family Nurse Practitioner) stated she did a video telehealth visit with R1 on [DATE] due to her being a New Admission. V9 stated generally she reviews the new admissions electronic health record for diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . V9 stated that R1 was admitted the previous day and R1's orders should have already been verified. V9 stated she was unaware of R1 having a hospital order for insulin pump or insulin. V9 stated she was not notified or called and had no clarification requests for R1. V9 stated that the facility should be clarifying these orders upon admission and checking all medications and reaching out for clarification if they need it. V9 stated that she does not have any clarification requests regarding an insulin pump, insulin or blood glucose monitoring for R1. V9 stated usually the DON initiates the telehealth visits and meets with V9 and lets V9 know if there are any concerns or resident needs that need met. V9 stated that the DON, a Nurse or CNA will round with V9 and then V9 will circle back to the Nurse or DON if V9 needs orders, clarifications or for whatever is needed. The DON initiated the telehealth visit on [DATE] and never mentioned anything about an insulin pump, insulin, or glucose monitoring for R1. V9 stated that R1 did not mention anything about this to V9 or any complaints to V9 other than constipation. On [DATE] at 1:20 pm, V8 R1's PCP (Primary Care Physician) stated he had not met R1 yet and was unaware of any concerns with her and did not receive any calls from the facility for clarification of a insulin pump or insulin orders for R1. V8 stated he would have expected the Nurse to get clarification orders, usually managed by their Endocrinologist. V8 stated that the facility should have at least been doing Accuchecks, R1 should have been on a sliding scale and maybe a long-[MEDICATION(S)] insulin. V8 stated, Of course when asked if not receiving insulin for a few days could have contributed to R1's death. On [DATE] at 3:03 pm, V14 County Coroner stated the immediate cause of R1's death was days of DKA (Diabetic Ketoacidosis) due to absent insulin pump/missed insulin injections. The Death Certificate for R1, dated [DATE] documents the immediate cause of R1's death as; Diabetic Ketoacidosis due to Absent insulin pump/missed insulin injections. The Immediate Jeopardy was identified on [DATE] at 1:23 pm. The Immediate Jeopardy began on [DATE] at 12:49 pm when the facility failed to clarify a Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . V1 Administrator and V3 Director of Operations was notified of the Immediate Jeopardy on [DATE] at 3:15 pm. The surveyor confirmed through interview and record review that the facility took the following action to remove the Immediate Jeopardy: 1. On [DATE] and [DATE], Inservice was held for licensed nurses regarding the Admission Policy and Procedures by V6 Former DON and again on [DATE] by V24 Regional Clinical Educator and V25 Regional Nurse Consultant. 2. On [DATE], Inservice was held for licensed nurses for clarification for new admission Physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . 3. On [DATE], Inservice was held for licensed nurses for process to obtain necessary equipment by V24 Regional Clinical Educator and V25 Regional Nurse Consultant. 4. A revised New Admission Check List was implemented that includes equipment needed for Resident care. 5. V24 Regional Clinical Nurse Educator completed Audit's for entire facility with residents with a Diabetes Mellitus diagnosis, including orally managed and insulin dependent residents. Resident Accuchecks were all reviewed and with ranges for sliding scale insulin. Hypoglycemic medications were ordered, and audits conducted to ensure medications were in the facility. Residents care plans were also audited and updated. V8 Medical Director was notified.

Based on interview and record review, the facility failed to notify the Physician of a change in a resident's condition for one (R1) of three residents reviewed for diabetic care in the sample of three. These failures resulted in R1 experiencing increased thirst, increased urination and vomiting which led to the continual decline in R1's condition leading to R1's unresponsiveness, absence of pulse and respiration, initiation of cardiopulmonary resuscitation, transfer to the local hospital and subsequent death. Findings include: The facility policy and procedure for Physician Notification of Change in Resident Condition, Revised 4/2019, documents, Staff observe, document and communicate to the Physician, changes in resident condition promptly. Change in condition may include but is not limited to the following: Nausea and vomiting. It is the responsibility of each nurse to notify the Physician of a significant change in condition before the end of the shift. On 5/20/22 at 10:00 am, R7 (R1's roommate) stated R1 was not feeling well that night (5/12/22), (R1) had nausea, throwing up, kept asking for water and staff were changing her (R1) (incontinence brief) frequently. On 5/22/22 at 1:35 pm, V19 CNA (Certified Nursing Assistant) stated she worked 5/12/22 6:00 pm to 5/13/22 6:00 am. V4 stated she noticed a change in R1, R1 was a bit confused from the previous day. V19 stated that R1 would say she was dry when she was wet. V19 stated around 10:00 pm, R1 had thrown up and was requesting her second pitcher of ice water, and after (V19's) break, around midnight R1 had asked another CNA for a third pitcher of ice water and these were both reported to V17 Former RN. V19 stated that V17 Former RN instructed her to reduce the amount of water and increase the ice if R1 requested any more. On 5/23/22 at 11:00 am, V21 CNA stated on 5/12/22 around 9:45 pm, R1 was complaining about upset stomach and a nasty taste in her mouth. V21 stated she grabbed a trash can and R1 threw up into the trash can which smelled sour. V21 stated she reported this to V17 RN and left the facility at the end of her shift at 10:00 pm. V21 stated she did not know that R1 was diabetic. On 5/23/22 at 3:35 pm, V18 Agency CNA stated she worked 5/12/22 at 9:45 pm until 5/13/22 at 6:00 am. V18 stated that R1 began throwing up shortly after she came on shift to work. V18 stated the first time she was in the room was around 10:00 pm, and R1 had thrown up all over herself and threw up again while V18 was cleaning R1 up. V18 stated that R1 was throwing up on and off throughout the shift. V18 stated that V18 gave her a basin to use and every time she turned her light on and V18 would go in there, she had more throw up in the basin. V18 stated that the vomiting started out with substance but, the last time she threw up it was as clear as water with a slight yellow mixed in. V18 stated that V18 had to change her bed at least three times during the night. V18 stated that R1 was only incontinent one time for V18 during the night but someone else may have checked or changed her and V18 may not be aware. V18 stated, What I thought was strange was that every time I went into her room, she was asking for another pitcher of water. V18 stated she told V17 Former RN every time R1 threw up and that R1 kept asking for water. V18 stated, I don't remember there being any odors, or her sweating and she (R1) never complained of pain. I did not know she was diabetic. No one told me that. (R1) never told me that either. On 5/22/22 at 8:31 am, V17 Former RN stated she was the Nurse assigned to R1 on 5/12/22 at 6:00 pm to 5/13/22 at 6:00 am. V17 stated around 10:30 pm V18 CNA reported (R1) had vomited and she had to do a complete bed change. V17 stated, I took (R1's) vitals and gave her nausea medicine she had ordered and checked her for COVID, and she was negative. (R1) asked for a bucket for vomiting, which we gave her. About 45 minutes later, (R1) vomited again. (R1) said she had GERD (Gastro-[CONDITION(S)] reflux disease), so I gave her Tums, and she was better and didn't vomit again. (R1) did ask for water quite a few times. (V19 CNA) brought (R1's) water pitcher out to get water and told me (V17) that this was the 3rd pitcher of water she had gotten for (R1) since her shift started at 6:00 pm. V17 stated, I didn't think anything of it because residents are always asking for things during the night and (R1) was voiding as well. V17 stated, (R1) was taking two antibiotics, and I thought that maybe this was causing her to have an upset stomach. I didn't know she was a diabetic, no one told me in report, or I would have checked her blood sugar. (R1) never said anything about being diabetic or needing insulin only said that (R1) had GERD. V17 stated that she didn't know R1 was diabetic until she worked the next day and reviewed R1's medical record and saw the diagnosis. V17 stated, No, I did not call her doctor. I was terminated for not calling the Physician and for giving Tums without a Physician order. On 5/19/22 at 9:50 am, V3 Regional Director of Operations stated she terminated V17 RN (Registered Nurse) due to not notifying V8 (R1's) PCP (Primary Care Physician) of R1's change in condition and giving R1 a medication, Tums, that was not ordered. On 5/23/22 at 11:40 am, V9 FNP (Family Nurse Practitioner) stated she did a video telehealth visit with R1 on 5/12/22 due to her being a New Admission. V9 stated generally she reviews the electronic health record for diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . V9 stated that R1 was admitted the previous day and R1's orders should have already been verified. V9 stated, I was not notified or called and have no clarification requests for (R1). They (the nursing staff) should be clarifying these orders upon admission and checking all medications and reaching out for clarification if they need it. I do not have any clarification requests regarding an insulin pump, insulin or blood glucose monitoring (for R1). On 5/19/22 at 1:20 pm, V8 (R1's) PCP stated he was unaware of any problems or concerns with R1 and did not receive any calls from the facility regarding insulin orders, diabetic monitoring or R1's vomiting, increased thirst, or increased urination. The Employee Disciplinary Action form for V17 RN, signed and dated 5/18/22, documents that V17 RN's employment was terminated due to, Unsatisfactory job performance, or substandard quality of work with description of the violation documented as Failure to report resident condition/symptoms to MD (Medical Doctor), dispensing OTC (over the counter) medication without orders. The Death Certificate for R1, signed and dated 5/16/22, documents Immediate cause of death as Diabetic Ketoacidosis due to Absent insulin pump/missed insulin injections.