Every finding on record at Autumn Lake Healthcare at Parkville

Based on observation, and interview, the facility failed to maintain a resident's dignity by failing to ensure a resident's meal was protected from environmental contaminants in accordance with the resident's expressed preference to have the meal covered when not actively eating. This deficient practice affected 1 (#42) of 12 residents reviewed for dignity and had the potential to compromise the resident's dignity and dining experience.Findings include:During observational rounds conducted on 07/30/2026 at approximately 11:00 a.m., Resident #42 was observed in bed with eyes closed and appeared to be sleeping. The resident's breakfast tray remained on the overbed table with the food uncovered. Multiple flies were observed flying around and landing on the resident's uncovered food.At the time of the observation, the surveyor asked GNA#21why the resident's meal had been left uncovered. GNA #21 stated the resident had refused to allow staff to remove the breakfast tray.The resident was interviewed and stated that although it takes time to eat and the resident prefers to keep the meal in the room, the resident routinely asks staff to cover the meal tray when it is delivered because of the fly/gnat problem. Despite the resident's expressed preference, the breakfast tray remained uncovered while flies landed on the food.The Director of Nursing (DON) was informed of the observation on 07/30/2026 at approximately 11:45 a.m. The DON stated she would investigate the incident.During an interview on 07/31/2026 at approximately 9:00 a.m., the DON and Administrator stated the facility had since provided in-service education to staff regarding assisting residents with meals and ensuring residents' meal trays are covered when residents choose to keep meals in their rooms.

Based on observation and staff interviews it was determined that the facility failed to maintain infection control practices in the laundry room. This was evident during the recertification/complaint survey.The findings include:On 7/24/25 at 9:30 AM an inspection of the laundry room was conducted by the surveyor to ensure compliance with infection control. In a pile on the folding table were resident clean linen in various stages of folding and packaging. Also noted on top of the folding table were:2 cups of ice water in 12 oz plastic water cups1 super Sani Disinfectant wipe #21 Super Sani Disinfectant wipe #41 8 oz bye-bye odor spray1 8oz Aloe soft lotion (Geri-Geri)I pkt of wash clothIn an interview with Staff #19 a laundry assistant on 7/24/25 at 9:50 AM , she was asked to explain the laundry process from collection to delivery to residents, She stated that she picks up laundry in the morning from the nursing units, sorts the dirty laundry with PPE in the dirty area, and loads them in the wash. Once the wash is done, she brings them to the clean side where they are dried and then to the clean folding table for folding and packaging to return to residents. She was asked if she got training on infection prevention control on hire and she said she did. She was asked if the above supplies should be on the clean table with the residents clean laundry and she said it should not. On 7/24/25 at 9:57 AM, the Environmental Services manager (EVS) was called in and was shown the supplies on the clean folding table and asked if the cleaning supplies and ice water should be on the folding table. She acknowledged that they should not, she was made aware that this was a concern.

Based on observation and staff interviews, it was determined that the facility failed to ensure that a resident's room was clean, comfortable and homelike. This was evident for 1 of 2 nursing units reviewed during the recertification/complaint survey.The findings include: On 7/16/25 at 9:20 AM during the initial tour of the building, the surveyor walked into Resident #106's room and perceived an overwhelming strong smell of urine. The pungent smell seemed to be coming from all over the room including the bathroom. Inside the room, at the bedside was a commode less than one quarter full of urine, it was uncovered. Also observed was a vent by the bedroom window, it had a brown rusty color all over it. The resident was lying in bed watching TV, their clothing and bedding did not look or feel wet. The surveyor tried talking to the resident, but their speech was impaired, and the resident was difficult to understand. The surveyor asked for the nurse to come to the resident's room. Staff # 7, a licensed Practical Nurse (LPN) came in and was asked about the strong urine odor, he said he was not sure where it was coming from and proceeded to empty the bedside commode.On 7/17/2025 at 2:20 PM in an Interview with Staff #4 the maintenance director, He was asked about the rusty colored vent in Resident #106's room including the foul smell of urine. He said that he had fixed the vent before, had it all cleaned up and painted. That it all came back because the resident pees on it and caused it to rust again. That he will probably need to replace it. He was asked if the resident was able to stand and walk, he said he did not know. He was asked if he had seen the resident peeing at the vent, he said he had not. He was asked how often they check the resident's room, and he said they do daily rounds.In another interview with Staff #16, a housekeeper on unit 2 on 7/17/2025 at 2:56 PM, She was asked how often they clean the residents' rooms. She stated that they clean it every day, sweep, mop, dust over bed, take out trash, and clean the bathrooms daily. She was asked if she was aware of the strong urine odor coming from Resident #106's room and what they are doing about it. She stated that the resident pees on the floor, pees in a cup and throws it on the floor, that every time she goes in there, there was pee on the floor. Staff #14, the Environmental Services (EVS) Manager who was with the housekeeper at the time of the interview said that she had ordered mattress covers for the resident's bed, deep clean the room and that they go back and forth in the room but still can't get rid of the pungent urine smell.On 7/17/2025 at 3:28 PM The Director of Nursing (DON) and the Nursing Home Administrator (NHA) were asked what the facility was doing about the Pungent smell of urine in Resident #106's room including the rusty vent. They said they have discussed the issue before and decided to do more frequent cleaning and also had a discussion about taking out the floor. The NHA said he will reach out to the regional office again to see what they can do. They were made aware that the resident's room was not clean or homelike and that this was a concern.

Based on observation, record review and interview it was determined that the facility failed to develop and implement a person-centered comprehensive care plan as required. This was evident for 1 (Resident #82) of 33 care plans reviewed during the survey process.The findings include: Hemiplegia refers to paralysis on one side of the body, meaning a complete inability to move the affected limbs.Hemiparesis: refers to weakness on one side of the body, which may involve difficulty with movement or a reduced range of motion The Minimum Data Set (MDS) is a standardized comprehensive assessment tool that measures health status in nursing home residents.On 07/16/2025 at 9:35 AM, in an interview with Resident #82, the resident stated that he/she had a decline in function since admission, he/she was able to get to and from the wheelchair by themselves and now they need help with transfers. On 07/23/2025 at 9:10 AM, a review of the resident medical history revealed that the resident had a history of hemiplegia and hemiparesis. A June 10, 2025 MDS assessment showed that Resident #82 was dependent and required substantial/max assistance for all activities of daily living. The resident also had an order for physical therapy, occupational therapy and speech evaluation. On 07/23/2025 at 9:23 AM, a review of Resident #82's care plan revealed that there was no documentation to support that care plan was developed to address the resident's impaired mobility. On 7/23/2025 at approximately 11AM, in an interview with the Director of Nursing (DON), the DON was notified that the facility failed to developed a comprehensive person-centered care plan that reflect the mobility needs of the resident including appropriate interventions and services provided.

Based on observation, medical record review, and staff interview, it was determined the facility staff failed to review and revise the interdisciplinary care plans to reflect accurate and current interventions for residents. This was evident for 1 (Resident #126) of 50 residents reviewed during a recertification/complaint survey.The findings include:A care plan is a guide that addresses the unique needs of each resident. It is used to plan, assess, and evaluate the effectiveness of the resident's care. The care plan is to be reviewed and revised at each assessment time of the resident to ensure the interventions on the care plan are accurate and appropriate for the resident.On 7/16/2025 at 2:15 PM, during initial pool screening, surveyor observed Resident #126 in bed awake and alert but non-verbal. The resident's roommate confirmed that the resident did not talk. However, surveyor did not observe any communication systems (board, cards, note pad, tablet, etc.) at the resident's bedside.On 7/16/2025 at 2:20 PM in an interview with the resident's nurse, Licensed Practical Nurse (LPN #7), he stated that the resident hears but cannot respond verbally. When asked if there were any communication systems used by staff to enable the resident express himself/herself, LPN #7 said no. However, LPN #7 stated that the staff who work with Resident #126 knew how to communicate with him/her using cues, and added that the resident's spouse visited regularly.On 7/23/2025 at 9:25 AM, a follow up observation was made of Resident #126 in their room. Resident #126 was awake in bed and could nod and/or shake their head in response to simple yes or no questions. Surveyor did not observe any communication systems/devices at the resident's bedside.On 7/23/2025 at 9:30 AM, An interview was conducted with the Unit Manager (UM #5). When asked how staff were communicating with Resident #126, UM #5 stated that the resident shakes him/her head for yes or no questions and facial grimaces. UM #5 added that the resident was able to point out stuff that s/he needed like the TV remote control. When asked if staff used any communication devices, UM #5 stated that they had a Picture board kept in the resident's closet. On 7/23/2025 at 9:45 AM Surveyor accompanied UM #5 to Resident #126's room. UM #5 searched the resident's closet and drawers but did not find the Picture board. UM #5 then asked Resident #126 if their spouse took the picture board home, the resident shook their head to indicate no.On 7/23/2025 at 4:26 PM Review of Resident #126's care plan revealed a care plan focus for [Resident's name] has a communication problem r/t Expressive Aphasia, Stroke initiated on 8/26/2023 with revision on 8/26/2023. Goal was [Resident's name] will be able to make basic needs known through the review date initiated on 8/26/2023 with revision on 12/19/2024. Interventions included but not limited to Monitor effectiveness of communication strategies and assistive devices (Communication board) initiated on 8/26/2023 with revision on 8/26/2023.[Of note: There was no communication board found in the resident's room and the care plan interventions have not been updated/revised since 8/26/2023].On 7/24/2025 at 9:43 AM, in an interview with Speech Therapist (ST #20), she confirmed that there was no communication board in the resident's room and staff did not use any communication board/assistive devices with Resident #126 as mentioned in the care plan interventions. ST #20 stated that the staff were very familiar with Resident #126 and knew how to communicate with the resident by asking closed ended questions since s/he (resident) responds via head nod/shake. On 7/24/2025 at 10:59 AM, in an interview with the Director of Nursing (DON), she stated that Speech therapy had evaluated Resident #126 and decided that the resident did not need the communication board. DON added that Resident #126 usually communicates with head nod and hand gestures and has padded call bell that s/he (resident) knows how to use. DON confirmed the facility staff failed to review and revise the care plan for Resident #126 to reflect current and appropriate interventions. However, DON stated that she was going to revise the resident's care plan right away.

Based on observation, medical record review, and interviews, it was determined the facility staff failed to provide treatment and care in accordance with professional standards. This was evident for 3 (Resident #45, #74, #5) of 50 residents reviewed during a recertification/complaint survey.The findings include: A piston syringe, often referred to as a syringe, is a medical device and tool used across various fields for both injecting and withdrawing fluids. It is also used for irrigating feeding tubes and adding liquid medication to existing gastrostomy tubes. 1) On 7/16/2025 at 8:00 AM Surveyor observed Resident #45 in bed awake, alert, and oriented to person, place, and situation. Surveyor observed the resident was connected to a tube feeding pump that was turned off. The tube feed bottle (Glucerna 1.5cal) was dated 7/15/2025, shift noted as 12N and rate 70. The bottle was almost empty. There was also a water flush bag that was not dated connected to the pump. Hanging on the pole beside the water flush bag was a piston syringe dated 7/14/2025. Surveyor asked Resident #45 when the tube feeding pump was turned off and the resident stated that s/he did not know. On 7/16/2025 at 8:15 AM, Both the Unit Manager (UM #21) and night shift supervisor, Licensed Practical Nurse (LPN #22), verified and confirmed that the tube feeding bottle was almost empty and pump turned off but still connected to Resident #45. They confirmed the date on the tube feed bottle was 7/15/2025 and piston syringe 7/14/2025. UM #21 stated that the resident had a down time but acknowledged that the feeding set should have been disconnected from the resident. Night shift supervisor, LPN #22 stated that the piston syringe was supposed to be changed daily. On 7/22/2025 at 9:13 AM, a review of physician orders revealed the following active orders dated 7/4/2025: Enteral Feed: Change syringe every 24 hours. On 7/22/2025 at 9:34 AM, a review of Resident #45's Medication Administration Record (MAR) and Treatment Administration Record (TAR) for July 2025 revealed staff documentation that the syringe was changed on 7/14/25, 7/15/2025, and 7/16/2025. However, when surveyor made observations on 7/16/2025 at 8:00 AM, the piston syringe was dated 7/14/2025, hence, not changed every 24 hours as ordered. On 7/22/2025 at 11:14 AM, in an interview with the Director of Nursing (DON), surveyor reviewed above observations made on 7/16/2025. DON stated she was made aware by staff of surveyor's findings and corrections were made immediately. 2) On 7/22/25 at 1:20 PM, the surveyor went to see Resident #74 per request. The resident complained that their medications were always given late, and that some of their renal medications were given randomly and not with meals as ordered. On 7/22/25 at 2:30 PM, the Director of Nursing (DON) was asked to print a copy of Resident #106's medication administration record (MAR) showing the actual time their medications were given. A review of the Medication administration policy dated 12/14/22 on 7/23/25 at 10:14 AM had on Section 11c that Medications (Meds) are to be administered 60 minutes prior to or after scheduled time unless otherwise ordered by the physician. Review of the residents' actual medication administration records showed that: On 6/7/25, residents 6pm meds were given at 8:09 PM On 6/15/25 residents 4pm meds were given at 6:27 PM On 6/23/25, residents' 4pm meds were given at 6:08 PM On 7/19/25, residents 5pm meds were given at 7:21 PM In an Interview with Staff #17 a Registered Nurse (RN) on 7/23/25 @ 10:45, she was asked to explain their medication administration policy. She stated that medications are expected to be given one hour before and one after the administration time. She explained that sometimes staffing could be a cause of the delay in medications administration. She was asked about dialysis residents, and she stated that their medications are given post dialysis. Resident #106 was a dialysis resident, but review did not show that the late medications were given on dialysis days. On 7/23/25 at 1:45 PM the DON was made aware of the above concerns. She said she will provide more staff education. 3) On 07/16/2025 at 2:41 PM, in an interview with Resident #5 the resident stated that he/she had a possible urinary tract infection and as a result a urine sample was collected, and the result was pending. On 07/21/2025 at 3:01 PM, a review of Resident #5's laboratory orders revealed that an order was placed on 7/15/25 for a urine culture and analysis for dysuria for 1 Day. A review of the laboratory results reported on 07/17/2025 at 02:01 PM, revealed that the urine sample was contaminated. A progress note written by a nurse practitioner on 7/17/2025 at 4:06 PM stated Recollect urine for urinalysis and culture. On 07/22/2025 10:27 AM, in an interview with the resident's nurse #17, she acknowledged that the Nurse Practitioner (NP) wrote a note that the urine sample should be recollected however, she stated an order was not placed in the resident's Electronic Health Record (EHR) and as a result nursing was not notified that the urine sample was to be recollected. Nurse #17 stated that she will obtain the order as soon as possible. On 07/22/2025 at 10:33 AM, in an interview with the unit manager #21, the surveyor asked unit manager #21 to describe the process of obtaining/reviewing lab results. She explained that the laboratory results are sent to the healthcare provider, the provider would typically write a note and then place the order, if applicable. She stated that if an order was not placed in the EHR the nurse would not be aware. She stated that they will follow up with the healthcare provider to find out if the urine sample should be recollected. On 07/22/2025 at 10:36 AM, unit manager #21 reported that the specimen will be recollected per order. On 07/22/2025 at 11:14 AM, in an interview with the Director of Nursing (DON), the DON stated that 24-hour chart check/reviews were completed by the nursing staff; she acknowledged that nursing staff failed to follow up with lab results to ensure the appropriate treatment was in place. This had the potential to result in a delay of treatment. The DON explained that the issue will be addressed moving forward.

Based on record reviews and staff interviews, it was determined that the facility failed to accurately complete a resident's skin assessment sheet and failed to follow a physician's order for wound treatment. This was evident for 1(Resident #142) of 1 resident reviewed for pressure ulcers during the recertification/complaint survey.The findings include: On 7/22/25 at 9:00 AM a review of a complaint intake #310260, had that Resident #142 had bedsores, but the family member was not sure if they were facility acquired or not and if they were the cause of the resident's death.A review of the resident's medical records on 7/22/25 at 9:12AM revealed that Resident #142 was admitted to the facility on [DATE] and had many comorbidities, was cognitively impaired and immunocompromised. On admission the skin assessment sheet documented 3 pressure ulcer (PU) areas to the Right gluteal fold 6.5cm x 4.5 cm, R thigh(rear) 6x5cm X 6cm and Coccyx 4.5cm x 4.0cmx 1.0cm, meaning that resident came in to the facility with multiple wounds. Review of the care plans related to skin integrity on 7/22/25 at 9:17AM had: Resident has actual impairment to skin integrity (Right hip, left hip, BLE and ankles, sacrum, l foot, left knee, left heel, right ischium) r/t fragile skin, boney prominences, incontinence, limited mobility Date Initiated: 09/10/2024 Revision on: 10/29/2024.On 7/22/25 at 9:30 AM a review of a wound care note revealed that Resident #142 had up to 15 wound areas, some with eschar that was debrided by the wound care doctor. Continued review of the admission/readmit screener documents, dated 6/8/24, showed that the wounds were assessed on admission, measured and documented indicating that the resident came in with them.Further review of the skin assessment sheet revealed that on 6/17, 6/18, and 6/25/24, the weekly skin eval was not completed to reflect the wounds. On 9/16/24, nothing was documented and on 10/22/24, no area was documented.A review of the June 2024 Treatment Administration Record (TAR) on 7/22/25 at 9:47AM, revealed an order for an antiseptic wound medication Oxychlorosene Sodium Powder 0.004 grams every day and evening shift for wound. It was ordered on 6/7/24. This wound treatment was not signed off as done on 6/11, 6/13, and 6/19- on the day shift and, on 6/15 and 6/20 evening shift. Also, the Left butt wound treatment was not ordered until 6/21/24.On 7/22/25 at 10:26 AM in an interview with the Director of Nursing (DON) she was asked about the skin assessment sheets and how often they should be completed and she said weekly. She was asked how to indicate that treatment was completed, and she said that the nurse should sign it off. She was made aware of the skin assessment sheets not completed and the wound treatment that was ordered late. She validated that nurses did not sign the TAR to indicate that treatments were done and did not thoroughly complete the skin assessment sheets.

Based on observation, medical record review, and interview, it was determined the facility staff failed to label the oxygen tubing when oxygen therapy was initiated. This was evident for 1 (#57) of 50 residents reviewed during a recertification/complaint survey.The findings include:Oxygen (O2) therapy is a treatment that provides you with extra oxygen to breathe in. It is also called supplemental oxygen. It is only available through a prescription from your health care provider.On 7/15/2025 at 9:55 AM during initial pool screening, the surveyor observed Resident #57 in bed. The resident was wearing a nasal cannula (a device that delivers extra oxygen through a tube and into your nose) that was connected to an oxygen concentrator set at 2LPM (liters per minute). The LPM oxygen flow rate of 2 indicates that 2 liters of oxygen should flow into the resident's nose in 1 minute. There was no date/time and/or staff initials noted on the oxygen tubing. On 7/15/2025 at 10:20 AM, Registered Nurse (RN #18) verified and confirmed that Resident #57's oxygen tubing was not labelled with the date/time it was hung. She stated that the expectation was to date label the oxygen tubing when it was changed. However, RN #18 stated that she was going to change the oxygen tubing right away so as to label it. During a review of Resident #57's medical record conducted on 7/21/2025 at 8:06 AM, surveyor noted an active physician order dated 7/15/2025 for: Oxygen at 2L/min via nasal cannula continuously for SOB (Shortness of Breath) every shift for hospice. There were additional orders dated 7/17/2025 for Oxygen Equipment - Change tubing and date tubing every week, every night shift every Sun . [of note, this order was put in after surveyor's observation on 7/15/2025).On 7/21/2025 at 9:19 AM, in an interview with the Director of Nursing (DON), surveyor reviewed the above observation regarding Resident #57's oxygen tubing not labelled. DON stated she was aware of surveyor's findings and they have already made the necessary changes.

Based on record review and interviews, it was determined that the facility failed to develop and implement a person-centered comprehensive care plan as required. This was evident for 1 (Resident #84) of 33 care plans reviewed during the recertification/complaint survey process.Findings Included:A care plan is a tool used to summarize the resident's healthcare needs, treatments, and care goals. This tool is to be developed within 7 days after completion of the comprehensive assessment and prepared by an interdisciplinary team.On 07/15/2025 at 1:05 PM, in an interview with Resident #84 during the initial screening phase, the resident complaint of severe back pain 9/10, and staff was made aware of the complaint.On 07/16/2025 at 11:44 AM, Resident#84 was resting in bed and reported 8/10 back pain. The resident stated that pain medication was administered that morning, including a pain patch but he/she was still in pain. LPN #7 and Unit manager #5 were notified of the resident's pain. On 07/17/2025 at 3:35 PM, a record review of the Medication Administration Record (MAR) revealed that the resident had orders for HYDROmorphone HCl Oral Tablet 2 MG (Hydromorphone HCl) Give 0.5 tablet by mouth two times a day for Pain and Acetaminophen Oral Tablet 325 MG (Acetaminophen) Give 2 tablet by mouth every 6 hours as needed for Pain.On 07/21/2025 at 11:07 AM, a review of Resident's 84's care plan revealed that the facility failed to develop a person-centered care plan that adequately addressed the resident's pain.On 07/22/2025 at 12:05 PM, in an interview with unit manager #5, she was asked who was responsible for updating the resident's care plan and she stated that the care plan updates were done by the unit manager. She was made aware that the resident's care plan was not updated to reflect pain management as a focus area, even though the resident's pain was an active issue. She stated that the resident received additional pain management interventions from a third-party service; however, she acknowledged that Resident #84's care plan does not specifically address the resident's treatment plan for pain. She stated that the care plan will be updated.On 07/22/2025 at 2:00 PM, in an interview with the Director of Nursing (DON), she was made aware that Resident #84's care plan failed to adequately address pain management. The DON stated that the care plan addressed pain. The surveyor explained that Resident #84's care plan revealed a focus area of potential for alteration in comfort related to acute illness and chronic morbidities. However, the resident was having actual pain and had a diagnosis of chronic pain which the care plan failed to address using person- centered interventions.

Based on record review and interview, it was determined that the facility failed to adequately monitor resident's blood pressure and heart rate prior to administering the medication. This is evident for 1(Resident #51) of 5 resident reviewed for unnecessary medications during the survey process. The findings include:On 07/24/2025 at 12:17 pm, a review of Resident #51's medical records revealed that the resident had an order for Lisinopril oral tablet 40 mg, give 1 tablet by mouth one time a day for hypertension hold for systolic blood pressure less than 110 or heart rate less than 60. A review of Resident #51 vital signs records revealed that the facility obtained vital signs twice in the month of July (July11, 2025 at 3:31 AM and July 17, 2025, at 4:25 AM). However, a review of the Medication Administration Records (MAR) revealed that the medication was administered daily (at approximately 10 am) in the Month of July; however, there was no documentation to suggest that the facility monitored blood pressure and/or heart rate prior to administering the medication.On 7/24/2025 at approximately 4:30 PM the Director of Nursing was notified of the finding, and she stated that the MAR failed to have a place to document the blood pressure and/or heart rate therefore the results were not documented. She acknowledged that the staff should document the pertinent vital signs as ordered in the resident medical record. She stated that the issue would be addressed.

Based on medical record review and review of pertinent documents and interviews it was determined the facility staff failed to notify the resident's representative when there was a significant change in the resident's condition and a change in the resident's treatment plan. This was evident for 1 (Resident #11) of 22 residents reviewed for a complaint during the complaint survey. The findings include: On 4/10/25 at 10:19 AM a review of complaint #MD00203408 alleged that Resident #11's representative was not notified when the resident had a change in condition and was started on oxygen. The complaint alleged the resident representative found out Resident #11 was on oxygen when s/he saw the resident using oxygen during a visit on 1/29/24, and the resident's body appeared swollen and full of fluid. When Resident #11 was asked why s/he hadn't called the representative, the resident said it was because s/he was scared & exhausted from the experience. Resident #11's representative spoke with the nurse on duty, who stated s/he was new to the facility, then reviewed the resident's chart and told him/her that Resident #11 had had an x-ray, and there was excess fluid throughout his/her body. Then, on 1/30/24 at 8:30 AM, the resident representative received a call from the resident's nurse who apologized for not contacting either one of the resident's 2 representatives about Resident #11's change in condition. On 4/10/25 at 10:32 AM, a review of Resident #11's electronic medical record (EMR) was conducted and revealed Resident #11 was admitted to the facility in January 2024 following an acute hospitalization with multiple diagnosis which included stage 4 kidney disease, diabetes, hypertension (high blood pressure), atrial fibrillation (irregular heartbeat), cellulitis (bacterial skin infection). The medical record further documented Resident #11 was transferred to the hospital in February 2024 and subsequently discharged from the facility. In a change in condition note, on 1/27/24 at 11:31 PM, the nurse documented that Resident #11 was short of breath (SOB) and the resident reported s/he could not breath. The nurse wrote that Resident #11 was breathing heavily, and his/her oxygen saturation (02 sat) (a measure of how much oxygen is in the blood) was 68% (normal 95% - 100%) on room air. The nurse wrote Resident #11 was given oxygen at 3 liters via nasal cannula with no improvement, that the oxygen was increased to 6 liters, and the resident was given a nebulizer (changes medication from a liquid to a mist so it can be inhaled) treatment with positive results. The nurse further documented the physician was notified on 1/27/24 at 11:43 PM, and recommended labs and a chest x-ray. In the change in condition note, the date and time of resident representative notification was documented 1/30/24 at 8:00 AM. Further review of Resident #11's medical record revealed, on 1/30/24 at 8:25 AM, in a general nurses note, the nurse documented that a clinical update was given to Resident #11's representative. No other documentation was found in the medical record to indicate that following Resident #11's change in condition on 1/27/24, the resident's representative had been informed of the significant change in Resident #11's health status or that the representative had been notified of the change in the resident's treatment plan when oxygen was implemented and an x-ray and labs were ordered. The above concerns were discussed with the Nursing Home Administrator (NHA) and Director of Nurses (DON) on 4/11/25 at approximately 1:00 PM. The NHA and DON acknowledged the concerns, and no further comments were offered at that time.

Based on medical record review and interview with staff it was determined that the facility failed to develop a person-centered Hospice plan of care with individualized needs and preferences. This was evident for 1 (Resident #12) of 1 residents reviewed for Hospice services during the complaint survey. The findings include: Hospice is a program that gives special care to people who are near the end of life and have stopped treatment to cure or control their disease. Hospice offers physical, emotional, social, and spiritual support for patients and their families. A care plan is a guide that addresses the unique needs of each resident. It is used to plan, assess and evaluate the effectiveness of the resident's care. Resident #12's medical record was reviewed on 4//8/25 at 1:52 PM. Resident #12 was admitted to Hospice Services on 7/11/23. A Hospice Plan of Care was developed by the facility on 7/10/23 with the focus: The resident has a terminal prognosis r/t (relate to) Resident is on [company name] Hospice services. The resident's goals were identified as: Resident #12's comfort would be maintained; and the resident's dignity and autonomy would be maintained at the highest level. The facility identified 11 interventions to assist the resident in reaching his/her goals. However, they were general interventions that did not include/reflect Resident #12's specific individual care needs or preferences. One intervention: assess the resident's coping strategies and respect his/her wishes - it did not identify what his/her coping strategies were nor his/her wishes. Another intervention stated: Consult with physician and Social Services to have Hospice care for resident in the facility. It was not resident centered. The intervention: Encourage support system of family and friends failed to identify the family and friends the resident wished to include in his/her support system. The plan did not identify Resident #12's end of life wishes, specific choices, or preferred comfort measures for staff to implement when providing end of life care. An interview was conducted on 4/9/25 at 11:12 AM with Staff #3 the Director of Social Services regarding Hospice Services and Care Plan development related to Hospice services. She confirmed that she is the facility's Hospice Liaison. The Administrator was present in the room and joined the interview. They were asked how the facility ensured that resident specific end of life wishes were identified and provided. When asked to clarify, the surveyor reviewed Resident #12's Hospice Plan of Care with them. They were made aware that the plan had not identify any resident preferences or wishes for end-of-life care needs including but not limited to end of life wishes, any specific comfort measures or if/who she would like to have at his/her bedside at end of life. They acknowledged these findings.

Based on medical record review, interviews, and review of pertinent documentation, it was determined the facility failed to keep residents free from a significant medication error by failing to ensure medication was available in a timely manner for the facility to administer. This was evident for 1 (Resident #16) of 22 residents reviewed for a complaint during the complaint survey. The findings include: On 4/11/25 at 9:00 AM, a review of complaint #MD00195309 alleged Resident #16 was told that his/her medications would be at the facility when s/he arrived at the facility, however it took 2 days to get the medication and the complaint alleged that the nurse attempted to give Resident #16 another resident's insulin. Following the review of the complaint, a review of Resident #16's electronic medical record (EMR) revealed documentation that Resident #16 was admitted to the facility on [DATE], at 7:30 PM, following an acute hospitalization and discharged from the facility in the beginning of September 2023. The medical record documented Resident #16 had multiple diagnoses including type 1 diabetes. Review of Resident #16's August 2023 electronic Medication Administration Record (eMAR) revealed insulin order that had administration times signed with the code 9 (other/see nurses note). When a medication administration was coded 9, the medication order populates in an eMar medication administration note in the progress notes for the practitioner to document the reason the medication was not administered or any other pertinent information about the medication. 1) Review of Resident #16's August 2025 electronic Medication Administration Record revealed an 8/1/23 order for Basaglar (Insulin glargine) (long-acting insulin) KwikPen Subcutaneous (sq) Solution Pen-injector 100 unit/ml (milliliter) Inject 15 units subcutaneously (sq) (in fatty tissue, under the skin) at bedtime related to type 1 diabetes. On 8/2/23 at 8:00 PM, the administration time was signed off with the code 9 (other/see nurses notes). Review of Resident #16's eMar medication administration notes for when the Basaglar insulin was signed 9 revealed on 8/2/23 at 9:00 PM, the practitioner documented awaiting delivery from pharmacy, indicating the Basaglar insulin was not available in the facility for the staff to administer to the resident. 2) An order for Sliding Scale insulin means the person's blood sugar is checked prior to administration of the insulin and the amount of insulin to be administered changes or slides up or down based on the person's blood sugar. Normal fasting blood sugar levels are generally considered to be between 70 and 100 mg/dL 2a) Review Resident #16's of the MAR revealed an 8/1/23 order for Novolog (fast-acting insulin) FlexPen subcutaneous (sq) solution, administer per sliding scale sq before meals and at bedtime related to type 1 diabetes revealed on 8/3/23, 2 (6:00 AM, 4:00 PM) administration times were signed off with the code 9: - on 8/3/23 at 0600 AM, the resident's blood sugar result was documented as 343 and the administration time was signed off with the code 9. - on 8/3/23 at 4:00 PM, blood sugar result was documented as NA (nor applicable), indicating the resident's blood sugar was not checked, and the order was coded 9 Review of Resident #16's eMar medication administration notes for when the order for Novolog sliding scale insulin administration time was signed off with the code 9 revealed the Novolog insulin was not available in the facility for the staff to administer to the resident and documented the following: - on 8/3/23 at 7:28 AM, Notified on call [Staff #6, Nurse Practitioner], no coverage for Aspart (Novolog insulin) due to not being available at facility. Per on call NP, continue monitoring and assess for s/s of stress. - on 8/3/23 at 7:34 AM, Not available on call NP made aware - on 8/3/23 at 4:26 PM, Resident insulin in transit from the pharmacy. MD aware 2b) Further review of Resident #16's order for Novolog FlexPen sq solution to be administered per sliding scale in the August 2023 MAR revealed on 8/3/23 at 11:00 AM, Resident #16's blood sugar was documented as 275, and documented that 6 units of insulin were given. This was in contravention to documentation indicating Novolog insulin for Resident #16 was not in the facility to give to the resident. Review of Resident #16's eMar medication administration notes for Novolog insulin per sliding scale revealed documentation indicating the Novolog insulin was not available for the staff to administer, and documented the following: - on 8/3/23 at 11:52 AM insulin still on order, NP aware. Pt. monitored for s/s of hyperglycemia high blood sugar) (none noted) - on 8/3/23 at 2:47 PM, meds still on order, pharmacy called in for stat delivery . NP aware 3) Continued review of Resident #16's August 2023 MAR revealed an 8/1/23 order for NovoLog (fast-acting insulin) FlexPen Subcutaneous (sq) Solution Pen-injector 100 unit/ml, Inject 4 units sq with meals related to type 1 diabetes, indicating the Novolog insulin should be administered routinely at 6:00 AM, 11:00 AM, and 4:00 PM. The MAR documented on 8/3/24 the Novolog order was signed off with the code 9 on 3 (6:00 AM, 11:00 AM, and 4:00 PM) administration times. Review of Resident #16's eMar medication administration notes for when the order for Novolog insulin, 4 units, administer routinely with meals was signed off with the code 9 revealed the Novolog insulin was not available in the facility for the staff to administer to the resident and documented the following: - on 8/3/23 at 7:33 AM, Not available. - on 8/3/23 at 11:56 AM , insulin on order , pharmacy called in for stat delivery, NP aware - on 8/3/23 at 4:25 PM, Resident insulin in transit from the pharmacy, Md (medical doctor) aware On 4/14/25 at approximately 11:30 AM, the Nursing Home Administrator and the Director of Nurses were made aware of the above concern that prescribed medication was not available in the facility in a timely manner resulting in missed administrations, and made aware of the concern that, in the MAR, the order for Novolog per sliding scale was documented as given on 8/3/23 at 11:00 AM with no evidence the Novolog insulin prescribed for Resident #16 had been available to give. The NHA and DON acknowledged the concerns, with no further comments offered at that time.

Based on medical record review and interview with staff it was determined facility staff failed to maintain complete and accurately documented medical records. This was evident for 1 (Resident #12) of 1 residents reviewed for Hospice services during the complaint survey. The findings include: Resident #12's medical record and facility's Hospice contract were reviewed on 4//,d+[DATE] at 1:52 PM. The record revealed that Resident #12 was admitted to Hospice services on [DATE]. The facility's contract with Resident #12's Hospice provider included: 2.Responsibilities of Facility (d) coordination of care, (iv) Notification of Change in Condition. Facility shall immediately inform Hospice of any change in the condition of a Hospice Patient. It included but was not limited to the death of a Hospice Patient. A Nursing Progress Note dated [DATE] at 20:04 [8:04 PM] indicated Low blood pressure. Action: Monitoring resident blood pressure, Response: Resident is hospice and declining. There was no documentation indicating the resident's representative or Hospice provider were made aware of these findings. Another progress note dated [DATE] at 11:47 AM indicated: Patient expired this morning at 9:30 am, family came to be with the patient at bed side. Patient body was release to Maryland Cremation services at 11:00am. The note was not clear if the resident's family was with him/her when he/she expired or arrived afterward. There was no documentation of an assessment of the resident with the findings that led the nurse to conclude that the resident had expired. The documentation did not indicate when, if or how the contracted Hospice provider was notified that Resident #12 had expired. The Administrator and Director of Nursing were made aware of these concerns and confirmed the above findings on [DATE] at 1:20 PM.

Based on clinical record review, staff interview it was determined that the facility nursing staff failed to initiate Cardiopulmonary Resuscitation (CPR) on a resident without a pulse (#167). This was evident for 1 out 55 residents that were in the survey sample. After the incident the facility developed, initiated, and completed a plan of correction to prevent further incidents of CPR not being initiated. Therefore, this deficiency will be cited as past non-compliance immediate jeopardy. The date of correction was [DATE]. The findings are: Review of intake MD00175813 on [DATE], [DATE] and [DATE] revealed the following: Resident #167 completed a Maryland Medical Orders for Life-Sustaining Treatment (MOLST) on [DATE] and the resident requested to receive Cardiopulmonary Resuscitation (CPR). Cardiopulmonary resuscitation is an emergency procedure that includes chest compressions and sometimes includes artificial ventilation in an effort to preserve intact brain function until further measures are taken to restore blood circulation and breathing in a person who is in cardiac arrest. The resident entered palliative care (an interdisciplinary approach aimed at optimizing quality of life and mitigating suffering) on [DATE]. The resident completed a form listing Five Wishes: focus on aggressive care at all costs, move to the Intensive Care Unit (ICU) if clinically worsens, wants a breathing tube, wants medication to treat low blood pressure, and wants CPR if heart stops. Clinical Record review revealed that on [DATE] at 5:38 PM that the nurse (Staff #27) caring for the resident found the resident without a pulse. 911 was called by the nursing staff. CPR was not initiated. A review of the Emergency Medical Services (EMS) report on [DATE] revealed that 911 was called on [DATE] at 6:25 PM. The EMT's arrived on [DATE] at 6:32 PM. They donned Personal Protective Equipment (PPE) and entered the room at 6:35 PM. Staff were standing in the room and the resident was in bed. No CPR in progress. An Automated External Defibrillator, (AED) is a device used to assist individuals in cardiac arrest. It is an easy to use device that can analyze the heart's rhythm and, if necessary, deliver an electric shock to help the heart re-establish an effective rhythm) was not on the resident. Staff stated the resident had COVID and had been having respiratory issues since 5:00 PM. EMT's noted that the resident did not have a pulse. EMT pronounced resident deceased . A review of Staff #27's personnel file on [DATE] revealed that she failed to initiate CPR per policy and procedure, failed to seek assistance from co-workers, failed to overhead page a STAT (an immediate response) for the resident's room, and that the employee's failure to initiate CPR violated the resident's wishes. A review of the policies and procedures for administering CPR during the pandemic for a resident with COVID were: If an Automated External Defibrillator (AED) is present, then apply and initiate. If not, then initiate CPR. Call 911 then physician. Designate someone to record events. Continue until CPR is no longer needed and/or appropriate. The Administrator, the Director of Nursing, and Regional Nurse (staff #18) were interviewed on [DATE] at 9:30 AM regarding the incident. They were not employed by the facility at the time of the incident and could not provide additional information. Interview with the unit manager (Staff # 17) on [DATE] at 11:10 AM revealed she was working in the facility at that time but not on the unit. She did not recall the incident but did recall the training. She was one of the trainers and participated in the demonstrations. She did recall Resident #167's name and that the resident had COVID and required CPR. When asked how to perform CPR on someone with COVID. She replied that you cover the resident with a plastic sheet from neck down and begin the CPR process. She also stated the procedures according to the policy manual. In response to the incident, Quality Assurance had nursing staff re-trained regarding how to respond to a resident in need of CPR. The in-services were entitled Response to STAT for a Covid + pt and regular CPR. The training sessions were held on [DATE], [DATE], [DATE], and [DATE]. A practice drill on how to respond to an individual with COVID in need of CPR was held on [DATE]. Staff #27 was terminated because she failed to initiate CPR per policy and procedure, failed to seek assistance from co-workers, and failed to overhead page a STAT alert. The facility is now owned by a different company with different management. Upon review of actions of the previous facility administration and interview with the current Director of Nursing it was determined the immediate jeopardy was past non-compliance secondary to the previous management staff terminating the nurse. Furthermore, the nursing staff employed by the previous nursing home company were educated and the training department held a practice drill to ensure the nursing staff understood their roles and responsibilities. The facility corrected the deficiency on [DATE]. A review of the current facility's policies and procedures revealed that current staff were informed of the proper response.

Based on medical record review, observation and interview, it was determined the facility staff failed to administer medications as ordered by the physician (Resident #3,and #42). This was evident for 2 out of 56 residents reviewed during an annual survey. The findings include: 1. Review of Resident #3's medical record on 11/2/22 revealed the Resident was admitted to the facility on [DATE] with a diagnosis of heart disease. Further review of the Resident's medical record revealed the Resident had a cardiology consult on 10/11/22. Review of the Cardiology Office/Clinic Note revealed the Cardiologist ordered the Resident to start on Imdur 30 mg daily. Imdur is used to prevent chest pain in patients with coronary artery disease. Review of Resident #3's Medication Administration Records for October and November 2022 revealed the Resident was not receiving Imdur. Interview with the Director of Nursing on 11/4/22 at 10:05 AM confirmed the facility staff failed to order Imdur for the Resident following his/her cardiology consult on 10/11/22. 2. Observation of medication administration for Resident #42 on 11/3/22 at 9:15 AM revealed RN (registered nurse) #1 failed to administer Eliquis 5 mg and Potassium 20 meq to the Resident. At that time RN #1 stated the medications were not available in the medication cart and she would notify Unit Manger #1. Review of Resident #42's medical record on 11/4/22 revealed the Resident was readmitted to the facility from the hospital on 10/31/22. At that time the physician ordered Eliquis 5 mg two times daily for atrial fibrillation. Atrial fibrillation is when the heart beats too slowly, too fast, or in an irregular way. On 10/31/22 the physician also ordered Potassium Chloride 20 meq one time a day for supplement. Review of the Resident's November 2022 Medication Administration Record on 11/4/22 revealed the Resident did not receive the 11/3/22 9:00 am dose of Eliquis or Potassium. On 11/7/22 at 10:00 AM the Director of Nursing provided the Surveyor with the list of medications stored in the facility. Included in that list was Eliquis 5 mg and Klor-Con M20. Klor-Con M20 is a brand name for potassium chloride. Interview with the Director of Nursing on 11/7/22 at 12:50 PM confirmed the facility staff failed to administer Eliquis and Potassium to Resident #42 on 11/3/22 at 9:00 AM.

Based on clinical record review and staff interview it was determined that the facility staff failed to administer medications according to the physician orders. This was evident for 3 out 6 residents in the survey sample. Documentation is an integral part of medication administration. Documentation communicates the timing, dosing, and effect of any medications received by a patient. In the setting of skilled nursing care, residents are often prescribed multiple medications for significant medical conditions. They are also often more vulnerable to medication error and more prone to changes in condition that require review and adjustment of their medication regimen. Inaccurate medication documentation has the potential to place residents at significant risk of medication error, provide incomplete or inaccurate information for providers and care givers to evaluate, and represents a failure of basic medication administration principles. Late documentation is a form of inaccurate documentation and is worsened if the documentation does not document when medications were actually given. 'Late administration' is defined as giving medication greater than 1 hour after a medication is due. 'Late documentation' is defined as not documenting immediately after administration. The findings include: A review of Resident #164's medication administration record (MAR) for a period covering 3/1/21 to 4/30/21 revealed a significant pattern of late documentation for every medication that the resident was prescribed. The resident was prescribed: 1. Sevelamer carbonate 800 mg (supplement). The medication was administered late for 73 out of 79 opportunities. 2. Lantus Solostar pen injector 100 units/ml inject 8 units (treats diabetes). The medication was administered late for 35 out of 40 opportunities. 3. Humalog 100 unit/ml to be dosed on a sliding scale (treats diabetes). The medication was administered late for 47 out of 63 opportunities. 4. Protonix 20 mg (treats Gastrointestinal Reflux disease). The medication was administered late for 2 out of 3 opportunities. 5. Heparin 5000 units/ml inject 5000 units (prevents clotting). The medication was administered late for 11 out of 17 opportunities. 6. Aspirin 81 mg (stroke prevention). The medication was administered late for 24 out of 28 opportunities. 7. Clopidogrel 75 mg (blood clot prevention). The medication was administered late for 23 out of 24 opportunities. 8. Nephro vitamins 0.8 mg (supplement). The medication was administered late for 20 out of 20 opportunities. 9. Oxcarbazepine 300 mg (prevents seizures). The medication was administered late for 29 out of 34 opportunities. The Director of Nursing was interviewed on 11/15/21 at 10:15 AM. The late medications were discussed and she said she understood the findings. 30428 The findings include: 1. Review on 11/14/2022 at 11:00 AM of the facility reported incident #MD00151309 revealed an incident occurring on 2/9/2020 and 2/10/2020 where Resident #114 reportedly received between 4 and 8 times his/her ordered dose of an anticonvulsant (anti-seizure) medication, Vimpat. Continued review of the medical record for Resident #114 revealed diagnosis including traumatic brain injury (an injury that affects how the brain works), epileptic syndromes (unique combination of symptoms in the brain where the seizures originate) and flaccid hemiplegia (decrease or lack of muscle movement where the affected body part becomes floppy or without muscle tone and with diminished reflexes) affecting dominant side. A physician medication order was in place for the treatment of the seizures starting on 1/23/2020 for 4 tablets of Vimpat 50 milligrams (mg), twice a day at 9 AM and 9PM. Review on 11/15/2022 at 9:00 AM of the facility reported incident revealed that on 2/7/2020 the resident's attending physician, staff # 36, ordered a refill of the Vimpat. However, instead of ordering the administration of 4 tablets of 50 mg, he ordered for the administration of 1 tablet, 200mg Vimpat twice a day. Surveyor contacted the pharmacy responsible for dispensing medications to the facility on [DATE]. According to the Pharmacist in charge of operations, staff # 35, 60 tablets of the 200 mg Vimpat was ordered and delivered on 2/7/2020. The current Director of Nursing and Administrator provided the survey team with what they had available from the investigation that occurred in 2020. Although the actual narcotic log sheet was not available for review, the Controlled substance prescription form completed by the physician, staff #36 was in the investigation packet. According to the new order for Resident #114, s/he was to take 1 tablet twice a day of 200mg Vimpat. According to the facility investigation, the nurse on duty who received the medication from the pharmacy failed to update the order in the electronic health record, including the medication administration record (MAR) to reflect the changed physician order from 4 tablets of 50 mg to 1 tablet of 200mg. On 2/8/2020 at 9 AM and 9 PM, Resident #114 received 4 tablets of 200mg Vimpat, eight times the ordered dose. On 2/9/2020 Resident #114 received the 9 PM dose of Vimpat. At 10:11 PM according to a Nursing Home transfer form, Resident #114 was sent to the hospital secondary to abnormal vital signs. Under Additional Relevant information noted on the form included 'resident was given extra dose of Vimpat 200 mg yesterday and this am.' According to Unit Manager RN staff # 17 who was interviewed on 11/15/2022 at 1:51 PM, she stated that prior to the hospital transfer of Resident #114, LPN staff #34 identified that he erroneously administered 2 tablets of the 200mg Vimpat at 9 AM and 9 PM on 2/9/2020 and reported to her the error. The failure of the nursing staff to follow physician orders and transcribe medications correctly was reviewed with the DON and Administrator throughout the survey and again during exit on 11/17/2022.

Based on interview from residents, record review and interview with facility staff, it was determined that the facility failed to ensure that residents were aware of the current facilities rules and regulations after a change in ownership. This was evident during the resident council meeting and has the potential it effects all residents. The findings include: During the resident council meeting held on 11/3/2022 at 10:30 AM as part of the survey process, surveyor questioned the residents in attendance if they were aware of the facility rules and regulations and their rights under the new ownership that took place May 0f 2021. Five of the five residents in attendance were all residents in the facility prior to the transition of the facility from one company to another. The residents jointly agreed and spoke out that they were not informed or aware of any rule changes, nor were they asked to sign anything acknowledging new ownership of the facility and the expectations of the new owners. The facility Administrator and the Director of Nursing (DON) were interviewed on 11/4/2022 at 11:15 AM regarding the findings at the resident council meeting. They were asked if they were aware if residents were notified of the change in ownership and expectations including rules and regulations set forth by the new company. At the time of the interview and exit on 11/17/2022 neither were aware of any notification to the residents nor providing the residents with notification of a new admission contract.

Based on review of resident council meeting minutes and interview with residents and facility staff, it was determined that the facility failed to give adequate responses to grievances presented by the resident council. This was found evident in the review of the monthly resident council meeting minutes and facility responses for the months of February through October 2022. The findings include: Review of the resident council meeting minutes on 11/1/2022 at 9:56 AM revealed repeat concerns 5 of 7 months, regarding failure of staff or significant delay of staff to answer call bells timely and concern regarding the presence of staff specifically geriatric nursing assistance (GNA) to provide care as needed. These concerns were also reported to the surveyors through interviews during the annual survey during initial screening. In the April Resident Council meeting agenda under 'old business' regarding concerns from March documented that residents were informed of recent increased in nursing staff members joining the team. April 2022 concerns also noted continued concerns regarding staffing and call bell responses. However, there was no reported, or documented interventions or intermediate plan put in place to address the residents' concerns, besides stating that the facility is trying to hire new staff. Staffing concerns and call bell responses were reported again in June and July, August, October 2022 and again during the surveyor held resident council meeting on 11/3/2022. In the resident council meeting residents stated that they could push the call-bell and wait 1-2 hours for assistance. The GNA would come and silence it and they would have to wait another 45 minutes to get assistance. Collectively the residents in the meeting stated that when staff do provide care, they complain that 'they are short staffed' or 'everyone is short.' They feel that that is not their problem, they need care and here for a reason and need certain services provided to them that is not being provided timely. Residents also reported concerns related to dietary services in the resident council meetings. These concerns included temperatures of the food served on the unit and the presentation of the food service cart. These concerns continued for 7 of the 7 months of resident council meeting minutes reviewed according to what was provided to the survey team. The response to the concerns included monitoring of the temperatures prior to serving, in-servicing staff on proper cleaning of food carts put in as an intervention twice (May and July) and again implemented random checks of food temperatures. The same complaints and concerns occurred from February 2022 to October 2022. According to the resident council president, resident #78, s/he stated that people have stopped coming to the meetings because there are no responses to the grievances. The identified concerns from the resident council meeting and meeting minutes were reviewed with the DON and the Administrator on 11/4/2022 at 11:15 AM.

Based on surveyor observation and interview with staff it was determined that the facility fail to maintain a homelike environment this was evident in four out of four rooms observed. The findings include: On 11/03/22 at 1:33 PM the surveyor entered and began the initial tour of the facility. Observation and Brief walk of second floor hallway with the Maintenance Manager, no issued with lighting, adequate lighting and Comfortable lighting observed. Starting from room [ROOM NUMBER] of second floor hallway observed two 4x4 inch holes on baseboard of room [ROOM NUMBER] and room [ROOM NUMBER] respectively. A distinct smell of urine was observed by surveyor and was persistent throughout this portion of the hallway of the facility on 2nd floor. A 3x3 inches hole was also observed on room [ROOM NUMBER] baseboards. A missing tiles was also observed on room [ROOM NUMBER] by the window ac/heat vent. The baseboards was also observed coming off from the wall, leaky and wet with water inside the Nourishment room located in front of the Nursing station on second floor. These finding were confirmed with the maintenance manager at the time of the observation. The Administrator was made aware of these findings on 11/17/2022 during the exit conference.

Based on medical record review and interview, the facility staff failed to provide [CONDITION(S)] services for a resident (Resident #1). This was evident for 1 of 6 residents reviewed during a complaint survey. As a result of these findings, a state of immediate jeopardy (IJ) was declared on 6/10/21 at 11:20 AM. An IJ summary tool was provided to the facility at that time. The facility submitted a draft of their plan to remove the immediacy at 2:25 PM and it was not accepted. The facility submitted a second plan at 4:17 PM and it was accepted by the state agency at 4:30 PM. After removal of the immediacy, the deficient practice remained at a level of harm for the resident with at a scope and severity of, G. An extended survey was completed on 6/10/21 and 6/11/21. The Immediate Jeopardy was removed on 6/11/21 at 1:00 PM after on-site confirmation of the completion of the facility's plan of removal. The findings include: Review of Resident #1's medical record on 6/9/21 and 6/10/21 revealed the resident was admitted to the facility from the hospital on 5/12/21 with diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . [CONDITION(S)] is a treatment that filters and purifies the blood using a machine. This helps keep your body in balance when the kidneys cannot perform this function. Review of the resident's hospital discharge summary dated 5/12/21 revealed the resident was receiving [CONDITION(S)] services 3 days a week on Mondays, Wednesdays and Fridays and was recommended to continue [CONDITION(S)] at the facility. Review of NP (Nurse Practitioner) #1 note dated 5/17/21 at 12:56 PM revealed as noted, end stage [CONDITION(S)] continues on hemodialysis three times weekly. Review of Physician #1's note dated 5/18/21 at 9:23 PM revealed as documented, end stage [CONDITION(S)] resume HD (hemodialysis). Further review of the resident's medical record revealed [MEDICAL RECORD OR PHYSICIAN ORDER] . Based on the resident's [CONDITION(S)] schedule from the hospital this would indicate the resident missed 5 [CONDITION(S)] sessions (on 5/14/21, 5/17/21, 5/19/21, 5/21/21 and 5/24/21). Interview with the Director of Nursing (DON) on 6/9/21 at 8:41 AM confirmed the resident did not receive [CONDITION(S)] while a resident at the facility. During interview with Nurse #1 on 6/9/21 at 1:46 PM, Nurse #1 stated that she admitted the resident to the facility but forgot to enter the [CONDITION(S)] orders for the resident. Interview with the Regional Nurse on 6/9/21 at 3:00 PM confirmed that the resident was sent to the hospital on 5/24/21 when the facility discovered the resident had not received [CONDITION(S)] services while at the facility. Review of the resident's hospital record on 6/10/21 revealed at the time of readmission to the hospital on 5/24/21 the emergency room physician documented, Labs ordered and reviewed, patient noted to be hypercalcemic with acute on chronic renal failure, consistent with patient not having his/her [CONDITION(S)] over the past 12 days. Review of the resident's emergency room lab results revealed, the resident was found to have elevated Calcium of 14.2, BUN (Blood Urea Nitrogen) of 153 and Creatinine of 13.68. Hypercalcemia is a condition in which the calcium level in your blood is above normal. Too much calcium in your blood can weaken your bones, create kidney stones, and interfere with how your heart and brain work. Normal Calcium level is 8.6 to 10.3. BUN and Creatinine are blood laboratory tests that are used to evaluate kidney function. Normal BUN level is 9 to 23 and normal Creatinine level is 0.5 to 1.10. Further review of the resident's hospital record revealed the resident was seen in the emergency room by nephrology who documented: The patient now has evidence of end-stage kidney disease maintained on hemodialysis via a left upper arm arteriovenous fistula. Note that he/she apparently missed hemodialysis since his/her admission to the subacute nursing home facility on 5/12/2021. This will explain his/her significantly elevated BUN to 153 mg/dL with a creatinine of 13.68 mg/dL. The patient will have a slow hemodialysis session to avoid precipitating disequilibrium syndrome. It is possible that his/her uremia is contributing to his/her altered mental status so we will see if that will improve with hemodialysis. Uremia is a raised level in the blood of urea and other nitrogenous waste compounds that are normally eliminated by the kidneys. The resident was scheduled for [CONDITION(S)] the next morning on 5/25/21. The surveyor reviewed the resident's lab results on admission to the facility on [DATE] to get the resident's baseline lab results prior to missing the 5 [CONDITION(S)] services and found on 5/12/21 that the resident's Calcium was 10.2, BUN 58 and Creatinine 6.0. As a result of these findings, a state of immediate jeopardy (IJ) was declared on 6/10/21 at 11:20 AM. An IJ summary tool was provided to the facility at that time. The facility submitted a draft of their plan to remove the immediacy at 2:25 PM and it was not accepted. The facility submitted a second plan at 4:17 PM and it was accepted by the state agency at 4:30 PM. The Immediate Jeopardy was removed on 6/11/21 at 1:00 PM after on-site confirmation of the completion of the facility's plan of removal. The provisions of the plan to remove the immediacy had a completion date of 6/10/21 and included the following: A.The following process began on 5/27/21: When referral is received in facility, Facility admissions will send [CONDITION(S)] clinical to admissions Concerto ([CONDITION(S)] contractor). Upon approval Concerto admissions will send an email to facility admissions with the approval or denial. Facility will not admit a new [CONDITION(S)] resident without approval from concerto. Facility DON will be copied on all communication from referral to approval. A communication will be placed in the front of the medical chart by admissions to communicate that the patient is to receive [CONDITION(S)] with their schedule. An email will be sent from admissions to in-house [CONDITION(S)] and DON to communicate the estimated transport time and shift. Facility Admissions director was educated of the new process by the DON on 5/27/21. B. Staff educator will coordinate reeducation of all nursing staff in the facility for multiple systems which include: 1. Admissions process. Nurses will receive a notice from admissions that a patient who requires [CONDITION(S)] will admit to the facility. This will be identified inside the chart on a communication sheet. 2. HD (hemodialysis) orders: Upon arrival of the patient, the nurse will review the admission summary and transcribed orders and have the orders verified by a second nurse. 3. Clinical Review: admission charts will be reviewed daily in clinical meeting by DON and clinical team on weekdays and by nurse supervisor on weekends. C. Daily audits of nursing documentation will be coordinated by DON on all [CONDITION(S)] residents to ensure that [CONDITION(S)] was completed and if resident does not get [CONDITION(S)], a change in condition will be completed. Provider and Resident/designee will be notified of the same. Daily audits will be coordinated by DON x 30 days then weekly x 4 weeks for 3 months. All findings from the audits will be reported and reviewed monthly at QAPI (Quality Assurance Performance Improvement) for recommendations. D. DON will coordinate the audit of new admission clinical review and communications from admissions to nursing. Daily audits will be completed x 30 days, then weekly x 4 weeks for 3 months. All findings will be reported to QAPI for recommendations. The Immediate Jeopardy was removed on 6/11/21 at 1:00 PM after on-site confirmation of the completion of the facility's plan of removal.

Based on review of facility documentation and medical records, observations and interviews it was determined the facility failed to ensure an effective system to ensure that a vulnerable resident at known risk for elopement could not elope, when he/she was allowed to smoke in an unsecure courtyard without supervision. This failure resulted in the resident climbing a fence and eloping from the nursing home on 2/1/20. This was evident for 1 (#11) of 3 residents reviewed for elopement. Evidence was provided by the facility that an action plan was developed and corrective measures were implemented on 2/1/2020 immediately after the incident to remove the immediacy of the noncompliance and correct the deficient practice. On 9/16/20 a determination of immediate jeopardy was made in regard to the deficient practice with the potential for past non-compliance. The Administrator and Director of Nursing were informed at 4:26 PM. Review of all facility corrective actions implemented prior to the survey start date, revealed that the facility had met minimum standards for plans of correction and the concern was, therefore, deemed past noncompliance. On 9/18/2020 at 2:00 PM it was determined that that the facility completed the necessary actions to correct the concern by 2/5/20. Additionally, the facility instituted a system change increasing the height of the courtyard fence to 8 feet on 3/18/20. The findings include: Review of Resident #11's medical record on 9/10/20 at 9:46 AM revealed Resident #11, was admitted to the facility in November 2019 from the hospital after an emergency procedure. His/her [DIAGNOSES REDACTED]. Resident #11's Brief Interview of Mental Status (BIMS) assessments dated 11/25/19, 1/2/20 and 4/1/20, revealed that he/she scored 9 out of 15. A score of 8-12 indicates moderate cognitive impairment. The record revealed that Resident #11 was certified by 2 physicians on 11/20/19 as lacking adequate decision making capacity (including decisions about life sustaining treatments). The [DIAGNOSES REDACTED]. The resident's initial elopement evaluation dated 11/26/19, Resident #11 was not identified as an elopement risk. However, on 12/21/19 Resident #11 left the facility and was observed by a staff member approximately 1 block away and accompanied him/her back to the facility safely. Another elopement evaluation was completed on 12/21/19 upon his/her return. It identified wandering that places the resident at a significant risk of getting to a potentially dangerous place. Resident #11 was placed on elopement precautions at that time, the Physician was notified and a Wander Guard Device was ordered due to poor safety awareness. A Wander Guard is a device that is worn as a bracelet on the ankle, the device causes an alarm to sound when close to a door on the system. A plan of care was initiated on 12/21/20 with the focus: Risk for elopement related to: Impulsive behavior related to [MEDICAL CONDITION] (TBI) or psychiatric disorder(s). The resident's Goal: Resident will not attempt to leave the facility without an escort by next review. The identified Interventions: Monitor (Resident's) location with visual checks at least every 2 hours, as needed. Monitor the nature and circumstances (i.e., triggers) of attempted elopement. Utilize and monitor security bracelet per protocol. Listen to (resident) and try to calm. As appropriate redirect (resident) if near exits or doorways. A review was conducted on 9/10/20 of facility reported incident #MD 773. The facility's report and investigation documentation revealed that Resident #11 eloped from the facility on 2/1/20 between 3:45 PM and 4:30 PM. The report indicated that Resident #11 had expressed to another resident his/her intention to scale the fence surrounding the patio and exit the center. Written statements obtained from staff during the facility's investigation revealed that Staff #15 last observed Resident #11 on 2/1/20 around 3:45 PM out back smoking. Housekeeping Staff #14 indicated that he/she observed Resident #11 at 4:30 PM at a nearby convenience store. Staff #14 immediately returned to the facility and informed the nursing staff however when staff returned to the convenience store Resident #11 was no longer there. Police were notified and a search of the facility and surrounding area was conducted. Resident #11 was located later that night by the facility Administrator and Police at his/her former residence after a concerned neighbor reported a light on at the residence. Resident #11 was encouraged to return to the facility however, he/she refused to return at that time. On 2/2/20 a concerned community Social Worker familiar with the resident went to the resident's former home with police and he/she was there. In an interview on 9/14/20 at 11:03 AM the community Social Worker indicated that after consulting with the police, he/she issued an emergency petition for medical evaluation. Resident #11 then went willingly to the hospital emergency roiagnom on [DATE]. Resident #11 was evaluated and discharged on [DATE] back to the facility. A corrective action plan was developed and started on 2/1/20: 1. Resident #11 was located at his/her home. Executive Director and Regional VP went to his/her home at 0110 on 2/2/20. Resident refused to return to the center. Balt. City Police confirmed resident was safe. Date completed 2/2/20; Responsible Person(s) = Center Executive Director. 2. Elopement evaluations on all residents completed by nursing staff. Responsible Person(s) = Nurses, Unit Managers; Completed 2/2/2020, Audited by unit managers on 3/10/2020. 3. All doors inspected for functionality, door alarms, wander guard and magnetic locking systems Responsible Person(s) = Unit managers, Center Nurse Executive, ADON (Assistant Director of Nursing); Date completed 2/1/2020. This continues to be done weekly by Maintenance Director. 4. After learning that resident #11 may have exited the patio, center staff initiated door monitoring to include the receptionist, as well as, periodic rounding by staff to include the Executive Director, Maintenance Director, and others until the door was locked at 2000 (8 PM). This door monitoring will continue during hours in which the patio door is unlocked. Patio doors are unlocked from 8AM - 8PM daily. Staff including Genesis Staffing Services staff were immediately posted at the patio doors when unlocked and monitored the courtyard. Administrator indicated that facility staff were immediately posted to monitor the doors on 2/1/20 after the elopement. Logs were documented by monitors starting on 2/5/20 recording residents who utilized the courtyard with time going out and time returning to the building. This continued through 3/31/2020. Responsible Person(s) = Maintenance Director; Date completed 2/1/2020. 5. Elopement care plans initiated or reviewed based on the evaluation tool by Unit Managers, Clinical Nurse Educator and ADON - completed 2/5/2020. 6. Residents assessed as appropriate for a monitoring device (wander guard). Responsible Person(s) = Memory Support Director, Unit Managers. Date completed 2/4/2020. Center Nurse Executive (CNE) cross referenced residents who were coded as smokers and an elopement risk. Only one resident was identified. CNE assessed this resident and confirmed that he/she is wheelchair bound and not a risk of exiting the patio. Responsible Person(s) = CNE; Completed 2/2/2020. 7. Chart review for wander guard residents to determine MD (Physician) order with expiration date, placement checks and functionality checks on TAR. Responsible Person(s) = CNE or designee; Date completed 2/4/2020 - initial. Continues to be reviewed monthly by CNE or designee. 8. Residents at risk for elopement book updated with current information and picture. Book is at each nursing station and front desk. Responsible Person(s) = CNE/Memory Care Director; Date completed 2/3/2020; Ongoing reviews weekly and as needed for changes by Memory Care Director. 9. Elopement evaluations on all new admits and readmits, to be quarterly on at risk residents and as needed. Responsible Person(s) = Unit Managers, ADON. Initially completed 2/3/2020, continues ongoing. 10. Nurse Practice Educator (NPE) will re-educate all staff on the elopement policy before their shift begins. In addition, the NPE will educate staff to bring the resident back to the center or immediately contact the center supervisor, the individual shall remain with a resident until joined by others. Responsible Person(s) = NPE; continues upon hire and annually. Date completed indicated ongoing and 2/28/2020 however documentation from the NPE reflected that the majority of the staff received elopement in-service training by 2/7/20. Later dates for agency/staffing personnel as they reported for duty. Based on interviews with staff including agency staff, training was completed. Training documentation reflected that training started on 2/1/2020 immediately after incident. 11. Elopement drills to be conducted on all three shifts monthly x 2 and then every 6 months. Results of drills to be presented to Quality Assurance Performance Improvement (QAPI) monthly. Responsible Person(s)= IDT; The QA follow up monitoring drills began 2/1/20. Date completed 4/3/20 (monthly x 2), every 6 months is ongoing. Sign in sheets for drills provided. 12. QAPI ad hoc meeting held on February 1, 2020 to determine root cause, discuss revisions or recommendations to the plan, assess for completion. Responsible Person(s)= Unit Managers, ADON, CNE. Date completed 2/1/2020. Review to continue monthly x 3 months. During an interview the Administrator indicate that due to coronavirus (COVID), the monthly QAPI meetings were waived however action plan interventions, audits and effectiveness were discussed during weekly CAR (Customer At Risk) meetings and clinical meetings. He explained that the CAR meetings are essentially QAPI meetings with a specific focus on risks and processes. It is attended by the nursing management team, head of therapy, medical director, Social Worker, Administrator, Dietician and Director of Memory Care unit. 13. An IDT meeting prior to any resident's wander guard being discontinued. Responsible Person(s)= IDT. Completion date 2/4/2020 and ongoing. 14. RMS to be completed immediately on any resident that has eloped and care plan updated. Responsible Person(s)= CNE or designee - ongoing. 15. Center to install a 6 foot fence around the patio area. Responsible Person(s)= Maintenance Director. Updated to 8 foot fence. Date completed 3/18/2020. An interview was conducted on 9/11/20 at 10:45 AM with Staff #1 (the Administrator). He confirmed that the patio door was equipped with a wander guard alarm, that Resident #11 was an elopement risk and had a wander guard bracelet. When asked how Resident #11 was able to access the patio if he/she had a wander guard bracelet Staff #1 indicated Resident #11 was allowed to go out unsupervised on the patio to smoke. He indicated that Resident #11 would let the staff at the reception desk know that he/she wanted to go out and they would turn off the alarm long enough for him/her to pass through the door. During the interview on 9/11/20 at 10:45 AM Staff #1, also, indicated that when Resident #11 returned to the facility after the elopement on 2/1/20, he/she was immediately placed on 1:1 observation with a sitter and the courtyard was monitored at all times when open until 3/31/20. All smoke breaks are held at scheduled times and are supervised by staff, all resident's on elopement risk status are supervised by staff while in the courtyard. During another interview with the Administrator on 9/14/20 at 8:50 AM, the Administrator was asked why Resident #11 was allowed to go out to smoke unsupervised despite being an elopement risk. He indicated that the center had no previous issues related to the fence and thought it was sufficient. He indicated that this was their practice since before he started at the facility and to his knowledge there had been no issues. He confirmed that Resident #11 was ambulatory, that he/she used a walker at times but would also ambulate without the walker. Staff #17 (the Maintenance Director) was also present during the interview and indicated that the fence around the courtyard was a 4 foot tall [MEDICATION NAME] chloride (PVC) picket fence at the time Resident #11 eloped. On 9/17/20 at 11:21 AM Staff #17 further indicated in an interview that he was called in to the facility when Resident #11 eloped. He revealed that he saw a pallet sitting in the courtyard flipped up next to the fence. He indicated that the pallet had been used as a step for the shed for the past 5 years and thought that Resident #11 may have pulled it over and climbed onto the pallet to get over the fence. Staff #17 also indicated that Resident #11 kept saying he was leaving and would try to leave through the front door. From 9/11/20 - 9/19/20 the facility's action plan and implementation of interventions were reviewed. Interviews with multiple staff, review of facility documentation including education, drills, audits, logs, invoices, and elopement books, as well as, observation of the courtyard fence, gates and staff practices confirmed the above interventions were implemented by the facility. Cross reference F 656.

Based on medical record review, observation and interview, it was determined that the facility staff failed to provide appropriate medication management that met the basic standards of nursing practice when a nurse (LPN #1) intentionally administered a high risk medication incorrectly to a resident (Resident #19). When the resident reported the error to multiple staff, the facility then failed to identify, report, and investigate the incident until surveyor intervention and allowed the nurse (LPN #1) to continue working without additional supervision. This multisystem failure which involved medication mismanagement and an ineffective system of incident investigations placed Resident #19 and other facility residents at potential risk of significant harm to their health and well-being. As a result, an immediate jeopardy was called on 8/11/17. The immediate jeopardy was abated on 8/11/17 at 3:50 PM when the facility plan of correction included medication administration education and competency to all licensed staff. The Plan also included education to all staff on identifying, investigating and reporting resident concerns. This was evident for 1 of 30 residents selected for review in the stage 2 survey sample. The findings include: On 8/10/17 at 1:00 PM, Resident #19 requested to talk to the surveyors and stated LPN #1 had used someone else's insulin [MEDICATION NAME] (a device loaded with doses of insulin with a needle at the end) on him/her on 8/4/17. Resident #19 stated on 8/4/17 in the morning LPN #1 could not find his/her [MEDICATION NAME] vial from which his/her ordered insulin is given. LPN #1 got another resident's [MEDICATION NAME] to administer to Resident #19. Resident #19 refused and LPN #1 convinced then Resident #19 to take the other resident's insulin by stating: any long acting insulin is better than no insulin and injected Resident #19 with an unknown type of insulin from an unknown resident's [MEDICATION NAME]. On 8/5/17 in the morning, Resident #19 stated that he/she reported the incident to the daytime Weekend Nursing Supervisor (WNS). At noon on 8/5/17, Resident #19 reported the medication incident to the Administrator on Call (A(NAME)). Resident #19 could not remember when Unit Manager (UM #2) was told about the medication incident and that UM #2 only said: how do you know it wasn't a new [MEDICATION NAME] and Resident #19 told UM #2 because I get my insulin from a vial. Medical record review and interview found Resident #19 to be alert and oriented to person, place and time. The 5/24/17 Brief Interview for Mental Status conducted by the facility social worker revealed a score of 15/15 on the cognition scale. Review of Resident #19's medical record revealed an order for [REDACTED]. Medical record review showed no documentation by LPN #1 or any facility staff on 8/4/17 or subsequently that the physician was notified of the wrong insulin being administered. The MAR indicated [REDACTED]. On 8/10/17 at 1:30 PM, the Director of Nursing (DON) was asked for the investigation into the medication incident of 8/4/17 with Resident #19. The DON expressed no knowledge of the incident and stated that he/she would investigate. The WNS stated in an interview on 8/11/17 at 9:45 AM, that he/she did not follow-up on Resident #19's concern because he/she thought UM#2 was aware of it. The WNS stated he/she did not report the incident to anyone else because he/she got busy and forgot. The WNS did not include Resident #19's concern in the 8/7/17 Monday morning written report to facility management. During interview on 8/11/17 at 9:00 AM the A(NAME) (Administrator on Call) stated he/she asked Resident #19 if the WNS was notified and Resident #19 said yes. The A(NAME) stated he/she did not follow-up because Resident#19 had told the WNS and it was a nursing concern. The A(NAME) stated they verbally reported the medication incident at the 8/7/17 morning meeting to the facility management team. Interview with UM #2 on 8/11/17 at 8:45 AM, revealed they had been told of the incident by Resident #19 on either 8/7/17 or 8/8/17 or possibly the Monday morning management meeting. UM#2 stated the Director of Nursing (DON) had not been told because UM#2 was investigating. UM#2 stated he/she found Resident #19's [MEDICATION NAME] vials in the medication refrigerator. UM#2 stated he/she had been unable to ask LPN #1 what had happened due to LPN #1 being off a few days. Facility records indicated the DON was present at the 8/7/17 morning management meeting when the A(NAME) reported Resident #19's concern. Facility staffing schedules and surveyor observation and interview revealed both UM#2 and LPN #1 had worked at the facility on 8/9/17. On 8/11/17 at 8:30 AM the DON confirmed Resident #19 had told WNS, A(NAME) and UM#2 of the medication incident and an investigation was not done nor was facility management notified of the incident. Resident #19 was not assessed for injuries or side effects nor was the physician notified until surveyor intervention on 8/10/17. On 8/4/17 the regular ordered blood sugar results of 4:30 PM revealed the level to be 284 for which Resident #19 received the ordered 4 units of Humalog insulin. LPN #1 continued to work as evidenced by 8/9/17 staffing schedules. Interview with Unit Manager #1 (UM#1) stated on 8/11/17 at 2:00 PM that LPN #1 worked on the first floor with UM#1 on 8/9/17. On 8/11/17 at 8:30 AM, the DON stated yes when asked if a system failure had occurred which allowed Resident #19's concern of 8/5/17 to go without investigation, despite 3 facility staff members being told, until surveyor intervention on 8/10/17. Results of the 8/10/17 facility investigation revealed LPN #1 did administer an unknown resident's [MEDICATION NAME]to Resident #19 on 8/4/17. LPN #1 admitted to the DON on 8/10/17 that he/she did not know the type of insulin administered, which resident's [MEDICATION NAME] was used or the amount from the opened [MEDICATION NAME]. He/she also admitted not documenting any of these actions on 8/4/17 on Resident #19's medication administration record. Cross reference to F155, F281, F333 and F441.

Based on a complaint allegation, medical record review and interview of facility staff it was determined the facility staff failed to initiate interventions related to the early detection, prevention/development of pressure ulcer. This is evident for 1 of six residents in the survey sample. (#4) The findings include: Resident #4 was admitted to the facility on [DATE]. The resident's closed medical record was reviewed on 3/29 and 3/30/2015. Review of the medical record revealed the resident had complained of difficulty with breathing beginning 10/21/2015. Nursing note of 10/21/2015 at 11:39 PM states, resident had shortness of breath, difficulty breathing, lung sounds diminished at the bases Further documentation described the administration of oxygen to the resident and prescribed medicated nebulizer treatments. On 10/22/2015 documentation reflected that the resident's condition had improved as documented in a nurse's note at 6:39 AM on 10/22/2015. Day shift documented at 2:39 PM that resident remained in bed today. Evening shift note of 10/22/2016 at 10:35 PM documented, resident in bed throughout this shift. The overnight shift in to the morning of 10/23/2016 documented at 6:25 AM a follow-up note from the change in condition -medical that occurred on 10/21/2015: Status of condition is improved. Day shift on 10/23/2015 at 1:25 PM writes status of condition improved, resident remained in bed today. At 2:56 PM nurses' note indicates the resident has a new onset/change in skin integrity as evidenced by ulcer-pressure. Location: Stage 3 noted on right buttock . Review of a skin integrity report for Resident #4 dated 10/23/2016 reveals buttock wound is assessed to have been acquired in-house and the pressure ulcer stage is listed as unstageable. The appearance of the wound is documented as 75% necrotic and 25 % granulated, length of wound is 4.4 centimeters by a width of 2.2 centimeters with the depth of the wound unable to determine. The tissue surrounding the wound is purple and dark, wound edges documented as unhealthy - ischemic. This unstageable pressure wound is documented as first observed late in the dayshift of 10/23/2015. The resident has had a previous order dated 9/5/2015 for barrier cream to sacrum/buttocks every shift and as needed. Staff on all three shifts have signed the treatment administrative record as done/barrier cream applied. The staff failed to identify the pressure wound at the wound inception for this resident that is assessed to be at a mild risk for the development of a pressure ulcer. The resident was admitted to the hospital on [DATE] for c/o troubled breathing for several days. The hospital documented that Resident #4 has a new non stageable sacral wound.

Based on medical record review it was determined the facility staff failed to promptly and appropriately intervene when a resident experienced a change in mental status and agitation. This was evident for 1 of 5 sampled residents selected for review. Resident #1 is a [AGE] year old with [DIAGNOSES REDACTED]. The resident was admitted to the facility on [DATE] after being hospitalized and treated for [REDACTED]. By way of history, the resident had been brought to the emergency roiagnom on [DATE] by her son on the same day she had been discharged from a rehabilitation facility to home. Review of the resident's medical record on [DATE] revealed that the resident's admission physician's orders [REDACTED]. two times per day for the treatment of [REDACTED]. A CMP is done to assess kidney and liver function, sugar (glucose) and protein levels in the blood and the body's electrolyte and fluid balance. On [DATE] the results of the CMP revealed that the resident had an elevated blood glucose of 307 mg/dL. A normal blood glucose level is 65 - 140 mg/dL. The results of the CMP also revealed that the resident had a low [MEDICATION NAME] level. The physician gave an order for [REDACTED]. On [DATE] the results of the CMP revealed that the resident again had an elevated blood glucose level of 312 mg/dL. The physician did not order further evaluation of the resident's blood glucose levels. On [DATE] the resident was evaluated by the dietitian due to the low [MEDICATION NAME] level. The dietitian recommended: no salt packet, consistent carbohydrate desserts, diabetic condiments, Supercereal at breakfast and pudding 3 times per day. Review of the resident's weight record on [DATE] revealed that on [DATE] the resident's weight was 127.6 pounds. On [DATE] the resident's weight was 119 pounds. The resident had experienced a significant weight loss of 8.6 pounds, which is 6.7% of the resident's body weight in one week. There was no documentation that the resident had [MEDICAL CONDITION] or fluid overload on admission. There is no documented evidence that the physician or dietitian was notified of the resident's weight loss at that time. Review of the nurse's progress note dated [DATE] at 8:43 a.m. revealed that the physician, dietitian and responsible party were notified of the resident's weight loss noted on [DATE]. On [DATE] at 10:43 a.m. the nurse documented in the progress note that the resident was "agitated". On [DATE] at 11:21 a.m. the resident was seen and examined by the nurse practitioner after the nurse reported that the resident had a worsening rash to the sacral and groin areas and was noted to be agitated at times, trying to get out of the chair and not following commands. The nurse practitioner noted the resident's weight of 119 pounds. The nurse practitioner also reviewed the resident's laboratory blood work of [DATE], but did not specifically comment on the resident's elevated blood glucose levels of [DATE] and [DATE]. The nurse practitioner ordered a urinalysis and urine culture due to a questionable urinary tract infection being the cause of the increased agitation and change in mental status. The nurse practitioner also ordered [MEDICATION NAME] 0.5 mg. by mouth every 12 hours as needed for anxiety and agitation. [MEDICATION NAME] is an antianxiety medication. The nurse practitioner did not thoroughly evaluate potential underlying causes of the change in mental status and worsening agitation in a resident who lost 8.6 pounds in one week and had elevated blood glucose levels on [DATE] and [DATE]. The nurse practitioner also prescribed [MEDICATION NAME] for agitation, a drug that may mask an underlying problem and have significant side effects in [AGE] year old individuals. Review of the nursing progress notes and the resident's Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. on [DATE], [DATE], [DATE] and [DATE]. There was no further evaluation by the physician or the nurse practitioner despite the resident's continued agitation. Further review of the nursing progress notes on [DATE] revealed that on [DATE] at 11:40 a.m. the nurse documented that the resident was lethargic, verbally unresponsive, had tremor-like movements to her extremities and did not respond to tactile stimuli. The nurse further documented that the resident's blood pressure was ,[DATE]. The nurse did a finger stick to check the resident's blood glucose level which was elevated at 474. The resident was transferred to the hospital on [DATE] due to a change in mental status and [MEDICAL CONDITION] (low blood pressure). Review of medical records obtained by the hospital on [DATE] revealed that the resident was diagnosed with [REDACTED]. Diabetic ketoacidosis is a complication of diabetes that occurs when the body produces very high levels of blood acids called [MEDICATION NAME] which can be triggered by infection or other illness. Due to the resident's very poor prognosis, the decision was made by her family member to allow natural death and the resident eventually expired on [DATE].