Every finding on record at Bethesda Care Center

Based on medical record review, observation, resident and staff interviews, and review of facility policies, the facility failed to ensure personal protective equipment was utilized for residents in contact precautions. This affected one (Resident #85) of one resident reviewed for contact precautions. Additionally, the facility failed to ensure hand hygiene was performed while delivering meal trays to resident rooms. This affected four (Residents #8, #14, #51, and #85) of 13 residents observed for meal tray delivery.Findings include:1. Review of the medical record for Resident #85 revealed she was admitted on [DATE] with diagnoses including Type Two Diabetes Mellitus, direct infection of left ankle and foot, unspecified psychosis, stage three chronic kidney disease, osteoarthritis, skin transplant status, and osteomyelitis.Review of the Minimum Data Set 3.0 assessment dated [DATE] for Resident #85 revealed she was cognitively intact and did not display any behaviors nor refusals of care at the time of this assessment. Resident #85 required moderate assistance with activities of daily living and ambulation. She had a peripherally inserted central catheter and received intravenous antibiotics.Review of the care plan dated 03/22/26 for Resident #85 revealed focus areas related to fall prevention and intravenous antibiotic therapy for a wound infection to her left lower extremity.Review of physician orders for Resident #85 revealed an order dated 03/20/26 for single room isolation with contact precautions every shift.Observation of Resident #85's door to her room revealed personal protective equipment (PPE) and a contact isolation sign hanging on the door. The contact isolation sign indicated all visitors and staff were to perform hand hygiene prior to entering the room and all staff were to don gloves and a gown prior to entering the room.Interview on 03/30/26 at 9:17 A.M. with Resident #85 revealed staff were not donning the required PPE for contact precautions prior to entering her room.Observation on 03/30/26 at 8:00 A.M. of Certified Nurse Assistant #309 revealed she delivered a breakfast tray to Resident #85's room, set the tray on her bedside table next to the bed, and did not perform hand hygiene nor don the required PPE for contact precautions prior to entering the room.Interview on 03/30/26 at 8:15 A.M. with CNA #309 confirmed she did not perform hand hygiene nor don the required PPE prior to delivering Resident #85's breakfast tray to her bedside table located inside the room next to the bed.Observation on 03/30/26 at 9:45 A.M. of Social Services Assistant (SSA) #220 revealed she entered Resident #85's room and did not perform hand hygiene nor don the appropriate PPE for contact precautions.Interview on 03/30/26 at 9:51 A.M. with SSA #220 confirmed she did not perform hand hygiene nor don the required PPE as required for contact precautions prior to entering Resident #85's room to assist with her needs.Observation on 03/30/26 at 1:33 P.M. of Licensed Practical Nurse (LPN) #202 revealed she was sitting on Resident #85's bed, accessing the resident's peripherally inserted central catheter (PICC), and was not wearing a gown as required for contact precautions.Interview on 03/30/26 at 1:39 P.M. with LPN #202 confirmed she did not don a gown as required for contact precautions prior to entering Resident #85's room to provide care involving the resident's PICC line.Review of in-service documentation revealed LPN #202 had been trained on contact precautions, including the necessary PPE and how to use it, on 12/04/25.Review of in-service documentation with the Director of Nursing revealed CNA #309 had been trained on hand hygiene and contact precautions, including the necessary PPE and how to use in, on 12/01/25. Review of facility policy titled Isolation - Categories of Transmission-Based Precautions, dated October 2018, revealed visitors and staff would don gloves and a gown prior to entering the room of a resident in contact precautions.2. Review of the medical record for Resident #8 revealed he was admitted on [DATE] with diagnoses including heart failure, chronic obstructive pulmonary disease, Parkinson's disease, Lewy body dementia, diverticulosis, venous insufficiency, and Type Two Diabetes Mellitus.Review of the medical record for Resident #14 revealed she was admitted on [DATE] with diagnoses including disease of the pancreas, pulmonary nodule, jaundice, diaphragmatic hernia, arteriovenous malformation, and unspecified intra-abdominal and pelvic swelling with a mass and lump.Review of the medical record for Resident #51 revealed she was admitted on [DATE] with diagnoses including pyloric stenosis, intestinal obstruction, hypovolemia, ulcerative colitis, malignant neoplasm of rectum, and protein-calorie malnutrition.Review of the medical record for Resident #85 revealed she was admitted on [DATE] with diagnoses including Type Two Diabetes Mellitus, direct infection of left ankle and foot, unspecified psychosis, stage three chronic kidney disease, osteoarthritis, skin transplant status, and osteomyelitis.Observation on 03/30/26 at 8:00 A.M. of Certified Nurse Assistant (CNA) #309 revealed she delivered breakfast trays to Residents #8, #14, #51, and #85 who was in contact precautions, and did not perform hand hygiene between deliveries. She touched the bedside tables in each of the rooms. While in Resident #14's room she touched the resident. While in Resident #51's room she touched a water cup and personal belongings on the bedside table.Interview on 03/30/26 at 8:15 A.M. with CNA #309 confirmed she did not perform hand hygiene while passing breakfast trays to Residents #8, #14, #51, and #85.Review of in-service documentation with the Director of Nursing revealed CNA #309 had been trained on hand hygiene on 12/01/25. Review of facility policy titled Handwashing/Hand Hygiene, dated August 2024, revealed facility staff would perform hand hygiene before and after direct contact with residents and after contact with objects in the immediate vicinity of residents.This deficiency represents non-compliance investigated under Complaint Numbers 2702693 and 2697818.

Based on observation, staff interview, and policy review, the facility failed to ensure food that was opened was properly stored. This had the potential to affect 79 residents who the facility identified to receive food from the kitchen. The facility census was 82. Findings include:Observation and concurrent staff interview with the Dietary Director (DD) #156 on 03/30/26 at 6:39 A.M. of reach in freezer #1 revealed a bag of broccoli that was opened and undated, beef fritters that were opened, unlabeled, and undated, pizza crusts that were opened, unlabeled, and undated, and dinner rolls that were opened, unlabeled, and undated. Observation of the dry storage revealed a bag of croutons to be opened and undated. DD #156 confirmed the findings as listed above. Observation and concurrent staff interview with the Dietary Director (DD) #156 on 03/30/26 at 6:48 A.M. of reach in refrigerator #2 revealed shredded lettuce that was opened, undated, and unlabeled, and sliced ham that was opened, undated, and unlabeled. DD #156 confirmed the findings as listed above. DD #156 confirmed the findings as listed above. Review of the undated facility policy titled food storage revealed the facility staff should cover, label, and date food products.

Based on observation, interview, and review of facility policy, the facility failed to provide a comfortable and homelike environment for residents on Memory Care (MC) unit. This had the potential to affect all 24 residents who reside on the MC unit. The facility census was 82. Findings Include: Observation of the MC unit on 03/30/26 at 12:06 P.M. revealed the wall carpet was peeling and unsightly, wallpaper between resident rooms [ROOM NUMBERS] was peeling, two air vents near the nurse's station were visibly soiled, and a ceiling tile near the nurse's station was missing. Interview on 03/30/26 at 12:07 P.M. with Licensed Practical Nurse (LPN) #230 confirmed the wall carpet and wallpaper were peeling and unsightly. Interview on 03/30/26 at 12:08 P.M. with Registered Nurse (RN) #270 confirmed the air vents were dirty and the ceiling tile was missing. RN #270 further stated the ceiling tile had not been replaced following recent remodeling in the MC unit. Observation on 03/31/26 at 12:35 P.M. revealed peeling paint at the nurse's station. Interview on 03/31/26 at 12:36 P.M. with LPN #310 confirmed the paint at the nurse's station was peeling. Observation on 04/01/26 at 1:00 P.M. revealed three lights in the MC dining/common area were flickering and partially illuminated. Interview on 04/01/26 at 1:02 P.M. with LPN #301 and Receptionist #170 confirmed the lights were flickering and not fully functioning. Review of the facility policy titled Quality of Life - Homelike Environment, dated May 2017, indicated the facility is to provide a clean, orderly, and well-maintained environment with adequate lighting and homelike characteristics. This deficiency represents non-compliance investigated under Complaint Number 2677052.

Based on observations, staff interview, and policy review, the facility failed to provide activities to meet the residents' needs and cognitive capabilities. This affected 24 residents who reside in the memory care unit. The facility census was 82.Findings include:Observation of the memory care unit activities calendar for March 2026 revealed the week of 03/01/26 the facility had juice and news, and table talk everyday of the week. The facility had one day a week on Wednesdays where the residents did an activity called morning stretch.Observation on 03/31/26 at 10:00 A.M. of the memory care unit revealed five residents sitting around the dining room table. There was nothing provided for the residents besides music on the television.Observation on 04/01/26 at 9:06 A.M. revealed seven residents sitting in the dining room, with only music playing on the television. Additional observation on 04/01/26 at 9:27 A.M. revealed Activity Aide #247 distributing word searches to the residents sitting around the dining room table. Resident #9, Resident #59, and Resident #32 were sitting in recliner chairs in front of the television. Activity Aide (AA) #247 did not offer the residents in the recliners an activity.Interview on 04/01/26 at 9:10 A.M. with Certified Nursing Assistant (CNA) #315 revealed she was from agency but frequently picked up at the facility in the memory care unit. CNA #315 stated there were no activities for the residents and confirmed that residents were not offered any type of mental stimulation between scheduled activities.Interview on 04/01/26 at 9:35 A.M. with AA #247 revealed Resident #9 was blind, so AA #247 did not offer activities to Resident #9 but would let her sit next to her during the activity. AA #247 confirmed Resident #9 should be offered an alternative activity to accommodate her needs. AA #247 stated Resident #59 wanders and exit seeks, therefore if Resident #59 is sitting when no activity is offered. AA #247 further stated that she did not know what Resident #32's name was but knew that he liked to wander and gets agitated easily and confirmed he was not offered an activity.Review of the facility policy titled Memory Care Unit Activity Programming not dated, revealed Activity Programming on the Memory Care Unit will offer a diverse variety of events throughout the day, including both structured and spontaneous options as the residents prefer. Activities will be adapted and modified based on resident abilities day to day and with the progression of their dementia.This deficiency represents non-compliance investigated under Complaint Number 2678071 and Complaint Number 2677052.

Based on record review, staff interview, and facility policy review the facility failed to ensure the Minimum Data Set (MDS) was accurately coded. This affected four residents (#25, #31, #36 and #15) and had the potential to affect 13 residents the facility identified as receiving respiratory services at the facility. The facility census was 82.Findings included:1 - Review of Resident #25 revealed an admission date of 08/02/24. Diagnosis included chronic kidney disease, obstructive sleep apnea, chronic obstructive pulmonary disease, and obesity. Review of Resident #25's quarterly Minimum Data Set (MDS) dated [DATE] revealed she had an intact cognition. The resident was coded as requiring invasive mechanical ventilation. Review of Resident #25's medical record revealed a physician's order dated 12/04/25 for ventilator/volume targeted pressure support. VT-325 PEEP minute-5 PEEP max-15 PS max-15 auto I Time=auto rise-3. Oxygen (O2) may titrate to maintain saturation greater than or equal to 90% nightly and during naps. May titrate settings for patient comfort/tolerance every shift for ventilator dependence. Daily use required. Observation on 03/31/26 at 3:10 P.M. revealed Resident #25 was in his wheelchair in the hallway free of invasive mechanical ventilation. 2 – Review of Resident #31's medical record revealed an admission date of 08/04/20. Diagnosis included chronic obstructive sleep apnea and dependence on a respirator status. Review of Resident #31's annual MDS dated [DATE] revealed the resident had an intact cognition. The resident was coded as requiring an invasive mechanical ventilator. Review of Resident #25's medical record revealed a physician's order dated 12/04/25 for ventilator/volume targeted pressure support. VT-325 PEEP minute-5 PEEP max-15 PS max-15 auto I Time=auto rise-3. O2 may titrate to maintain saturation greater than or equal to 90% nightly and during naps. May titrate settings for patient comfort/tolerance every shift for ventilator dependence. Daily use required. Observation of Resident #25 on 04/01/26 at 7:52 A.M. revealed the resident was free of invasive mechanical ventilation. 3 – Review of Resident #36's medical record revealed an admission date of 06/23/20. Diagnosis included chronic obstructive pulmonary disease, dependence on respirator ventilator status, and acute respiratory failure with hypoxia. Review of annual Resident #36 annual MDS dated [DATE] revealed the resident was coded as requiring an invasive mechanical ventilator. Review of Resident #36's medical record revealed a physician's order dated 12/04/25 for ventilator/volume targeted pressure support. VT-325 PEEP minute-5 PEEP max-15 PS max-15 auto I Time=auto rise-3. O2 may titrate to maintain saturation greater than or equal to 90% nightly and during naps. May titrate settings for patient comfort/tolerance every shift for ventilator dependence. Daily use required. Observation of Resident #36 on 04/01/26 at 8:04 A.M. revealed the resident was free of invasive mechanical ventilation. Interview with the Ohio Department of Health Resident Assessment Instrument (RAI) and (outcome and Assessment Information set (OASIS) Education Coordinator on 03/31/26 revealed the average volume-assured pressure support (AVAPS) is a non-invasive ventilation that integrates the characteristics of both volume and pressure-controlled non-invasive ventilation. AVAPS is most closely aligned with BiPAP and should be coded at O0110G2, BiPAP when used during the look-back period. A National Institute of Health StatPearls available at https://www.ncbi.nlm.nih.gov/books/NBK560600/ addresses 'Average Volume-Assured Pressure Support.' That article states, Different modalities of non-invasive ventilation exist, with continuous positive airway pressure (CPAP) and bilevel positive airway pressure (BiPAP) being the most commonly used modes. Interview with the MDS Nurse #251 on 03/31/26 at 11:05 A.M. verified Resident #25, #31, and #36's MDS was coded as receiving an invasive mechanical ventilator because the MDS manual directed him to do so. Review of the RAI manual coding instructions for Invasive Mechanical ventilator (ventilator or respirator) revealed: Code any type of electrically or pneumatically powered closed-system mechanical ventilator support device that ensures adequate ventilation in the resident who is or who may become (such as during weaning attempts) unable to support their own respiration in this item. During invasive mechanical ventilation the resident's breathing is controlled by the ventilator. Residents receiving closed-system ventilation include those residents receiving ventilation via an endotracheal tube (e.g., nasally or orally intubated) or tracheostomy. A resident who has been weaned off of a respirator or ventilator in the last 14 days or is currently being weaned off a respirator or ventilator, should also be coded here. Do not code this item when the ventilator or respirator is used only as a substitute for BiPAP or CPAP. Review of the facility policy titled Resident Assessment revised 2019 revealed all persons who have completed any portion of the MDS Resident Assessment Form must sign the document attesting to the accuracy of such information. 4 - Review of Resident #15's medical record revealed an admission date of 11/14/24. Diagnoses included acute respiratory failure with hypoxia, Chronic Obstructive Pulmonary Disease (COPD), heart failure, hypertension, Type Two Diabetes Mellitus, and generalized anxiety disorder. Review of Resident #15's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #15 had severely impaired cognition with a Brief Interview for Mental Status (BIMS) score of seven. Further review of the MDS assessment revealed Resident #15 did not require the use of oxygen therapy. Review of Resident #15's care plans dated 03/26/26, 01/02/26, 10/09/25, and 09/29/25 revealed oxygen therapy was not included in the care plan. Review of Resident #15's physician orders dated 03/23/26 revealed no order for oxygen administration. Review of Resident #15's progress notes dated 03/25/25, 05/06/25, 05/07/25, 05/10/25, 05/19/25, 05/21/25, 06/13/25, 07/06/25, and 03/28/26 revealed Resident #15 was receiving oxygen via nasal canula. Interview on 03/30/26 at 10:38 A.M. with LPN #303 verified Resident #15 was receiving oxygen at two liters per minute (lpm) via nasal canula. LPN #303 verified Resident #15 did not have an order for oxygen. LPN #303 stated she thought Resident #15's oxygen order was as needed for shortness of breath and she stated Resident #15 had always worn oxygen. Interview on 03/31/26 at 10:22 A.M. with the Director of Nursing (DON) verified Resident #15 had been receiving oxygen therapy since 03/25/25 and had no physician order for oxygen therapy. Furthermore, the DON verified oxygen administration was not included in Resident #15's care plan and the MDS assessment was inaccurate as Resident #15 had received oxygen since 03/25/25. Review of the facility policy with a last revised date of November 2019 titled Resident Assessments revealed a comprehensive assessment of every resident's needs is made at intervals designated by Omnibus Budget Reconciliation Act of 1987 (OBRA) and Prospective Payment System (PPS) requirements. Furthermore, all persons who have completed any portion of the MDS resident assessment form must sign the document attesting to the accuracy of such information.

Based on observation, staff interview, and policy review, the facility failed to ensure hazardous chemicals and medications were properly stored. This had the potential to affect 10 residents (#9, #11, #22, #26, #32, #45, #54, #59, #63, and #73) who the facility identified to be cognitively impaired and independently mobile on the 200 hall. The facility census was 82. Findings include:Observation on 04/01/26 at 9:30 A.M. of the 200 Memory Care (MC) hall revealed the door to the soiled linen room did not require a code to enter the room and the door was unlocked. One Certified Nursing Assistant (CNA) was observed to open the door without entering a code as the door was unlocked.Interview on 04/01/26 at 9:34 A.M. with Business Office Manager (BOM) #212 verified the door to the soiled linen room did not require a code to enter the room and was unlocked. Furthermore, BOM #212 verified inside of the soiled linen room in an unlocked cabinet above the sink contained antifungal powder - miconazole nitrate 2 percent (%), two tubes of antifungal cream - miconazole nitrate 2%, moisture barrier cream 12% zinc oxide and 1% dimethicone, and spill magic all-purpose spill clean-up absorbent powder. All medications and the chemical had a label that stated to keep out of reach of children.Review of the facility policy with a revised date of July 2023 titled Hazardous Areas, Devices, and Equipment revealed all hazardous areas, devices, and equipment in the facility will be identified and addressed appropriately to ensure resident safety and mitigate accident hazards to the extent possible.This deficiency represents non-compliance investigated under Complaint Number 2678071.

Based on record review, staff interview, review of the Gradual Dose Reduction (GDR) document, and policy review, the facility failed to ensure a GDR was acknowledged and signed by the physician for one resident (#72) of five residents reviewed for unnecessary medications. The facility census was 82.Findings include:Review of Resident #72's medical record revealed an admission date of 04/26/24. Diagnoses included schizoaffective disorder, Chronic Obstructive Pulmonary Disease (COPD), history of pulmonary embolism, hypertension, depression, anxiety, and hyperlipidemia.Review of Resident #72's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #72 had severely impaired cognition with a Brief Interview for Mental Status (BIMS) score of zero. Further review revealed Resident #72 was on an antipsychotic, antianxiety, antidepressant, anticoagulant, and anticonvulsant medication.Review of Resident #72's care plan dated 02/02/26 revealed Resident #72 utilized psychotropic medications related to her diagnoses of schizophrenia, delirium, depression, and hallucinations. Interventions included to administer psychotropic medications as ordered by the physician and to discuss with the Medical Doctor (MD) and family regarding the need for use of these medications. Furthermore, the facility would review behaviors and interventions and alternate therapies attempted and their effectiveness as per the facility policy. Review of Resident #72's physicians orders revealed an order for Clonazepam (antianxiety) 0.5 milligrams (mg) by mouth twice a day for anxiety, Risperidone (antipsychotic)3mg by mouth in the morning for and 4mg by mouth at bedtime for schizoaffective disorder, and Seroquel (antipsychotic) extended release 400mg two tablets by mouth two times a day for increased behaviors. Review of Resident #72's Consultant Pharmacist's Medication Regimen Review document revealed for the month of August 2025, the Pharmacist recommended a GDR for three medications; Clonazepam, Risperidone, and Seroquel. Further review revealed the physician had not acknowledged the GDR or signed the document.Review of Resident #72's Medication Administration Record (MAR) for the month of March 2026 revealed Resident #72 received Clonazepam 0.5mg by mouth twice a day for anxiety, Risperidone 3mg by mouth in the morning for and 4mg by mouth at bedtime for schizoaffective disorder, and Seroquel extended release 400mg two tablets by mouth two times a day for increased behaviors.Interview on 03/31/26 at 3:44 P.M. with the Director of Nursing (DON) verified the physician had not acknowledged or signed the GDR for the month of August 2025 and the GDR had not been attempted as Resident #72 was still on the same medications. Review of the facility policy with an effective date of 08/2020 titled Medication Regimen Review revealed recommendations are acted upon and documented by the facility staff and/or the prescriber. The prescriber accepts and acts upon recommendation or rejects and provides an explanation for disagreeing.

Based on record review, staff interview, and policy review, the facility failed to ensure a compreshensive care plan was completed including the use of oxygen therapy for one resident (#15) of three residents reviewed for oxygen. The facility census was 82. Findings include:Review of Resident #15's medical record revealed an admission date of 11/14/24. Diagnoses included acute respiratory failure with hypoxia, Chronic Obstructive Pulmonary Disease (COPD), heart failure, hypertension, Type Two Diabetes Mellitus, and generalized anxiety disorder. Review of Resident #15's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #15 had severely impaired cognition with a Brief Interview for Mental Status (BIMS) score of seven. Further review of the MDS assessment revealed Resident #15 did not require the use of oxygen therapy. Review of Resident #15's care plans dated 03/26/26, 01/02/26, 10/09/25, and 09/29/25 revealed oxygen therapy was not included in the care plan. Review of Resident #15's physician orders dated 03/23/26 revealed no order for oxygen administration. Review of Resident #15's progress notes dated 03/25/25, 05/06/25, 05/07/25, 05/10/25, 05/19/25, 05/21/25, 06/13/25, 07/06/25, and 03/28/26 revealed Resident #15 was receiving oxygen via nasal canula. Observation and Interview with Resident #15 on 03/30/26 at 10:15 A.M. revealed the resident had Oxygen at 2 liters per nasal cannula and stated the doctor wantes her to wear the oxygen all the time but she only wears it when she needs it. Interview on 03/30/26 at 10:38 A.M. with Licensed Practical Nurse (LPN) #303 verified Resident #15 was receiving oxygen at two liters per minute (lpm) via nasal canula. LPN #303 verified Resident #15 did not have an order for oxygen. LPN #303 stated she thought Resident #15's oxygen order was as needed for shortness of breath and she stated Resident #15 had always worn oxygen. Interview on 03/31/26 at 10:22 A.M. with the Director of Nursing (DON) verified Resident #15 had been receiving oxygen therapy since 03/25/25 and had no physician order for oxygen therapy. Furthermore, the DON verified oxygen administration was not included in Resident #15's care plan and the MDS assessment was inaccurate as Resident #15 had received oxygen since 03/25/25. Review of the facility policy with a revision date of September 2013 titled Care Planning - Interdisciplinary Team revealed the facilities care planning/interdisciplinary team were responsible for the development of an individualized comprehensive care plan for each resident.

Based on medical record review, observation, staff interview, family interview, and policy review, the facility failed to ensure Activities of Daily Living (ADL) care was provided for dependent residents. This affected two residents, (#54 and #63) of three residents reviewed for ADL care. The facility census was 82. Findings include: 1.Review of Resident #63's medical record revealed an admission date of 08/12/24. Diagnoses included hypertensive chronic kidney disease, hypertension, dementia without behavioral disturbance, muscle weakness, and aortic ectasia. Review of Resident #63's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #63 required supervision or touching assistance for personal hygiene and partial or moderate assistance for showering and bathing. Review of Resident #63's care plan dated 01/14/26 revealed Resident #63 had a self-care deficit related to weakness and cognitive impairment with interventions that included for staff to assist with ADL's as needed and to report improvement or decline in Resident #63's participation with ADL's. Interview on 04/01/26 at 9:05 A.M. with Resident #63's Medical Power of Attorney (POA) revealed Resident #63 had not had her hair or teeth brushed that morning before leaving her bedroom for breakfast. Observation on 04/01/26 at 9:12 A.M. of Resident #63 sitting at the dining table revealed Resident #63's hair to be disheveled. Interview on 04/01/26 at 9:14 A.M. with Certified Nursing Assistant (CNA) #315 verified she had not brushed Resident #63's hair or teeth during morning personal hygiene care. 2. Review of the medical record for Resident #54 revealed an admission on [DATE]. Diagnoses included unspecified dementia, major depressive disorder, chronic kidney disease. Review of the quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #54 was cognitively impaired. Further review of the MDS revealed Resident #54 required supervision or touching assistance with Activities of Daily Living (ADLs). Review of the care plan dated 01/14/26 revealed Resident #54 had an ADL self care deficit related to disease process. Interventions included assisting with ADL as needed. Report improvement or decline in resident participation with ADLs. Observation on 03/30/26 at 10:39 A.M. revealed Resident #54 sitting at the dining room table with hair sticking out on the right side, appearing unkept. Observation on 04/01/26 at 9:36 A.M. revealed Resident #54 sitting at the dining room table with hair sticking out on the right side, appearing unkept. Interview on 04/01/26 at 9:26 A.M. with Certified Nursing Assistant (CNA) #307 revealed CNA #307 was not sure who was to take care of Resident #54. CNA #307 verified Resident #54's hair was unbrushed, and her morning care was not complete. CNA #307 stated there were two CNA's on the dementia unit and then stated Resident #54 was actually on her assignment for the day. CNA #307 further confirmed that Resident #54 requires assistance with Activities of Daily Living (ADLs). Review of the facility policy titled Activities of Daily Living (ADLs), Supporting dated 03/2024, revealed appropriate care and services will be provided for residents who are unable to carry out ADLs independently.

Based on medical record reviews, review of an Emergency Medical Service (EMS) run report, staff and resident interviews, and review of facility policies, the facility failed to ensure follow up care was provided when skin breakdown was noted, failed to document skilled assessments, vital signs, and failed to notify the physician regarding a change of condition. The facility also failed to implement physician orders following an office visit. This affected two (Residents #77 and #91) of two residents reviewed for quality of care. The facility census was 82.Findings include:1.Review of the closed medical record for Resident #91revealed an admission on [DATE] and a discharge date of [DATE]. Diagnoses included Parkinsons Disease, essential hypertension, and dorsalgia. Further review of the medical record revealed no care plan or Minimum Data Set (MDS) had been completed due to time of admission and discharge. Review of the nurse progress notes revealed Resident #91 arrived at the facility on [DATE] from the hospital with a diagnosis of weakness. Review of the admission and readmission packet dated [DATE] revealed Resident #91's blood pressure was 145/82, pulse was 68, and temperature was 97.6. Resident #91 was alert to person, place and time. Review of the vital signs for Resident #91 revealed a blood pressure was last obtained on [DATE] at 8:01 P.M. of 148/75, a pulse oximetry of 98 percent (%) on two liters of oxygen via nasal cannula, pulse of 80, respiratory rate of 20, and temperature of 97.5 degrees Fahrenheit (F). There were no further vitals obtained throughout Resident #91's stay at the facility. Review of the physician's orders revealed no order for oxygen. Review of the nurse progress note dated [DATE] revealed a late entry for skilled documentation on [DATE] at 6:31 A.M. There were no vitals obtained. Skilled documentation charting for [DATE] at 6:36 A.M. revealed no vitals were obtained. Skilled documentation and assessment were not charted on [DATE], [DATE], and [DATE]. Review of the physician progress note dated [DATE] revealed Resident #91 was admitted to the facility on [DATE]. Resident #91 had a history of thoracic spine fracture and was being seen for significant muscle spasms and pain in the lower back and hips. Additional review of the physician progress note revealed the physician used the vital signs from [DATE]. Review of the Occupational Therapy Treatment Encounter Notes dated [DATE] revealed Resident #91's response to treatment was, Resident #91 had decreased alertness and lethargy during evaluation. Resident #91 was constantly falling asleep and required verbal cues to stay awake. Review of the physician's orders revealed an order on [DATE] for before and after nebulizer and incentive spirometry treatment, check the following, lung sounds, pulse rate, and pulse oximetry. Document the number of minutes for set up and cleanup of equipment, every shift document total time it takes for set up, assessment, and monitoring. Review of the Treatment Administration Record for Resident #91 revealed on [DATE] through [DATE] the staff documented fifteen minutes of set up time, but there was no documentation of lung sounds, pulse rate, or pulse oximetry. Review of the nurse progress notes dated [DATE] at 2:36 A.M. revealed a urine was obtained as ordered for a urinalysis by straight catheterization without incident. Resident #91's urine was dark in color and odorous. Licensed Practical Nurse (LPN) #311 noted an open area on right abdominal fold and groin area to outer right hip. Both noted areas were cleaned with soap and water and patted dry. LPN #311 applied Peri-Protect to right abdominal fold and groin area, and Resident #91's brief was left open. LPN #311 stated the Nurse Practitioner was notified. LPN #311 also noted an approximately two centimeters by two centimeter raised area to Resident #91's left outer labia. Review of the TAR from [DATE] through [DATE] revealed no monitoring of skin, or open areas to the right abdominal fold and groin area. There was no monitoring of the raised area to Resident #91's left outer labia. Review of the nurse progress notes dated [DATE] at 5:27 A.M. revealed Resident #91's Cyclobenzaprine (muscle relaxer)10 milligram (mg) tablet was held due to Resident #91 being lethargic. LPN #311 was unable to keep Resident #91 awake for a conversation. There was no notification to the physician documented. Review of the nurse progress notes dated [DATE] at 1:54 P.M. revealed LPN #666 administered morning medication to Resident #91. Upon vital assessment LPN #666 had concerns for Resident #91. LPN #666 was alerted by aides that Resident #91 was breathing different. LPN #666 returned to Resident #91's room to find Resident #91 unresponsive. Full code was initiated per advanced directives. LPN #666 called for crash cart, 911, to be called. LPN #666 and another nurse continued Cardiopulmonary Resuscitation (CPR) until Emergency Medical Services (EMS) arrived. EMS called time of death on [DATE] at 10:15 A.M. Review of the Medication Administration Record (MAR) revealed on [DATE] morning medications were administered at 8:56 A.M. There were no vital signs documented. Review of the EMS run report revealed EMS arrived at the facility at 9:47 A.M. for a verbally unresponsive female. Per nurse Resident #91 presented with lethargy and hypotension the morning of [DATE] and medications were withheld due to this. Interview on [DATE] at 1:54 P.M. with Resident #91's family revealed on [DATE], Resident #91's family had attempted to contact Resident #91 multiple times without success. The family was able to get a nurse to answer Resident #91's cell phone and Resident #91 stated that something was not right, and she was going to be sent to the emergency room. Resident #91's family stated they did not hear from the facility until after Resident #91 had been pronounced dead. Resident #91's family stated before arriving at the facility Resident #91 was alert and was receiving therapy at the facility. Resident #91's family stated a nurse informed them the morning that Resident #91 had passed she had not voided all night. Resident #91's family could not remember the time they spoke to Resident #91. Resident #91's family stated that during a visit on [DATE] Resident #91 was hallucinating and it was reported to the nurse, but the family was never notified what the physician had said. Interview on [DATE] with Director of Nursing (DON) at 7:27 A.M. confirmed that Resident #91 was a skilled resident and should have had a skilled assessment twice daily containing vital signs. DON further confirmed that Resident #91 had no vitals obtained from [DATE] through [DATE]. DON confirmed staff was not monitoring Resident #91's open area to the abdomen and groin, and there was no follow-up documented regarding the raised area to Resident #91's labia. DON confirmed it was documented that Resident #91 was wearing oxygen and further confirmed Resident #91 did not have an order for oxygen. DON also confirmed that staff should have been documenting lung sounds, pulse and pulse oximetry twice a day as ordered for use of incentive spirometry as documented. Interview on [DATE] at 11:13 A.M. with LPN #311 revealed Resident #91did not receive the Cyclobenzaprine 10mg because she was difficult to arouse. LPN #311 stated it must not have been concerning if she did not notify the physician. LPN #311 further stated the charting pertaining to the abdominal fold, groin and labia notification was written in a book and the nurse practitioner was not verbally notified or faxed. Interview on [DATE] at 11:30 A.M. with Certified Nursing Assistant (CNA) #229 revealed on the morning of [DATE] Resident #91 refused to get out of bed which was not normal for her. CNA #229 stated she reported her findings to LPN #666. Interview on [DATE] at 11:40 A.M. with Medical Director (MD) #313 revealed staff should notify the physician or on call Nurse Practitioner (NP) any time there is a change in condition with a resident. MD #313 confirmed if Resident #91 received medication at 8:56 A.M. on [DATE]. 2. Review of the medical record for Resident #77 revealed she was admitted on [DATE] with diagnoses including diverticulosis, anemia, obstructive sleep apnea, atrial fibrillation, sick sinus syndrome, and unspecified hemorrhoids. Review of the quarterly Minimum Data Set 3.0 (MDS) assessment dated [DATE] for Resident #77 revealed she was cognitively intact, did not display behaviors toward others, and did display refusals of care at the time of this assessment. She utilized a walker with supervision and a wheelchair independently, required minimal to moderate assistance with activities of daily living, and was independent with bed mobility and transfers. Review of gynecology visit notes and orders dated [DATE] revealed Resident #77 was diagnosed with a labial cyst, and sitz bath treatments were ordered. Review of a facility physician progress note dated [DATE] for Resident #77 revealed a labial cyst was being managed by gynecology with recommendations to continue sitz bath treatments as ordered. Review of the physician orders and care plan for Resident #77 revealed no documented orders nor care plan interventions for sitz bath treatments for management of the labial cyst. Interview on [DATE] at 6:46 A.M. with Resident #77 revealed the facility did not have the necessary equipment to perform sitz baths. She stated her first sitz bath occurred on [DATE] after her representative provided a sitz bath basin and Epsom salt. Resident #77 reported improved comfort following initiation of treatments. Interview on [DATE] at 11:10 A.M. with Licensed Practical Nurse #202 confirmed Resident #77 began sitz baths during the week of [DATE]. Interview on [DATE] at 12:44 P.M. with the Assistant Director of Nursing #252 confirmed the sitz bath treatments ordered on [DATE] for Resident #77 were not implemented in a timely manner. Interview on [DATE] at 12:46 P.M. with Resident #77's representative revealed the facility was verbally notified by him of the sitz bath order upon return from the gynecology appointment on [DATE], in addition to receiving written provider orders. The representative stated the facility did not provide the treatments due to lack of equipment, and he obtained the necessary supplies during the week of [DATE]. Review of facility policy titled Charting and Documentation, dated [DATE], revealed the facility ensured resident medical records facilitated communication between the interdisciplinary team regarding resident condition and response to care. Review of facility policy titled Medication and Treatment Orders, dated [DATE], revealed treatment orders would be implemented consistent with principles of safe and effective order writing. This deficiency represents non-compliance investigated under Complaint Numbers 2702693, 2678071, and 2650249.

Based on observation, resident interview, staff interview, record review, and review of facility policy, the facility failed to ensure implementation of physician-ordered pressure ulcer prevention interventions for one (Resident #7) of two reviewed for pressure ulcer. The facility census was 82.Findings Include: Review of the medical record for Resident #7 revealed an admission date of 12/09/25 with multiple diagnoses, including peripheral vascular disease, congestive heart failure, chronic obstructive pulmonary disease, and generalized weakness.Review of Resident #7's most recent quarterly Minimum Data Set (MDS) assessment, dated 02/16/26, revealed a Brief Interview of Mental Status (BIMS) score of 12, indicating moderate cognitive impairment. Further review revealed Resident #7 required assistance with all activities of daily living, including bed mobility and repositioning.Review of the care plan dated 02/25/26 revealed the resident was at risk for impaired skin integrity with an intervention to utilize offloading boots while in bed.Review of Resident #7's medical record revealed a physician order dated 02/25/26 for offloading heel boots to be worn while in bed, with removal permitted for bathing.Observation on 04/01/26 at 7:30 A.M. revealed Resident #7 was in bed and not wearing the physician-ordered offloading heel boots. Further observation revealed the heel boots were present in Resident #7's room on the vanity shelf.Interview on 04/01/26 at 7:31 A.M. with Resident #7 confirmed he was not wearing the ordered offloading heel boots at the time of observation.Interview on 04/01/26 at 7:32 A.M. with Certified Nursing Assistant (CNA) #318 confirmed the resident was in bed and not wearing the physician-ordered offloading heel boots.Review of facility policies titled Pressure Ulcer Prevention and Risk Identification and Pressure Ulcer Prevention Intervention revealed the facility is to implement preventative measures based on assessed risk, including offloading heels, use of heel protectors, and following physician orders to reduce pressure and prevent skin breakdown.

Based on observation, staff interview, resident interview, medical record review, and review of facility policy, the facility failed to ensure orders for supplemental oxygen were in place for one residents (#15). This affected one residents (#15) of four residents reviewed for respiratory care. The facility census was 82.Findings Include: Review of Resident #15's medical record revealed an admission date of 11/14/24. Diagnoses included acute respiratory failure with hypoxia, Chronic Obstructive Pulmonary Disease (COPD), heart failure, hypertension, type two diabetes mellitus, and generalized anxiety disorder. Review of Resident #15's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #15 had severely impaired cognition with a Brief Interview for Mental Status (BIMS) score of seven. Further review of the MDS assessment revealed Resident #15 did not require the use of oxygen therapy. Review of Resident #15's care plans dated 03/26/26, 01/02/26, 10/09/25, and 09/29/25 revealed oxygen therapy was not included in the care plan. Review of Resident #15's physician orders dated 03/23/26 revealed no order for oxygen administration. Review of Resident #15's progress notes dated 03/25/25, 05/06/25, 05/07/25, 05/10/25, 05/19/25, 05/21/25, 06/13/25, 07/06/25, and 03/28/26 revealed Resident #15 was receiving oxygen via nasal canula. Interview on 03/30/26 at 10:38 A.M. with LPN #303 verified Resident #15 was receiving oxygen at two liters per minute (lpm) via nasal canula. LPN #303 verified Resident #15 did not have an order for oxygen. LPN #303 stated she thought Resident #15's oxygen order was as needed for shortness of breath, and she stated Resident #15 had always worn oxygen. Interview on 03/31/26 at 10:22 A.M. with the Director of Nursing (DON) verified Resident #15 had been receiving oxygen therapy since 03/25/25 and had no physician order for oxygen therapy. Furthermore, the DON verified oxygen administration was not included in Resident #15's care plan and the MDS assessment was inaccurate as Resident #15 had received oxygen since 03/25/25. Review of facility policy titled Oxygen Administration, dated April 2023, revealed oxygen would be administered under physician orders and tubing would be changed weekly and as needed.

Based on medical record review, interview, and review of the facility policy, the facility failed to ensure a dialysis port was monitored. This affected one (#4) of one resident reviewed for dialysis. The facility census was 82.Findings include:Review of the medical record for Resident #4 revealed an admission on [DATE]. Diagnoses included chronic kidney disease, stage four, Type Two Diabetes Mellitus, and chronic respiratory failure with hypoxia. Review of the admission Minimum Data Set (MDS) dated [DATE] revealed Resident #4 was cognitively impaired. Further review of the MDS revealed Resident #4 received dialysis. Review of the care plan dated 01/29/26 revealed Resident #4 needed resident care. Interventions included dialysis port in right chest. Further review of the care plan revealed Resident #4 received dialysis in-house. Interventions included monitor, documenting, and reporting any signs and symptoms to access site such as redness, swelling, warmth, or drainage. Review of the physicians' orders revealed no order to monitor dialysis port to the right side of chest.Review of the Medication Administration Record (MAR) and Treatment Administration Record (TAR) for March 2026 revealed no documentation that staff were monitoring the dialysis port daily.Interview on 03/31/26 at 10:22 A.M. with Licensed Practical Nurse (LPN) #310 revealed the staff only monitor the dialysis port on Monday, Wednesday, and Friday when Resident #4 goes to dialysis. LPN #310 further confirmed that there was no documentation in the MAR or TAR for monitoring the dialysis port site.Interview on 03/31/26 with Director of Nursing (DON) confirmed there was documented monitoring of the dialysis port site and further confirmed the staff should be monitoring each shift.Review of the facility policy titled End-Stage Renal Disease, Care of a Resident with dated 09/2024 revealed staff caring for residents with end stage renal disease, including residents recieving diaysis care outside of the facility shall, monitor care of grafts and fistulas, and assess data that is to be gathered about the resident's condition on a daily or per shift basis.

Based on Self-Reported Incident review, medical record review, and staff interview, the facility failed to ensure medications documentation was completed accurately for one (Resident #10). This had the potential to affect 18 residents (#4, #5, #10, #25, #27, #29, #31, #36, #37, #41, #50, #56, #57, #58, #60, #65, #68, #70) the facility identified as receiving opioid medication in the facility. The census was 82. Findings Include:Review of Resident #10's medical record revealed an admission date of 06/21/25. Diagnosis included congestive heart failure, end stage heart failure, Diabetes Mellitus Type II, and chronic obstructive pulmonary disease. Review of Resident #10's quarterly Minimum Data Set (MDS) dated [DATE] revealed the resident had an intact cognitionReview of Resident #10's most recent care plan revealed she had a potential for alteration in comfort related to the disease process. interventions included educating the resident to request pain medication before her pain became severe.Review of Resident #10's medical record revealed a physician's order dated 09/06/25 for Oxycodone HCI oral tablet five milligrams (mg) to administer two every six hours as needed (PRN) for pain level of six to 10. Review of Resident #10's Medication Administration Record dated September 2025, and October 2025 revealed the resident was administered Oxycodone HCL 5 mg two tablets on 09/09/25 at 8:01 P.M. for a pain level of four, the medication was noted to be effective. On 09/11/25 at 2:03 A.M. the resident was administered Oxycodone HCL 5 mg two tablets for a pain level of eight, the medication was noted to be effective. On 10/02/25 at 9:01 P.M. the resident was administered Oxycodone HCL 5 mg two tablets for a pain level of four, the medication was noted to be effective. Review of Resident #10's Controlled Drug Administration Record revealed Oxycodone HCL 5 mg two tablets were documented as removed from the secured narcotic lock box on the following dates and time for Resident #10; 09/06/25 at 3:00 P.M., 09/07/25 at 7:00 A.M. and 4:00 P.M., 09/10/25 at 8:05 A.M. and 10:40 A.M., 09/11/25 at 2:03 A.M. and 10:00 A.M., 09/12/25 at 7:30 A.M. and 1:00 P.M. Review of the facility completed self-reported incident number 266988 revealed upon review of narcotic documentation, a facility nurse License Practical Nurse (LPN) #666 was found to have signed for a narcotic on the controlled drug administration record, but failed to document administration in the electronic Medication Administration Record (MAR). Review of LPN #666's Disciplinary Action Report dated 11/05/25 revealed the nurse failed to properly document the administration of controlled substances on multiple occasions and shifts. The decision was made fto terminate the employee following repeated failures to properly document the administration of controlled substances, which violates company policy and regulatory standards. Despite prior warnings and guidance, the issue persisted and had compromised the facility compliance and patient safety protocols.Interview with the Administrator and Director of Nursing on 04/01/26 revealed neither were employed by the facility during that time and were unfamiliar with the investigation.This deficiency represents non-compliance investigated under Control Numbers 2673873 and 2664387.

Based on medical record review, staff interview, family interview, and review of the facility policy, the facility failed to ensure the physician was notified timely when a resident had a change of condition. This affected one (Resident #91) of one reviewed for notification of change. The facility census was 82.Findings include:Review of the medical record for Resident #91 revealed an admission on [DATE] and a discharge date of [DATE]. Diagnoses included Parkinson's Disease and essential hypertension.Review of the Occupational Therapy (OT) Treatment Encounter Notes dated [DATE] revealed Resident #91 had decreased alertness and lethargy during evaluation. Resident #91 was constantly falling asleep and required verbal cues to stay awake. There was no evidence the physician was notified of Resident #91's change in condition.Review of the nursing progress note dated [DATE] at 5:57 A.M. revealed Licensed Practical Nurse (LPN) #311 held Resident #91's cyclobenzaprine (muscle relaxant) 10 milligrams (mg) tablet due to Resident #91 being lethargic, unable to keep resident awake for conversation. Resident #91 stated I'm just tired. There was no evidence the physician was notified of Resident #91's change in condition and holding a medication.The nursing progress notes dated [DATE] at 1:54 P.M. revealed LPN #666 was alerted by certified nursing aides (CNAs) that Resident #91 was breathing different. LPN #666 returned to Resident #91's room to find Resident #91 unresponsive. Full code was initiated per advanced directives. LPN #666 called for crash cart and 911 to be called. Emergency Medical Services (EMS) arrived and called time of death on [DATE] at 10:15 A.M.Interview on [DATE] with Director of Nursing (DON) at 7:27 A.M. confirmed there was no documentation the physician was notified on [DATE] when OT identified a change in condition in Resident #91 and on [DATE] when LPN #311 held a medication and noted a change in condition. The DON confirmed the physician should have been notified on [DATE] and [DATE].Interview on [DATE] at 11:40 A.M. with Medical Director (MD) #313 revealed staff should notify the physician or on call Nurse Practitioner (NP) any time there was a change in condition with a resident. MD #313 confirmed if Resident #91 was presenting with lethargy and hypotension, the on call physician should have been called immediately.Review of the facility policy titled Charting and Documentation dated 07/2023 revealed the following information is to be documented in the resident medical record: treatments or services performed, changes in the resident's condition, assessment data and any unusual finding obtained during the procedure.This deficiency represents non-compliance investigated under Complaint Numbers 2702693, 2678071, and 2650249.

Based on medical record review, resident interviews, staff interview, and review of facility policy, the facility failed to ensure residents completed bathing according to their preferences. This affected one (Resident #85) of one resident investigated for choices. The facility census was 82.Findings include:Review of the medical record for Resident #85 revealed she was admitted on [DATE] with diagnoses including Type Two Diabetes Mellitus, direct infection of left ankle and foot, unspecified psychosis, stage three chronic kidney disease, osteoarthritis, skin transplant status, and osteomyelitis.Review of the Minimum Data Set 3.0 assessment dated [DATE] for Resident #85 revealed she was cognitively intact and did not display any behaviors nor refusals of care at the time of this assessment. Resident #85 required moderate assistance with activities of daily living and ambulation. She had a central catheter and received intravenous antibiotics.Review of the care plan dated 03/22/26 for Resident #85 revealed focus areas related to fall prevention, intravenous antibiotic therapy for a wound infection to her left lower extremity, and an intervention for one-assist with showering.Interview on 03/30/26 at 9:17 A.M. with Resident #85 revealed she was told by facility staff she could not take showers and instead had to take sponge baths due to the infection in her left lower extremity. She expressed her preference for taking showers opposed to baths and revealed she had showered while in the hospital; hospital staff wrapped her left lower extremity to keep it dry.Review of the admission packet dated 03/20/26 revealed Resident #85 preferred to take showers daily.Review of the resident preference questionnaire dated 03/25/26 for Resident #85 revealed choosing between a bath or shower was very important to her.Interview on 04/01/26 at 2:00 P.M. with Assistant Director of Nursing #252 revealed Resident #85 had not been permitted to use the shower due to a physician order and her peripherally inserted central catheter.Review of physician orders for Resident #85 revealed no orders regarding the method for bathing.Interview on 04/02/26 at 7:45 A.M. with Resident #85 revealed she continued sponge baths and had not been permitted to use the shower.Review of facility policy dated December 2023 and titled Resident Rights revealed the facility would ensure the basic resident right of self-determination.

Based on review of Self-Reported Incident Investigation, facility investigation, medical record review, staff interview, and policy review, the facility failed to ensure one (Resident #10) was free of misappropriation of narcotic medications. This affected one, Resident #10 of one reviewed for misappropriation. This had the ability to affect 18 Residents (#4, #5, #10, #25, #27, #29, #31, #36, #37, #41, #50, #56, #57, #58, #60, #65, #68, and #70) identified as receiving narcotic medication. The facility census was 82.Findings included:Review of Resident #10's medical record revealed an admission date of 06/21/25. Diagnosis included congestive heart failure, end stage heart failure, Diabetes Mellitus Type II, and chronic obstructive pulmonary disease. Review of Resident #10's quarterly Minimum Data Set (MDS) dated [DATE] revealed the resident had an intact cognitionReview of Resident #10's most recent care plan revealed she had a potential for alteration in comfort related to the disease process. Interventions included educating the resident to request pain medication before her pain became severe.Review of Resident #10's medical record revealed a physician's order dated 09/06/25 for Oxycodone HCI oral tablet five milligrams (mg) to administer two every six hours as needed (PRN) for pain level of six to 10. Review of Resident #10's Medication Administration Record dated September 2025, and October 2025 revealed the resident was administered Oxycodone HCL 5 mg two tablets on 09/09/25 at 8:01 P.M. for a pain level of four, the medication was noted to be effective. On 09/11/25 at 2:03 A.M. the resident was administered Oxycodone HCL 5 mg two tablets for a pain level of eight, the medication was noted to be effective. On 10/02/25 at 9:01 P.M. the resident was administered Oxycodone HCL 5 mg two tablets for a pain level of four, the medication was noted to be effective. Review of Resident #10's Controlled Drug Administration Record revealed Oxycodone HCL 5 mg two tablets were documented as removed from the secured narcotic lock box on the following dates and time for Resident #10; 09/06/25 at 3:00 P.M., 09/07/25 at 7:00 A.M. and 4:00 P.M., 09/10/25 at 8:05 A.M. and 10:40 A.M., 09/11/25 at 2:03 A.M. and 10:00 A.M., 09/12/25 at 7:30 A.M. and 1:00 P.M. Due to unaccounted doses of Oxycodone which were signed out the Controlled Drug Administration Record but not documented as administered on Resident #10's MAR as administered, the facility initiated an investigation. Review of the facility investigation dated 10/30/25 revealed the investigation included a local police department investigation report dated 10/30/25. The report stated a facility employee reported the theft of Oxycodone belonging to Resident #10 and it continued to be under investigation. Further review revealed Licensed Practical Nurse (LPN) #319 stated LPN #666 forgot to sign out two narcotic pills. LPN #319 revealed LPN #666 wasn't signing narcotics out. LPN #319 stated she was worried about LPN #666 because she and her boyfriend have psychiatric issues. On 10/30/25 LPN #666 had to leave early so LPN #319 signed out narcotics which LPN #666 had administered earlier in the day. LPN #319 revealed she and LPN #666 failed to count narcotics prior to her taking over the cart on night shift.Review of Resident #10's interview dated 10/31/25 revealed she did have pain. The resident pointed to her amputation and stated it was phantom pain. She revealed she took Tylenol at times but had not taken any Oxycodone in quite a while.Review of Resident #10's drug test completed on 10/30/25 revealed she was negative for opiates and Oxycodone.Review of the facility completed self-reported incident number 266988 revealed upon review of narcotic documentation, nurse was found to have signed for a narcotic on the controlled drug administration record but failed to document administration in the electronic Medication Administration Record (MAR). The nurse was suspended pending investigation. Through investigation it was noted of the 41 times PRN Oxycodone was signed out, the nurse in question signed for 35 of the removals of medication. The nurse in question had signed in the narcotic sign off book during several shifts for administration of the Oxycodone to the resident, often times, twice through the shift. Upon interview of the resident, resident stated she has pain at times to her amputation site. She stated, it's phantom pain. When asked about what she takes to help with her pain the resident stated she took Tylenol and it is helpful. When asked if she takes anything stronger for her pain the resident stated she had taken something stronger before, but it has been a while since she has needed it. The social services designee completed Brief Interview of Mental Status (BIMs) on resident with result of 15, cognitively intact. Interview of staff member in question conducted who stated she signed the medication out in the narcotic book, and it was requested at the time of sign out by the resident. She stated each time she signed the medication out she provided the medication to the resident. The facility stated the available evidence was inconclusive, but suspected.Review of LPN #666's Disciplinary Action Report dated 11/05/25 revealed the nurse failed to properly document the administration of controlled substances on multiple occasions and shifts. A verbal warning was given on 09/25/25 and a written warning on 10/04/25. Termination was effective on 11/05/25. The letter confirmed the termination of her employment effective 11/05/25. The decision was made following repeated failures to properly document the administration of controlled substances, which violates company policy and regulatory standards. Despite prior warnings and guidance, the issue persisted and had compromised the facility compliance and patient safety protocols.Interview with the Administrator and Director of Nursing on 04/01/26 revealed neither were employed by the facility during that time and were unfamiliar with the investigation.Interview with Resident #10 on 04/01/26 at 2:11 P.M. revealed she was aware a nurse had stolen some of her Oxycodone and she volunteered to take a blood test which revealed she had not been administered Oxycodone in a long time.Email interview with the Healthcare Investigation Specialist on 04/06/26 at 1:30 P.M. revealed the investigation was ongoing regarding the case against LPN #666.Review of the facility policy titled Abuse, Neglect, Exploration, and Misappropriation of Resident's Property and Injuries of Unknown Sources undated revealed misappropriation of resident property meant the deliberate misplacement, exploitation or wrongful, temporarily or permanent, use of a resident's belongings or money without the resident's consent.This deficiency represents non-compliance investigated under Control Numbers 2673873 and 2664387.

Based on medical record review and staff interview, the facility failed to ensure resident code status orders accurately reflected their wishes as documented in their Advance Directives Form. This affected one resident (#40) of three residents (#33, #40, and #68) reviewed for code status. The facility census was 75.Findings Include:Review of the medical record for Resident #40 revealed an admission date of 07/23/25. Diagnoses included local infection of the skin and subcutaneous tissue, sepsis, bloodstream infection due to central venous catheter, cellulitis of left lower limb, morbid obesity, type two diabetes mellitus (DM2), disorder of vein, hypertension, tubulointerstitial nephritis, thrombocytopenia, streptococcus, non-pressure chronic ulcer of skin, disorder of arteries and arterioles, nonrheumatic mitral valve insufficiency, chronic lymphocytic leukemia of b-cell type, disorder of brain, chronic ischemic heart disease, pneumonia, viral hepatitis, stage three chronic kidney disease, dependence on renal dialysis, heart disease, glomerular disorders, anemia, lymphedema, acute kidney failure, peripheral vascular disease (PVD), cardiac murmur, hypoxemia, unspecified kidney failure, unspecified hearing loss, unspecified open would of lower leg, anemia, and other disorders of phosphorus metabolism. Review of the most recent Medicare Five-Day Minimum Data Set (MDS) assessment, dated 08/28/25, revealed a Brief Interview of Mental Status (BIMS) score of 15, indicating Resident #40 was cognitively intact. Further review of this MDS assessment revealed Resident #40 required at least some assistance for all functional abilities. Review of the medical record for Resident #40 revealed a signed Advanced Directives Form (a form that indicated the persons wishes should the have a catastrophic cardiac or pulmonary event that would require life sustaining measures), dated 06/20/25, that indicated Resident #40 wished to be Do Not Resuscitate (DNR) Comfort Care-Arrest (DNR CC-A), meaning that providers will treat Resident #40 as any other without a DNR order, until the point of cardiac or respiratory arrest (the sudden loss of cardiac function or cessation of breathing) at which point all interventions will cease and the DNR Comfort care (DNR-CC) protocol will be implemented. Review of the physician order for Resident #40 dated 07/23/25 revealed Resident #40's code status was full code (all resuscitation procedures will be provided in the event of a catastrophic cardiac or pulmonary event that would require life-sustaining measures). Review of the physician order for Resident #40 revealed an order dated 09/23/25 that Resident #40's code status was changed to DNR CC-A from full code. Interview on 09/24/25 at 7:28 A.M., with the Director of Nursing (DON) verified Resident #40 had a signed Advanced Directives form, dated 06/20/25. She further verified Resident #40 had an order in place to be a full code from 07/23/25 through 09/23/25 and the order was changed to DNR CC-A on 09/23/25. Review of the facility policy titled, Advance Directives, dated December 206, revealed advance directives will be respected in accordance with state law and facility policy and that the plan of care of reach resident will be consistent with his or her documented treatment preferences and/or advance directives. This deficiency represents non-compliance investigated under Complaint Number 2607054.

Based on medical record review and staff interview, the facility failed to ensure resident care plans accurately documented their code status. This affected one resident (#40) of three residents (#33, #40, and #68) reviewed for care planning. The facility census was 75.Findings Include:Review of the medical record for Resident #40 revealed an admission date of [DATE]. Diagnoses included local infection of the skin and subcutaneous tissue, sepsis, bloodstream infection due to central venous catheter, cellulitis of left lower limb, morbid obesity, type two diabetes mellitus (DM2), disorder of vein, hypertension, tubulointerstitial nephritis, thrombocytopenia, streptococcus, non-pressure chronic ulcer of skin, disorder of arteries and arterioles, nonrheumatic mitral valve insufficiency, chronic lymphocytic leukemia of b-cell type, disorder of brain, chronic ischemic heart disease, pneumonia, viral hepatitis, stage three chronic kidney disease, dependence on renal dialysis, heart disease, glomerular disorders, anemia, lymphedema, acute kidney failure, peripheral vascular disease (PVD), cardiac murmur, hypoxemia, unspecified kidney failure, unspecified hearing loss, unspecified open would of lower leg, anemia, and other disorders of phosphorus metabolism.Review of the most recent Medicare Five-Day Minimum Data Set (MDS) assessment, dated [DATE], revealed a Brief Interview of Mental Status (BIMS) score of 15, indicating Resident #40 was cognitively intact. Further review of this MDS assessment revealed Resident #40 required at least some assistance for all functional abilities. Review of the medical record for Resident #40 revealed a signed Advanced Directives Form (a form that indicated the persons wishes should they have a catastrophic cardiac or pulmonary event that would require life sustaining measures), dated [DATE], that indicated Resident #40 wished to be Do Not Resuscitate Comfort Care-Arrest (DNR CC-A), meaning that providers will treat Resident #40 as any other without a DNR order, until the point of cardiac or respiratory arrest (the sudden loss of cardiac function or cessation of breathing) at which point all interventions will cease and the DNR Comfort care (DNR-CC) protocol will be implemented. Review of an physician order for dated [DATE] revealed Resident #40 ' s code status was DNR CC-A. Review of the most recent Care Plan for Resident #40 dated [DATE] revealed care planned interventions reflecting that the resident/responsible party have chosen that CPR (cardio-pulmonary recusation) will be attempted during cardiac/pulmonary arrest. Listing goals of if cardio/pulmonary arrest occurs, resident will receive artificial resuscitation. Full CPR will be performed by staff. Listed interventions included provide full resuscitative measures and initiate 911. Interview on [DATE] at 7:28 A.M. with the Director of Nursing (DON) verified Resident #40 had a signed Advanced Directives form, dated [DATE]. She further verified Resident #40 had an order in place to be to DNR CC-A on [DATE]. She also verified that Resident #40 was care planned to be a full-code, not a DNR CC-A. Review of the facility policy titled, Advance Directives, dated [DATE], revealed advance directives will be respected in accordance with state law and facility policy and that the plan of care of reach resident will be consistent with his or her documented treatment preferences and/or advance directives.This deficiency represents non-compliance investigated under Complaint Number 2607054.

Based on medical record review and staff interview, the facility failed to ensure resident code status orders accurately reflected their wishes as documented in their Advance Directives Form. This affected one resident (#40) of three residents (#33, #40, and #68) reviewed for code status. The facility census was 75.Findings Include:Review of the medical record for Resident #40 revealed an admission date of 07/23/25. Diagnoses included local infection of the skin and subcutaneous tissue, sepsis, bloodstream infection due to central venous catheter, cellulitis of left lower limb, morbid obesity, type two diabetes mellitus (DM2), disorder of vein, hypertension, tubulointerstitial nephritis, thrombocytopenia, streptococcus, non-pressure chronic ulcer of skin, disorder of arteries and arterioles, nonrheumatic mitral valve insufficiency, chronic lymphocytic leukemia of b-cell type, disorder of brain, chronic ischemic heart disease, pneumonia, viral hepatitis, stage three chronic kidney disease, dependence on renal dialysis, heart disease, glomerular disorders, anemia, lymphedema, acute kidney failure, peripheral vascular disease (PVD), cardiac murmur, hypoxemia, unspecified kidney failure, unspecified hearing loss, unspecified open would of lower leg, anemia, and other disorders of phosphorus metabolism. Review of the most recent Medicare Five-Day Minimum Data Set (MDS) assessment, dated 08/28/25, revealed a Brief Interview of Mental Status (BIMS) score of 15, indicating Resident #40 was cognitively intact. Further review of this MDS assessment revealed Resident #40 required at least some assistance for all functional abilities. Review of the medical record for Resident #40 revealed a signed Advanced Directives Form (a form that indicated the persons wishes should the have a catastrophic cardiac or pulmonary event that would require life sustaining measures), dated 06/20/25, that indicated Resident #40 wished to be Do Not Resuscitate (DNR) Comfort Care-Arrest (DNR CC-A), meaning that providers will treat Resident #40 as any other without a DNR order, until the point of cardiac or respiratory arrest (the sudden loss of cardiac function or cessation of breathing) at which point all interventions will cease and the DNR Comfort care (DNR-CC) protocol will be implemented. Review of the physician order for Resident #40 dated 07/23/25 revealed Resident #40's code status was full code (all resuscitation procedures will be provided in the event of a catastrophic cardiac or pulmonary event that would require life-sustaining measures). Review of the physician order for Resident #40 revealed an order dated 09/23/25 that Resident #40's code status was changed to DNR CC-A from full code. Interview on 09/24/25 at 7:28 A.M., with the Director of Nursing (DON) verified Resident #40 had a signed Advanced Directives form, dated 06/20/25. She further verified Resident #40 had an order in place to be a full code from 07/23/25 through 09/23/25 and the order was changed to DNR CC-A on 09/23/25. Review of the facility policy titled, Advance Directives, dated December 206, revealed advance directives will be respected in accordance with state law and facility policy and that the plan of care of reach resident will be consistent with his or her documented treatment preferences and/or advance directives. This deficiency represents non-compliance investigated under Complaint Number 2607054.

Based on review of electronic medical records, review of emergency medical squad report, review of hospital records, review of staff education, staff interviews, review of text message review of facility policies, and resident family interview, the facility failed to ensure Resident #76 received medications to prevent seizure activity and notify the physician of resident not receiving medications and having seizure activity. This resulted in Immediate Jeopardy and serious life-threatening harm on 11/14/24 when, as a result of not having his prescribed medications, Resident #76 subsequently experienced continual tonic-clonic seizures (also known as a grand mal seizure - a type of seizure characterized by a sudden stiffening of the body muscles [tonic phase] followed by rapid jerking movements [clonic phase], usually causing loss of consciousness and violent muscle contractions throughout the body), requiring emergency Intramuscular (IM) and Intravenous (IV) administration of Versed (a medication used to treat severe seizures), was transferred to the emergency room with critical laboratory values and subsequently transferred to a tertiary care facility where he was admitted to the neurological intensive care unit (ICU). This affected one (#76) of six residents reviewed for receiving medications and treatment for change in condition. This facility identified six current residents (#05, #17, #21, #30, #42, and #48) who have seizure and convulsant disorders. The facility census was 75. On 11/26/24 at 1:15 P.M., the Administrator and Director of Nursing (DON) were notified Immediate Jeopardy began on 11/14/24 when Resident #76 was admitted to the facility with diagnoses including epilepsy with unspecified convulsions, did not receive his prescribed seizure medications as ordered and subsequently began having seizures, which ultimately resulted in Resident #76 having to be transported to the emergency roiagnom on [DATE] via emergency medical services (EMS), requiring 5 milligrams (mg) of IV Versed and 5 mg of IM Versed during this transportation. Upon arrival at the hospital, it was documented that Resident #76 had critically elevated laboratory (lab) test results from not receiving physician ordered medications and continually having untreated seizure activity. Review of the emergency department (ED) physician notes revealed the elevated lab values are due to Resident #76's persistent seizures. It is further documented that Resident #76's Valproic acid level (the laboratory test utilized to determine the therapeutic dosage range or blood, plasma, or serum concentration usually expected to achieve desired therapeutic effects) of Depakote (divalproex sodium) was 21 micrograms liters (mcg/l). The therapeutic level for Valproic acid is 50-100 mcg/l indicating that Resident #76's Depakote level was subtherapeutic (less than therapeutic). Upon evaluation of Resident 76's clinical presentation and laboratory findings, it was determined that Resident #76 needed to be transferred to another hospital where he would be admitted into the neurological ICU for further evaluation and treatment of his persistent tonic-clonic seizures. Immediate Jeopardy was removed on 11/26/24 when the facility implemented the following corrective actions: On 11/16/24 at 1:40 A.M., Resident #76 was transferred to the hospital for seizure like activity. On 11/19/24, upon review of the medical record, the DON identified that Resident #76 did not receive his scheduled Lyrica, lacosamide and Risperdal. A self-imposed plan of correction (SIPOC) was completed on this date. SIPOC included review of resident charts who had been admitted within the last 30 days by the DON/Designee, to ensure all physician's orders were transcribed correctly and are administered per order, and all resident medications are available to be administered at the facility. Facility nurses were educated by the DON/designee regarding medication order transcription as well as documentation of medication administration, including medications not available and on order from pharmacy, physician notification, and alternate medication administration and representative (RP) notifications. On 11/19/24, the Medical Director was notified via AD Hoc Quality Assurance Review. Review of processes for medication transcription, medication administration and notification of medications not available to physicians and RP. The Medical Director found these items to be appropriate and to proceed with staff training. On 11/19/24, the DON completed education to all licensed nurses regarding admission order transcription and obtaining medications from the pharmacy. On 11/19/24, all residents admitted within the last 30 days were reviewed by the DON and/or the Assistant Director of Nursing (ADON), to ensure all orders were transcribed accurately and all medications were available for administration and no discrepancies were identified. Beginning 11/19/24, the DON/Designee will complete a comprehensive medication order review of all admissions/readmissions within 24 hours to verify accuracy of order transcription and availability of medication for administration. Since 11/19/24, the facility has had three admissions (Resident #40, Resident #72, and Resident #75), and all medication orders were audited to be accurate and ensure medication availability. New admissions and readmissions will continue to be reviewed for transcription accuracy and availability of medications for 4 weeks and reviewed with Quality Assurance and Performance Improvement (QAPI) for compliance. On 11/25/24, education was initiated by Staff Development Coordinator (SDC) #158 with licensed nurses on Seizures: Clinical Protocol, Assessment and Recognition. On 11/26/24, an Ad hoc Policy Review was held with the Administrator, DON, Regional Director of Clinical Services (RDCS) #103, and the Medical Director to confirm the systems implemented and reviewed on 11/19/24 to ensure that residents receive medications as ordered by the physician and to meet their total care needs. Policies reviewed were Admission Assessment and Follow Up: Role of the Nurse, Reconciliation of Medications on Admission, Administering Medications, Change in Resident's Condition or Status, and the procedure for obtaining medications from pharmacy if not available. No changes were made, and policies and processes remain appropriate. On 11/26/24, the DON and the ADON verified all prescribed medications for current residents have been transcribed accurately. Current orders were verified for all residents with no discrepancies identified. On 11/26/24, all residents were assessed by the DON, the ADON, and/or Infection Preventionist (IP) Registered Nurse (RN) # 176. Four residents were noted to have a change in condition and physicians/physician assistants were notified per policy and orders received as indicated. Seventy residents remained at their medical baselines. On 11/26/24, all licensed nurses were re-educated by the DON and/or SDC #158 on the policies and procedures for Admission Assessment and Follow Up: Role of the Nurse, Reconciliation of Medications on Admission, Administering Medications, Change in Resident's Condition or Status, and the procedure for obtaining medications from pharmacy if not available. Previously initiated seizure education was also completed at this time. Education to include 13 licensed nurses. Agency staff will be educated upon arrival for and prior to their scheduled shift. All newly hired licensed nurses will be educated at the time of orientation. On 11/26/24, an Ad hoc Resident Council meeting was held with Activities Director #115 and the DON to review the process for obtaining medications and change in resident condition notification. Residents #04, #13, #09, #71, and #74 were in attendance. There were no concerns verbalized during the resident council meeting regarding policies shared and information reviewed, and residents were appreciative of the information. Beginning on 11/26/24 the DON/Designee will complete a comprehensive medication order review of admission/readmission charts within 24 hours of admission/readmission. Medication orders will be verified for accurate transcription and implementation of medications, and proper medication administration of ordered medications. The DON/Designee will complete ongoing auditing of medical records to ensure changes in condition are reported per policy. Ad hoc education will be completed as indicated. Beginning on 11/26/24, admission and readmission orders will be reviewed for transcription and receipt of medications from pharmacy for 4 weeks and reviewed by QAPI for continued compliance. Review of all resident medication availability and administration will continue 5 times/week for 4 weeks with QAPI review for compliance. Interviews on 11/26/24 with Licensed Practical Nurse (LPN) #133 and LPN #143, revealed they had all been educated on medication borrowing, the procedure for new resident admissions, reconciling orders with the provider for new admissions, process and procedure for if a medication is not available, and medication misappropriation. Review of facility education, dated 11/26/24, revealed all 13 licensed nurses were re-educated by the DON and/or SDC #158 on the policies and procedures for seizure assessment, Admission Assessment and Follow Up: Role of the Nurse, Reconciliation of Medications on Admission, Administering Medications, Change in Resident's Condition or Status, and the procedure for obtaining medications from pharmacy if not available. Although the Immediate Jeopardy was removed on 11/26/24, the facility remained out of compliance at Severity Level 2 (no actual harm with potential for more than minimal harm that is not Immediate Jeopardy) as the facility is still in the process of implementing their corrective action plan and monitoring to ensure on-going compliance. Findings include: Review of the electronic medical record for Resident #76 revealed an admitted [DATE] and a discharge date of [DATE]. Diagnoses included epilepsy, athetoid cerebral palsy, thrombocytopenia, unspecified protein-calorie malnutrition, unspecified convulsions, hypothyroidism, obstructive sleep apnea (OSA), dysphagia, hypomagnesemia, personal history of other diseases of the nervous system and sense organs (eyes, ears, nose, tongue and skin), cervical idiopathic scoliosis, congenital non-neoplastic nevus, and constipation. Due to the short duration of admission for Resident #76, there was no Minimum Data Set (MDS) assessment data available. Review of the discharge paperwork from the hospital for Resident #76 dated 11/14/24 revealed discharge medications to treat seizure activity including: clobazam oral tablet 10 milligram (mg), 1 tablet by mouth two times a day, for seizures; carbamazepine extended release (ER) oral tablet 12-hour 100 mg, 3 tablets by mouth two times a day, for seizures; divalproex sodium ER oral tablet 24-hour 500 mg, give 1 tablet by mouth two times a day, for seizures; lacosamide oral tablet 200 mg, give 1 tablet by mouth two times a day, for seizures; levetiracetam oral tablet 500 mg, 3 tablets by mouth two times a day, for seizures; pregabalin oral capsule 200 mg, 1 capsule by mouth two times a day, for seizures; pregabalin oral capsule 300 mg, 1 capsule by mouth two times a day, for epilepsy and risperidone oral tablet 2 mg, 1 tablet by mouth in the morning, for personal history of other diseases of the nervous system and sense organs. Valtoco (diazepam) 15 mg dose nasal liquid therapy pack 7.5 mg/0.1 milliliter (ml) was discontinued upon discharge from the hospital. Review of the admitting physician orders dated 11/14/24 included medication orders for: lacosamide oral tablet 200 mg, give 1 tablet by mouth two times a day, for seizures; carbamazepine ER oral tablet extended release 12-hour 100 mg, give 1 tablet by mouth twice a day, for seizures; clobazam oral tablet 10 mg, give 1 tablet by mouth two times a day, for seizures; divalproex sodium ER oral tablet extended release 24-hour 500 mg, give 1 tablet by mouth two times a day, for seizures; levetiracetam oral tablet 500 mg, give 3 tablets by mouth two times a day; and lactulose solution 20 gram/30 milliliters gm/ml, give 30 ml by mouth before meals, for supplement. Review of physician orders dated 11/15/24 revealed medication orders for: Valtoco 15 mg dose nasal liquid therapy pack 7.5 mg/0.1 ml, 1 spray in each nostril as needed (PRN) for seizures; lacosamide oral tablet 200 mg, give 1 tablet by mouth two times a day, for seizures; carbamazepine ER oral tablet extended release 12-hour 100 mg, give 1 tablet by mouth twice a day, for seizures; risperidone oral tablet 2 mg, give 1 tablet by mouth in the morning, related to personal history of diseases of the nervous system and sense organs; pregabalin oral capsule 200 mg, give 1 capsule by mouth two times a day, related to epilepsy; pregabalin oral capsule 300 mg, give 1 capsule by mouth two times a day, related to epilepsy; valium oral tablet 5 mg, give 5 mg by mouth PRN for anxiety/agitation for 14 days at HS/PM (bedtime) daily. Review of the medication administration record (MAR) revealed the following medications were scheduled to be administered: risperidone was scheduled to start on 11/16/24 at 7:00 A.M., and was discontinued on 11/17/24 at 2:54 P.M. There were no doses recorded as being administered. lacosamide was scheduled to start on 11/14/24 at 3:00 P.M., and was discontinued on 11/15/24 at 6:59 A.M., with no doses administered. Another order for lacosamide was scheduled to start on 11/15/24 at 7:00 A.M., and was discontinued on 11/17/24 at 2:54 P.M. There were no recorded doses administered. pregabalin 200 mg and the 300 mg doses were scheduled to start on 11/15/24 at 3:00 P.M., and were discontinued on 11/17/24 at 2:54 P.M. There were no recorded doses administered. Valtoco 15 mg, administer 1 spray in each nostril as needed (PRN) for seizure was scheduled to start on 11/15/24 at 5:45 A.M., and was discontinued on 11/17/24 at 2:54 P.M. There were no recorded doses administered. carbamazepine ER oral tablet extended release 12-hour 100 mg, 1 tablet by mouth two times a day, for seizures. Documented as being 100 mg being administered on 11/14/24 evening dose, and 11/15/24 morning and evening dose. diazepam oral tablet 5 mg, give 5 mg by mouth as needed (PRN) for anxiety/agitation for 14 days at HS (bedtime)/PM daily. This order began on 11/15/24 at 5:30 P.M., and was discontinued on 11/17/24 at 2:54 P.M. There were no recorded doses administered. Review of the discharge paperwork for Resident #76 revealed an order for carbamazepine ER oral tablet extended release 12-hour 100 mg for three tablets (300 mg) to be taken by mouth two times a day, for seizures. Review of the progress note for Resident #76 dated 11/14/24 at 8:39 P.M., revealed the lacosamide oral tablet 200 mg was not available. Review of the progress note for Resident #76 dated 11/15/24 at 7:52 A.M., revealed the ergocalciferol oral tablet was not available and pharmacy will send out. Review of the progress note for Resident #76 dated 11/15/24 at 7:53 A.M. revealed the lacosamide oral tablet 200 mg was not available, the pharmacy was notified and will send out. Review of the progress note for Resident #76 dated 11/15/24 at 6:30 P.M., revealed the pregabalin oral capsule 300 mg was on order. Review of the progress note for Resident #76 dated 11/15/24 at 6:40 P.M., revealed the resident was up in the wheelchair 3 times this shift. Increased anxiety noted during the morning and afternoon. Co-nurse (unidentified nurse working in facility) called the resident's mother to inform her of the resident's increase in agitation and anxiety. The resident was moving and turning in the wheelchair and staff had to keep repositioning the resident several times this shift. The resident's mother brought in the resident's wheelchair from home which was better for the resident. The resident's mother stated the resident was having a seizure. The writer observed resident moving backward and forward in a slow but steady position. Review of a progress note dated 11/15/24 at 6:54 P.M., documented by LPN #100, revealed the nurse called the pharmacy to check on the resident's lacosamide, nasal spray for seizure and the spray has diazepam in it. The pharmacy stated they didn ' t have the order and needed a C2 form or prescription. The writer updated management of the resident's status and received the C2 form for Valtoco 7.5 mg/ 0.1 ml from the physician and also received a new order for diazepam 5 mg at HS or evening for agitation and anxiety for 14 days until he can be seen or evaluated by a neurologist. All forms were faxed to the pharmacy. Review of the progress note for Resident #76 dated 11/16/24 at 1:24 A.M., revealed a change of condition was noted with this resident and he was seizing. At this time the facility called the physician and received an order to send Resident #76 to the emergency room . Review of a progress note for Resident #76 dated 11/16/24 at 7:11 A.M., revealed Resident #76 was sent to the ER for seizure activity on the previous shift. Review a progress note dated 11/16/24 at 12:15 P.M., written by Registered Nurse (RN) #160, revealed Resident #76 was sent to the emergency room for seizure activity on the previous shift. Further review of the medical record revealed no evidence of the physician being notified of Resident #76 not receiving medications as ordered or seizure activity until 11/16/24 at 1:24 A.M. Review of the emergency medical squad (EMS) patient care record for Resident #76 dated 11/16/24, revealed the first contact documented between EMS and Resident #76 was at 12:51 A.M. At 12:52 A.M., oxygen 2 liters per minute (lpm) was applied to Resident #76 via a nasal cannula (a small, flexible tube that contains two open prongs intended to sit just inside the nostrils) and an intravenous (IV) was started in his right hand. At 12:54 A.M., 2.5 mgs of Versed (a medication used to stop a seizure that has gone too long or if many seizures occur in a short period of time) was administered intramuscular (IM). At 12:58 A.M., Resident #76 was secured to the stretcher for transport. At 1:01 A.M., 2.5 mg of Versed was administered IM. At 1:07 A.M., Resident #76 received 150 ml of normal saline (NS) through his IV. At 1:09 A.M., 2.5 mgs of Versed was administered IV to Resident #76. At 1:13 A.M., 2.5 mgs of Versed was administered IV to Resident #76. At 1:20 A.M., Resident #76 arrived at the emergency room via ambulance and was transferred from the ambulance to the hospital cot. Review of the emergency department (ED) physician notes dated 11/16/24 at 1:40 A.M., revealed Resident #76 continued to have tonic-clonic seizures upon arrival to the ED, despite the interventions provided by EMS. The facility indicated Resident #76 did not have his medications since arrival to the facility as they did not have access to his medications. Due to the condition of Resident #76, the ED physician requested staff to prepare for possible intubation (inserting a tube into the airway to establish an airway for mechanical ventilation). Review of the ED physician notes dated 11/16/24 at 2:20 A.M., revealed Resident #76 had a critically elevated Myoglobin level (test for muscle damage) of 745.7 micrograms per liter (mcg/l), with a normal value range of 5-70 mcg/l; a critically elevated creatine kinase (CK) level (test to evaluate muscle damage) of 544 units per liter (U/l) with normal value range of 24-204 U/l; an elevated Troponin I (test of a protein found in cardiac and skeletal muscles that help regulate calcium-mediated muscle contractions and relaxation) of 10 nanogram per milliliter (ng/ml) with normal value range of 0.0-0.4 ng/ml; and a critically elevated Lactate level (by product of the body's normal metabolism and exercise. Blood lactate can increase during intense physical activity) of 5.5 millimoles per liter (mmol/l) with normal value range of 0.5-1 mmol/l. These elevated lab values are due to Resident #76's persistent seizure. Resident #76's Valproic acid level (the laboratory test utilized to determine the therapeutic level of Depakote (divalproex sodium) was 21 mcg/l. The therapeutic level for Valproic acid is 50-100 mcg/l indicating Resident #76's Depakote level was subtherapeutic. Upon evaluation of Resident 76's clinical presentation and laboratory findings, it was determined Resident #76 needed to be transferred to another hospital where he would be admitted into the neurological ICU for further evaluation and treatment of his persistent tonic-clonic seizures. Review of the ED Physician Notes date 11/16/24 at 2:53 A.M., revealed the ED physician initiated a transfer to a tertiary care facility for admission to the neurological ICU for further care and treatment. Interview on 11/25/24 at 11:50 A.M. with the DON revealed the order for lacosamide was changed and not obtained because the physician had not sent the order to the pharmacy. The DON verified no doses of lacosamide was administered during Resident #76's admission. The DON verified Resident #76 did not receive any of the ordered pregabalin due to the orders were not entered immediately upon admission as it was on the third page of medication orders the facility received from hospital. The facility staff did not see the third page of orders until the morning of 11/15/24 during the 24-hour admission check and were subsequently entered at 7:26 A.M., with the first scheduled administration to occur on 11/16/24 at 7:00 A.M. The DON verified the Valtoco nasal spray was ordered to be restarted by the facility physician on 11/15/24 at the request of Resident #76's mother. The DON stated the physician, or facility should have faxed a prescription for this medication to the pharmacy at this time, but there is no record of the physician or facility faxing a prescription to the pharmacy for this medication. The DON verified the physician was not notified of pregabalin was not administered as ordered and not scheduled to be administered until 11/16/24. Interview on 11/25/24 at 1:32 P.M., with Resident #76's mother revealed she had been the primary care provided to Resident #76 for the entirety of his life, but his increasing care needs necessitated seeking a facility to provide the additional care he required. She stated on 11/14/24, upon his discharge from the hospital, she provided transportation to the facility via a private car. Upon arrival at the facility, she gave the admitting nurse a folder which contained a face sheet, Resident #76's discharge paperwork with orders, 12 tablets of clobazam 20 mg, and a bottle containing an unidentified quantity of carbamazepine 100 mg tablets. Resident #76's mother stated she spoke to the admitting nurse for approximately one hour to ensure that all items needed for admission were complete. Resident #76's mother stated she informed the facility she was willing to provide medication from home for Resident #76 to ensure that he had all necessary medications, but was assured by the facility that the pharmacy would have all of Resident #76's medications. Upon returning to the facility later in the evening on 11/14/24, Resident #76's mother asked the facility nurse if he had received all of his medication, and she was told he did. Resident #76's mother states that on the morning on 11/15/24, the facility called and asked her to provide Resident #76's personal wheelchair as he appeared to be uncomfortable in the facility wheelchair. Upon her arrival to the facility at approximately 1:30 P.M., she noted Resident #76 was seizing and appeared to have been up all night. At this time, Resident #76's mother notified facility staff. Upon noting Resident #76's seizure activity, his mother inquired from the nursing facility staff if he had received his seizure medications, and she was again assured that he had. At this time, she requested his PRN Valtoco nasal spray be administered. Per Resident #76's mother, the facility staff told her that the medication was not at the facility. Resident #76's mother stated she would go home and retrieve it from there and facility nursing staff replied that it would be faster if the facility pharmacy supplied it. Resident #76's mother stated she waited for the medication to arrive for one hour and at that time she left the facility and went home to obtain the medication. Upon returning to the facility with the Valtoco 15 mg Dose Nasal Liquid Therapy Pack 7.5 mg/0.1 ml, Resident #76's mother stated she administered it to him. Resident #76's mother stated she received a telephone call on 11/16/24 at approximately 1:10 A.M. from the facility and was told the facility had called 911 to transport Resident #76 to the emergency room (ER) due to Resident #76 seizing uncontrollably. She stated the facility told her they had administered two doses of Valium overnight on 11/15/24 into 11/16/24. She stated she arrived at the ER prior to the arrival of Resident #76 and was taken back to await his arrival. She stated that upon arrival to the ER, Resident #76 was seizing uncontrollably. Review of a text message dated 11/25/24 at 3:50 P.M. sent from LPN #100 to the DON stated: To whomever is concerned in regard to Resident #76's Valtoco, seizure medication was not available. This nurse called the pharmacy and inquired about medication. Pharmacy technician stated need C2 form. This nurse received a C2 form from the DON and faxed the order to the pharmacy. This nurse explained to the resident's mom that it would take a while before the pharmacy brings medication. Resident#76's mom stated that he had a dose or 2 at home and that she would bring it in. This nurse received a call from the receptionist stating that the resident's mom had returned with medication. This nurse spoke with Resident #76's mom, and she stated, this is Resident #76's last dose. Resident #76's mom gave resident the Valtoco medication, and resident was calm and up in his wheelchair for supper and no distress noted. The medication was effective. The pharmacy received an order, and the medication order was being prepared. Interview on 11/25/24 at 4:16 P.M. with the DON revealed Resident #76 received no doses of Risperidone during his admission. Concurrent interview with the DON revealed this medication order was not entered immediately upon admission as it was on the third page of medication orders the facility received from the hospital upon Resident #76's admission and it was missed by the facility until the morning of 11/15/24 during the 24-hour admission check and entered at 7:26 A.M. with the first scheduled administration to occur on 11/16/24 at 7:00 A.M. Further interview with the DON revealed Resident #76 received no doses of Risperidone during his admission. The DON stated that LPN #100 stated to her that the mother of Resident #76 brought in his Valtoco and administered it herself. Interview on 11/26/24 at 10:45 A.M. with the DON revealed she was not aware of any communication between the facility and the physician between the afternoon hours on 11/15/24 and approximately 1:00 A.M. regarding the change in condition of Resident #76. Interview on 11/27/24 at 7:32 A.M. with the DON verified the dose discrepancy for carbamazepine between the facility order for 100 mg by mouth twice a day, for seizures, and the hospital discharge order for three 100 mg (300 mg) by mouth twice a day for seizures. The DON verified Resident #76 did not receive the physician ordered amount of carbamazepine. Interview on 11/27/24 at 9:25 A.M. with the DON verified Resident #76 received no doses of diazepam during his admission. Review of the policy titled, Seizures and Epilepsy - Clinical Protocol, with a revision date of September 2018, revealed the physician and staff will help identify individuals who have a history of seizure or epilepsy. Seizures and epilepsy are not identical. Review of the policy titled, Delivery and Receipt of Routine Deliveries, dated 12/01/07, revealed the pharmacy and facility should coordinate to determine delivery day(s) and time(s) as soon as possible. Review of the policy titled, Change in a Resident's Condition or Status, revised May 2017, revealed the facility shall promptly notify the resident, his or her attending physician, and representative (sponsor) of changes in the resident's medical/mental condition and/or status. Review of the policy titled, Admission Assessment and Follow Up: Role of the Nurse, revised September 2012, revealed the facility will reconcile the list of medications from the medication history, admitting orders, the previous MAR (if available), and the discharge summary from the previous institution, according to established procedures. Review of the policy titled, Administering Medications, revised April 2019, revealed medications are administered in a safe and timely manner. Medications are administered in accordance with prescriber orders, including any required time frame. This deficiency represents non-compliance investigated under Complaint Number OH001160040.