Every finding on record at Autumn Lake Healthcare at Summit Park

Based on observations, interviews, clinical record reviews, and review of facility policy, the facility failed to ensure care was provided in accordance with the written plan of care for two (2) of 24 sampled residents (Resident #3, and Resident #8). Resident #8 did not receive intravenous (IV) fluids as ordered by the physician, and Resident #3 was not provided wound care in accordance with physician's orders. The findings include: 1. On [DATE] at 2:30 PM the facility's Emergency Crash Cart and Automated External Defibrillators (AEDs) policy dated [DATE] was reviewed and noted It is the policy of this facility to ensure that the facility will maintain at least one emergency cart per nursing care floor with additional carts added as deemed necessary in the case of the need for basic life support.Compliance Guidelines: 1. The facility will store the emergency crash cart in a location that is readily accessible.3. Equipment/supplies used from the emergency crash cart are noted and replaced promptly. 4. The emergency crash cart is checked every 24 hours and after every use. Missing or expired items are replaced, when applicable. Review done on [DATE] at 10:00 AM of Resident #8 's clinical record revealed the resident was admitted into the facility on [DATE] with diagnoses that included atherosclerotic heart disease of native coronary artery without angina pectoris, essential hypertension, chronic kidney disease, and chronic systolic (congestive) heart failure. Review done on [DATE] at 10:05 AM of Resident #8's admission Minimum Data Set (MDS) assessment dated [DATE] revealed the resident was cognitively intact, and the MDS triggered a care plan for dehydration/fluid maintenance. Review done on [DATE] at 10:15 AM of Resident #8's Progress Notes revealed the following: [DATE] at 5:29 AM Change in Condition – New order for IV hydration. [DATE] at 9:25 AM General Nurses Note – 0925 – patient was observed by this nurse to be in acute distress/discomfort; V/S [vital signs] were obtained to include BP [blood pressure]: 97/54; RR [respiratory rate]: 25 O2 [oxygen]: 96% R/A [room air] temp [temperature] 98.9 tympanic; HR [heart rate] 62 with notable pacer; Patient was re positioned in bed by this nurse and medication aide; and patient was still observed to be in discomfort/acute distress.NP [Nurse Practitioner] 31 - 0959 [9:59 AM] at bedside to assess this pt.[patient] along with [Unit Manager (UM) 8]. Patient was noted to have a BP of 84/47 with RR of 25; UM 5 states there is no IV supplies on the unit, despite a detailed list on the code cart checked by this nurse. [DATE] at 10:15 AM – Pt VS are currently 93/56, with RR of 28; NP 31 at bedside to coordinate care of this patient with attd [attending] physician; Current plan of care is to obtain STAT Labs and await results pending pt clinical presentation. [DATE] at 1:34 PM Change in Condition Brief Synopsis of Change: Resident observed to be hypotensive with BP 91/52 R 22. Summary of Change of Condition: Resident observed to be hypotensive with BP 91/52 R 22. [DATE] at 1:59 PM – Change in Condition Data: new order for IV hydration Action: completed and will continue to monitor Response: will continue to monitor. Review done on [DATE] at 10:45 AM of Physician's Orders revealed: [DATE] at 5:10 PM – Sodium Chloride Solution .9% - Use 1 liter intravenously one time only for hydration for 1 day rate 75 cubic centimeters (cc)/hour-No flushing required for continuous therapy. Observe Site for signs/symptoms (s/s) of infiltration/extraction at a frequency based on therapy and resident condition. Last ordered [DATE] and End [DATE] at 5:09 PM. [DATE] at 5:45 PM – Insert Midline for IV hydration one time only for IV hydration for 1 day. Review done on [DATE] at 9:45 AM of the Medication Administration Record (MAR) from [DATE] through [DATE] revealed that IV fluids were administered on [DATE] at 10:13 AM, the day after the order was initiated from NP #31. Observation on [DATE] at 11:15 AM, the surveyor, accompanied by UM 5, observed the crash cart on Unit D, and reviewed the crash cart log to reconcile the item in the cart matched what was indicated on the log. The log indicated that all required items were checked and present for [DATE]; however, upon opening the crash cart and auditing each compartment item by item, there were three (3) missing supply categories, as follows: 1. IV starter kits (3 missing) 2. Primary IV tubing (1 missing) 3. IV catheters (3 missing) in varying sizes These items were not present despite being marked as available on the crash cart checklist for the date of the observation just as the IV starter kit was not available on the morning of [DATE] when NP #31 ordered for Resident #8 to receive IV fluids. Interview on [DATE] at 12:15 PM with UM 5 who was a Licensed Practical Nurse (LPN) on D Unit revealed the nurse recalled that Resident #8 admitted into the facility from the hospital and had several comorbidities and issues with dehydration and low blood pressure. UM 5 said that on [DATE], an agency nurse was assigned to care for Resident #8. UM 5 said that he/she could not recall the exact orders NP #31 gave that day for Resident #8. When asked about where the IV starter kit was to be kept, UM 5 said there should have been an IV starter kit in the emergency crash cart, and one in a box in the medication room. UM 5 said that Resident #8's assigned nurse may not have looked in the right place for the IV starter kit on that day. UM 5 did not recall who started Resident #8's IV that day; and said that the facility's Assistant Director of Nursing (ADON) took over Resident #8's care once the assigned nurse was removed from providing care for R#8. During an interview on [DATE] at 2:20 PM, UM 8 said that Resident #8's assigned (agency) nurse notified him/her in trying to reach NP #31 because the agency nurse felt that Resident #8 was not stable and needed to go to the hospital. UM 8 said the resident's vitals were taken and the resident's blood pressure was low. UM 8 said that they were not sure about whether the IV starter kit was available in the crash cart and said that it should have been. UM 8 said he/she left the area and went back to his/her unit after NP #31 gave their orders. Interview on [DATE] at 3:55 PM with the facility's Assistant Director of Nursing (ADON) said that they did not start the IV per NP #31 order and was not aware if the IV starter kit was on the crash cart. The ADON said that a third-party company came in and started Resident #8's IV because nursing staff in the building was unable to do so. The ADON was not aware of when the IV was started. Interview with NP #31 on [DATE] at 1:38 PM revealed that the NP gave verbal orders for STAT labs and IV fluids on the morning of [DATE] for Resident #8. The NP recalled that the agency assigned nurse and UM 8 could not locate an IV starter kit to start the IV fluids. By the time NP #31 left the building the IV had not been started yet. The NP said he/she intended for Resident #8's IV fluids to be started on [DATE]. The NP confirmed that he/she documented the order for IV fluids in Resident #8's record on the afternoon of [DATE] and further stated that he/she thought Resident #8 was receiving the IV fluids at that time. The NP said it was not intended for Resident #8 to start the IV fluids on the following morning, [DATE], and the resident did not receive his/her medication in accordance with physician's orders. 2. Resident #3 was admitted to the facility on [DATE] with diagnoses that included dementia, hypertension, peripheral artery disease, and chronic kidney disease. A review of Resident #3's quarterly Minimum Data Set (MDS), dated [DATE], was conducted on [DATE] at 3:00 p.m. The review revealed the resident had moderate cognitive impairment and a venous/arterial ulcer. A review of Resident #3's care plan, dated [DATE], was conducted on [DATE] at 3:15pm. The review showed Resident #3 had a vascular impairment. The goal was for the wound to show signs of improvement. Interventions included following the wound provider's orders for wound treatment. A review of Resident #3's physician orders, dated [DATE], was conducted on [DATE] at 12:25pm. The review revealed an order for wound care to the right lower medial leg venous wound: clean with normal saline (NS), pat dry, apply calcium alginate, cover with border gauze, and wrap with Kerlix every evening shift. On [DATE] at 12:07 p.m., an observation was conducted of ADON3 performing wound care on Resident #3's right lower extremity. ADON3 performed hand hygiene, donned personal protective equipment (PPE), removed the old border gauze dressing, cleansed the wound with normal saline, patted it dry with gauze, applied calcium alginate to the wound bed, covered it with an abdominal pad, and wrapped it with Kerlix. The dressing applied did not follow the physician's order, which required border gauze rather than an abdominal pad. On [DATE] at 3:59 p.m., an interview was conducted with ADON3. She/he stated the order was not followed because another nurse had read the order, and she/he believed the treatment applied matched the written order. ADON3 stated, I should have read the order myself. On [DATE] at 3:49 p.m., an interview was conducted with the Director of Nursing (DON). She/he stated it was expected that ADON3 should have checked the wound order herself/himself. The DON stated she/he would provide in services to ADON3 and the rest of the nursing staff.

Based on record review, resident interview, and staff interview, it was determined that the facility failed to maintain an effective pest control program. This was evident in 4 out of 4 units and had the potential to affect all residents. The findings include:On 8/26/2025 at 9:18 AM, a review of Complaint #330032 was completed. The complainant alleged that Resident #52's room had a common problem with mice.On 8/26/2025 at 9:43 AM, an observation and resident interview was conducted of Resident #52 and their room. No observation made of mice, but mouse droppings observed by another surveyor during the initial pool process along with gnat and fly sightings made by all surveyors through out all units and the facility. Resident #52 stated that the last mouse sighting was about 2 weeks prior. On 8/26/2025 at 9:47 AM, the pest control logs were reviewed. The pest control logs showed evidence that a mouse was spotted on 7/27/25 in room D10 and treated by the pest management company on 8/1/25. On 8/13/25, another observation logged indicated mouse droppings were found in Resident #52's room (D18) with glue boards on 8/15/25. 08/26/2025 10:40 AM interview with maintenance director. The survey team expressed concern with gnats observed throughout the survey. Maintenance director stated that pest control company is doing better sprays of rooms for gnats, and furniture was moved to ensure old food was picked up and cleaned appropriately as of 8/18/2025 - 8/22/2025. On 8/26/2025 at 11:01 AM, a review of Pest Service Report was conducted. On the report from 8/8/2025, the pest management company treated for reported fly activity in the D wing.

Based on observations and staff interview, it was determined that the facility failed to treat residents with Dignity while dining. This was evident for 8 out 13 residents observed during the dining observation task in recertification survey. The findings include:On 8/12/2025 at 12:19 PM, During the dining observation for lunch in the 2nd floor dining room, this surveyor observed 13 residents receiving meals via a tray cart with the assistance of 1 staff member (Staff #1). Throughout the process, Staff #1 was observed to be handing out 1 tray to a table at a time. Each table had at least 2 residents and there were 5 tables with residents in the dining room. The first go around 5 out of 13 residents received their tray. Once 1 resident from each table got a tray, another resident from each table got their tray. The residents who received their tray the second go around, had to wait approximately 4 to 7 minutes after the 1st tray at the table was served to receive their tray. During this wait time, the residents who received their tray first go around had already begun eating the food on their tray. On 8/12/2025 at 2:12 PM, An interview was conducted with Staff #1. When asked to describe the process of handing out trays and how they decide who gets the trays first, Staff #1 stated that they try to serve the residents who need less help first and then serve those who need help after regardless of where they are sitting. This surveyor expressed concern about serving residents at the same table 4 to 7 minutes apart.

Number of residents sampled: Number of residents cited: Based on observations, record reviews and interviews, it was determined that the facility failed to provide activities to meet the needs and preferences of residents. This was evident to 2 (Resident #88 and Resident #103) out of 3 residents reviewed for activities during the recertification survey.The findings include: 1). On 8/13/2025 at 2:00 AM Resident #88 was observed in their room. TV was off.On 8/14/2025 at 9:10 AM A review of Resident #88's medical record was conducted. The review revealed that the resident had activities on 8/3/25 and 8/13/25. On 8/14/2025 at 9:12 AM A review of the resident's care plan indicated that they had expressed the desire to participate and be involved in more activity programs but needed guidance and transport to participate.Further review revealed a note entered on 7/2/2025 that stated facility staff would conduct one to one visit with Resident #88 if they did not wish to participate in group activities. On 8/14/2025 at 9:30 AM A review of activities log provided by the facility revealed that Resident #88 was offered activities 4 days out of 31 days in July. In August, the resident had activities for 2 days from August 1st to August 13th. On 8/15/2025 at 8:45 AM An interview with the Activity Assistant, Staff #11, was conducted. She reported that for dependent residents the expectation is to conduct one-to-one activities 3 times a week. Additionally, she stated for Resident #88, the facility had not provided one-one as frequently as expected. A review of July and August activities log was conducted with the surveyor and Staff #11. Staff #11 confirmed that for Resident #88 had no refusals for activities offered and that the resident had received 1-1 activity twice from august 1st to august 13th and only 4 sessions of activities were provided for the month of July. On 8/15/2025 at 9:11 AM The Director of Nursing (DON) was made aware of the activities' concerns. 2). On 8/12/2025 at 10:46 AM A resident representative interview was conducted. Resident #103 representative stated that they were concerned that the resident always stayed in bed and did not participate in any activities. On 8/15/2025 at 10:05 AM A review of Resident #103's electronic medical records was conducted. The review failed to show that the resident had participated in activities. The facility was asked to provide evidence of activities provided to the resident in July and August 2025. On 8/15/2025 at 1:06 PM The facility provided Resident #103's July and August activities log. A review of these documents revealed that the resident was not provided with any activities for the month of July. Additionally, from August 1st to August 14th, the resident was provided activities for 3 days (August 3rd, 4th, and 6th) On 8/15/2025 at 1:17 PM An interview with Staff #11 was conducted. Staff #11 confirmed that Resident #103 was not provided with any 1-1 activities in July, and it was the facility's expectation to provide dependent residents with 1-1 activities 3 times a week. Staff #11 was made aware that this was a concern. On 8/15/2025 at 1:20 PM The DON was made aware of concerns with activities provision for dependent residents.

Number of residents sampled: Number of residents cited: Based on review of Geriatric Nursing Assistant (GNA) personnel files and staff interview, it was determined that the facility staff failed to conduct yearly performance evaluations at least every 12 months for 3 (Staff #13, Staff #14 and Staff #15) of 3 GNAs reviewed for annual performance evaluation. The findings include: On 8/19/2025 at 9:06 AM as part of sufficient and competent nurse staffing task, the facility was asked to provide employee files for Staff #13, Staff #14 and Staff #15. On 8/19/2025 at 9:46 AM review of facility provided documents indicated that Staff #13 was hired on 12/14/28, Staff #14 was hired on 6/20/2010, and Staff #15 date of hire was 5/21/24. However, the review of the employees' files failed to reveal any performance evaluations that were completed in the last 12 months. On 8/19/2025 at 1:41 PM an Interview with Human Resource Director, Staff #18, was conducted. When asked who was responsible for completing the annual nurse assistant's performance evaluations, she stated that it was the responsibility of the Director of Nursing (DON). She also confirmed that Staff #15 had no performance evaluation on file, Staff #13 last performance evaluation was done on 10/25/2023 and Staff #14 was completed on 8/14/2023. On 8/19/2025 at 2:21 PM an interview with the DON was conducted. He confirmed that he had not completed performance evaluations for Staff #13, Staff #14, and Staff #15 yet. On 8/20/2025 at 12:26 PM the Regional DON and Facility Administrator were notified of the concern.

Based on resident interview, observations, and staff interviews, it was determined the facility failed to maintain a homelike environment. This was evident in 2 (Room A21 and Room D18) out of 9 rooms reviewed for environment. The findings include:1.) On 8/12/2025 at 8:12 AM, During an interview with Resident #4, the resident stated that their bathroom sink had no working hot water. This surveyor observed the bathroom sink to only have the hot-water faucet handle to functioning. When opening the cold-water faucet handle there was no water coming out of the faucet. This surveyor made the Unit manager on the A-wing (Staff #2) aware of the findings. On 8/15/2025 at 2:15 PM, this surveyor asked the Director of Nursing (DON) about the progress of the malfunctioning water faucet in Resident #4's bathroom. The DON stated they were not aware but would address the concern.On 8/18/2025 at 2:44 PM, This surveyor verified with observation that the sink is now functioning. Furthermore, an interview was conducted with the Maintenance Director (Staff #20) and stated that on Friday 8/15/2025 a call to a plumber was made because the resident's pipe was clogged. Staff #20 confirmed that the plumber fixed the issue by replacing pipe that same day. 2.) On 8/26/2025 at 9:43 AM, an observation and interview was conducted with Resident #52. Resident #52 stated that the curtains in the room were always dusty and that staff was not cleaning them appropriately. The resident stated that there were black dots all over the door frame of the bathroom. This surveyor confirmed the resident's concerns and obtained photographs of the areas. The curtain on the window had large pieces of dust and white particles. The black dots on the door frame started on the top of the frame and extended to the wall above the door frame.On 8/26/2025 at 10:40 AM, an interview was conducted with the Maintenance Director (Staff #20). This surveyor expressed Resident #52's concerns about the Black dots and Dusty curtains. Staff #20 stated they will address dust and particles on the curtains and the black dots on the wall and bathroom door frame.

Based on medical record review and interview with staff, it was determined that the facility staff failed to ensure a resident's Preadmission Screening and Resident Review (PASARR) form was completed on admission to the facility. This was evident during the review of 1 (Resident #56) of 3 residents reviewed for PASARR screening. The findings include:Preadmission Screening and Resident Review is a federal requirement to help ensure that individuals are not inappropriately placed in nursing homes for long term care. Everyone who applies for admission to a nursing facility must be screened for evidence of serious mental illness (MI) and/or intellectual disabilities (ID), developmental disabilities (DD), or related conditions.On 8/13/2025 at 8:25 AM Review of Resident #56's medical records was conducted. The review failed to reveal Level 1 PASARR screening documentation. On 8/14/2025 at 11:00 AM The facility was asked to provide evidence of PASARR screening documentation. On 8/14/2025 at 11:04 PM Further review of Resident #56's record indicated that they were initially admitted into the facility on 1/22/25. The resident had diagnoses of Schizoaffective disorder, Bipolar, and generalized anxiety disorder. On 8/14/2025 at 11:59 AM An Interview with the social worker was conducted. She reported that Resident #56's PASSAR Level 1 was not fully completed by the hospital. Additionally, the social worker provided a letter from Telligen dated 1/23/25 that stated the PASARR screening submitted by the hospital would not be reviewed due to lack of psychiatric notes. When asked whose responsibility it was to verify that the PASARR was completed prior to a resident's admission into the facility, the social worker stated it was her responsibility. The Social worker confirmed that she became aware that Resident #56 had no approved Level 1 PASARR screening on 8/14/25. On 8/14/2025 at 12:12 PM The Facility Administrator was made aware of the concerns.

Number of residents sampled: Number of residents cited: Based on record review and interviews, it was determined that the facility failed to ensure that residents were provided with summaries of their baseline care plans including a list of their medications. This was evident for 1 (Resident #15) of 3 residents reviewed for baseline care plans.The findings include:On 8/14/2025 at 10:32 AM A Review of Resident #15's medical record was conducted. The review indicated that the resident was admitted on [DATE] and a baseline care plan was completed on 1/24/25. However, the electronic copy of the baseline care plan had no signatures that indicated the resident had reviewed or was provided a summary of the baseline care plan. On 8/14/2025 at 10:52 AM The Director of Nursing (DON) was asked to provide evidence that a summary of baseline care plan was provided to Resident #15. On 8/14/2025 at 11:38 AM An interview with the social worker was conducted. The social worker reported that the facility did not have evidence that the baseline care plan summary was provided to the resident. She further stated that the current facility process was to document a progress note to indicate that the baseline summary was reviewed and provided to residents. On 8/14/2025 at 11:48 AM Further review of Resident #15's progress notes failed to show any documentation that a baseline care plan summary was provided to the resident. The social worker confirmed that there was no note on the resident's file that addressed baseline care plan. On 8/14/2025 at 11:52 AM Administrator and the DON were made aware of the concerns.

Number of residents sampled: Number of residents cited: Based on record review and staff interview, it was determined the facility failed to develop an individualized care plan for 1) a resident receiving oxycodone and 2) a resident with an indwelling foley catheter . This was evident for 2 (Resident #12 and Resident #125) out 20 residents reviewed for care planning. 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. 1) On 8/27/2025 at 9:03 AM, a review of Resident #12’s care plans was conducted. No care plan addressing Oxycodone (an opioid used to treat pain) was found. On 8/27/2025 at 9:31 AM, a review of Resident #12’s medication orders were conducted. The resident was ordered 1 Oxycodone 10 mg oral tablet to be given orally every 6 hours as needed for pain. On 8/27/2025 at 9:46 AM, a review of the Medication Administration Record for the month of August for Resident #12 was conducted. The resident received the oxycodone 10 mg tablet twice a day for 24 days in August 2025. On 8/27/2025 at 10:16 AM, an Interview was conducted with the Director of Nursing DON. When asked who is responsible for creating care plans, the DON stated that the unit managers, supervisors, and Minimum Data Set Nurse are responsible for creating the care plans and inputting them into the chart. When asked if there should be a care plan addressing oxycodone for Resident #12 in place, the DON agreed that if Resident #12 is ordered Oxycodone that there should be a care plan addressing that order along with monitoring interventions. 2) On 08/21/2025 at 9:44 AM, a review of medical records revealed that the resident was admitted [DATE] to the facility, from a hospital, with an indwelling foley catheter. On 08/21/2025 at 9:45 AM a review of the baseline care plan, completed on 4/15/2025, revealed that the resident had a foley catheter. On 8/21/2025 at 9:47 AM a review of the admission MDS, completed on 4/21/2025, under section H (Bowel and Bladder) indicated that the resident had a foley catheter. On 8/21/2025 at 9:50 AM a review of the resident’s care plans revealed that the facility failed to implement a focus area, goals, and interventions for the indwelling foley catheter. On 8/21/2025 at 12:02 PM during an interview with the director of social work (Staff #17), she confirmed that the resident did not have a care plan for the indwelling foley catheter. At this time she was made aware of the concern. On 8/21/2025 at 12:20 PM the Director of Nursing was made aware of the concern and again on exit on 8/27/2025.

Number of residents sampled: Number of residents cited: Based on interviews, record reviews and observations, it was determined that the facility failed to ensure that dependent resident's personal hygiene needs were adequately met by offering and providing showers as scheduled. This was evident for 2 (Resident #103 and #88) out 3 residents reviewed for activities of daily living. The findings include:The MDS is a federally mandated assessment tool that helps nursing home staff gather information on each resident's strengths and needs. Information collected drives resident care planning decisions. MDS assessments need to be accurate to ensure each resident receives the care they need. On 8/12/2025 at 10:47 AM A resident representative interview was conducted. Resident #103's representative stated that the resident's hair is often not combed, and they were concerned that the resident did not receive adequate personal hygiene. On 8/14/2025 at 9:19 AM A review of Resident #103's medical record was conducted. The review revealed a care plan that indicated the resident was totally dependent on 1 staff to provide a bath daily and shower twice a week for personal hygiene.Further review of the records revealed that Minimum Data Set (MDS) section GG indicated that Resident #103 was coded as dependent on staff for showers.On 8/15/2025 at 10:52 AM A review of the residents' shower binder located at the nurses' station indicated that Resident #103 was scheduled to shower on Wednesdays and Saturdays every week.The records in the binder failed to indicate that Resident #103 received or refused showers. The facility was then asked to provide documentation that showers were provided for the resident for the month of July and August. On 8/15/2025 at 1:44 PM The facility provided Resident #103's shower log. The review of these documents revealed that the resident had showers 2 days (July 21st and July 24th) out of 31 days. There was a note that the resident was offered a shower on July 17th but had refused. From August 1st to 14th, Resident #103 showed only 2 days (August 4th and 11th).On 8/15/2025 at 1:48 PM The Director of Nursing (DON) confirmed that shower records for Resident #103 were accurate, and that the resident had received showers only 2 days in July, and 2 showers as of August 14th, 2025. The DON was notified that this was a concern. 2). On 8/12/2025 at 12:46 PM An interview with Resident 88's representative was conducted. The representative stated that the resident did not receive appropriate personal hygiene and that the resident's wore the same clothes for several days. On 8/13/2025 at 9:24 AM Resident #88 was observed wearing the same clothes she had worn the day before, on 8/12/25. On 8/15/2025 at 9:55 AM A review of Resident #88's medical records was conducted. MDS section GG indicated that the resident was coded as dependent on staff for showers and personal hygiene. A review of the resident's care plan failed to show that the resident had refusals to personal hygiene. On 8/15/2025 at 10:15 AM An interview with Staff #9 was conducted. Staff #9 reported that Resident #88 had dementia and therefore S/he was unable to distinguish clean from dirty clothes. Staff #9 also added that it was the nursing staff responsibility to change the residents' clothes daily, bathe and shower the residents.When asked how often Resident #88 showered, Staff #9 stated that the resident was supposed to get a shower 2 days per week, and often if needed.On 8/15/2025 at 10:26 AM A review of Shower logs located in the unit shower binder were reviewed. The review revealed that the resident was showered 1 day (July 11th) out of 31 days. There was another date entry on 8/5/25 that indicated the resident was offered a shower but refused. On 8/15/2025 at 10:34 AM An interview with the unit manager, Staff #10, was conducted. Staff #10 confirmed that Resident #88 was supposed to receive showers every week on Tuesdays and Fridays. She also reported that residents' showers or refusals are documented in the electronic health record or the unit's shower binder. The unit manager further stated that shower refusals are to be notified to the family and if there is a pattern, the resident is care planned for refusal. On 8/15/2025 at 10:49 AM The surveyor and Staff #10 reviewed the shower documentation for Resident #88 and confirmed that the resident was not getting showers as required. The unit manager was made aware that this is a concern. On 8/15/2025 at 11:00 AM The DON was notified of the concerns identified with personal hygiene and showers for dependent residents.

Number of residents sampled: Number of residents cited: Based on observations, record reviews and interviews, it was determined that the facility failed to ensure that residents received treatment and care to promote the highest practicable wellbeing as evidenced by 1) failure to follow physician orders and 2) failure to provide toileting hygiene for residents who were incontinent of bowel and bladder. This was evident for 3 (Resident #88, #126, and #137) out of 5 residents reviewed for quality of care during the recertification survey. The findings include:1) On 8/12/2025 at 11:24 AM Resident #88 was observed with redness around the left eye. When asked what happened to his/her eye, the resident answered that they fell last week. On 8/12/2025 at 11:30 AM An observation of Resident #88's room was conducted. An opened pack of regular briefs was observed in the bathroom and on top of the resident's dresser. Additionally, the resident showed the surveyor that they wore regular briefs at that time. On 8/12/2025 at 12:44 PM A review of Resident #88's medical record was conducted. The review revealed orders that stated Resident #88 should 1) wear Hipster Padded Brief q shift while awake for fall interventions and 2) float heels when the resident is in bed. Further review of the resident's record indicated that S/He was care planned to wear hip padded briefs every shift and float heels when in bed. On 8/13/2025 at 10:52 AM Resident #88 was observed without any hipster padded briefs. On 8/14/2025 at 7:00 AM Resident #88 was observed sleeping in bed, heels were not floated. On 8/14/2025 at 7:30 AM A review of resident's medical records indicated that the resident was wearing hip padded briefs on 8/12/25 and 8/13/25. Additionally, there was documentation that the resident had heels floated on 8/13/25. On 8/14/2025 at 8:10 AM Another observation was conducted with the surveyor and Staff #5. Staff #5 confirmed that the resident was not wearing hipster padded brief and heels were not floated. On 8/14/2025 at 8:13 AM An interview with the staff #5 was conducted. Staff #5 stated that she inaccurately documented that the hipster padded briefs were worn and the heels were floated. On 8/14/2025 at 11:10 AM The Director of Nursing (DON) was made aware of the concerns.2a) On 8/14/2025 at 10:45 AM A review of confidential complaints reported to the state agency revealed Complaint #330006. The complaint alleged that Resident #137 did not get their diaper changed on December 1st, 2023. On 8/14/2025 at 10:55 AM An interview with the complainant was conducted. They reported that the facility staff did not change Resident #137's diaper during various shifts. On 8/25/2025 at 9:00 AM Review of record revealed that Resident #137 was admitted into the facility on [DATE] and was discharged on 12/07/2023. Review of resident's MDS section H indicated that the resident was coded as always incontinent for bowel and bladder. Also, MDS section GG revealed that the resident was coded as dependent on staff for toileting hygiene.Further review of Resident #137's care plan indicated that the resident needed assistance with toileting and that they were dependent on staff.On 8/25/2025 at 9:20 AM The DON was asked to provide records for toileting hygiene provision for Resident # 137 for November 30th and December 1st.On 8/25/2025 at 10:10 AM Facility provided documentation for bladder and bowel incontinence for [DATE]th and [DATE]st. Review of these documents revealed no documentation on bowel and bladder incontinence for November 30th night shift 11-7. There was documentation that the resident received dressing and bladder incontinence care December 1st at 14:19.On 8/25/2025 at 10:29 AM An interview with the DON was conducted. He stated that he would expect toileting hygiene documentation if bowel and bladder incontinence care was provided to a resident. The surveyor notified the DON that this was a concern that will be taken back to the office. 2b) On 8/21/2025 at 9:45 AM A review of confidential complaints reported to the state agency revealed Complaint #330065. The complaint alleged that residents at the facility had poor hygiene. The complainant reported that Resident #126 did not get their diaper changed in a timely manner. On 8/21/2025 at 10:12 AM Review of Resident #126's medical record was conducted. The review revealed that the resident was admitted into the facility on 5/10/24 and was discharged to the hospital on 2/16/25. Further review of the records revealed MDS completed and accepted on 11/16/24 that indicated the resident was dependent on staff for toileting hygiene, oral hygiene, shower/bathe and personal hygiene. Also, MDS Section H for Bowel and Bladder indicated that the resident was always incontinent.On 8/21/2025 at 10:33 AM Facility was asked to provide documentation for bowel and bladder incontinence care provided to the resident for the months of January and February 2025. On 8/21/2025 at 11:05 AM The surveyor received documentation for bowel and bladder incontinence care from the facility for the month of January only. The review of these documents revealed several days in January (1, 3, 6, 8, 25, 26, and 28) that indicated the resident was not available to receive toileting hygiene care. Additionally, there was no documentation on 1/13, 1/20, 1/27, 1/29 and 1/30). However, review of Resident #126 medication administration record and progress notes, revealed that the resident never left the facility.On 8/21/2025 at 11:25 AM The DON was asked to provide documentation that indicated the resident was not available to receive care in the facility.On 8/21/2025 at 12:00 PM An interview with the DON was conducted. DON stated it was the expectation of facility staff to complete personal hygiene, bowel and bladder incontinence for the residents every shift. He further stated that it would be very unlikely for a resident to be away the entire shift for the staff to lack an opportunity to provide or assess for bladder and bowel incontinence. On 8/25/2025 at 12:30 PM The DON reported to the surveyor that the resident was in the facility for the days marked as resident not available. He also stated that there was no additional information that the resident was provided with toilet hygiene care. The surveyor notified the DON that this was a concern.

Number of residents sampled: Number of residents cited: Based on record review and staff interview, it was determined that the facility failed provide the necessary treatment and services to promote healing. This was evident for 1 (Resident #131) out of 5 residents reviewed for pressure injuries. The findings include: On 8/18/2025 at 10:20 AM, Complaint #330046 was reviewed. The Complainant alleged the facility failed to clean and turn Resident #131 when appropriate. On 8/18/2025 at 11:02 AM, weekly wound assessments for Resident #131 were reviewed. A Stage 4 sacral wound with an onset date of 7/16/24 was documented to have worsened in the 8/14/24, 8/22/24, and 8/30/24 wound assessments. On 8/18/2025 at 12:25 PM, a review of Resident #131's Documentation Survey report for the month of August in 2024 was conducted. On the following shifts the GNAs documented that the resident was not turned or repositioned every two hours: 8/1/24 Day, 8/8/24 Night, 8/10/24 Day, 8/14/24 Day, 8/19/24 Day, 8/21/24 Evening, 8/23/24 Day, 8/29/24 Night, and 8/30/24 Day/Evening. On the following shifts the GNAs did not document anything for the Turn and reposition task: 8/7/24 Day, 8/15/24 Day, 8/21/24 Day, 8/24/24 Day, 8/25/24 Day, 8/26/25 Day, 8/31/25 Night. On 8/18/2025 at 1:52 PM, the Director of Nursing (DON) was made aware of concerns with Pressure injury treatment. DON stated that they were not here in August of 2024 but acknowledged concern of GNAs not turning or repositioning every two hours for Resident #131.

Number of residents sampled: Number of residents cited: Based on record review and interviews, it was determined that the facility failed to ensure the resident had an identification wrist band on which led to the wrong resident having their blood drawn. This was evident for 1 (Resident #44) of 28 complaints that were reviewed during the annual survey. The Findings Include: On 8/13/25 at 11:39 AM, complaint #330059 was reviewed and it mentioned that the resident had their blood drawn by mistake due to the resident not having an identification wrist band on. On 8/13/25 at 12:15 PM, the complainant was interviewed. They stated that on 12/9/2024, during a visit with the resident, they noticed that there was gauze and tape on the resident's hand. The complainant then asked the resident's roommate what had happened, they informed the complainant that the lab tech had come into their room and drew Resident #44's blood by mistake. The complainant stated that he asked the facility staff what had happened and they were unaware of the incident. The complainant stated that a grievance was then filed. On 08/18/2025, at 11:21 AM, a review of the facility grievances that were filed in December of 2024 revealed that the complainant did report the incident to the facility on [DATE]. The results, after the investigation, substantiated that the lab error did occur and that the resident did not have an armband on at the time the error occurred.On 08/19/2025 at 12:14 PM, during an interview with the Assistant Director of Nursing, she confirmed that the incident had occurred. She stated that, following the facility's investigation into the incident, it was substantiated that Resident #44 did not have an identification wrist band on which led to the wrong resident's blood being drawn. At this time she was made aware of the concern.

Based on record review and staff interview, it was determined that the facility failed to provide the necessary treatment and services to promote healing. This was evident for 1 (Resident #131) out of 5 residents reviewed for pressure injuries. The findings include:On 8/26/2025 at 1:30 PM, a review of Resident #12's orders was conducted. An order for Oxygen to be given at 2 liters per minute via Nasal Cannula every 24 hours as needed at bedtime. On 8/26/2025 at 1:43 PM, an observation was made of Resident #12's room. The resident was not in the room, but oxygen was set to 10 liters per minute. Staff #21 confirmed this observation and confirmed Resident #12's current order in the resident's chart as 2 liters per minute as needed at bedtime. On 8/26/2025 at 1:46 PM, an interview was conducted with Resident #12. When asked when they use Oxygen, they stated that they use oxygen to sleep and when they are sick. When asked how much oxygen they are using at night, they stated that they use 7 liters per minute at night to sleep comfortably. On 8/26/2025 at 1:57 PM, an interview with the Assistant Director of Nursing (ADON) was conducted. Resident #12's oxygen usage was shared with the ADON, the ADON stated that they would consult with the provider, nursing team, and resident. When asked for residents who have oxygen ordered should nursing be monitoring the rate of oxygen delivery, the ADON stated that the liters per minute should be monitored by nursing when the resident is using oxygen. While interviewing the ADON, this surveyor reviewed Resident #12's Medication and Treatment Administration Record with the ADON. This surveyor confirmed with ADON that the nursing staff had not been documenting that the resident was receiving Oxygen therapy as needed.

Based on interviews, observations and record reviews, it was determined that the facility failed to provide residents with individualized care based on assessments and physician orders. This was evident for 1 (Resident #88) out of 4 residents reviewed for nursing skills and competency during the recertification survey.The findings include:On 8/12/2025 at 11:24 AM an interview with Resident #88 was conducted. The resident reported that they had a fall last week. Resident was observed with redness around the left eye. On 8/12/2025 at 11:30 AM an observation of Resident #88's room was conducted. An opened pack of regular briefs was observed in the bathroom and on top of the resident's dresser. Additionally, the resident showed the surveyor that they wore regular briefs at that time.On 8/12/2025 at 12:44 PM a review of Resident #88's medical record was conducted. The review revealed orders that stated Resident #88 should 1) wear Hipster Padded Brief q shift while awake for fall interventions and 2) float heels when the resident is in bed and 3) place sling on Right arm. Further review of the resident's record indicated that the resident had a fracture of the right clavicle from a fall. S/He was care planned to wear hip padded briefs every shift for fall prevention and float heels when in bed. The care plan also indicated that the resident refused to wear the ordered sling. On 8/13/2025 at 10:52 AM Resident #88 was observed without any hipster padded briefs or a sling on the right arm. On 8/14/2025 at 7:00 AM Resident #88 was observed sleeping in bed, heels were not floated. On 8/14/2025 at 7:30 AM A review of resident's medical records indicated that the resident was wearing a sling and hip padded briefs on 8/12/25 and 8/13/25. Additionally, there was documentation that the resident had heels floated on 8/13/25. On 8/14/2025 at 8:10 AM Another observation was conducted with the surveyor and Staff #5. Staff #5 confirmed that the resident was not wearing a sling, a hipster padded brief, and heels were not floated while sleeping. On 8/14/2025 at 8:13 AM An interview with the staff #5 was conducted. Staff #5 stated that she inaccurately documented that the resident was wearing a sling and hipster padded briefs. She also acknowledged that the resident's heels were not floated. Additionally, Staff #5 stated that the resident is not compliant with floating heels, but there was no care plan for refusals to this order. On 8/14/2025 at 11:10 AM The Director of Nursing (DON) was made aware of the concerns with documentation of interventions that were not implemented.

Based on resident interview, record review, and staff interview, it was determined that the facility failed to prevent a significant medication error. This was evident for 2 (Resident #105 and #52) out of 6 resident's review for unnecessary medications. The findings include:1.) On 8/12/2025 at 11:45 AM, a review of Complaint #330061 was completed. The complaint alleged Resident #105 received the incorrect dose of medication.On 8/12/2025 at 12:02 PM, an interview with Resident #105's representative was conducted. The Resident's representative stated in November of 2024, there was a med error.On 8/15/2025 at 10:04 AM, a review of Resident #105's progress notes was conducted. The change of condition note on 11/10/2024 stated that the resident received 2 mg of Clonazepam instead of the ordered 1 mg of Clonazepam. Order was placed to hold the next dose of Clonazepam, vital signs every shift, and to complete neuro checks every 24 hours. On 11/10/2024 at 00:15, the note stated, during med count writer found out that the clonazepam came in 1mg, so one tablet should've been given. Nurse Practitioner notified.On 8/15/2025 at 10:18 AM, a review of Resident #105's Medication Administration Record indicated that Staff #23 was the Licensed Practical Nurse who gave Clonazepam prior to the change of condition note and the order of Clonazepam being held. On 8/15/2025 at 10:49 AM, a review of Resident #105's orders was completed. The clonazepam Oral Tablet 0.5 mg Controlled Drug was ordered to give via G-Tube every 8 hours for seizures on 10/19/24 and discontinued on 11/9/24. The order was revised and stated, PLEASE GIVE ONLY ONE TABLET, on 11/9/24. On 8/15/2025 at 11:05 AM, a review of Facilities investigation was conducted. A statement from Staff #23 states the staff found out the medication was given incorrectly at narcotic count on change of shift on 11/9/2024 at 11:00 PM.On 8/15/2025 at 1:53 PM, an interview was conducted with the Director of Nursing. When asked about the medication error, they stated medication error was confirmed and staff were educated. 2.) 8/26/2025 8:48 AM, a review of Complaint #330032 was conducted. The complaint stated that a nurse gave Resident #52 the wrong medication. The complaint extended from 2/20/2024 to 8/15/2025.On 8/26/2025 at 9:34 AM, a review of Resident #52's progress notes was conducted. In a change of condition note from 3/4/2025 at 5:39 PM, it stated, Med error, administer 4-unit lispro due to wrong identification of resident picture by name. MD and Supervisor was notified. Md recommend q6 b/s monitoring. Vital signs was stable; b/s 107 @ 5.39pm, 113 @ 11.54pm. pt alert x4, No sign of hypoglycemia or hyperglycemia. Non-adverse reactions noted. call light within reach. Family notified.On 8/26/2025 at 11:15 AM, a review of the facilities incident report regarding the medication error was conducted. In the incident report, there was education provided to the Licensed Practical Nurse (Staff #22) who administered the medication to the incorrect resident (Resident #52) on 3/4/2025.On 8/26/2025 at 11:20 AM, an interview with the Director of Nursing (DON) and Assistant Director of Nursing (ADON) was conducted. It was confirmed that Staff #22 made a medication error by not identifying the correct resident and giving a dose of 4 units of Lispro to the incorrect resident. Per the ADON, the nurse was placed back on 3-day orientation after the error and another competency was completed on 3/11/25.

Number of residents sampled: Number of residents cited: Based on record review and interview, it was determined that the facility failed to obtain laboratory tests as ordered by the physician. This was evident for 1 (Resident #120) of 27 residents reviewed during the investigation portion of the survey. The Findings Include: On 08/18/2025 at 7:27 AM, Resident #120's record review revealed a change in condition stating the resident had a change in mental status with paranoid delusions on 6/17/2025. The physician placed an order to obtain a urine analysis (UA) to rule out a possible urinary tract infection on 6/18/2025. On 08/18/2025 at 7:40 AM, a review of the resident's documented lab results revealed that there were no results for the ordered urine analysis. Further review revealed that there was no documentation of refusal. On 08/18/2025 at 1:52 PM, during an interview with the Director of Nursing (DON), he explained that the reason the UA was not obtained was due to the resident refusing. When asked to provide documentation proof of refusal he stated that there was no documentation. At this time, and again at exit on 8/27/2025, the DON was made aware of the concern of the order for the UA not being obtained.

Number of residents sampled: Number of residents cited: Based on record review, observation and interview, it was determined that the facility failed to use appropriate infection control practice of hand hygiene when performing wound care. This was evident during a wound care and dressing change observation conducted for 1 (Resident #7) of 2 residents who had pressure ulcers. The findings include:A pressure ulcer, also known as a bed sore or decubitus ulcer, is a skin injury that develops when prolonged pressure is applied to the same area of the bodyA stage 4 pressure ulcer is a severe skin injury that involves complete loss of the skin, underlying tissue (subcutaneous tissue), muscle, and sometimes bone.On 8/18/2025 at 9:00 AM, review of Resident #7's record indicated that they had multiple pressure ulcers. The resident had a facility acquired stage 4 pressure ulcer of the sacrum and unstageable ulcer of the right foot.On 8/19/2025 at 9:28 AM, an observation of wound dressing change on Resident #7 was conducted. The wound care and dressing change was performed by Staff #12. On 8/19/2025 at 9:39 AM, Staff #12 performed hand hygiene, wore clean gloves and removed the old dressing on the sacrum. The old dressing was observed to have yellow substance. Staff #12 failed to perform hand hygiene and wore clean gloves then cleaned the resident's wound with wound cleanser and Dankin solutions. Flagyl powder was applied and lastly a labeled calcium alginate dressing was applied to the resident's sacrum. Hand hygiene was then performed when staff #12 was leaving the room. Throughout the wound care and dressing change, Staff #12 only performed hand hygiene at the beginning and upon completion of the task.On 8/19/2025 at 10:22 AM An interview with the Staff #12 was conducted. She was asked to outline when hand hygiene is supposed to be performed. Staff #12 answered that after removal of dirty dressing, staff is expected to perform hand hygiene. Staff #12 stated she forgot to perform this step.The surveyor pointed out that this was an infection control concern due to failure to perform hand hygiene between the removal of contaminated dressing and the application of clean dressing. On 8/19/2025 at 10:29 AM The Director of Nursing was notified of the concerns.

Based on record review and staff interviews, it was determined that the facility failed to: 1) accurately monitor residents for weight loss and to communicate dialysis residents' accurate condition (body weight loss reported as weight gain) with the dialysis center, which resulted in harm for Resident #78 due to an 8-day hospitalization for low blood volume; 2) report the resident's weight to the dialysis center and physician before Resident #76's blood pressure dropped, and 3) ensure an effective communication system between the dialysis center; 4) report and/or document the dialysis residents' conditions with physicians. This was evident in 2 (Resident #76 and #78) of 2 dialysis residents' records reviewed during the survey. The findings include: Dialysis is a procedure to remove waste products and excess fluid from the blood when the kidneys stop working properly. Peritoneal dialysis uses the peritoneum in a person's abdomen as the membrane through which fluid and dissolved substances are exchanged with the blood. It is used to remove excess fluid, correct electrolyte problems, and remove toxins in those with kidney failure. Dialysis solution (also known as Dialysate) comes in 1.5 percent, 2.5 percent, and 4.25 percent concentrations. The higher (stronger) the concentration of the dialysate, the more fluid, electrolytes, and waste are removed from the blood. The percentage (concentration) of the dialysate for each occurrence of dialysis is based on the person's fluid balance, which is determined by weighing the person daily before and after receiving dialysis. Accurate and frequent monitoring of fluid gain and loss in a person who is receiving daily peritoneal dialysis is essential and accurate communication of the person's body weight is also essential to ensure providers are making correct clinical decisions. Removing too much fluid can cause low blood pressure and other complications which can be life-threatening. (Reference: National Institute of Health, Peritoneal Dialysis. National Institute of Health, National Library of Medicine. Davita (health care company for kidney disease and dialysis information) website) 1a) A review of Resident #78's medical record on 12/11/23 at 10:59 AM revealed that the resident was admitted to the facility on [DATE] with diagnoses that included but were not limited to, End Stage Renal Disease, essential hypertension, and dependence on Peritoneal Dialysis. On 12/11/23 at 11:10 AM, a review of instructions from the dialysis center, which was filed in the resident's paper chart, indicated that the facility staff needed to notify the dialysis center when the resident's body weight had a difference of more than 3 pounds. Also, the paper chart included a form named dialysis record which had a table format with the resident's name, date, body weight, pulse, blood pressure, Dialysate, initial drain, total UF (total water out from the body), average dwell time, and comment section. During an interview with Registered Nurse (RN #32) on 12/14/23 at 4:34 PM, she confirmed that the facility provided Peritoneal Dialysis in the building, not sending the resident out to the dialysis center. The facility staff used the dialysis record form to communicate with the dialysis center and/or monitor the residents' daily condition, including body weight and blood pressure. Surveyor review of Resident #78's body weight and blood pressure in the EHR revealed the vital sign section listed body weights twice a day. The resident's admission weight was 166 lbs, and fluctuated from 160.4 lbs to 165.2 lbs from 11/08/23 to 11/17/23 (in the morning, post-dialysis). Resident #78's blood pressure were documented as: 11/07/23 at 10:43 PM, blood pressure was 140/98 mmHg 11/08/23 at 10:41 PM, blood pressure was 80/45 mmHg 11/09/23 at 11:24 AM, blood pressure was 86/49 mmHg 11/10/23 at 9:07 PM, blood pressure was 100/56 mmHg 11/11/23 at 12:42 PM, blood pressure was 120/78 mmHg 11/12/23 at 9:11 AM, blood pressure was 114/54 mmHg 11/12/23 at 5:25 PM, blood pressure was 108/61 mmHg 11/13/23 at 12:33 PM, blood pressure was 105/62 mmHg 11/13/23 at 11:52 PM, blood pressure was 89/50 mmHg 11/14/23 at 1:56 AM, blood pressure was 81/45 mmHg 11/14/23 at 6:16 AM, blood pressure was 94/49 mmHg 11/14/23 at 9:25 PM, blood pressure was 81/43 mmHg 11/15/23 at 8:23 AM, blood pressure was 132/76 mmHg 11/15/23 at 9:04 PM, blood pressure was 81/46 mmHg 11/16/23 at 9:21 AM, blood pressure was 77/46 mmHg 11/16/23 at 10:10 PM, blood pressure was 83/51 mmHg 11/17/23 at 10:12 AM, blood pressure was 120/67 mmHg 11/17/23 at 10:54 PM, blood pressure was 95/57 mmHg On 12/15/23 at 08:20 AM, a review of the dialysis record revealed that Resident #78 had 9.4 pounds weight loss from 164 pounds (lbs) on 11/16/23 to 154.6 lbs on 11/17/23. Further review revealed a change in condition form dated 11/17/23 at 4:30 PM that documented a weight gain of more than 3 lbs after dialysis. However, the dialysis record form documented a 9.4 pound weight loss. The form recorded that the facility nurse contacted the dialysis center nurse about the weight gain and received an order to change dialysate order to a stronger prescription of one bag of 2.5% dialysate and one bag of 1.5% dialysate instead of 2 bags of 1.5% dialysate. The new order was to be given for three days, from 11/17/23 to 11/19/23. Also, Resident #78's dialysis record form documented the resident's blood pressure as follows: 75/49 on 11/18/23 72/45 on 11/19/23 76/45 on 11/20/23 71/43 on 11/21/23 Surveyor review of Resident #78's progress note written on 11/22/2023 at 2:38 PM revealed the resident was found unresponsive in a wheelchair and was transferred to the hospital for further evaluation. The surveyor interviewed the dialysis center charge nurse (staff #56) via phone on 12/15/23 at 2:13 PM. Staff #56 verified that the facility and dialysis center used the dialysis records form for communication. The facility faxed the dialysis record form weekly; and based on that documentation, the dialysis center managed the resident. Also, Staff #56 confirmed the expectation to receive notice regarding residents' weight changes. She explained that the same-day weight difference would not be meaningful. The dialysis center focused on more than 3 pounds of weight differences from the previous day. Also, she verified that a stronger dialysate would be used for documented weight gain. On 12/18/23 at 09:20 AM, a review of Resident #78's discharge summary from the hospital dated 11/29/23 revealed that the resident was also admitted to a different hospital earlier the same month for weakness and hypocalcemia. The resident was hypotensive during that admission and was discharged on midodrine (medication for treating low blood pressure). The hospital discharge summary said the resident's initial blood pressure in the emergency department on 11/22/23 was 72/43 (lower than 90/60 is considered to be low blood pressure), and the resident was admitted to the Intensive Care Unit for further management. The hospital record stated they treated the resident with volume resuscitation (extra fluids given rapidly intravenously) and gave stress dose steroids. The resident's low blood pressure was determined to be due to low blood volume, and with the correction of the resident's volume status, his/her mentation and overall clinical condition improved. An interview was conducted with the Director of Nursing (DON) on 12/20/23 at 03:50 PM. The DON confirmed that facility staff faxed dialysis records form weekly to the dialysis center for communication. During the interview, the surveyor shared concerns about Resident #78's 9.6 lbs loss on 11/17/23 and inaccurate notification (the resident had actual weight loss but the dialysis center was notified of a weight gain, per the change in condition documentation) which resulted in using 2.5% dialysate solution for three days. Three days after the resident completed the dose of higher dialysate, the resident was found unresponsive. The DON invited the unit manager (Staff #38) for an interview on 12/20/23 at 4:10 PM. Staff #38 insisted that based on EHR (Electronic Health Record) records, Resident #78's weight was trending up overall. That's why she contacted the dialysis center for weight gain on 11/17/23. 1b) On 12/20/23 at 08:05 AM, the surveyor comparison of Resident #78's dialysis records and body weight on PCC revealed: On 11/11/23, the PCC recorded 154.1 lbs, and the dialysis record form documented 163.2 lbs. On 11/17/23, the PCC recorded 158 lb, and the dialysis record form documented 154.6 lb. Also, the review revealed discrepancies in dialysate on Resident #78's MAR (Medication Administration Record) and the dialysis record. The dialysis record form documented the resident had been using three bags of 1.5% dialysate since his/her admission on 11/08/23. However, a review of order summary revealed that two bags of 1.5% ordered from 11/08/23 to 11/16/23, one bag each of 1.5% and 2.5% from 11/17/23 to 11/19/23, and three bags of 1.5% dialysate from 11/30/23 to present. During an interview with the DON on 12/21/23 at 3:30 PM, the DON confirmed again that the facility faxed the dialysis record form to communicate with the dialysis center and that the dialysis center did not have access to what was documented in the facility EHR. The surveyor shared concerns regarding discrepancies in two documentation (PCC and dialysis record forms). The DON said, I understand. 1c) Reviews of Resident #78's medical records from 12/11/23 to 12/20/23 revealed that there was no documentation from physicians regarding the above dialysis complications like weight loss or gain or low blood pressure. During an interview with an attending physician (Staff #34) on 12/18/23 at 3:27 PM, Staff #34 stated that he expected to get notice regarding dialysis residents' weight fluctuations or condition changes. Staff #34 did not recall any notification received from the facility regarding Resident #78. 2a) On 12/20/23 at 7:30 AM, Resident #76's medical records were reviewed. The review revealed that the resident was admitted to this facility in October 2023 with a diagnosis of end-stage renal disease on peritoneal dialysis. The resident's paper chart contained instructions from the dialysis: If there is weight gain of more than 3 lb, please call [dialysis center name] patient nurse. Further review of the dialysis record for Resident #76 revealed that the resident had 5 lb. weight loss on 10/20/23 from 133 lb. on 10/19/23 to 128 lb. on 10/20/23. The Medication Administration Record (MAR) documented that the resident's dialysis started at 7:30 PM on 10/20/23, and no documentation was found under EHR regarding the resident's weight loss. The change in condition form dated 10/20/23 at 8:23 PM indicated the facility's Nurse Practitioner was notified of Resident #76's low blood pressure at 6:00 PM on 10/20/23 and received an order for administering Midodrine 2.5 mg if blood pressure is < 110 mmHg. Also, a progress note written by Licensed Practical Nurse (LPN #14) on 10/21/23 at 00:35 AM said, [Dialysis center] and [ the facility's NP] was notified of resident low blood pressure. CRNP ordered midodrine to be given for BP <110 mmHg, and the on-call nurse at [dialysis center] stated to use two yellow bags (1.5% dialysate) instead of 1 green (2.5% dialysate) and one yellow bag. Report will be given to the dialysis nurse at the clinic to adjust solutions. On 12/20/23 at 7:70 AM, a review of Resident #76's blood pressure revealed the following: 10/19/23 at 8:48 AM, blood pressure was 115/61 10/19/23 at 4:44 PM, blood pressure was 84/42 10/20/23 at 2:36 PM, blood pressure was 84/39 10/20/23 at 9:17 PM, blood pressure was 104/57 An average blood pressure from 10/05/23 to 10/19/23 was 120's/60's During an interview with LPN #14 on 12/20/23 at 8:50 AM, she confirmed that the facility staff checked dialysis residents' body weights before dialysis (around 7:30 PM) and after dialysis was completed (around 7 AM). She put the weight on the TAR (Treatment Administration Record), and it populated under the vital sign section on EHR. Also, she stated when they noted more than a 3 pound difference, they would call the dialysis center and receive a new order (like fluid restriction or change of dialysate solution bags). During an interview with the DON on 12/20/23 at 3:50 PM, the surveyor shared concern regarding Resident #76's weight loss on 10/20/23, which was not reported prior to when dialysis was started and may have resulted in the resident's blood pressure drop. 2b) On 12/20/23 at 4:30 PM, a review of Resident #76's MAR and dialysis records revealed: On 11/05/23 and 11/24/23, the MAR recorded the resident used one bag each of 2.5% and 1.5% dialysate. However, the dialysis record form documented the resident had two bags of 1.5% and a bag of 2.5%. On 11/19/23, the MAR recorded two bags of 1.5% used. However, the dialysis record form documented the resident had one bag each of 1.5% and 2.5%. On 11/25/23 (Saturday), Resident #76 had an active order as Peritoneal Dialysis with two bags of 1.5% dialysate on every Tuesday, Thursday, and Saturday, and the MAR was documented as so. However, the dialysis record form showed the resident used two bags of 2.5% dialysate. On 11/26/23, the MAR documented that the resident used one bag each of 1.5% and 2.5% dialysate. However, the dialysis record form documented two bags of 2.5% dialysate were used. 2c) Reviews of Resident #76's medical records from 12/11/23 to 12/20/23 revealed that there was no documentation from physicians regarding the above dialysis complications like weight loss or gain or low blood pressure.

Based on surveyor observation and staff interview it was determined the facility staff failed to keep the building clean, neat, attractive and in good repair. This was evident in the four nursing units on both floors of the facility. The findings include: On 12/13/23 observations were made in the resident shared room B-14 and the findings were corroborated with the unit manager (staff #24) at 11:10 AM. Both wheeled IV feeding poles (utilized for enteral liquid feeding) bases appeared to have splashes of built up dried enteral liquid feeding. The unit manager suspected that both IV feeding pole bases were dirty with dried enteral liquid feeding, and she attempted to remove the substance with a paper towel. She validated the noticeable cobwebs inside the room attached to the upper and lower window sashes. Additionally, she had confirmed cracks and peeling paint chips on both sides of the window casings. An environmental tour was conducted with the maintenance director (staff #43) on 12/19/23 at 10 AM. The maintenance director revealed that he has been at the facility for 7 months. The maintenance department is comprised of himself and one assistant. He was asked if there were any current capital plans and he indicated that there were not any. He was asked about HVAC (Heating Ventilation, and Air Conditioning)workers that were observed during the first week of the survey. He indicated that the administration called in contractors as he and his assistant had plenty to do. The maintenance director was informed of the accumulated environmental concerns by multiple members of the survey team during the initial days of the survey beginning on 12/3/23, but did not represent a thorough review of every room. The following observations were confirmed by the Maintenance director: 1. Beginning on D wing, room [ROOM NUMBER] the front grate of the window air-conditioning unit was noted with darkened black accumulations throughout the grille/grate. Staff #43 indicated that it looked like growing black mold and he took pictures of the unit. 2. In the D wing corridor on the right-hand side of the nursing station revealed noticeable growth of dust accumulated along the bottom of the AC/heat unit (the maintenance director identified the AC/heat as PTAC unit. The hairy dust and grim was easily observed and he acknowledged the dust ball condition. 3. Rm D-16, the resident was utilizing the bathroom during the tour and the maintenance director Staff #43 was informed that the toilet paper holder appeared rusted with rough discolored metal. 4. Room D6 and the adjoining room were currently not in use with accumulations of extra furniture. The maintenance director Staff #43 shared ongoing issues since his first day, with odors in the room and the work to find the drainage pipes and attempts to correct the issues. B-wing: 1. RM B-1 Noted under the window and above the PTAC unit approximately 4 by 6 ft damaged wall. 2. Observed from the corridor into room [ROOM NUMBER] B was an unfinished/unpainted wall repair (white spackle) on the windowed outer wall. 3. RM B-6 The plastic door frame molding was missing top caps. Staff #43 indicated that he has tried to get replacements, but they are difficult to find. Staff #43 worked on the molding pulling it up to hide the exposed metal on each side of the door. It was noted that there were numerous rooms that had damaged and/or missing plastic caps. During the tour Staff #43 adjusted several of the door frame moldings lifting the molding to cover the exposed metal. This was also identified on the first and second floor of the elevator entrance. 4. Rm B9 - Dirty window, with the PTAC unit noted with missing paint chips in the top grille. Along the bottom of the bottom of the unit noted rust spots on bare metal. The floor below the PTAC unit appeared dirty. The wall adjacent to the unit had wheelchair damage with gouges into the wall board. The wall left of the entrance to room had marring and indentations into the wall board, along the lower sections of wall approximately 4 feet long. The threshold into the adjoining restroom appeared dirty. 5. Rm B-11- The window was filthy and difficult to see out the window. Staff #43 revealed that the facility's dryer vents were directly below the window. There was rust spots on the bottom front frame of the PTAC unit. The front panel was not centered leaving a gap on one side and protrusion on the other. In the shared restroom, the metal grate with vents on the wall was noted with rust like areas spanning side to side. The bathroom door appeared dirty with blackened wheelchair marring and brown rust-like color. 6. RM B-14 - The floor below the PTAC unit and over towards the restroom threshold appeared dirty with mixed colors. The cove molding was separating from the wall near the PTAC unit. Molding was missing at the closet. The insides of both bathroom doors were worn at the lower portions of the doors. The door frames had multiple rust like discolorations. The escutcheon plate under the sink was rusted and the bathroom floor appeared dirty. 7. RM B-16 it was noted on the window wall, an incomplete wall repair of un-sanded and unpainted white spackle and wall board 5-foot section of the lower wall. One of the bedside tables was noted with a missing section of top veneer approximately 6 inches in length. 8. RM B-18 - Residents in the room were receiving care at the time of the environmental tour. Staff #43 appeared to take notes when he was informed that the cove molding at the entrance to the restroom was separating off the wall. He was informed of the state requirement that each resident bedroom should provide a comfortable chair. Many rooms did not have comfortable chairs, and this was one of the rooms. C-wing: 1. RM C-4 Observed from the corridor on the outside wall between he PTAC unit and bathroom was a white unpainted spackled of ill repaired wall section with an approximately sized area of 1 foot by 6 foot. 2. RM C-5 There was an unfinished repair under the TV approximately 1 x 2 feet (un-sanded and not painted) 3. RM C10 There was a loose ceiling tile above the bed by the window. 4. RM C-9 Entering the room the door frame molding was missing top plastic pieces and the right side door frame molding was separating from the wall. The wall behind the window side bed was damage with deep wide gouges into the wall board. The bathroom window was dirty. The toilet escutcheon plate was rusted behind the toilet and rusted color around the base of the toilet. The units holding the sink to the wall were encrusted with white scale. Staff #43 was the one to identify the built up scale on the metal parts attached to the sink and wall. A-wing: 1. Staff #43 was informed that in RM-A-5 that the incomplete/ ill repaired window wall could be seen from the hallway. The environmental tour with the maintenance director Staff #43 concluded at approximately 11 AM on 12/19/23.

Based on observation, staff interviews, and review of medical records and other pertinent documentation, on (MONTH) 15, 2019, it was determined that the facility failed to maintain a safe environment for a resident with documented high-risk elopement behavior (Resident #10), in addition to providing proper supervision to residents identified at risk for wandering, elopement and potentially unsafe smoking. This was evident for 3 (Resident #10, #3, #75) of 8 (Resident #10, #28, # 91, #25, #89, #2, #3 and #75) residents reviewed for accidents. The facility's failures in this case led to the determination that immediate jeopardy existed, and the facility was notified of this determination on (MONTH) 15, 2019 at 1:40 PM. The immediate jeopardy was removed on (MONTH) 21, 2019 at 5:45 PM prior to survey exit. After removal of the immediacy, the deficiency remained with a potential for more than minimal harm at a scope and severity of D. The Findings Include: Review of the medical record for Resident #10 on 3/15/19 at 10:12 AM revealed [DIAGNOSES REDACTED]. In addition, Resident #10 had a care plan in place identifying him/her as an elopement risk related to adjustment to the nursing home, disorientation to nursing home and impaired safety awareness. The care plan was initiated in (MONTH) (YEAR) and revised in (MONTH) (YEAR). Resident #10 was assessed as having a Brief interview for mental status (BIMS) of 5, showing severe impairment, in (MONTH) (YEAR). An elopement assessment completed on 10/23/18 noted he/she had an increased risk for elopement with a score of 12, which meant the resident was categorized as at risk for elopement. The score increased from previous assessments as the resident had verbalized desire or plan to leave the facility unauthorized/unsupervised. Review of Resident #10's nursing notes revealed documentation of other attempts or verbalizations of wanting to leave the facility: On 10/19/18 at 1:28 PM nursing documented that Resident #10 pushed past staff .began cursing .saying s/he was leaving this (explicative) place. A psychiatry consult was ordered regarding this incident. The resident was placed on an antipsychotic for behaviors. On 11/7/18 at 2:54 PM nursing documented that Resident #10 was noted packing his/her stuff and wanted to leave. S/he was noted mad at staff and tired of being told by staff members to do this and that. A new order was received to close monitor and notify (physician) for aggressive behavior. On 12/7/18 at 9:31 PM nursing documented that Resident #10 was wandering the hallway seeking exit the facility. Despite the change in Resident #10's elopement assessment, exit seeing behaviors, and verbalizations regarding elopement, the resident's elopement care plan was not updated until his/her quarterly assessment in (MONTH) (YEAR). Review of a facility reported incident (FRI) MD 638 on 3/15/19 revealed that Resident #10 had eloped from the facility during the evening shift on 1/18/19. Further review of the FRI revealed the facility reported that; Approximately 11PM during shift change rounds, staff noted resident (#10) was not in his/her room. Supervisor was notified, facility search was initiated, perimeter outside the facility was initiated, resident was located in front of elementary school next door to the facility .was redirected back to the facility by facility staff easily without difficulty. Closer review of the facility reported incident revealed that Resident #10 was able to elope from the facility in the evening of 1/18/19. The facility has not been able to confirm and identify how it occurred however, believes that a staff may have inadvertently hit the buzzer and let the resident out of the front entrance. Resident #10 was allegedly seen in his/her room and the lobby simultaneously prior to shift change. At shift change the resident was not noted not in his/her room. A code was called, and the resident was found down at the local school with 2 gentlemen not associated with the facility. The temperature that night was 21 degrees. The nurse writing the report that found the resident stated; We found him/her in front of the elementary school next door to the facility. Two men were standing there talking to him/her and asked if I knew who s/he was. I requested that they ask the resident if s/he knew me. When the resident identified how s/he knew me, resident accompanied myself and the 11-7 PM nurse into the automobile and returned to the facility without incident. According to the report a head to toe assessment was completed and nothing was found. Further review of the resident's medical record revealed [REDACTED]. The residents care plan was updated on 1/18/19 for every 15-minute checks to monitor resident's whereabouts after the identified elopement that occurred on 1/18/19 at around 11:00 PM. Review of the resident's physician orders [REDACTED]. Review of the interventions that the facility implemented secondary to the elopement revealed that the resident was placed on 15-minute checks and the lobby was to be monitored every 1-hour when there was not a receptionist on duty. Review of the 15-minute logs documented on a shift to shift form revealed that there was an opportunity for 33 entries. Further review of the shift to shift documentation revealed multiple days where there were less than the required number of entries to account for the 8-hour shift. According to the nursing notes from 1/22/19, Resident #10 attempted to elope the building again and was given an intramuscular (IM) injection of [MEDICATION NAME] an antipsychotic. Resident #10 was noted by the front door. However, per the nursing note documented at 00:42 AM s/he was able to be brought calmly back to his/her room. On 1/23/19, according to shift to shift log, the resident was documented in his/her room at 11 PM, however, according to the lobby log for 11:00 PM s/he is documented in the lobby banging on the door. There were also no 15-minute checks documented after 2/13/19, as still documented as required per the resident's care plan. This concern was reviewed with the DON on 3/15/19 at 2:53 PM. No further information was provided to the survey team regarding the conflicting documentation and the missing days. The lobby checks were also documented as stopped on (MONTH) 2/19/19. According to the Administrator, DON and the Director of Clinical Services, on 3/15/19 at 2:53 PM, the lobby checks were discontinued because they had maglocks and keypads installed on the doors leading to the lobby. However, they were unable to explain why the 15-minute checks on the resident were stopped on 2/12/19. The concern that the resident was given a chemical restraint on 1/22/19 was reviewed with the DON on 3/19/19 at 9:33 AM and the additional concern that there were multiple documentation of the resident seeking exit from the facility with no subsequent documentation of interventions until the 3rd documented attempt when the care plan was updated. Further review of the resident's medical record revealed [REDACTED]. Interview with Resident #10 on 3/15/19 at 10:14 AM, s/he reported that s/he loves to go outside, s/he is a runner and 'they' let him/her out and s/he goes out all the time. As part of the facility's plan to remove the immediate jeopardy they placed Resident #10 on 1:1 monitoring on 3/15/19. On 3/19/18 from 3:05-3:10 PM Resident #10 was observed walking down the A hallway unattended. S/he turned just before the nurse's station and walked back up the hall to his/her room, passing the elevator to the first floor twice. Staff #29 was observed at the nursing station and was asked if she was assigned to Resident #10 as the residents 1:1. She stated yes. Surveyor notified her and the nurse Staff #1 who was also present, of the surveyors' observations. Staff #29 reported that s/he was in the bathroom and thought that the resident was in his/her room and that she was only gone for a few minutes. At 3/19/19 at 3:22 PM the observations and concerns observed regarding Resident #10 was reported to the DON, the Director of Clinical Services and the Administrator. During the review of Resident #10's elopement, 5 other Residents (#28, # 91, #25, #89, #2) were identified in the facility's Elopement binder as needing supervision. Additionally, there was 1 Resident (#89) of which also needed supervision with smoking. An additional resident was identified that needed supervision with smoking (Resident #3) that was allowed outside alone. According to an interview completed with the main receptionist, Staff #28 on 3/15/19 at 12:27 PM s/he will usually call the unit to let the staff know that one of those identified residents is in the front lobby. The DON or other identified staff will come and take them back. Regarding Resident #10, s/he usually gets really worked up if s/he is made to go back to his/her room. Resident #3, identified as in the elopement book as needing supervision with smoking, was observed outside on multiple occasions during random observations without supervision smoking during the survey by multiple surveyors, prior to any of the surveyor's knowledge that s/he was not allowed out smoking without supervision. This was reported to the DON and Administrator on 3/15/19. After the immediate jeopardy was called on 3/15/19 at 1:40 PM the facility implemented a new elopement assessment and identified additional residents at risk for elopement from the facility. During the review of the identified residents on 3/18/19, Resident #75 was newly identified as at risk as s/he had a history of [REDACTED]. Further review of the resident's medical record revealed [REDACTED]. Prior to that staff at the facility had no knowledge that s/he had left the facility and for how long the resident had been out of the facility. Resident #75's BIMS in (MONTH) (YEAR) and again in (MONTH) was assessed at 12 and 10 respectively, both scoring as moderately impaired cognition. During a random observation of the smoking area and parking lot on 3/19/19 of the facility, Resident #75 was observed at 2:16 PM in the parking lot of the facility unattended. According to the new elopement assessment the resident was noted as an elopement risk and was to be monitored if s/he was outside. The DON was made aware of the surveyors' observation. The ongoing observations of residents unattended in and around the facility caused the Office of Health Care Quality to determine on 3/19/19 that the facility's initial plan that was received on 3/15/19 at 5:45 PM in response to the immediate jeopardy, was not carried out as written. The facility elected to revise their originally accepted plan and submitted subsequent plans of removal on 3/19/19, 3/20/19 and 3/21/19. The final revised plan of removal was found to be acceptable on 3/21/19 at 2:00 PM. The facility's plan included the following: The plan included to; relocate the employee entrance, nursing leadership educated all licensed nursing staff on the new elopement assessment beginning on 3/18/19 and no staff could return to work until they were in-serviced on the new process. The Elopement binder was updated and kept at the front desk. The Elopement assessments will now be completed on admission, quarterly and with any change in condition per the new plan. Designated staff will be assigned to monitor all residents that are outside of the facility from 8 AM to 8 PM 7 days a week. The designated staff members are given a communication device and educated regarding protocol for outside observation of residents. On 3/21/19 after confirmation of training and the execution of the revised plan, the immediate jeopardy was then removed on 3/21/19 at 5:45 PM prior to survey exit.

Based on medical record review, facility reports, and interview with facility staff, it was determined that the facility staff failed to report abuse allegations timely, thoroughly complete abuse investigations, and provide education to staff and interventions to protect the resident from further abuse after the initial incident. This was evident for 1 of 4 residents (#152) reviewed for allegations of abuse. Due to this failure, on October 18, 2017 at 4:22 PM an Immediate Jeopardy was identified by the Office of Health Care Quality (OHCQ) related to the facility's failure to ensure that Resident #152 was free from abuse. The Immediate Jeopardy was removed on October 18, 2017 at 9:10 PM after the facility's plan of action was reviewed and accepted by survey team and Office of Health Care Quality. After removal of the immediacy, the deficient practice continued with a scope and severity of D with potential for than minimal harm for the remaining residents. The findings include: Review of Resident #152's medical record was conducted on 10/17/17 at 2:34 PM. This review revealed a [DIAGNOSES REDACTED]. The resident had limited mobility of upper extremities and he/she lacked mobility in her/his lower extremities. A review of the facility incident report submitted to the OHCQ on 9/12/17 indicated that on 9/11/17 Resident #152 was visited by a former resident (Visitor #1). After Visitor #1 left, the resident stated to a geriatric nursing assistant (GNA- #12) that Visitor #1 had inappropriately touched her/him. GNA #12 reported this information to the Charge Nurse (Nurse #15) at 2:40 PM. The report also stated that the Director of Nursing (DON) was alerted at 8 PM by the House Supervisor (Nurse #16). Law enforcement was notified, a skin assessment was performed, and plans were made to place a photo of Visitor #1 at the front desk that evening to prohibit her/him from re-entering the building. Further review of the facility's investigation documentation revealed that there was no documentation that the DON followed up on the investigation with interviews of Resident #152 or with witnesses. The Charge Nurse (Nurse #15) indicated in her statement that the resident confirmed that Visitor #1 made unwanted advances. Nurse #15 also indicated in her statement that she asked Resident #152 if he/she was abused. Additionally, the reporting staff, GNA #12, indicated in her written statement that Resident #152 was told by Visitor #1 of plans to visit the resident again in a week. A review of an investigation report submitted to the OHCQ on 9/18/17 and supplemental investigation documents revealed that on 9/18/17 Visitor #1 was seen by a Charge Nurse (Staff #15) leaving Resident #152's room. The charge nurse then entered the resident's room and was informed by the resident that Visitor #1 had once again and without permission touched the resident inappropriately. Witness statement by Assistant Director of Nursing (ADON) indicated that she was notified of the incident and went downstairs to find Visitor #1 exiting the building. The statement went on to report that the ADON asked Visitor #1 if he/she was aware they were not to be in the building visiting Resident #152, in which the visitor replied that she/he had no knowledge of the restriction. During an interview with the DON on 10/17/17 at 3:50 PM she acknowledged that there were statements in the investigation packet but did not state she read them. The investigation packet provided by the facility indicated that Nurse #15 was inserviced on the facility abuse prohibition policy. When asked why Nurse #15 was the only staff in-serviced on the facility's abuse prohibition policy, the DON replied that the nurse's statements indicated that the abuse had occurred sometime in the past and was not a present event. She also shared that she was not aware that GNA #12's statement included that Visitor #1 had intended on returning to visit the resident. There was no documentation provided of any follow up interviews with the resident or the witnesses regarding this incident. An interview with the receptionist (Staff #2) on 10/18/17 at 8:30 AM revealed that a photo of Visitor #1 and re-entry restrictions were not given to her until 9/18/17. During a subsequent interview on 10/18/17 at 3:10 PM, the DON confirmed the actions of the details in the facility's report of the 9/12/17 incident, and stated that she was not made known of the incident until 8:00 PM that evening. Further interviews on 10/18/17 at 4:00 PM with multiple facility staff on all shifts was conducted. Interviews with staff on the Gateway unit revealed that the unit was responsible for after hour entries into the building. When asked if anyone was restricted from entering the building, the staff replied that they knew of no one who was not allowed into the building. Observation on the Gateway unit revealed that there was no posting of Visitor #1's photo on the unit. One other posting was noted on unit C Wing at the nurse's station. It was hidden behind several books and not easily visible to staff. Interview with the resident's nurse (Nurse #14) revealed he/she had no knowledge of Visitor #1 not being allowed on the unit and when asked, he/she could not identify the location of the photo on the unit. During a 4:16 PM interview on 10/18/17 with the DON and Administrator, they maintained that on 9/11/17 a picture of Visitor #1 was posted at the front desk. They indicated that management, shift supervisors, the Gateway, A and C wing staff, along with the Receptionist and her relief staff were instructed not to allow this visitor back into the facility. The Administrator and DON acknowledged surveyor's concerns that there was not sufficient investigation, planning, training, and intervention put in place after the first incident to ensure that this resident was safe from future encounters with Visitor #1 during an interview on 10/18/17 at 4:30 PM. On 10/20/17 at 9:00 AM an interview was conducted with Resident #152's GNA (GNA #12). The GNA stated that on the day of the incident (9/12/17) the resident told her how Visitor #1 had come into her/his room, touched him/her inappropriately without permission and told her/him that he/she would be back in a week for one last visit. The GNA also stated that the resident did not signal for help for fear of agitating the visitor. GNA #12 reported that she was not interviewed by anyone about the witness statement she submitted for the incident. In an interview with GNA #13 on 10/20/17 at 9:20 AM it was revealed that she frequently assisted in the care of Resident #152 and they were very familiar with each other. The GNA stated that the resident had shared the incident with her and expressed concerns about Visitor #1's unwanted touching and his/her inability to defend her/himself if the visitor had become aggressive or agitated with repeated refusals. She went on to say that because of this the resident was fearful that the visitor would return the following week as promised. Telephone interviews on 10/26/17 and 10/27/17 with the DON confirmed that it was only on 9/18/17 that Visitor #1's picture was posted at the front lobby and verbal instructions were given to Receptionist (Staff #2) to deny entry to Visitor #1. In addition, staff on the C - Wing were not trained until 9/18/17. Due to the facilities failures, an Immediate Jeopardy situation was identified on 10/18/17 at 4:22 PM by the Office of Health Care Quality related to the facility's failure to ensure that Resident #152 was free from abuse. An initial plan of action was submitted to surveyor team for review on 10/18/17 at 7:50 PM and rejected. The second plan of action was given to the survey team for review on 10/18/17 at 8:33 PM and was rejected. The 3rd plan of action was given to the survey team and the Office of Health Care Quality for review at 8:56 PM. The plan of action included but was not limited to: a head to toe assessment of Resident #152, acquisition of a 6 month restraining order for Visitor #1, Social Services follow-up with Resident #152 on 10/18/17, all Facility staff in-services specifically covering: Facility Abuse and Prohibition Policy, process on admitting/restricting visitors into the facility when receptionist is not present at the front desk. The Immediate Jeopardy was removed on October 18, 2017 at 9:10 PM after the facility's plan of action was reviewed and accepted by survey team and Office of Health Care Quality.

Based on complaint allegations, clinical record review, resident and staff interview it was determined that the facility staff failed to have a system in place to ensure that a follow up consultation was completed for a suprapubic catheter placement, which resulted in the use of a Foley catheter for an extended period of time, causing an injury that was not properly monitored and assessed to prevent further skin breakdown and to promote healing when first discovered. This was true for 1 of 3 residents (#128) reviewed for indwelling urinary (Foley) catheter use. The findings include: Review of Resident #128's medical record on 10/17/17 at 11:40AM revealed a [DIAGNOSES REDACTED]. (UTIs). Review of the Minimum Data Set (MDS) assessment dated [DATE], revealed that he/she was assessed as requiring extensive assistance of one person for bed mobility and toileting, and total assistance needed for locomotion and transferring. The Minimum Data Set (MDS) is a federally-mandated assessment tool used by nursing home staff to gather information on each resident's strengths and needs. Information collected drives resident care planning decisions. Further review of the medical record revealed a 12/08/16 Report of Consultation note from Urologist #1 documenting the following: Reports condom catheter is in place and has not been catheterized in a month since (she/he) had a UTI .Due to inconsistent management of the bladder Foley catheter was placed for management. The resident was advised of possible suprapubic catheter placement and Urologist #1 recommended follow-up in 2-3 weeks for reassessment. A Foley catheter is a thin, sterile tube inserted into the bladder to drain urine. Because it can be left in place in the bladder for a period of time, it is also called an indwelling catheter. A suprapubic catheter is a thin, sterile tube inserted directly into the bladder to drain urine from the body. A 2/24/17 urology follow-up note (from Urologist #1) documented that the Foley catheter was changed without difficulty. It also noted that the resident would be scheduled for a cystoscopy with suprapubic tube (catheter) placement. Appointment reminder information found in the medical record from Urologist #2 revealed Resident #128 was scheduled for a cysto with suprapubic tube placement procedure on 4/20/17. A urology progress note (from Urologist #1) dated 4/20/17 documented that the procedure to place the suprapubic catheter was cancelled due to the resident having a distended abdomen. The Foley catheter was changed at the appointment and the following was documented, .Foley catheter was inserted per the urethra and slowly advanced. A nursing note dated 4/21/17 documented that the resident returned to the facility at about 4:00 AM with Foley catheter in place, draining clear yellow urine. Review of Resident #128's care plan for risk of infection related to indwelling catheterization that originated on 3/9/16 and was reviewed on 6/6/17 revealed, but was not limited to the following: Goal-(Resident) will be/remain free from catheter-related trauma through review date; Interventions: hand washing before and after delivering care, position Foley catheter bag and tubing below the level of the bladder, observe/document for pain/discomfort due to catheter. Although the 9/13/17 follow-up nursing note documented that the resident's sister indicated that she would schedule the resident's follow-up appointment to discuss the Foley catheter, the facility failed to provide any additional documentation reflecting any follow up from the sister with the urologist concerning future appointments since 4/20/17. Further review of Resident #28's medical record revealed an incident report dated 9/22/17 at 9:00 AM. It indicated the discovery of a 2.0cm split tear to the urethral meatus. The report indicated that the resident's primary physician was notified and that the resident was not seen by the physician. The facilities investigation contained a written statement from the geriatric nursing assistant (GNA) assigned to the resident at the time of the incident (Staff #12) which indicated, There was a small split but now it looks bigger! A physician's orders [REDACTED]. A hospital transfer summary with a discharge date of [DATE] indicated one of the reasons the resident was sent to the hospital was due to a clogged Foley catheter. Once stabilized the resident was sent back to the facility. A late entry nursing note (from the wound nurse) created on 10/18/17 at 4:37 PM for 10/2/17 indicated that the resident refused a head to toe assessment on 10/2/17 because he/she was up and dressed. The resident was asked if she/he had an open area to her/his genitalia area and the resident stated, Its alright, and left the room to go outside. A neurology note in the medical record dated 10/17/17 at 2:00 PM, documented the following: Foley catheter balloon inflated in prostatic urethra needs to be repositioned. A subsequent progress note from Urologist #1 dated 10/17/17 at 5:17 PM documented that when asked, Resident #128 was unable to recall when the Foley catheter was last changed. The physician noted the resident had an erosive [DIAGNOSES REDACTED] from tensioned Foley catheter and that the catheter was deflated and removed. In the plan section of the note, the following was found: The Foley catheter was changed and a new catheter was placed and assured NOT to be under tension. The patient still has a distended abdomen .Possible scheduling for SPT for management of the patient bladder. The patient will follow-up in December or sooner if able to schedule procedure. This note also documented that the Urologist was asked to see the patient in conjunction with (name of neurologist from 10/17/17 appointment). During an interview on 10/18/2017 at 10:40 AM with Resident #128 and family member they expressed concerns that the surgery to place the suprapubic catheter had not been rescheduled. Additionally, they were concerned about the facility's lack of monitoring and treatment of [REDACTED]. The resident went on to say that they had no idea how bad it had become until 10/17/2017 when during an office visit their Neurologist examined the resident. A medical record review and interview was conducted with the A/B Unit Manager on 10/18/17 at 11:20 AM. When asked about the wound she insisted that it was not a wound but just a split, and that she was told by her nursing staff that it had always been there. Interview with the Wound Nurse on 10/19/17 at 12:25 PM regarding the tear in the genital area revealed that when she attempted to assess her/him, the resident refused said she/he was already up and out of bed to her/his chair. She indicated that she then spoke to Nurses (unable to recall which nurse) who reassured her that it (tear in the genital area) was fine. An interview with Staff #12, the resident's GNA was conducted on 10/20/17 at 9:00 AM. She stated that she noticed Resident #128 had a small tear in the genital area since she started to care for him/her in June 2017. It should be noted that Staff #12 began working at the facility in June 2017. She went on to say that since then she noticed the wound was getting progressively longer in length, and oftentimes found blood and with a mucous discharge around the tear. According to the GNA, each time she would report her discovery to the resident's nurses (Staff #15, #16, #17, and #18) but was unaware if the resident had received any assessment or treatments by them. She went on to state that on 9/22/17 while providing routine care for the resident she saw that the resident's genital tear had once again increased in length, bled onto the disposable brief, and had a mucous discharge. She called in a co-worker GNA (Staff #13) to verify her concern and was advised by her to speak with the resident's primary nurse (Staff #15) in front of the A/B unit manager. Interview with the other GNA (Staff #13) on 10/20/17 at 9:20 AM revealed that from January to June 2017, she frequently helped in the care of Resident #128. During that time the resident had a large opening where the Foley insertion was but she was not aware of any issues with the resident's genitalia until June when Staff #12 began reporting to the resident's nurses about a small tear near the Foley insertion. She also stated that on 9/22/17 she saw the wound and was shocked to find a skin tear the length of the tip of the resident's genitalia had developed. Later measurements by the nurse on 9/22/17 revealed the tear was 2cm in length. The two GNAs immediately reported their findings to the resident's nurse and unit manager. In another interview with the A/B Unit Manager with the Corporate Nurse Consultant present on 10/19/17 at 9:00 AM, the Unit Manager denied that she was informed that the resident had a wound prior to 09/22/17 and verbally retracted the 10/18/17 statement she made to surveyor. Review of Resident #128's medical record failed to reveal a consistent plan and implementation of standard wound care. Further review of the medical record revealed that there were no additional assessments, measurements, or monitoring documented by facility staff until 10/19/17 after surveyor intervention. During an interview with Resident #128's facility doctor (Physician #1) on 10/26/17 at 1:08 PM, he acknowledged that although the tear was not threatening, the resident should have the Foley replaced with a supra pubic catheter to prevent further injuries. Physician #1 also acknowledged that no physician assessment of the wound was done until 10/19/17.

Based on review of the facility report of abuse, medical record review and interview with the facility staff, it was determined that the facility failed to keep a resident free from abuse. The facility was aware of a situation occurring where a staff member was interacting with a resident in such a manner that did not adhere to the residents rights. In addition, the facility delayed conducting an investigation of the alleged incident and delayed removing the staff member allegedly involved in the incident from the care of residents. After the staff member allegedly grabbed and squeezed the resident's hand during a verbal miscommunication between the resident and the staff member, the resident was later found to have a fracture to the right hand. After the alleged incident, the resident was noted and documented as visibly upset and exposed to intimidating behavior by the staff member involved in the incident. This was evident for 1 out of 2 residents (#2) reviewed during a complaint survey. The findings include: On 7/20/17 a facility reported incident was reviewed regarding Resident #2. This review revealed that the resident had multiple co-morbidities which included [MEDICAL CONDITION] (A congenital disorder of movement, muscle tone, or posture) and unspecified intellectual disabilities, generalized muscle weakness, major [MEDICAL CONDITION] and documented difficulty in verbal expression. review of the resident's medical record revealed [REDACTED]. Review on 7/20/17 at 9:45 AM of the facility reported incident regarding Resident #2 revealed that according to the Resident, during care on 5/27/17 on the evening shift between 2 PM - 3 PM the he/she reported to the manager on duty (MOD; Staff #4), that the geriatric nursing assistant (GNA Staff #5), that cared for him/her was verbally and physically abusive between 2 PM - 3PM on 5/27/17. The facility reported incident stated that during activity of daily living care, when the GNA, asked the resident to turn over, Resident #2 stated that s/he was unable to secondary to the presence of a nephrostomy tube. This allegedly frustrated the GNA, who grabbed the hand of the resident and attempted to forcibly turn the resident over. According to the Resident, from documented accounts at the time of the incident and interview completed on 7/20/17, s/he stated that s/he and the GNA, exchanged inappropriate words, including the resident calling the GNA a derogatory name and the GNA telling the resident that he was going to, '(explicative) him/her up.' An x-ray was completed on 5/27/17. The x-ray report did not show any fractures of the right hand, just an old healed fracture. However, the resident continued to complain of pain and received medication, so another x-ray was completed on 6/8/17. The report showed positive fracture with tissue swelling. Additionally, staff documented on the pain evaluation assessment and Medication Administration Record [REDACTED]. The MOD immediately notified the DON (Director of Nursing) (at the time of the incident) of the incident. Further review of the facility reported incident and investigation revealed that the employee was scheduled to work on 5/27/17 from 7 AM - 11 PM. From approximately 4 PM - 11 PM, the GNA (Staff #5) was moved to another unit and continued to work the remainder of the shift with other residents. The GNA also worked the next two days while the investigation was ongoing. Witness statements from the MOD documented that the resident came to her on 5/27/17 around 3:00 PM and was crying and stated that s/he was scared from an incident that occurred with a certain GNA. Additionally, the MOD stated, while she was talking to the resident in the lobby s/he was extremely emotional telling the story. She stated that GNA #5 walked across the lobby and stood across from the resident starring at him, not saying anything. The MOD asked Staff #5 to please excuse them as they were having a private conversation and Staff #5 responded with 'whatever, all (s/he) is going to do is lie anyway.' It was at this time that the MOD, secondary to the statement and the stance the employee held that was perceived as aggressive, asked the GNA to leave the immediate area, according to an interview held with the MOD on 7/20/17 at 1:17 PM. The resident further stated to the MOD that s/he is even more afraid now as to what the Staff #5 would do to him/her now. According to Staff #5, he stated that while he was performing ADL care on the resident, he turned him/her to his/her side and s/he became irritated and started kicking and punching and yelling profanities at him. The GNA Staff #5 stated that he had a co-worker come in and assist with care and they asked the resident why s/he was acting like this and s/he stated 'I don't know.' About 20 minutes later the GNA, staff #5, stated that the resident came out of the room and apologized to them both for his/her behavior. The co-worker GNA, Staff #6, that was in the room stated that she did not witness any foul language or inappropriate behavior from the GNA, staff #5, but was not present during the initial encounters of the GNA, staff #5, and the resident. Interview on 7/20/17 at 10:34 AM with Resident #2 revealed that, although s/he is no longer scared and the alleged employee no longer cares for him/her, s/he said s/he did feel scared at the time of the incident and that the staff did work the entire shift with him/her and he/she felt uncomfortable with that. Interview with the current DON, Administrator and Corporate Nurse at 3:08 PM on 7/20/17 revealed that the resident was care planned for aggressive behavior and for having allegations towards staff and recanting and further approaching staff and apologizing within a few hours of the allegation. It was further noted that the resident had approached the GNA, staff #5, on 5/27/17 that was allegedly verbally and physically abusive towards him/her and apologized for his/her own behavior. This was corroborated by multiple witness statements. The corporate nurse further stated that the DON did not suspend the staff immediately because of the care planned behavior of the resident's potential aggression towards staff, the DON assumed that it was just another one of his/her incidents. She felt that the MOD had intervened and was a sounding board to alleviate the resident's agitation as noted in the care plan. The Administrator stated that when he became aware of the incident, the employee was suspended and a full investigation was implemented, including reporting to the state agency which included an initial and final report with staff training on abuse reporting initiated on 6/2/17 and completed on 6/13/17 to include all staff and management. Included in the training was: abuse recognition and reporting immediate notification to supervisor, Administrator and Director of Nursing, nursing staff utilizing Abaqis Abuse and Neglect interview questions weekly and ongoing to ensure deficient practice does not reoccur, and audits of weekly grievance logs concerns and adverse findings reported to QAPI committee monthly. Interview with the corporate nurse at 3:08 PM on 7/20/17 revealed that when they became aware they put in a 4 part plan in place to ensure that this incident of abuse and delayed reporting would not occur again. The plan included abuse training to all staff and management that was completed on 6/16/17. Also training with the management team on abuse recognition and reporting completed on 6/13/17.

Based on medical record review, facility investigation, staff and family interviews, it was determined that the facility failed to maintain the safety of a resident during transfer, resulting in a laceration to ( resident #6) right lower leg requiring 15 sutures. The finding included the following: The facility failed to maintain the safety of (resident #6) during transfer, resulting in a laceration to the right lower leg requiring 15 sutures. By way of history, according to the medical record, (resident #6) is paralyzed on the left side as a result of a stroke. The resident is totally dependent on staff for care. During investigation of complaint # MD 058, review of the medical record, and interview with the resident family member on 5/4/16 at 10am, it was revealed, on 12/31/15, the resident care specialist (GNA) transferred the resident from the wheelchair to the bed, during the transfer the resident sustained [REDACTED]. The resident was medicated for pain and transferred to ER via 911 where he/she received 15 stitches to the right lower leg. Continued of the medical record on 5/5/16, revealed the resident was assessed on 11/25/15, as a two person transfer with the use of a Hoyer Lift, to allow a safe, comfortable transfer. A Hoyer Lift is an assistive device that allows patient/patients, to be transferred between a bed and a chair or other similar resting places. Interviews with the Director of Nursing and the Administrator on 5/5/16 and 5/6/16, revealed the following outcome from the facilities investigation; (1.) the resident care specialist (GNA) was attempting to transfer the resident without proper transfer techniques and use of assistive device, (2.) failed to remove the leg rest from the wheelchair, (3) failed to perform a two person ' s transfer as per resident plan of care, resulting in the resident leg getting caught on a metal bar resulting in a laceration. The Director of Nursing and the Administrator, stated the facility has a no lift policy, and all staff members have been re-in serviced on proper transfer techniques .

Based on medical record review and staff interview, it was determined that the facility staff failed to use proper technique when putting an incontinent pad under a resident. A second incident occurred when a staff member failed to use the proper technique when turning a resident. This occurred with 1 of 37 residents selected for review in the stage 2 sample. The findings are as following: Resident # 27 has a left below the knee amputation. Review of resident # 27 medical record revealed a Transfer Form dated 8/8/12 that stated the following: Nurse was repositioning legs and resident fell backwards in wheelchair, hit head on floor. Review of the medical record (MR) revealed change of condition report dated 8/8/12 at 8:30 PM that stated the following: Resident had attended fall from wheelchair in hallway. Wheelchair tipped backwards when nurse attempted to reposition patient, sustained head injury to back of head. 911 called, neuro-checks initiated ( These checks provide a means of evaluating a patient's ongoing status, generally over the first 24 hours after injury), vital signs taken. Emergency medical team assessed and transferred resident to hospital for treatment. Incident report dated 8/8/12 stated the following: Resident was incontinent of urine in wheelchair while receiving evening medications. Urine had soaked through pants and was pooling on the floor under the wheelchair. This occurred in middle of the hall between rooms 24 and 25 on the A wing at 8:10 PM. Nurse got incontinence pad and towels for the floor because assigned GNA (geriatric nursing assistant) was on her dinner break. Nurse attempted to reposition resident's legs to put incontinence pad underneath him. Wheelchair became unbalanced and resident fell out of wheelchair. Blood started pooling beneath head. Unit supervisor arrived, 911 called, neuro checks initiated. Interdisciplinary Post Fall Review form dated 8/8/12 stated the following: Resident hit head on floor falling out of wheelchair. Sustained wound to back of head. Nurse attempted to reposition resident and wheelchair fell backwards. 911 called, transferred to hospital, Neuro checks initiated. Conditions that may contribute=weight unbalanced d/t (due to) amputation... Nurses note dated 8/9/12 at 7 AM stated the following: Resident brought back to facility from hospital on a stretcher at 2 AM. Had 3 staples on laceration on back of head... Review of the hospital's emergency room records indicated that the resident had a head injury resulting in pain (numerical pain score = 5). {The 0 to 10 pain scale is commonly and successfully used with hospitalized and nursing home patients, even those with mild to moderate dementia. This scale asks the person in pain to assign a number, from zero to ten, to the severity of their pain. The values on the pain scale correspond to pain levels as follows: 1 - 3 = mild pain 4 - 6 = moderate pain 7 - 10 = severe pain} The resident had soft tissue swelling/bruising, and a laceration with bleeding requiring 3 staples. During an interview with nurse # 1, on 9/24/12 at 3:04 PM she demonstrated the technique she used to position the incontinent pad under the resident. The nurse put her hand and forearm under the surveyor's posterior (back of ) thighs. The nurse stated that she lifted the resident's legs and the chair tipped backwards and the resident fell backward and hit the back of his head.. The nurse acknowledged that she used poor judgement and that she made a mistake. She stated that she will not make this mistake again. Following the incident the nurse was counseled by the facility's supervisor and the unit manager. Interview with the administrator, on 9/25/12 at 7:12 AM, revealed that after the incident the corporate instructor educated the staff on lifts and transfers. This same resident was involved in another accident on 9/16/12. Review of the medical record revealed a change in condition report dated 9/16/12 that stated the following: ...fell during AM care from bed with bed mattress. Landed on his side on a floor mat beside his bed... Review of the MDS ( (MDS - minimum data set - is a federally mandated assessment tool that helps nursing home staff gather information on each resident's strengths and needs. Information collected drives resident care planning decisions.), dated 6/8/12 revealed that the resident required extensive assistance with turning and positioning. During an interview with the GNA involved with the incident (GNA # 1), on 9/24/12 at 1:51 PM, she stated the following: Resident was incontinent, I was cleaning him up. When I turned resident (she stated that the resident can help turn himself) he kept on going and the mattress went with him. Resident landed on the mat next to the bed on the floor. When asked, did you turn the resident toward you or away from you? the GNA stated that I turned the resident away from me. During an interview with the administrator and the director of nursing (DON), on 9/24/12 at 2:10 PM, both acknowledged that the GNA should have turned the resident toward her and not away from her. The DON stated that she had educated the GNA on the proper way to turn the resident. This second incident did not cause harm.