Every finding on record at Bluebonnet Point Wellness

Based on observation, interviews and record reviews, the facility failed to provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of 5 of 6 medication carts (hallway 200 MA's cart, hallway 200 Nurse's cart, hallway 300 MA's cart, hallway 400 MA's cart, and hallway 400 Nurse's cart) reviewed for pharmacy services. 1.The facility failed to ensure the nursing staff responsible for the safekeeping of narcotics performed and documented change of shift narcotic counts on hallway 200 MA's cart, hallway 200 Nurse's cart, hallway 300 MA's cart, hallway 400 MA's cart, and hallway 400 Nurse's cart. 2. MA-C signed the Controlled Drugs-Audit Record count sheets for the end of their shift at the beginning of their shift on MA's cart station 200 on 07/08/2026. 3.MA-C did not sign the Narcotic Sheet Count on-coming signature at the beginning of her shift on MA cart hallway 200 on 07/08/2026. 4.LVN-D did not document the total count of narcotic sheet's in the book on the Narcotic Sheet Count at the beginning of her shift on MA cart hallway 300 on 07/08/2026. 5.LVN-B signed the Controlled Drugs-Audit Record count sheets for the end of their shift at the beginning of their shift on Nurse's Cart Station 400 on 07/08/2026. These failures could place residents at risk for loss of medications, inaccurate medication control practices and possible drug diversion. Findings included: 1.Record review of the June 2026 Narcotic Drug Shift Count Sheets for 5 of 6 medication carts indicated there were multiple missing signatures indicating change of shift narcotic counts were not completed as required from 06/01/2026 through 06/30/2026. The count sheets indicated the carts were to be counted at the beginning and end of each shift. Missing signatures for 06/01/2026 through 06/30/2026 were as follows: Hallway 200 MA's cart: June/2026 Change of Shift Narcotic Count6am-6pm shift - 10 missed signatures 6pm-6am shift - 12 missed signatures Hallway 200 Nurse's cart: June/2026 Change of Shift Narcotic Count6am-6pm shift - 14 missed signatures 6pm-6am shift - 14 missed signatures Hallway 300 MA's cart: June/2026 Change of Shift Narcotic Count6pm-6am shift - 6 missed signatures Hallway 400 MA's cart: June/2026 Change of Shift Narcotic Count6am-6pm shift - 6 missed signatures 6pm-6am shift - 6 missed signatures Hallway 400 Nurse's cart: June/2026 Change of Shift Narcotic Count6am-6pm shift - 5 missed signatures 6pm-6am shift - 4 missed signatures 2. During an observation on 7/08/2026 at 9:35 A.M., MA-C signed the controlled drugs audit record for both the on-coming and off-going shift at the beginning of the shift on MA's cart station 200 on 07/08/2026 a 6a.m. to 6p.m. shift. 3. During an observation on 7/08/2026 at 9:40 A.M., MA-C did not sign the narcotic sheet counts' (the total count of narcotic sheets in the book) for the on-coming witness signature at the beginning of her shift on MA's cart hallway 200 on 07/08/2026 a 6a.m. to 6p.m. shift. 4. During an observation on 7/08/2026 at 9:45 A.M., LVN-D did not document the number the total count of narcotic sheets in the book on the narcotic sheet count at the beginning of her shift on MA's cart hallway 300 on 07/08/2026 a 6a.m. to 6p.m. shift 5. During an observation on 7/08/2026 at 9:50 A.M., LVN-B signed the controlled drugs audit record count sheets for the on-coming and off-going shift at the beginning of their shift on Nurse's Cart Station 400 on 07/08/2026. During an interview on 07/8/2026 at 01:15 P.M., MA-C said change of shift narcotic counts was important for ensuring there were no missing or unaccounted narcotics. MA-C said she signed the controlled substance audit record for both the off-going and on-coming shifts and acknowledged she forgot to sign the narcotic count sheet as the oncoming witness before starting her day shift because she was rushed to begin her duties. She said the missing signatures indicated the change of shift narcotics count was not done. She further said this practice could delay detection of missing controlled substances. During an interview on 07/8/2026 at 01:30 P.M., LVN-B said there was no acceptable excuse for not performing change of shift narcotic counts. She stated she was aware that the off going controlled substance count documentation should not be signed until the end of her shift. She said the change of shift narcotic count was important for making sure there were no narcotics missing drugs. She said this practice could create the potential for inaccurate narcotic accountability. During an interview on 07/08/2026 at 01:37 P.M., LVN-D said the task of performing change of shift narcotic counts was important for ensuring all narcotics are accounted for. LVN-D acknowledged that she did not document the total narcotic count on the controlled substance audit record. She said the omission was an oversight. However, she signed as the oncoming nurse, indicated she had witnessed and verified the narcotic count. She said change of shift narcotic counts were supposed to be done by 2 staff persons, the nurse or medication aide coming on duty and the medication aide or nurse going off duty. She said the signatures on the narcotic count sheets were proof the change of shift count was done. During an interview on 07/08/2026 at 01:45 P.M., with the charge nurse RN-E, she said she was aware that the narcotic count sheet should be signed after each medication counted agreed with the quantity stated on the controlled count record. She said nurses should only sign and acknowledge the controlled drug count after verifying the medications on hand and confirmed the quantity of each medication matched the quantity documented on the controlled drug count record. She said forgetting to sign the controlled substances count at shift change could create the potential for inaccurate narcotic accountability. During an interview on 07/08/2026 at 02:05 P.M., the DON said she was responsible for ensuring change of shift narcotic counts were being done every shift. The DON acknowledged awareness of the missing documentation on the narcotic count sheets. She said the facility implemented corrective actions, including continued in-service education for nursing staff regarding controlled medication storage, shift-to-shift counting procedures, and required documentation. The shift-to shift controlled medication sign-out/count forms were reviewed, revised, and updated. She said the purpose of narcotic counts between the oncoming and off-going medication aides and nurses was to ensure all narcotics were accounted for and to reduce the risk of misappropriation or unaccounted for narcotics. A review of the facility's policy dated 2025 (revised 4/6/26), and titled Controlled Medication Administration indicated the following: Medications included in the Drug Enforcement Administration (DEA) classification as controlled substances are subject to special handling, storage, disposal, and record keeping in the nursing care center in accordance with federal, state, and other applicable laws and regulations. 8. At each shift change or when keys are surrendered, a physical inventory of all Schedule II, including refrigerated items, is conducted by two licensed nurses or per state regulation and is documented on the controlled substances accountability record or verification of controlled substances count report. The nursing care center may elect to count all controlled medications at shift change.

Based on observation, interview and record review, the facility failed to provide pharmaceutical services, including the accurate acquiring, administering, and receipt of all drugs and biologicals, to meet the needs of 1 of 2 residents (Resident #1) reviewed for pharmacy services. The facility failed to ensure that Resident #1's Atorvastin (for reducing cholesterol), Cetrizine (for allergies), Melatonin (for sleep), Ropinirole (for discomfort of restless legs), Venlafaxine (for depression-mood disorder causing persistent sadness and loss of interest affecting thoughts feelings and daily activities), Depakene (to prevent migraine headaches), Gabapentin (for neuropathy-numbness, tingling, and burning of feet and hands), and Biotin (for moisture in the mouth) were administered per physician's orders. This failure could place residents at risk for not receiving the therapeutic benefit of medications, or at risk of not having accurate records of medication administration.Findings included: Record review of the undated face sheet indicated Resident #1 was a [AGE] year-old female that admitted [DATE] and readmitted [DATE]. Record review of the physician's orders dated 1/14/26 indicated she had diagnoses that included: Hemiplegia (paralysis of one side of the body), Dementia (severe memory, thinking, and reasoning decline that interferes with daily life, caused by diseases damaging brain cells), gastrostomy status (a surgically created opening into the stomach for a feeding tube to provide nutrition, fluids, or medication) and depression (mood disorder causing persistent sadness and loss of interest affecting feelings, thoughts, and daily activities). Record review of the quarterly MDS dated [DATE] indicated Resident #1 had unclear speech, usually understood others, and was usually understood by others. Resident #1 had a BIMS of 2 indicating severe cognitive impairment. She had a feeding tube. Record review of the undated care plan indicated Resident #1 had hemiplegia and weakness on her right side related to a stroke, impaired cognitive function/dementia or impaired thought processes, and required tube feeding. Record review of Resident #1's physician's orders dated 12/22/25 indicated: 12/16/25 Biotin 10 ml orally three times per day for buccal moisture (moisture in the mouth).12/15/25 Cetirizine HCL tablet 5 mg via g-tube, one time per day related to allergic rhinitis (seasonal allergies)12/15/25 Atorvastin Calcium Oral 40 mg via g-tube one time a day related to hyperlipidemia (high cholesterol)12/18/25 Depakene oral solution 250 mg/5ml, 10 ml via peg tube two times daily related to cerebral infarction (death of brain tissue due to lack of oxygen).12/20/25 Gabapentin oral tablet 100 mg via g-tube two times a day for neuropathy (nerve damage causing numbness tingling or weakness).12/20/25 Melatonin 5 mg 2 tabs by mouth one time per day for sleep-aid.12/15/25 Ropinirole HCL oral table 0.25 mg via g-tube one time a day for restless legs syndrome12/15/25 Venlafaxine HCL tablet 75 mg via g-tube one time per day related to depression. Record review of the PIR, called into the state authority, dated 12/23/25 indicated on 12/23/25 Resident #1's family called the ADM and was questioning whether Resident #1's medications were provided on the night shift. RN C said she did not administer the g-tube medications because she had received written communication that the g-tube medications had been administered. LVN D said she had left written communication for the oncoming nurse, however she stated that she specified which rooms/beds where she had administered medications, and she did not indicate [Resident #1's room number] was administered. RN C failed to follow facility policy/procedures related to medication administration. There was also a miscommunication/misunderstanding between the exiting and the oncoming nurse as it related to medications. On 12/23/25 RN C was suspended pending investigation. Record review of a statement given by CNA E indicated during her shift 12/22/25 at 10:00 PM -12/23/25 at 6:00 AM (her shift) she did not specifically see RN C go into Resident #1's room, and Resident #1 told her she was not in pain. During an observation and interview on 1/14/26 at 9:46 AM, revealed Resident #1 was in bed, positioned with pillows. This surveyor asked if staff was nice to her and she said Yeah. She said staff was kind. She then closed her eyes and turned her head. She had feeding tube supplies in her room. During an interview on 1/14/26 at 10:37 AM, the RCN said Resident #1's family reported on 12/23/25 they did not believe she got her g-tube medication on 12/22/25. They suspended RN C pending the investigation. When they called RN C in to talk with her, RN C said she had not given the g-tube medication because LVN D had given Resident #1 her g-tube medication. LVN D had not given Resident #1 her g-tube medications. Resident #1 had labs drawn every Monday. They let the NP know Resident #1 had missed her PM medications on 12/22/25. The NP reviewed Resident #1's labs from 12/22/25 and assessed her to have no harm or negative effect. During an interview and record review on 1/14/26 at 1:01 PM, the RCN showed the surveyor a note from LVN D indicating she had given medications to rooms [rooms were listed] and the rooms did not indicate Resident #1's room as a room she had given medication to. She said RN C signed off on Resident #1's PM medications on the MAR and showed the MAR to the surveyor. The RCN and the surveyor reviewed the MAR for December 2025. The MAR reflected RN C had signed off on the following PM medications for Resident #1 on 12/22/25. The RCN said she assumed the following medications were not given to Resident #1 on 12/22/25: Atorvastin Calcium Oral 40 mg via g-tube one time a day related to hyperlipidemia. (high cholesterol) Cetirizine HCL Oral tablet 5 mg one time per day related to allergic rhinitis. (allergies) Melatonin 5 mg 2 tabs by mouth one time per day for a sleep aid. Ropinirole HCL oral table 0.25 mg via g-tube one time a day related to restless legs syndrome. (irresistible urge to move the legs often with unpleasant crawling, tingling, or aching sensations) Venlafaxine HCL oral tablet 75 mg, one time per day related to depression. (mood disorder causing persistent sadness and loss of interest affecting thoughts, feelings and daily activities) Depakene oral solution 250 mg/5ml, 10 ml viz peg tube two times daily related to cerebral infarction. Gabapentin oral tablet 100 mg via g-tube two times a day for neuropathy. (tingling, burning, and numbness in hands and feet) Biotin 10 ml orally three times per day for buccal moisture. (moisture in the mouth) During an interview on 1/14/26 at 1:39 PM, the RNC said the Melatonin by mouth was an error and she fixed it for g-tube administration. Resident #1 came back from the hospital 12/16/25 with a feeding tube, and they had to change all the orders to be administered by g-tube. She said RN C believed Resident #1's g-tube medications were already given. However, she did not understand why she would check off medications she had not given. During an interview on 1/14/26 at 2:17 PM, LVN D said RN C relieved her on the night of 12/22/25. She said she told RN C she would give the PO medications, but Resident #1 did not have any PO medications. She said it was possible RN C thought she had given the g-tube medications to Resident #1. LVN D said she left a note that said she had given the 8:00 PM medications for rooms: [rooms listed] but Resident #1's room was [room listed]. So, RN C should have known she did not give Resident #1's medications, but RN C could have read the note quickly, and she was working a lot of hours. She showed this surveyor the note LVN D had written. She said RN C was not the type of person that would say she gave medications she did not. She said RN C checked the medications off (as given) because she believed she (LVN D) had given them. She said sometimes she would give medications, only the PO's, to some of the residents to help out the night shift. She said if the medications did not pop up in the computer, she could sign off on them and that was why RN C would have signed off on them. During an interview on 1/14/26 at 2:25 PM, RN C said she did not give the PM g-tube medications to Resident #1 on 12/22/25. She said she did not get to work until 10 PM.She said when she got to work, there was a note from LVN D indicating LVN D had given the medications, but she must have misread the note, she realized later. She said she had signed off on medications she believed LVN D had given, but would not ever do that again. She said she signed off on Resident #1's PM medications and agreed she did not give Resident #1 her atorvastin, cetirizine, melatonin, ropinirole, venlafaxine, depakene, gabapentin, or biotin. She said since then she had in-services on the 5 rights of medications, not signing off on medications she did not give and several others. She said the harm that could come from not giving Resident #1 her medications could be so many things. She said it was clear to her now that she messed up. She said the medications that Resident #1 did not receive were for high cholesterol, pain, depression, trouble sleeping, allergies, and that was all she could think of. During an interview on 1/14/26 at 2:57 PM, the RCN said since the incident with Resident #1 and RN C on 12/22/25 they had 3 nurses all the time at night, and 3-4 during the day beginning 12/23/25. There were no more split shifts, so there were more nurses now. She said she knew, after the fact, that RN C had signed off on medications that LVN D had supposedly given. She said they did an in-service on the 5 rights of medication administration. The RCN said she did not know why LVN D would not check off the medications she had given because they can start those check-offs at 6:30 PM. She said the computer program did not allow staff to check off the evening medications before 6:30 PM. During an interview and observation on 1/15/26 at 8:35 AM, the ADM said Resident #1's family said the video in her room was motion activated. She said a person had to get to a certain point in the room before the video would pick up. She said the family agreed it did not pick up everything. From what she had seen it was not a continuous running video, it was only clips. Family emailed the videos to her and said that was all the camera picked up between 10:00 PM on 12/22/25 to 6:00 AM on 12/23/25. There were only clips, not full video that she was sent. The ADM had her computer and pulled up the emailed videos for Resident #1. This surveyor reviewed the following: Clip 1. Video clip dated 12/22/25 at 9:55 PM. The surveyor saw Resident #1 in bed. CNA E came in the room then the video stops. The CNA was talking to the resident and had some wipes in her hand. Clip 2. Video clip dated 12/22/25 at 9:56 PM. The surveyor saw the CNA performing incontinent care. Clip 3. Video clip dated 12/23/25 at 1:08 AM. The surveyor saw the resident moving around in her bed. Clip 4. Video clip dated 12/23/24 at 5:01 AM. THe surveyor saw CNA E going into the room. The surveyor did not see RN C or LVN D go into the room to administer g-tube medications. The ADM said she did not believe Resident #1 received her PM medications. The ADM said it was not appropriate for RN C to document medications she did not give because that was against the nursing standard of practice. She said there was a potential for harm to Resident #1, but according to nursing and the NP there was no harm. The ADM said when they notified the NP Resident #1 probably did not receive her PM medications on 12/22/25 the NP assessed Resident #1 on 12/23/25 and reviewed her labs. She had labs on 12/22/25 because she was a newer tube feeding. Other than changing the amount of water in the tube feedings, the NP had no new orders. Record review of Resident #1's CBC (Complete Blood Count) and BMP (Basic Metabolic Panel) labs dated 12/22/25 indicated she had low sodium. Her sodium was 129 mmol/l and normal was indicated to be 136.0-145.0 mmol/l. During an attempted phone interview on 1/15/26 at 9:10 AM, called Resident #1's Family Member K, her voice mail was full, and the surveyor could not leave a message. During an interview and record review on 1/15/26 at 9:15 AM, the RCN said they had an in-service on documentation. She showed this surveyor a Weight Watchers note dated 12/23/25 indicating: Resident #1 was NPO. The note indicated [Resident #1] recently admitted to the hospital from [DATE] to 12/15/25.She was placed on an NPO diet with enteral tube feedings. Diet change and g-tube are new for resident returning from hospital. CBC (Complete Blood Count) and BMP (Basic Metabolic Panel) drawn on 12/22/25. PM to 6:00 AM. Resident experienced no negative effects, labs reviewed by NP and enteral orders adjusted. The note was signed by the NP on 12/23/25 at 2:30 PM.The RCN showed the surveyor an in-service on Documentation dated 12/23/25 signed by the charge nurses. She provided the Medication Error Report dated 12/23/25 due to the possibly missed medications for Resident #1. The Med Error report indicated it was suspected Resident #1 did not receive her PM medications. RN C started her shift at 10:00 PM and was unsure if the medications were administered because there was a note left saying some PM medications had been administered. The NP was notified and indicated she would be at the facility to assess Resident #1. The RCN showed this surveyor the time sheet indicating LVN D had clocked out at 6:23 PM on 12/22/25. During an interview on 1/15/26 at 9:42 AM, the NP and this surveyor went over the medications Resident #1 had likely missed on 12/22/25 (Atorvastin, Cetrizine, Melatonin, Ropinirole, Venlafaxine, Depakene, Gabapentin, and Biotin). She said the missed medications were not a problem. She said Resident #1's depakene was for migraines, not seizures, she did not have seizures. She said she had done labs on Resident #1 on 12/22/25. She said the labs indicated she was getting too much water because her sodium was a little low, so she decreased the water that went with the feeding. She assessed the resident the next day (12/23/25) once she was told of the situation and there were no issues or problems with the resident. During an interview on 1/15/26 at 10:07 AM, RN F said checking off medications given by someone else was a medication error and had to be reported to the DON and the ADM. She said checking off a medication that you did not give yourself was a big no-no. She said if you did not do it, you do not document that you did. During an interview on 1/15/26 at 10:40 AM, LVN G said nurses did not chart they gave medications that someone else gave, that had to be reported to the ADM and DON. She said if medications were not given as ordered it could cause an adverse reaction to a resident depending on the resident and the medications. During an interview on 1/15/26 at 10:47 AM, the ADON said she had heard that RN C signed off on Resident #1's PM medications even though she did not administer them. She said something like that had to be reported to the DON and ADM. She said all nurses knew not to document giving medications if they did not give them. During an telephone interview on 1/15/26 at 1:37 PM, LVN D said the morning of 12/23/25 RN C reported off to her. RN C did not ask about Resident #1's PM medications nor did they discuss Resident #1's PM medications for 12/22/25. Record review of an undated Medication Administration and General Guidelines Policy indicated: Policy Medications are administered as prescribed, in accordance with State Regulations using good nursing principles and practices and only by persons legally authorized to do so. Personnel authorized to administer medications do so only after they have familiarized themselves with the medication. Procedure 1.Medications are prepared, administered, and recorded only by licensed nursing, medical, pharmacy, or other personnel authorized by state laws and regulations to administer medications. 2.Medications are administered in accordance with written orders of the attending physician.11.The resident's MAR is initialed by the person administering a medication, in the space provided under the date and on the line for that specific medication dose administration. Adheres to the 6 Rights of Medication Administration1.Right Dose2.Right Route3.Right Resident4. Right Medication5.Right Time6.Right Documentation.

Based on observation, interview and record review the facility failed to immediately inform the resident, consult with the resident's physician; and notify, consistent with his or her authority, the resident representative where there was a significant change in the resident's physical, mental, or psychosocial status and when there was a need to alter treatment significantly for 1 of 2 residents (Resident #1) reviewed for enteral nutrition. The facility failed to notify Resident #1's attending physician when her tube feeding was stopped early due to her diarrhea. The facility failed to notify Resident #1's attending physician when her tube feeding was held due to diarrhea. These failures could place residents at risk for delayed treatment, not receiving necessary treatments and medications, and a decreased quality of life. Findings included: Record review of the undated face sheet indicated Resident #1 was a [AGE] year-old female that admitted [DATE] and readmitted [DATE]. Record review of the physician's orders dated 1/14/26 indicated Resident #1 had diagnoses that included: Hemiplegia (paralysis of one side of the body), Cerebral Infarction (brain tissue death caused by a blockage in a blood vessel cutting off oxygen and nutrients), Dementia (severe memory, thinking, and reasoning decline that interferes with daily life, caused by diseases damaging brain cells), and gastrostomy status (a surgically created opening into the stomach for a feeding tube to provide nutrition, fluids, or medication). The physician's orders indicated: 12/16/25 Glucerna 1.2 at 65 ml/hr with water flush of 50 ml/hr. Record review of the quarterly MDS dated [DATE] indicated Resident #1 had unclear speech, usually understood others, and was usually understood by others. Resident #1 had a BIMS of 2 indicating severe cognitive impairment. She had a feeding tube. Record review of the undated care plan indicated Resident #1 had hemiplegia and weakness on her right side related to a stroke, impaired cognitive function/dementia or impaired thought processes, and required tube feeding. Record review of the facility PIR dated 12/23/25 indicated on 12/23/25 Resident #1's family called the ADM and was questioning whether the tube feeding was provided on the night shift. RN C reported she did not administer Resident #1's feeding on 12/22/25 due to her diarrhea and stopped the feeding early the prior night 12/21/25 for the same reason. CNA E's statement was consistent with RN C's account that Resident #1 was experiencing multiple bouts of diarrhea since beginning her new tube feeding. CNA E did not see a tube feeding bag hung or running on the night shift 12/22/25 - 12/23/25.RN C used clinical judgement based on Resident #1's status believing the tube feeding should be held due to diarrhea. However, she failed to follow facility policy/procedures related to medication/treatment administration and reporting on residents experiencing a change of condition. On 12/23/25 RN C was suspended pending investigation. Record review of a statement given by CNA E indicated she did not see a feeding tube running at all during her shift 12/22/25 at 10:00 PM -12/23/25 at 6:00 AM (her shift) and Resident #1 told her she was not in pain. Record review of Resident #1's progress notes 12/21/25 - 12/23/25 indicated RN C did not document anything regarding her diarrhea or tube feeding. There was no documentation of notification to the MD/NP. The progress notes dated 12/19/25 - 12/23/25 did not indicate any staff had documented Resident #1 had diarrhea or that any tube feedings had been stopped or held. There was no documentation of notification to the MD/NP. During an interview on 1/14/26 at 8:15 AM, the ADM said Resident #1's family had a camera in her room that was motion controlled. They reported they did not see her feeding hanging on the pole the evening/night of 12/22/25 or the early morning of 12/23/25. Resident #1 was new to tube feeding and had diarrhea. The ADM said RN C ended Resident #1's tube feeding early on 12/21/25 because the resident had diarrhea, then withheld the tube feeding the following night (12/22/25) and did not follow the procedure for notifying the MD, or documenting anything about her diarrhea, stopping the feeding early on 12/21/26 or holding the feeding on 12/22/26. During an observation and interview on 1/14/26 at 9:46 AM, revealed Resident #1 was bed, positioned with pillows. The head of the bed was up approximately 40 degrees. There was a sign in her room indicating NPO. Resident #1 was asked if staff was nice to her and she said Yeah. She said staff was kind. She then closed her eyes and turned her head. She had feeding tube supplies in her room. During an interview on 1/14/26 at 10:37 AM, the RCN said Resident #1's family reported on 12/23/25 that her feeding had not been hooked up. They suspended RN C pending the investigation. When they called the RN C in to talk with her, RN C said Resident #1 was a new g-tube (returned from the hospital with it in 12/15/25 or 12/16/25). RN C said Resident #1 was having diarrhea. The RCN said Resident #1 had bolus (a large single meal of liquid formula over a short period of time), feedings during the day and a continuous feeding at night. RN C did not document Resident #1 was having diarrhea or notify the MD and that was a problem. The RCN said the CNA at the time corroborated Resident #1 was having diarrhea. Resident #1 had labs drawn every Monday. They let the NP know Resident #1 had missed a feeding on 12/22/25 and had a feeding stopped early on 12/21/25. The NP reviewed Resident #1's labs from 12/22/25 and she felt like she might be getting too much water and decreased her water flushes. There were no changes with her skin. RN C said the night before (12/21/25) she had stopped the feeding early. She said the resident missed one feeding on 12/22/25 that should have started at 10:00 PM and run until 6:00 AM. RN C did not call the MD, she held the feeding on her own. She did not document anything regarding Resident #1's diarrhea or holding her feeding. She said it was a problem because the feeding was ordered for nutrition and hydration. Holding the feeding could lead to dehydration and poor nutrition. She said the RN C did not let anyone know. RN C documented she gave the nighttime feeding, but they know she did not because she told them she did not. RN C said the documentation was a mistake, she clicked it off but said it was marked in error, and she meant to document it as not administered. The RCN said RN C should have contacted the MD and notified her of the change with Resident #1 and followed whatever orders she was given. But, she did not do that. She was suspended pending investigation. During an interview on 1/14/26 at 2:25 PM, RN C said on the night of 12/21/25 she stopped Resident #1's feeding at approximately 4:00 AM, 2 hours before she was supposed to because Resident #1 had bad diarrhea. She said on 12/22/25 she decided not to give Resident #1 her night feeding because she had massive diarrhea. They had to change her bed several times due to diarrhea. She said she should have called the MD but she did not. She said she should have documented it but she did not. She did not know it could not wait until morning, but she did not call the MD or NP in the morning. RN C said now she realizes she should have called the MD/NP right then. She gave report the morning of 12/22/25 to the oncoming shift, LVN D. She said she thought she told LVN D she stopped Resident #1's feeding early but she did not remember. She said since that incident she had in-services with charge nurses on when to call the MD, documentation, change of condition, and several others. (This surveyor reviewed the in-services provided to the charge nurses. She did not document that she stopped Resident #1's feeding early on 12/21/25, did not document Resident #1 had diarrhea on 12/21/25 and 12/22/25, and did not document she held Resident #1's feeding on 12/22/25. She believed she had documented the feeding on 12/22/25 as not given. She said the harm that could come from not feeding a resident could be so many things, dehydration, malnutrition, electrolyte imbalance. She said it was clear to her now that she messed up. During an interview and observation on 1/15/26 at 8:35 AM, the ADM said the Resident #1's family said the video in her room was motion activated. She said a person had to get to a certain point in the room before the video would pick up. She said the family agreed it did not pick up everything that went on in the room when she had discussed the video camera with them. She said from what she had seen it was not a continuous running video, it was only clips. Family emailed the videos to her and said that was all the camera picked up between 10:00 PM on 12/22/25 to 6:00 AM on 12/23/25. There were only clips, not full video that she was sent. The ADM had her computer and pulled up the emailed videos for Resident #1 to show the surveyor. This surveyor reviewed: Clip 1. Video clip dated 12/22/25 at 9:55 PM. The surveyor saw Resident #1 in bed. CNA E came in the room then the video stopped. CNA E was talking to the resident and had some wipes in her hand. There was no feeding bag on the pole, and no indication Resident #1 had a feeding running. Clip 2. Video clip dated 12/22/25 at 9:56 PM. The surveyor saw CNA E performing incontinent care. There was no feeding bag on the pole, and no indication Resident #1 had a feeding running. Clip 3. Video clip dated 12/23/25 at 1:08 AM. The surveyor saw the resident moving around in her bed. There was no feeding bag on the pole, and no indication Resident #1 had a feeding running. Clip 4. Video clip dated 12/23/24 at 5:01 AM. The surveyor saw the same CNA (CNA E) going into the room. Resident #1 was in bed. There was no feeding bag on the pole, and no indication Resident #1 had a feeding running. The ADM said the nighttime tube feeding was not given to Resident #1 on 12/22/25. She said it was not appropriate for RN C to document a feeding she did not give because that was against the nursing standard of practice. She said there was a potential for harm to Resident #1, but according to nursing and the NP there was no harm. She said she understood why RN C stopped the feeding early, but she did not notify the MD/NP for a change of condition or follow the proper procedure for notifying the MD/NP. She did not document the diarrhea, stopping the feeding early on 12/21/25, or holding the feeding on 12/22/25. RN C not notifying the MD/NP caused a potential for harm because Resident #1 had a change of condition, and she did not know how the MD/NP would have addressed Resident #1's diarrhea. The ADM said when they notified the NP Resident #1 had a feeding stopped early on 12/21/25 and did not receive her nighttime feeding on 12/22/25 the NP assessed Resident #1 on 12/23/25 and reviewed her labs. She had labs on 12/22/25 because she was a newer tube feeding. Based on the labs, the NP thought Resident #1 was getting too much on the water, so she decreased the water Resident #1 received with her feedings. Record review of Resident #1's CBC (Complete Blood Count) and BMP (Basic Metabolic Panel) labs dated 12/22/25 indicated she had low sodium. Her sodium was 129 mmol/l and normal was indicated to be 136.0-145.0 mmol/l. During an attempted phone interview on 1/15/26 at 9:10 AM, called Resident #1's Family Member K. Her voice mail was full, and the surveyor could not leave a message. During an interview and record review on 1/15/26 at 9:15 AM, the RCN said they had an in-service on documentation. She showed the surveyor a Weight Watchers note dated 12/23/25 indicating: Resident #1 was NPO. The note indicated [Resident #1] recently admitted to the hospital from [DATE] to 12/15/25. CBC (Complete Blood Count) and BMP (Basic Metabolic Panel) drawn on 12/22/25.Nutritional needs reviewed by nurse practitioner and dietician. Enteral orders adjusted to Glucerna 1.2 at 65 ml/hr with h20 flush 40 ml/hr from 10:00 PM to 6:00 AM. Also, Glucerna 1.2 bolus 1 1/2 cartons, 375 ml 4 times during the day from 8:00 AM to 8:00 PM with 45 ml h20 flush before and after. Reason for physician notification and any new orders: Resident missed enteral feeding 12/22/25 from 10:00 PM to 6:00 AM. Resident experienced no negative effects, labs reviewed by NP and enteral orders adjusted from 10:00 PM to 6:00 AM for h20 flush to be 40 ml/hr. The note was signed by the NP on 12/23/25 at 2:30 PM.The RCN showed the surveyor an in-service on Documentation dated 12/23/25 signed by the charge nurses. She provided the Medication Error Report dated 12/23/25 which indicated Resident #1's enteral feeding was not administered on 12/22/25 from 10:00 PM to 6:00 AM. Action taken indicated: Education provided to staff on medication administration, medication error, notification of change in condition, documentation, and enteral nutrition/hydration. During an interview on 1/15/26 at 9:42 AM, The NP said she had done labs on Resident #1 on 12/22/25. She said the labs indicated she was getting too much water because her sodium was a little low, so she decreased the water that went with the feeding. She said the nurse should have notified her about Resident #1's diarrhea so she could have monitored her. She said if the nurse had called her, she probably would have agreed to stop the feeding due to the diarrhea, but she could have monitored her more closely. She assessed the resident the next day (12/23/25) once she was told of the situation and there were no issues or problems with the resident. During an interview on 1/15/26 at 10:07 AM, RN F said if a resident had a tube feeding and got diarrhea or any change of condition, she would immediately notify the MD/NP for new orders. She said she would document the changes with the resident and document she called the MD/NP and any new orders that were given. She would never just not give an ordered tube feeding, she would notify the MD. During an interview on 1/15/26 at 10:40 AM, LVN G said a nurse should always call the MD/NP if a resident had a change of condition. She said a nurse should never hold a feeding on their own, the MD/NP had to give an order. She said a nurse had to document everything, every change with a resident, and when the nurse notified the MD. She said if a tube feeding was held without an MD order it could cause an adverse reaction to a resident such as dehydration or malnutrition depending on the resident. During an interview on 1/15/26 at 10:47 AM, the ADON said she had heard that RN C had stopped a feeding early and held a feeding for Resident #1. She said nurses should absolutely call the MD with any change of condition with a resident. She said a nurse should document any changes the resident had and when they notified the MD/PA. During a telephone interview on 1/15/26 at 1:37 PM, LVN D said on the morning of 12/22/25, RN C reported off to her. RN C told her she had stopped Resident #1's feeding a couple of hours early. She did not call the MD because she assumed RN C had. She said the morning of 12/23/25 RN C reported off to her. RN C did not tell her she held Resident #1's feeding. She said when she got to the facility at 6:00 AM the feeding would have been finished, and the bag (that held the feeding) would have been discarded so she would not have thought anything of the feeding not being in the room. She said on 12/21/25 or 12/22/25 she did not see Resident #1 having diarrhea. She said she gave Resident #1 her daily bolus feedings at 8:00 AM, 12:00 noon, and 4:00 PM with no issues. Record review of an undated Enteral Nutrition Policy indicated: Enteral Nutrition We will provide nutritionally complete enteral or parenternal feedings as ordered by the physician for the nourishment of residents who are unable to eat by mouth. Procedure: 1.The Nursing Services Department is responsible for all feeding equipment and the administration of tube feedings. Record review of an undated Notifying the Physician of Change in Status Policy indicated: The nurse should not hesitate to contact the physician at any time when an assessment and their professional judgment deem it necessary for immediate medical attention. This facility utilizes the Interact tool, 'Change in condition - When to Notify the MD/NP/PA to review resident conditions and guide the nurse when to notify the physician. This tool informs the nurse if the resident condition requires immediate notification of the physician or non-immediate/Report on Next Work day notification of the physician.1.The nurse will notify the physician or their delegated nurse practitioner or physician assistant with change in status. The nurse will document signs and symptoms of significant change, time/date of call to physician, and interventions that were implemented in the resident's clinical record.7.The nurse will document all attempts to contact the physician, all attempts to notify the family and/or legal representative, the physician's response, the physician's orders and the resident's status and response to interventions.

Based on observation, interview, and record review, the facility failed to promote care for residents in a manner and in an environment that maintained or enhanced each resident's dignity and respect in full recognition of his or her individuality for 1 of 3 residents reviewed for dignity. (Resident #2) The facility failed to ensure Resident #2 was treated with dignity and respect when LVN A told him he was acting like a 2-year-old. This failure placed residents at risk for diminished quality of life, loss of dignity and decrease in comfort. Findings include: Record review of the undated face sheet indicated Resident #2 was a [AGE] year-old male that admitted [DATE].Record review of the physician's orders dated 1/14/26 indicated Resident #2 had diagnoses that included: hemiplegia and hemiparesis following cerebral infarction affecting left dominant side (impairments on one side of the body due to brain cell death from interrupted blood flow, a stroke), Bell's Palsy (a sudden temporary facial paralysis or weakness on one side of the face caused by inflammation or damage to the facial nerve), and Type 2 Diabetes (high blood sugar and lack of insulin). Record review of the quarterly MDS dated [DATE] indicated Resident #2 had minimal difficulty hearing, usually understood others and was usually understood by others. The MDS indicated he had a BIMS of 15 indicating he was cognitively intact. Record review of an undated care plan indicated Resident #2 had hemiplegia/hemiparesis related to a stroke. The care plan indicated his stroke was related to heart disease. Resident #2 had impaired cognitive function/dementia or impaired thought processes and problems communicating. The PIR provided to the state authority indicated family had reported to the ADM on 1/4/26 LVN A had spoken to Resident #2 in a demeaning manner stating, You are acting like a 2-year-old. This was a video recording. During an interview on 1/14/26 at 8:15 AM, the ADM said LVN A was suspended, was termed on Monday (1/12/26) after the investigation. She said LVN A admitted to saying Stop acting like a child or a 2-year-old or something similar. She said it was a condescending thing to say. She said Resident #2 did not have any lingering effects from her saying that to him. She said she believed it was a dignity issue. The ADM said she did not feel like LVN A was abusive but was discourteous and disrespectful. Record review of LVN A's personnel file indicated an Employee Disciplinary Report dated 1/5/26 revealed LVN A hired on 8/6/25 as a charge nurse and was suspended 1/5/26 due to suspicion of verbal abuse (LVN A to Resident #2) on 1/4/26. She was termed on 1/12/26. During an observation and interview on 1/14/26 at 9:36 AM, revealed Resident #2 was in his room in bed. He was slow to speak. He said a staff had been rude to him. He could not say what she said. The resident was asked if she said he was acting like a child, or a 2-year-old. He said yes that was close to what she said but he did not remember word for word. He said he felt about that tall. and indicated by moving his index finger to his thumb with approximately 3 inches in between. The surveyor asked, Small? He said Yes. He said, other than that, everyone was very kind to him. He said once the incident was over, he did not care about it anymore. He said he felt small at the time it happened but felt good about himself now. During an interview on 1/14/26 at 10:37 AM, the RCN said the ADM told her, on the video LVN A was trying to get Resident #2's blood pressure or something. She said he was probably giving her a hard time. Resident #2 would pick and play, and staff had to talk him through what they needed to do. She said she had not seen the video. The ADM told her LVN A's comment was demeaning and condescending. The RNC said LVN A said she probably said that. The RCN said LVN A had a gruff personality. She said it was a dignity issue, and she should not have said that because it could affect his dignity and make him feel bad about himself. That was why she was termed. During a telephone interview on 1/14/26 at 12:00 PM, LVN A said she did tell Resident #2 to stop acting like a child, or a 2-year-old or something like that; but when you have to constantly ask to care for a resident and they are moving around and not allowing you to do what you need to, they are acting like a child. She said it might have been wrong to say but it was not abuse, it was what he was doing. She would not talk to the surveyor anymore. During an observation on 1/14/26 at 1:26 PM, the ADM showed this surveyor a video on her computer dated 1/4/26. LVN A was attempting to get Resident #2's blood pressure as he was moving and grabbing at an item appearing to be the TV remote. LVN A was asking him to be still. Resident #2 continued wiggling and LVN A said You are acting like a 2-year-old. Nothing else was said. LVN A removed the blood pressure cuff and left the room. During an interview on 1/15/26 at 10:07 AM, RN F said if she heard a staff tell a resident they were acting like a 2-year-old she would immediately remove the staff from the room. She would then report it the Abuse Coordinator/ADM. She said that was definitely a dignity issue. During an interview on 1/15/26 at10:44 AM, CNA H said it would be completely wrong for a staff to tell a resident they were acting like a child or a 2-year-old. She said that was verbal abuse and had to be reported to the ADM/Abuse Coordinator. She said anything like that had to be reported. During an interview on 1/15/26 at10:47 AM, the ADON said if a staff told a resident they were acting like a 2-year-old, or a child that should be reported to the ADM immediately because it could be a dignity issue. During an interview on 1/15/26 at 11: 09, the SW said she was not on shift when LVN A told Resident #2 he was acting like a child/2-year-old. She said she viewed the video tape. She said it could have been a dignity issue and did not believe it was abuse. Some people just did not know how to talk to people. LVN A did not have a hateful tone when she said that, she was just very direct. She said she spoke with Resident #2 and he said he had no concerns about the incident with LVN A and he did not need to talk about it. He told her he was ok and had no problems. She said she did not believe he had any lasting effects. Record review of a trauma assessment for Resident #2 dated 1/5/25 indicated he had no issues or effects. Record review of an undated resident rights policy indicated: The resident has a right to a dignified existence, self-determination, and communication with and access to persons and services inside and outside the facility, including those specified in this policy. A facility must treat each resident with respect and dignity and care for each resident in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life, recognizing each resident's individuality. The facility must protect and promote the rights of the resident.

Based on observations, interviews, and record reviews the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 1 of 6 residents (Resident #36) and 1 of 6 staff (CNA E) reviewed for infection control. The facility failed to ensure CNA E changed gloves when going from dirty to clean and washed or sanitized her hands between glove changes when providing care to Resident #36 on 8/12/2025.These failures could place residents at risk of exposure to infectious diseases due to improper infection control practices.Findings included:Record review of a facility face sheet dated 8/13/25 for Resident #36 indicated she was a [AGE] year-old female admitted to the facility on [DATE] with diagnosis of dementia.Record review of a Quarterly MDS assessment dated [DATE] for Resident #36 indicated a BIMS score of 06 which indicated she had severely impaired cognition. She required substantial/maximal assistance with all ADLs. She was always incontinent to bowel and bladder. Record review of a comprehensive care plan dated 6/5/25 for Resident #36 indicated she had an ADL self-care performance deficit and was dependent on 2 staff members for toileting.During an observation on 8/12/25 at 9:20 am CNA E was observed to provide incontinent care to Resident #36 with assistance of 2 staff members. After performing care on pubic/groin area, resident was rolled over and CNA E cleaned rectal area and buttocks. Soiled brief was then removed from underneath resident, and without changing her gloves, CNA E then placed clean brief underneath resident and applied barrier cream. CNA E then proceeded to remove her gloves and without using hand sanitizer, or washing her hands with soap and water, she applied new gloves and applied clean brief to Resident #36.During an interview on 8/12/25 at 9:30 am CNA E said she did not use sanitizer or wash her hands between her glove change and said she did not change her gloves before placing clean brief on resident. She said she should have put on clean gloves before applying the clean brief, and she said she should have used hand sanitizer or washed her hands between her glove change. She said it could cause cross contamination and put residents at risk of infection if hand were not cleaned appropriately. During an interview on 8/12/25 at 9:40 am ADON C said she expected CNAs to appropriately change gloves when going from dirty to clean and the use sanitizer or wash hands between glove changes. She said it was an infection control risk if appropriate hand hygiene was not performed. During an interview on 8/12/25 at 2:45 pm ADON D said she expected her staff to perform appropriate hand hygiene during perineal care. She said residents could be at risk for cross contamination and spreading of infections if hand hygiene was not performed as required. During an interview on 8/13/25 at 1:42 pm DON said he expected his staff to follow policy and procedures. He said residents could be at risk of infections if gloves were soiled and not changed appropriately or if proper hand hygiene were not performed. He said residents and staff could be at risk for outbreaks of diseases. He said he and ADON D were both responsible for staff training/checkoffs. He said they would be doing check offs more often to improve compliance.During an interview on 8/13/25 at 2:55 pm Administrator said she expected her staff to follow infection control policy and procedures. She said residents could be at risk for infections if proper hand hygiene was not followed. She said going forward, she would be re-educating and training staff to ensure compliance.Record review of a facility policy titled Perineal Care dated 5/11/22 indicated after providing care to back (rectal/buttock) area: .doff (remove) gloves.perform hand hygiene. and .conclude: .provide resident comfort and safety by reclothing (if applicable - incontinent pad(s) and brief. and .always perform hand hygiene before and after glove use.

Based on observation, interview and record review, the facility failed to ensure assessments accurately reflected the resident status for 2 of 12 residents (Resident's #4 and #8) reviewed for MDS assessment accuracy.The facility failed to ensure a comprehensive MDS assessment dated [DATE] for Resident #4 captured oxygen use, suctioning, and tracheostomy care.The facility failed to ensure a quarterly MDS assessment dated [DATE] for Resident #8 was not inaccurately coded for tracheostomy, dialysis, and hospice care. These failures could place residents at risk of not receiving adequate care and services to meet their needs. Findings included:1.Record review of a facility face sheet dated 8/13/25 for Resident #4 indicated he was a [AGE] year-old male admitted to the facility on [DATE] with diagnosis of acute respiratory failure with hypoxia. Record review of a Comprehensive MDS assessment dated [DATE] for Resident #4 indicated a BIMS assessment should not be completed due to resident being rarely/never understood. He had moderate cognitive impairment. Assessment reference dated was 7/27/25 with Section O (Special Treatments, Procedures, and Programs) not reflecting use of oxygen therapy, suctioning or tracheostomy care during the previous 14 days, while a resident, or not a resident of the facility. Record review of a Physician's Order Summary Report dated 8/13/25 for Resident #4 indicated he had the following physician orders: .Trach care 2 times a day prn. dated 7/22/25.change inner cannula Q7day one time a day every Thursday. dated 7/22/25 .change trach ties one time a day every Thursday. dated 7/22/25 .tracheal suctioning Q HR prn (as needed) every shift. dated 7/22/25 .oxygen at 8LPM via trach collar with humidification at 28 FiO2 every shift. dated 8/9/25Record review of a comprehensive care plan dated 8/8/25 for Resident #4 indicated he had a tracheostomy with an intervention to suction as necessary, and that he received oxygen therapy. Record review of a physician progress note dated 7/23/25 for Resident #4 and signed by MD G read: .today.the nurses removed his cannula and cleaned it. Suction[ed] easily. Record review of a nursing progress note dated 7/27/25 for Resident #4 and signed by LVN F read: .O2 LPM: 8L/M (Liters per minute) trach. 2. Record review of a face sheet dated 8/11/2025 for Resident #8 indicated she was an [AGE] year-old female who admitted to the facility on [DATE] with diagnoses which included dementia, heart failure, diabetes, chronic obstructive pulmonary disease (a group of lung diseases that block airflow and make it difficult to breathe), and anemia. Observation on 8/11/25 at 9:45 AM revealed Resident #8 was lying in bed with her head slightly elevated. Resident was asleep. Respirations were even, unlabored, and quiet. No observation of a tracheostomy or ventilator were noted, and she was not receiving any oxygen therapy. No evidence of a dialysis shunt on the arms or neck was noted. Record review of a quarterly MDS assessment dated [DATE] for Resident #8 reflected she had a BIMS score of 4 indicating her cognition was severely impaired. The Assessment Reference Date was 6/9/2025 with Section O (Special Treatments, Procedures, and Programs) reflecting Resident #8 was receiving hospice, dialysis, and tracheostomy care and services. Record review of physician orders dated 06/11/15 for Resident #8 indicated no orders for dialysis, hospice, or tracheostomy care and services. Record review of a care plan dated 8/11/2025 for Resident #8 indicated no concerns for or interventions to address dialysis, hospice, tracheostomy, or ventilator care and services. During an interview on 08/11/25 at 3:15 PM, RN H said Resident #8 did not have a tracheostomy and was not receiving dialysis nor hospice care. RN H said Resident #8 had never had a tracheostomy. During an interview with MDS Coordinator A on 8/12/25 at 3:24 PM, who said Resident #8 had not been on hospice, received dialysis, nor had a tracheostomy. She said Resident #8's quarterly assessment dated [DATE] was incorrectly coded for dialysis, hospice, tracheostomy, and ventilator care and services. MDS Coordinator A said she was the nurse who coded the assessment. She said she must have been thinking of another resident when she coded the assessment. MDS Coordinator A said the facility used the RAI 3.0 Manual as their guide for coding MDS assessments. MDS Coordinator A said the MDS assessments needed to be accurate because they serve as a guide for determining residents' care needs. During an interview with the Administrator on 06/12/2025 at 3:45 PM, who said she expected the MDS Nurses to correctly code the MDS assessments. Review of CMS's RAI Version 3.0 Manual: Section 1.3 Completion of the RAI indicated the following: While its primary purpose as an assessment instrument is to identify resident care problems that are addressed in an individualized care plan, data collected from MDS assessments are also used for the Skilled Nursing Facility Prospective Payment System (SNF PPS) Medicare reimbursement system, many State Medicaid reimbursement systems, and monitoring the quality of care provided to nursing home residents.The RAI process has multiple regulatory requirements. Federal regulations at 42 CFR 483.20 (b)(1)(xviii), (g), and (h) require that (1) the assessment accurately reflects the resident's status.As such, nursing homes are responsible for ensuring that all participants in the assessment process have the requisite knowledge to complete an accurate assessment.

Based on interview and record review, the facility failed to ensure an encoded, accurate, and complete MDS assessment was electronically transmitted to the CMS System within 14 days after completion for 1 of 6 residents (Resident #74) reviewed for encoding/transmitting assessments.The facility failed on 08/04/2025 to transmit a quarterly assessment to CMS for Resident #74 within 14 days of completion when the assessment was completed on 07/21/2025 by the Corporate RN Assessment Coordinator and the facility submitted the quarterly assessment for Resident #74 to CMS 9 days pass due on 08/13/2025. This failure could place residents at risk of not having records completed and submitted in a timely manner as required.Findings included:Record review of a face sheet dated 08/13/2025 indicated Resident #74 was a [AGE] year-old female who admitted to the facility on [DATE] with diagnoses which included aortocoronary bypass graft (a surgical procedure to treat coronary artery disease), congestive heart failure (a chronic condition in which the heart does not pump blood as well as it should), atherosclerotic coronary heart disease (damage or disease of the heart's major blood vessels), and diabetes.Record Review of Resident #74's quarterly MDS dated [DATE] indicated the MDS target date was 07/07/2025 and was signed as completed on 07/21/2025 by the corporate RN Assessment Coordinator. The MDS was marked as accepted by CMS on 08/08/2025. The MDS was to be submitted to CMS by 08/04/2025 (within 14 days of completion): 07/21/2025 plus 14 days equals 08/04/2025.Record review of a MDS 3.0 NH CMS Submission Final Validation report printed 08/13/2025 indicated the facility tracking form assessment was submitted late indicated by: Warning: Record Submitted Late: The submission date is more than 14 days after Z0500B on this new (A0050 equals 1) assessment.During an interview on 08/13/2025 at 9:30 AM with the MDS Coordinator B, said she or the other MDS Coordinator were not responsible for submitting the MDS assessments. She said she did not know why it had not been transmitted timely to the CMS system because the RN that signs the MDS as being completed was the person responsible for uploading the MDS Assessments. The MDS Coordinator said it was important to complete and transmit the MDS assessments timely because they affect quality of care measures. She said failure to complete and transmit MDS assessments could result in inaccurate Quality Measures. The MDS Coordinator said the facility used the RAI 3.0 Manual's schedule for completing and transmitting all MDS assessments. During an interview with the Administrator on 08/13/2025 at 10:20 AM, she said she expected the MDS assessments to be completed and transmitted as scheduled and required by state and federal governing agencies. She said the person responsible for completing the submissions was the Corporate RN responsible for signing the MDS assessments as being completed. Record review of the CMS's RAI Version 3.0 Manual dated October 2023, Chapter 5: Submission and Correction of Resident Assessments indicated the following: Comprehensive assessments, including the CAA Summary (Section V), must be transmitted within 14 days of the Care Plan Completion Date (V0200C2 + 14 days). Other assessments, like Quarterly and Discharge assessments, must be submitted within 14 days of the MDS Completion Date (Z0500B + 14 days).

Based on observation, interview and record review, the facility failed to ensure each resident's drug regimen was free of significant medication errors for 1 (Resident #1) of 10 residents reviewed for pharmacy services. The facility failed to order Resident #1's valproic acid, topiramate, levetiracetam, and lacosamide after he re-admitted on [DATE]. Resident #1 had a seizure on 07/25/25. The noncompliance was identified as PNC. The Immediate Jeopardy (IJ) began on 07/22/2025 and ended on 07/26/2025. The facility had corrected the noncompliance before the survey began. This failure could place residents at risk of not receiving the intended therapeutic benefit of the medications and supplements, worsening or exacerbation of chronic medical conditions, and hospitalization.Findings included: Record Review of Resident #1's face sheet dated 07/27/25 indicated the resident was a [AGE] year-old male with an original admission date of 07/10/2025 and readmission date of 07/22/2025. The resident had diagnoses including acute respiratory failure with hypoxia (a life threatening condition where the lungs cannot adequately oxygenate the blood, resulting in low blood oxygen levels), epilepsy with status epilepticus (a serious neurological condition where seizures are prolonged or occur frequently without recovery between them, posing a risk of brain damage), stroke, and high blood pressure.Record Review of Resident #1's readmission assessment note dated 07/22/2025 indicated there was no BIMS score due to resident's inability to answer questions. Resident #1 was alert but unable to speak due to the presence of a tracheostomy tube (a curved hollow tube inserted into a surgically created opening in the neck to create and airway into the windpipe), he had an indwelling urinary catheter and was incontinent of bowel, required extensive to total assistance for ADLs, he had a feeding tube inserted into his abdomen, and had a cough and abnormal lungs sounds of rhonchi (low-pitched, continuous, and rattling sounds heard during breathing, often described as resembling snoring or gurgling.Record Review of Resident #1's care plan with initiation date 0710/2025 and revised 07/26/2025 indicated the resident had a seizure disorder and interventions included for the facility staff to: administer seizure medication as ordered by the doctor, and seizure documentation should have included location of seizure activity, type of seizure activity (jerks, convulsive movements, trembling), duration, level of consciousness, any incontinence, sleeping or dazed post-ictal state, after seizure activity.Review of Resident #1's Physician Orders last updated 07/26/25 included: Lacosamide Oral Solution 10 mg/ml Give 20 ml via G-tube two times a day for epilepsy, Levetiracetam 100 mg/ml Give 15 ml via G-tube twice a day for epilepsy, Topiramate 100 mg tablet Give one via G-tube two times a day for epilepsy, and Valproic Acid 250 mg/5 ml Give 10 ml via G-tube three times a day for epilepsy.Review of Resident #1's hospital after visit summary dated 07/23/2025 indicated the resident was to receive Lacosamide Oral Solution 10 mg/ml Give 20 ml via G-tube three times a day, Levetiracetam 100 mg/ml Give 15 ml via G-tube every 12 hours, Topiramate 100 mg tablet Give one via G-tube two times a day, and Valproic Acid 250 mg/5 ml Give 10 ml via G-tube every 8 hours.Review of Resident #1's electronic MAR dated July 2025 indicated the following:Lacosamide Oral Solution 10 mg/ml Give 20 ml via G-tube two times a day for epilepsy was marked as unavailable for the PM dose on 07/22/2025,the AM dose on 07/23/2025 was blank and not marked as given, the PM dose for 07/23/2025, the AM dose for 07/24/2025 was marked as given, the PM dose for 07/24/2025 was marked as not given and the AM dose on 07/25/2025 was marked as given. There was no reason given for the blank and not given marks.Review of Resident #1's electronic MAR dated July 2025 indicated the following:Levetiracetam 100 mg/ml Give 15 ml via G-tube twice a day. The 9:00 PM dose on 07/22/2025 was marked as unavailable, the 9:00AM on 07/23/2025 was blank and not marked as given, the 9:00 PM dose for 07/23/2025 was marked as given, the 9:00 AM dose for 07/24/2025 was marked as given, the 9:00 PM dose on 07/24/2025 was marked as not given, the 9:00 AM dose on 07/25/2025 was marked as unavailable. There was no reason given for the blank and not given marks. Review of Resident #1's electronic MAR dated July 2025 indicated the following:Topiramate 100 mg tablet Give one via G-tube two times a day the AM dose on 07/22/2025 was not marked as given and was blank. There was no reason given for the blank space.Review of Resident #1's electronic MAR dated July 2025 indicated the following:Valproic Acid 250 mg/5 ml Give 10 ml via G-tube three times a day for epilepsy was marked as unavailable for the 9:00 PM dose on 07/22/2025, the 9:00 AM dose and 3:00 PM doses on 07/23/2025 were blank and not marked as given. The 9:00 AM, 3:00 PM and 9:00 PM doses on 07/24/2025 were marked as given. The 9:00 AM, 3:00 PM and 9:00 PM doses on 07/25/2025 were marked as given. There was no reason given for the blank and not given marks.During an interview on 07/27/2025 at 8:23 AM, Resident #1's family member said she was visiting Resident #1 around 1:00 PM-1:45 PM on 07/25/2025, when he had a seizure. Resident #1's family member said she called the nurse to the room for assistance, and LVN A assessed Resident #1 and told them he would probably be a little sleepy. Resident #1's family member said LVN A told her she would call the doctor to see if he wanted to do any labs. Resident #1's family member said later in the evening of 07/25/2025 she went to check on Resident #1 and was informed by LVN B that Resident #1's seizure medications had not been administered prior to 07/25/2025. Resident #1's family member said LVN B told her his seizure medications had just arrived (07/25/2025). Resident #1's family member said she had LVN B print her Resident #1's medication administration record and his seizure medications were marked as unavailable or administered. Resident #1's family member said the nurses falsified the documentation because the seizure medications were not in the facility. Resident #1's family member said she was very concerned about her family member because he had a history of seizures, and in the past had been hospitalized due to uncontrolled seizures that would not stop. Resident #1's family member said she had contacted the DON and ADON C and explained her concerns regarding Resident #1's seizure medications. Resident #1's family member said the DON told her the pharmacy did not provide the medications because they were out. Resident #1's family member said the DON told her they had ordered the medications on 7/25/2025. During an observation of medication administration on 07/27/2025 starting at 9:08 AM, LVN A administered Resident #1's seizure medications: Lacosamide 10mg/ml give 20 ml 200 mg per g-tube twice daily, date received 7/25/25, 20 ml administered. Valproic Acid 250 mg/5 ml give 10 ml 500 mg via g-tube three times daily, date received 7/25/25, 10 ml administered. Levetiracetam 100 mg/ml give 15 ml 1500 mg per g-tube twice daily, date received 7/25/25, 15 ml administered. Topiramate 100 mg give 1 tab via g-tube two times a day, date received 7/25/25, 1 tab administered.During an interview on 07/27/2025 at 11:00 AM, LVN A said the process for when patients admitted /re-admitted was that they verified the orders with the doctor, and then they carried the orders out. LVN A said when they put the orders in the electronic health record the pharmacy sent the medications the same night. LVN A said she re-admitted Resident #1 on 07/22/2025, and she verified his admission orders. LVN A said she normally tried to call the pharmacy to notify them of admission, but she did not have the time to call because she had two admissions back-to-back. LVN A said she was off the 2 days following Resident #1's admission (did not work on 07/23/2025 and 07/24/2025). LVN A said when she returned to work on 07/25/2025, the night nurse LVN D told her not all of Resident #1's medications had been delivered. LVN A said she contacted the pharmacy and gave them a list of the medications that were missing, and they had them delivered that night. LVN A said if a resident was missing medications, they are supposed to call the pharmacy to check on the medications and notify the doctor. LVN A said she did not notify the doctor the medications were not delivered, and Resident #1 missed doses of his seizure medications. LVN A said on Friday, 07/25/2025, Resident #1 had a small seizure. LVN A said not administering medications could result in seizures and high blood pressures that it depended on the medication what adverse effect resulted. During an interview on 07/27/2025 at 11:38 AM, LVN D said when a resident admitted /re-admitted to the facility the admitting nurse was responsible for putting in the orders in the electronic health record. LVN D said the orders should be sent to the pharmacy or they should call the pharmacy to notify them of the resident's admission so the medications could be sent. LVN D said if a resident's medication was not delivered from the pharmacy, they should indicate on the MAR the medication was unavailable and notify the pharmacy and management. LVN D said they should also notify the doctor the medication was not given. LVN D said she did not attempt to order Resident #1's medications until Thursday (07/24/2025) night. LVN D said depending on the medication that was not administered the residents could have multiple adverse reactions such as high blood pressure and fluid buildup. During an interview on 07/27/2025 at 12:44 PM, LVN B said all medication were delivered through the facility's pharmacy to the facility. LVN B said if medications were placed in the electronic health record before 3 PM, they would be delivered the same night. LVN B said Resident #1 admitted sometime on the day shift on 07/22/2025. LVN B said Resident #1's medications were not delivered on 07/22/2025. LVN B said she had no idea why Resident #1's medications were not delivered on 07/22/2025. LVN B said she did not work on 07/23/2025 and 07/24/2025. LVN B said on 07/25/2025, when she arrived for her shift, LVN A informed her some of Resident #1's medications had not been delivered, but they would be delivered that night (07/25/2025). LVN B said Resident #1's seizure medications were delivered 07/25/2025 during her night shift, and she was able to administer all of them. During an interview on 07/27/2025 at 1:01 PM, LVN E said the ADONs and DON put in the resident's physician orders into the electronic health record, and from her understanding they went to the pharmacy automatically. LVN E said if there was a new admission they should fax the orders to the pharmacy for the medications to be sent to the facility. LVN E said she worked on 07/23/2025 and 07/24/2025 on the day shift. LVN E said she did not administer any medications to Resident #1 on 07/23/2025 because she sent him to the hospital. LVN E said she was not able to remember if she had signed off the medications as administered in his MAR or as hospitalized . LVN E said she might have inaccurately documented some of Resident #1's medications as administered, when she did not administer them because she was in a rush and had a lot going on. LVN E said 07/24/2025, she contacted the pharmacy about Resident #1's medications, and the pharmacy told her his medications would be delivered Monday (07/28/2025). During an interview on 07/27/2025 at 1:16 PM, the Pharmacist said the DON contacted them yesterday (07/26/2025) to ask about Resident #1's medications. The Pharmacist said when Resident #1 re-admitted to the facility for whatever reason they did not get the request to send his medications in their system. The Pharmacist said the facility possibly indicated the medications were on hand, which would result in the medications not being sent out to the facility. The Pharmacist said the request for Resident #1's medications was received on 07/25/2025. The Pharmacist said usually the electronic system used by the facility notified them when a resident admitted , and orders were put in because the facility's system was linked with the pharmacy. During an interview on 07/27/2025 at 1:22 PM, the DON said Resident #1 re-admitted on [DATE] or 07/23/2025. The DON said the nurses did not follow the facility's protocol and notify him Resident #1's medications were not delivered. The DON said the nurses should have notified him, so the doctor could be notified. The DON said late Friday evening (07/25/2025) Resident #1's family member notified him Resident #1 had not received his seizure medications, and he informed her the medications would be delivered to the facility that evening. The DON said they started in-services on abuse and neglect, medication errors, instructed the nurses to notify him of medications that were not available and notifying the doctor. The DON said LVN D and LVN E were suspended pending investigation due to them failing to notify the DON Resident #1's medications were not available and documenting medications as administered when they were not available in the facility. The DON said when a resident admitted to the facility, orders were put into their electronic health system and the pharmacy was notified electronically to send the medications. The DON said LVN A did not notify the doctor of Resident #1's seizure. The DON said he reported it to the doctor when he was notified that Resident #1 had a seizure. The DON said medications not being administered greatly increased the residents' chances of negative outcomes such as increased seizure activity and death. The DON said it was important to notify the doctor of changes in condition because it was the cornerstone of good patient care and so they could have documentation that something was done. During an interview on 07/27/2025 at 1:42 PM, ADON F said when a resident admitted to the facility the medications should be put into the electronic health record and the orders go to the pharmacy automatically. ADON F said when Resident #1 re-admitted to the facility nobody notified the pharmacy of his admission. ADON F said when Resident #1's medications were not delivered, they should have contacted the pharmacy. ADON F said she was not notified by the nurses that Resident #1's medications were not delivered. ADON F said the nurses should have notified the doctor of the medications that were not administered to Resident #1. ADON F said medications not administered as ordered could affect the residents' health, and they could end up dying or having a diminished quality of life. During an interview on 07/27/2025 at 2:34 PM, the Regional Compliance Nurse said she had reviewed the admissions/re-admissions to make sure their orders and medications were in the facility on 07/26/2025. The Regional Compliance Nurse said she completed care plan audits to ensure residents receiving anti-convulsant medications had a care plan for them on 07/26/2025. The Regional Compliance Nurse said she reviewed the physician orders of residents who received anti-convulsant medications and verified their medications were in the facility. The Regional Compliance Nurse said the doctor was notified of Resident #1's medication error and he ordered loading doses on Resident #1's seizure medications and labs for Wednesday 07/30/2025. The Regional Compliance Nurse said in-services on change in condition, abuse and neglect, medication errors, following the physician orders, new/admission/readmission ordering medications, seizure management, medication reconciliation, medication administration, and following the doctor's orders and standing orders for labs upon admission were conducted. During an interview on 07/27/2025 2:41 PM, ADON C said when a resident was admitted to the facility the pharmacy received notification of the admission. ADON C said there was some kind of error in their system, and the pharmacy was not notified of Resident #1's admission. ADON C said she spoke with Resident #1's family member regarding their concerns about Resident #1's seizure medications not being administered. ADON C said she talked to the nurses and started in-services with the nurses. ADON C said if a medication was unavailable the nurses needed to notify the doctor, DON, and pharmacy. ADON C said depending on the type of medication if a medication was not administered it could cause serious effects and the residents' labs could be affected. During an interview on 07/27/2025 at 5:21 PM, the Administrator said when a resident admitted to the facility she expected for the nurses to look at the doctor's orders, call the pharmacy, and let them know what medications the resident needed. The Administrator said if a medication was not available, the nurses should notify the physician and see what the physician wanted to order to replace the medication until the pharmacy filled the order. The Administrator said the nurse was responsible for ensuring the medications were in the facility and nurse management should provide oversight. The Administrator said it was important for the medications to be administered to prevent negative experiences. The Administrator said when Resident #1 returned on 07/22/2025 the nurses were supposed to contact the pharmacy to notify them of his return. The Administrator said the nurses failed to notify the pharmacy. The Administrator said she was notified yesterday morning (07/26/2025), that Resident #1 had not received his seizure medications. The Administrator said she was also notified Resident #1 had a seizure and the physician was not notified. During an interview on 07/27/2025 at 7:45 PM, the Medical Director said he was not notified that Resident #1's seizure medications were not administered. The Medical Director said he was not notified Resident #1 had a seizure. The Medical Director said the facility typically reached out to his NP for orders, but he believed she had not been notified either. The Medical Director said Resident #1 not receiving his seizure medications for a couple days could absolutely cause him to have seizures. The Medical Director said he was surprised Resident #1 only had a small seizure because the missed doses could have resulted in more severe seizures. During an interview on 07/27/2025 at 7:56 PM, the NP said she was not notified Resident #1's seizure medications were not administered or that he had a seizure. The NP said she expected the nurses to notify her if this occurred. The NP said she was in the facility often and typically the nurses notified her Monday-Friday of anything that happened. The NP said Resident #1's seizure medications not being administered could result in him having seizures. Review of In-service documentation indicated the following: No staff will be allowed to take a shift until in-service education is completed. The following in-services were initiated on 07/26/2025 at 10:15 AM by the DON, ADON and regional nurse. Staff were sent the in-services via email to review prior to reporting for their shifts. The training was still ongoing at the time of the investigation. All Staff: Change in Condition and Abuse and NeglectNurses and Medication Aides: Medication Administration, Unavailable medications, Medication Error, Following physician orders, New/Admission/readmission ordering medications, Seizure Management, Medication Reconciliation During an interview on 07/28/2025 at 8:45 AM the Division Director of Clinical Services said Resident #1 originally admitted to the facility on [DATE] but returned to the hospital that same day. She said he did not re-admit until 07/22/2025. She said he went back to the hospital on [DATE] and returned to the facility later that same day. She said the emergency medication kit did not contain any liquid medications but the tablet medications were available. She said the pharmacy did not have one of the liquid medications. She said the physician and DON were not notified of the medications being unavailable for administration. During an interview on 07/28/2025 at 9:05 AM the administrator said the in-services were sent by email to staff to read and then the staff members were required to read and sign the in-service sheets when they physically returned to the facility for work. The signature sheets were verified by the administrator, DON, or ADONs for completion prior to working their shifts. During an interview on 07/28/2025 the Regional Compliance nurse said when it was discovered in the late afternoon on 07/25/2025 medications had not been administered and no one had informed the management of the absence of the medications for Resident #1 she said they immediately began to remedy the situation. She said the resident had multiple admissions/re-admissions to the facility in a short period of time. She said she thought the pharmacy was not sure if the resident was actually in the facility. She said the facility should have called the pharmacy to verify the resident's admission and that the medications could be filled and delivered. She said the pharmacy delivers medications twice a day and if an order can be placed by 6 PM it would be delivered that night around 11 PM. She said the pharmacy had been known to fill and deliver a medication stat (needed immediately). She said the error occurred due to poor communication and follow through. She said Resident #1 admitted on the afternoon of 07/22/2025 and medications had been reviewed and input into the electronic health record. She said apparently the order button was not pushed to send the request to the pharmacy but she was not sure exactly what happened. She said the night nurse (coming on at 6 PM) thought the medications had already been ordered and so she did not order them. She said the admitting nurse was off the next 2 days and would have caught the missed medications the next day, but did not catch the error until her return on 7/25/2025. She said the crushable medications were available from the emergency medication kit. She said they began by auditing physician orders for residents receiving anticonvulsants and for the presence of the medications in the facility. She said the MARs were checked for administration. She said the care plans were audited for seizure medication and updated as needed. She said in-servicing of staff began 07/26/2025. She said 2 nurses were suspended pending the investigation as they had signed the MAR indicating they gave Resident #1 the medications that were not present in the facility. She said other nurses indicated the medications were unavailable but did not notify the DON or physician. During an interview on 07/28/25 at 10:00 AM with RN G said he was provided additional training on many things. He noted Abuse and Neglect, Change of Condition, Medication Administration, Notification of the physician, DON and responsible parties of changes and/or missed medications, ordering of medications and unavailability of medications. He said if their pharmacy did not have a medication available they had 24 hour local pharmacy and they could get their pharmacy to send the prescription there. He indicated a new posting at the nurses' station that listed the 2 local pharmacies available to them. During an interview on 07/28/2025 at 10:05 AM with MDS/LVN H said she received in-services on abuse, neglect, change of condition, missing medications, reporting to the DON, notifying the physician regarding changes and medications not being available. During an interview on 07/28/2025 at 10:10 AM with LVN J indicated Resident #1 resided n her hall. She said she received in-services on abuse, neglect, change of condition, missing medications, reporting to the DON, notifying the physician regarding changes and medications not being available. She said Resident #1's medications were present in the facility and she administered them that morning. She verified all his seizure medications had been given. During an interview on 07/28/2025 at 10:15 AM with ADON C said she completed the audit on the medication carts and verified the presence of anticonvulsant medications with the corresponding physician orders on 07/26/2025. She said all medications were present except one medication that would have been needed that evening and was not in the emergency kit. She said she called the pharmacy and it was delivered as a high priority and was available at time of administration. During an interview on 07/28/2025 at 10:17 AM MA K said she received in-services on abuse, neglect, change of condition, missing medications, reporting to the DON, notifying the physician regarding changes and medications not being available. She said they had to make sure medications were available in house and not just mark the MAR as unavailable and go on to the next resident. She said she would report it to her charge nurse if something was not available and they could possibly get it for her out of the emergency kit. She said if she finished a medication card she checked her cart for an extra card and if not in her cart she would go immediately to let the charge nurse know about the medication. She said she was able to re-order medications on her computer. During an interview on 07/28/2025 at 10:20 AM MA L said she was shadowing MA K and had started work last week. She said she received in-services on abuse, neglect, change of condition, missing medications, reporting to the DON, notifying the physician regarding changes and medications not being available. During an interview on 07/28/2025 at 10:25 AM MA M said she received 5 or 6 in-services on Saturday and 2 more that morning and they included abuse, neglect, change of condition, missing medications, reporting to the DON, notifying the physician regarding changes and medications not being available. She said they were told to report unavailable meds to the charge nurse, ADON or DON so they could re-order it or possibly get it from the emergency kit. During an interview on 07/28/2025 at 10:30 AM with LVN N said she received in-services on abuse, neglect, change of condition, missing medications, reporting to the DON, notifying the physician regarding changes and medications not being available. During an interview on 07/28/2025 at 10:35 AM MA O said she received in-services and they included abuse, neglect, change of condition, missing medications, reporting to the DON, notifying the physician regarding changes and medications not being available. She said they were told to report unavailable meds to the charge nurse, ADON or DON so they could re-order it or possibly get it from the emergency kit. During multiple interviews on 07/28/2025 with general staff from the day shift (6AM-6PM) (Housekeeper P, Housekeeper Q, Housekeeper R, Dietary Manager T, Housekeeping Supervisor U, DA W, [NAME] X, DA FF) from 1:04 PM-1:47 PM indicated they said they had been trained on abuse and neglect and change of condition. They said they were given examples of how to identify a change of condition and report it to the charge nurse. They said the abuse coordinator was the administrator and was who they reported to. During multiple interviews on 07/28/2025 with nurses, CNAs, and Mas from both shifts (6AM-6PM and 6PM-6AM) (CNA S, CNA V, CNA Y, NA Z, HA AA, CNA BB, CNA DD, CNA EE, RN GG, MA HH, MA JJ, LVN KK, RN LL, LVN MM, MA NN, MA OO) from 1:08 PM-2:15 PM indicated they said they had been trained on abuse and neglect, change of condition, medication administration, notification of the physician, DON and responsible parties of changes and/or missed medications, ordering of medications and unavailability of medications. Review of Resident #1's electronic MAR dated July 2025 indicated the following:Lacosamide Oral Solution 10 mg/ml Give 20 ml via G-tube two times a day for epilepsy was marked as given at 6:00 PM on 07/26/2025 and 12:00 AM and 6:00 AM on 07/27/2025.Review of Resident #1's electronic MAR dated July 2025 indicated the following:Levetiracetam 100 mg/ml Give 15 ml via G-tube twice a day. The 9:00 PM dose on 07/25/2025 was marked as given and the 9:00 AM dose was marked as given on 07/26/2025. Review of Resident #1's electronic MAR dated July 2025 indicated the following:Topiramate 100 mg tablet Give one via G-tube two times a day was marked as given two times on 07/25/2025 and two times on 07/26/2025.Review of Resident #1's electronic MAR dated July 2025 indicated the following:Valproic Acid 250 mg/5 ml Give 10 ml via G-tube three times a day for epilepsy was marked as given at 10:00 PM on 07/26/2025 and 9:00 AM, 3:00 PM on 07/27/2025 were marked as given. On 07/28/2025 at 12:54 PM, the Administrator was informed of the Immediate Jeopardy and provided the IJ template. The non-compliance was identified as past non-compliance. The Immediate Jeopardy began on 07/22/2025 and ended on 07/26/2025. The facility had corrected the noncompliance before the survey began.

Based on observation, interview and record review, the facility failed to immediately consult with the resident's physician and notify the resident representative of a significant change in the resident's physical, mental, or psychosocial status (that is, a deterioration in health, mental, or psychosocial status in either life-threatening conditions or clinical complications) for 1 (Resident #1) of 10 residents reviewed for notification of changes.The facility failed to notify Resident #1's physician when they did not administer his valproic acid, topiramate, levetiracetam, and lacosamide on 07/22/25-07/25/25 as ordered.The facility failed to notify Resident #1's physician after he had a seizure on 07/25/25.The noncompliance was identified as PNC. The Immediate Jeopardy (IJ) began on 07/22/2025 and ended on 07/26/2025. The facility had corrected the noncompliance before the survey began. Findings included: Record Review of Resident #1's face sheet dated 07/27/25 indicated the resident was a [AGE] year-old male with an original admission date of 07/10/2025 and readmission date of 07/22/2025. The resident had diagnoses including acute respiratory failure with hypoxia (a life threatening condition where the lungs cannot adequately oxygenate the blood, resulting in low blood oxygen levels), epilepsy with status epilepticus (a serious neurological condition where seizures are prolonged or occur frequently without recovery between them, posing a risk of brain damage), stroke, and high blood pressure.Record Review of Resident #1's readmission assessment note dated 07/22/2025 indicated there was no BIMS score due to resident's inability to answer questions. Resident #1 was alert but unable to speak due to the presence of a tracheostomy tube (a curved hollow tube inserted into a surgically created opening in the neck to create and airway into the windpipe), he had an indwelling urinary catheter and was incontinent of bowel, required extensive to total assistance for ADLs, he had a feeding tube inserted into his abdomen, and had a cough and abnormal lungs sounds of rhonchi (low-pitched, continuous, and rattling sounds heard during breathing, often described as resembling snoring or gurgling. Record Review of Resident #1's care plan with initiation date 0710/2025 and revised 07/26/2025 indicated the resident had a seizure disorder and interventions included for the facility staff to: administer seizure medication as ordered by the doctor, and seizure documentation should have included location of seizure activity, type of seizure activity (jerks, convulsive movements, trembling), duration, level of consciousness, any incontinence, sleeping or dazed post-ictal state, after seizure activity. Review of Resident #1's Physician Orders last updated 07/26/25 included: Lacosamide Oral Solution 10 mg/ml Give 20 ml via G-tube two times a day for epilepsy, Levetiracetam 100 mg/ml Give 15 ml via G-tube twice a day for epilepsy, Topiramate 100 mg tablet Give one via G-tube two times a day for epilepsy, and Valproic Acid 250 mg/5 ml Give 10 ml via G-tube three times a day for epilepsy.Review of Resident #1's hospital after visit summary dated 07/23/2025 indicated the resident was to receive Lacosamide Oral Solution 10 mg/ml Give 20 ml via G-tube three times a day, Levetiracetam 100 mg/ml Give 15 ml via G-tube every 12 hours, Topiramate 100 mg tablet Give one via G-tube two times a day, and Valproic Acid 250 mg/5 ml Give 10 ml via G-tube every 8 hours.Review of Resident #1's electronic MAR dated July 2025 indicated the following:Lacosamide Oral Solution 10 mg/ml Give 20 ml via G-tube two times a day for epilepsy was marked as unavailable for the PM dose on 07/22/2025,the AM dose on 07/23/2025 was blank and not marked as given, the PM dose for 07/23/2025, the AM dose for 07/24/2025 was marked as given, the PM dose for 07/24/2025 was marked as not given and the AM dose on 07/25/2025 was marked as given. There was no reason given for the blank and not given marks.Review of Resident #1's electronic MAR dated July 2025 indicated the following:Levetiracetam 100 mg/ml Give 15 ml via G-tube twice a day. The 9:00 PM dose on 07/22/2025 was marked as unavailable, the 9:00AM on 07/23/2025 was blank and not marked as given, the 9:00 PM dose for 07/23/2025 was marked as given, the 9:00 AM dose for 07/24/2025 was marked as given, the 9:00 PM dose on 07/24/2025 was marked as not given, the 9:00 AM dose on 07/25/2025 was marked as unavailable. There was no reason given for the blank and not given marks. Review of Resident #1's electronic MAR dated July 2025 indicated the following:Topiramate 100 mg tablet Give one via G-tube two times a day the AM dose on 07/22/2025 was not marked as given and was blank. There was no reason given for the blank space.Review of Resident #1's electronic MAR dated July 2025 indicated the following:Valproic Acid 250 mg/5 ml Give 10 ml via G-tube three times a day for epilepsy was marked as unavailable for the 9:00 PM dose on 07/22/2025, the 9:00 AM dose and 3:00 PM doses on 07/23/2025 were blank and not marked as given. The 9:00 AM, 3:00 PM and 9:00 PM doses on 07/24/2025 were marked as given. The 9:00 AM, 3:00 PM and 9:00 PM doses on 07/25/2025 were marked as given. There was no reason given for the blank and not given marks. During an interview on 07/27/2025 at 8:23 AM, Resident #1's family member said she was visiting Resident #1 around 1:00 PM-1:45 PM on 07/25/2025, when he had a seizure. Resident #1's family member said she called the nurse to the room for assistance, and LVN A assessed Resident #1 and told them he would probably be a little sleepy. Resident #1's family member said LVN A told her she would call the doctor to see if he wanted to do any labs. Resident #1's family member said later in the evening of 07/25/2025 she went to check on Resident #1 and was informed by LVN B that Resident #1's seizure medications had not been administered prior to 07/25/2025. Resident #1's family member said LVN B told her his seizure medications had just arrived (07/25/2025). Resident #1's family member said she had LVN B print her Resident #1's medication administration record and his seizure medications were marked as unavailable or administered. Resident #1's family member said the nurses falsified the documentation because the seizure medications were not in the facility. Resident #1's family member said she was very concerned about her family member because he had a history of seizures, and in the past had been hospitalized due to uncontrolled seizures that would not stop. Resident #1's family member said she had contacted the DON and ADON C and explained her concerns regarding Resident #1's seizure medications. Resident #1's family member said the DON told her the pharmacy did not provide the medications because they were out. Resident #1's family member said the DON told her they had ordered the medications on 7/25/2025. During an interview on 07/27/2025 at 11:00 AM, LVN A said the process for when patients admitted /re-admitted was that they verified the orders with the doctor, and then they carried the orders out. LVN A said when they put the orders in the electronic health record the pharmacy sent the medications the same night. LVN A said she re-admitted Resident #1 on 07/22/2025, and she verified his admission orders. LVN A said she normally tried to call the pharmacy to notify them of admission, but she did not have the time to call because she had two admissions back-to-back. LVN A said she was off the 2 days following Resident #1's admission (did not work on 07/23/2025 and 07/24/2025). LVN A said when she returned to work on 07/25/2025, the night nurse LVN D told her not all of Resident #1's medications had been delivered. LVN A said she contacted the pharmacy and gave them a list of the medications that were missing, and they had them delivered that night. LVN A said if a resident was missing medications, they are supposed to call the pharmacy to check on the medications and notify the doctor. LVN A said she did not notify the doctor the medications were not delivered, and Resident #1 missed doses of his seizure medications. LVN A said on Friday, 07/25/2025, Resident #1 had a small seizure. LVN A said she failed to notify the doctor Resident #1 had a seizure. LVN A said she should have notified the doctor, but she did not because she was busy and was sending out a different resident to the hospital when Resident #1 had his seizure. LVN A said it was important to notify the doctor of changes in condition because the doctor may want to order labs and adjust medications. LVN A said not notifying the doctor of changes in condition could result in seizures and hospitalizations. LVN A said not administering medications could result in seizures and high blood pressures that it depended on the medication what adverse effect resulted. During an interview on 07/27/2025 at 11:38 AM, LVN D said when a resident admitted /re-admitted to the facility the admitting nurse was responsible for putting in the orders in the electronic health record. LVN D said the orders should be sent to the pharmacy or they should call the pharmacy to notify them of the resident's admission so the medications could be sent. LVN D said if a resident's medication was not delivered from the pharmacy, they should indicate on the MAR the medication was unavailable and notify the pharmacy and management. LVN D said they should also notify the doctor the medication was not given. LVN D said she did not attempt to order Resident #1's medications until Thursday (07/24/2025) night. LVN D said she had not notified the doctor of Resident #1's missed doses because she thought she did not have to notify the doctor unless 3 doses were missed. LVN D said she tried to document unavailable or not administered for Resident #1's medications that she did not administer. LVN D said depending on the medication that was not administered the residents could have multiple adverse reactions such as high blood pressure and fluid buildup. LVN D said it was important to notify the doctor of missed medications to prevent hospitalizations. During an interview on 07/27/2025 at 12:44 PM, LVN B said all medication were delivered through the facility's pharmacy to the facility. LVN B said if medications were placed in the electronic health record before 3 PM, they would be delivered the same night. LVN B said Resident #1 admitted sometime on the day shift on 07/22/2025. LVN B said Resident #1's medications were not delivered on 07/22/2025. LVN B said she had no idea why Resident #1's medications were not delivered on 07/22/2025. LVN B said she did not work on 07/23/2025 and 07/24/2025. LVN B said on 07/25/2025, when she arrived for her shift, LVN A informed her some of Resident #1's medications had not been delivered, but they would be delivered that night (07/25/2025). LVN B said Resident #1's seizure medications were delivered 07/25/2025 during her night shift, and she was able to administer all of them. LVN B said the doctor should be notified when medications were not available for administration. LVN B said she did not notify the doctor Resident #1 had missed doses of his seizure medications. LVN B said the doctor should have been notified because they were medications that should not be missed, and it placed Resident #1 at risk for seizures and cardiac arrest and it affected the resident's overall health. LVN B said if a resident had a seizure, the doctor, DON, oncoming nurse, and the family should be notified. LVN B said not notifying the physician led to lack of care because the doctor would not know what was going on and it caused a gap in care that the residents needed. During an interview on 07/27/2025 at 1:01 PM, LVN E said the ADONs and DON put in the resident's physician orders into the electronic health record, and from her understanding they went to the pharmacy automatically. LVN E said if there was a new admission they should fax the orders to the pharmacy for the medications to be sent to the facility. LVN E said she worked on 07/23/2025 and 07/24/2025 on the day shift. LVN E said she did not administer any medications to Resident #1 on 07/23/2025 because she sent him to the hospital. LVN E said she was not able to remember if she had signed off the medications as administered in his MAR or as hospitalized . LVN E said she might have inaccurately documented some of Resident #1's medications as administered, when she did not administer them because she was in a rush and had a lot going on. LVN E said 07/24/2025, she contacted the pharmacy about Resident #1's medications, and the pharmacy told her his medications would be delivered Monday (07/28/2025). LVN E said she did not notify the doctor that Resident #1's medications were not delivered and were not administered. LVN E said at the time she was not aware she was supposed to notify the doctor. LVN E said it was important for the doctor to be notified of missed doses of medication to see if he wanted to order something different. LVN E said Resident #1 not receiving his seizure medications could result in him having seizure. During an interview on 07/27/2025 at 1:16 PM, the Pharmacist said the DON contacted them yesterday (07/26/2025) to ask about Resident #1's medications. The Pharmacist said when Resident #1 re-admitted to the facility for whatever reason they did not get the request to send his medications in their system. The Pharmacist said the facility possibly indicated the medications were on hand, which would result in the medications not being sent out to the facility. The Pharmacist said the request for Resident #1's medications was received on 07/25/2025. The Pharmacist said usually the electronic system used by the facility notified them when a resident admitted , and orders were put in because the facility's system was linked with the pharmacy. During an interview on 07/27/2025 at 1:22 PM, the DON said Resident #1 re-admitted on [DATE] or 07/23/2025. The DON said the nurses did not follow the facility's protocol and notify him Resident #1's medications were not delivered. The DON said the nurses should have notified him, so the doctor could be notified. The DON said late Friday evening (07/25/2025) Resident #1's family member notified him Resident #1 had not received his seizure medications, and he informed her the medications would be delivered to the facility that evening. The DON said they started in-services on abuse and neglect, medication errors, instructed the nurses to notify him of medications that were not available and notifying the doctor. The DON said LVN D and LVN E were suspended pending investigation due to them failing to notify the DON that Resident #1's medications were not available and documenting medications as administered when they were not available in the facility. The DON said when a resident admitted to the facility, orders were put into their electronic health system and the pharmacy was notified electronically to send the medications. The DON said LVN A did not notify the doctor of Resident #1's seizure. The DON said he reported it to the doctor when he was notified that Resident #1 had a seizure. The DON said medications not being administered greatly increased the residents' chances of negative outcomes such as increased seizure activity and death. The DON said it was important to notify the doctor of changes in condition because it was the cornerstone of good patient care and so they could have documentation that something was done. During an interview on 07/27/2025 at 1:42 PM, ADON F said when a resident admitted to the facility the medications should be put into the electronic health record and the orders go to the pharmacy automatically. ADON F said when Resident #1 re-admitted to the facility nobody notified the pharmacy of his admission. ADON F said when Resident #1's medications were not delivered, they should have contacted the pharmacy. ADON F said she was not notified by the nurses that Resident #1's medications were not delivered. ADON F said the nurses should have notified the doctor of the medications that were not administered to Resident #1. ADON F said medications not administered as ordered could affect the residents' health, and they could end up dying or having a diminished quality of life. ADON F said when a resident had a change in condition the doctor should be notified. ADON F said it was important to notify the doctor to see if it was a one-time thing or to see if medications needed to be adjusted. During an interview on 07/27/2025 at 2:34 PM, the Regional Compliance Nurse said she had reviewed the admissions/re-admissions to make sure their orders and medications were in the facility on 07/26/2025. The Regional Compliance Nurse said she completed care plan audits to ensure residents receiving anti-convulsant medications had a care plan for them on 07/26/2025. The Regional Compliance Nurse said she reviewed the physician orders of residents who received anti-convulsant medications and verified their medications were in the facility. The Regional Compliance Nurse said the doctor was notified of Resident #1's medication error and he ordered loading doses on Resident #1's seizure medications and labs for Wednesday 07/30/2025. The Regional Compliance Nurse said in-services on change in condition, abuse and neglect, medication errors, following the physician orders, new/admission/readmission ordering medications, seizure management, medication reconciliation, medication administration, and following the doctor's orders and standing orders for labs upon admission were conducted. During an interview on 07/27/2025 2:41 PM, ADON C said when a resident was admitted to the facility the pharmacy received notification of the admission. ADON C said there was some kind of error in their system, and the pharmacy was not notified of Resident #1's admission. ADON C said when a resident had a change in condition the physician should be notified. ADON C said it was important for the physician to be notified of changes in condition for continuation of care and so they addressed the residents' changes in condition. ADON C said she spoke with Resident #1's family member regarding their concerns about Resident #1's seizure medications not being administered. ADON C said she talked to the nurses and started in-services with the nurses. ADON C said if a medication was unavailable the nurses needed to notify the doctor, DON, and pharmacy. ADON C said depending on the type of medication if a medication was not administered it could cause serious effects and the residents' labs could be affected. During an interview on 07/27/2025 at 5:21 PM, the Administrator said when a resident admitted to the facility she expected for the nurses to look at the doctor's orders, call the pharmacy, and let them know what medications the resident needed. The Administrator said if a medication was not available, the nurses should notify the physician and see what the physician wanted to order to replace the medication until the pharmacy filled the order. The Administrator said the nurse was responsible for ensuring the medications were in the facility and nurse management should provide oversight. The Administrator said it was important for the medications to be administered to prevent negative experiences. The Administrator said when Resident #1 returned on 07/22/2025 the nurses were supposed to contact the pharmacy to notify them of his return. The Administrator said the nurses failed to notify the pharmacy. The Administrator said she was notified yesterday morning (07/26/2025), that Resident #1 had not received his seizure medications. The Administrator said she was also notified Resident #1 had a seizure and the physician was not notified. The Administrator said she expected for all changes in condition to be reported to the physician. The Administrator said it was important for the physician to be notified of changes in condition to prevent things from happening such as a seizure. During an interview on 07/27/2025 at 7:45 PM, the Medical Director said he was not notified that Resident #1's seizure medications were not administered. The Medical Director said he was not notified Resident #1 had a seizure. The Medical Director said the facility typically reached out to his NP for orders, but he believed she had not been notified either. The Medical Director said Resident #1 not receiving his seizure medications for a couple days could absolutely cause him to have seizures. The Medical Director said he was surprised Resident #1 only had a small seizure because the missed doses could have resulted in more severe seizures. During an interview on 07/27/2025 at 7:56 PM, the NP said she was not notified Resident #1's seizure medications were not administered or that he had a seizure. The NP said she expected the nurses to notify her if this occurred. The NP said she was in the facility often and typically the nurses notified her Monday-Friday of anything that happened. The NP said Resident #1's seizure medications not being administered could result in him having seizures. Review of In-service documentation indicated the following: No staff will be allowed to take a shift until in-service education is completed. The following in-services were initiated on 07/26/2025 at 10:15 AM by the DON, ADON and regional nurse. Staff were sent the in-services via email to review prior to reporting for their shifts. The training was still ongoing at the time of the investigation. All Staff: Change in Condition and Abuse and NeglectNurses and Medication Aides: Medication Administration, Unavailable medications, Medication Error, Following physician orders, New/Admission/readmission ordering medications, Seizure Management, Medication Reconciliation During an interview on 07/28/2025 at 8:45 AM the Division Director of Clinical Services said Resident #1 originally admitted to the facility on [DATE] but returned to the hospital that same day. She said he did not re-admit until 07/22/2025. She said he went back to the hospital on [DATE] and returned to the facility later that same day. She said the emergency medication kit did not contain any liquid medications but the tablet medications were available. She said the pharmacy did not have one of the liquid medications. She said the physician and DON were not notified of the medications being unavailable for administration. During an interview on 07/28/2025 at 9:05 AM the administrator said the in-services were sent by email to staff to read and then the staff members were required to read and sign the in-service sheets when they physically returned to the facility for work. The signature sheets were verified by the administrator, DON, or ADONs for completion prior to working their shifts. During an interview on 07/28/2025 the Regional Compliance nurse said when it was discovered in the late afternoon on 07/25/2025 medications had not been administered and no one had informed the management of the absence of the medications for Resident #1 she said they immediately began to remedy the situation. She said the resident had multiple admissions/re-admissions to the facility in a short period of time. She said she thought the pharmacy was not sure if the resident was actually in the facility. She said the facility should have called the pharmacy to verify the resident's admission and that the medications could be filled and delivered. She said the pharmacy delivers medications twice a day and if an order can be placed by 6 PM it would be delivered that night around 11 PM. She said the pharmacy had been known to fill and deliver a medication stat (needed immediately). She said the error occurred due to poor communication and follow through. She said Resident #1 admitted on the afternoon of 07/22/2025 and medications had been reviewed and input into the electronic health record. She said apparently the order button was not pushed to send the request to the pharmacy but she was not sure exactly what happened. She said the night nurse (coming on at 6 PM) thought the medications had already been ordered and so she did not order them. She said the admitting nurse was off the next 2 days and would have caught the missed medications the next day, but did not catch the error until her return on 7/25/2025. She said the crushable medications were available from the emergency medication kit. She said they began by auditing physician orders for residents receiving anticonvulsants and for the presence of the medications in the facility. She said the MARs were checked for administration. She said the care plans were audited for seizure medication and updated as needed. She said in-servicing of staff began 07/26/2025. She said 2 nurses were suspended pending the investigation as they had signed the MAR indicating they gave Resident #1 the medications that were not present in the facility. She said other nurses indicated the medications were unavailable but did not notify the DON or physician.During an interview on 07/28/25 at 10:00 AM with RN G said he was provided additional training on many things. He noted Abuse and Neglect, Change of Condition, Medication Administration, Notification of the physician, DON and responsible parties of changes and/or missed medications, ordering of medications and unavailability of medications. He said if their pharmacy did not have a medication available they had 24 hour local pharmacy and they could get their pharmacy to send the prescription there. He indicated a new posting at the nurses' station that listed the 2 local pharmacies available to them. During an interview on 07/28/2025 at 10:05 AM with MDS/LVN H said she received in-services on abuse, neglect, change of condition, missing medications, reporting to the DON, notifying the physician regarding changes and medications not being available. During an interview on 07/28/2025 at 10:10 AM with LVN J indicated Resident #1 resided n her hall. She said she received in-services on abuse, neglect, change of condition, missing medications, reporting to the DON, notifying the physician regarding changes and medications not being available. She said Resident #1's medications were present in the facility and she administered them that morning. She verified all his seizure medications had been given. During an interview on 07/28/2025 at 10:15 AM with ADON C said she completed the audit on the medication carts and verified the presence of anticonvulsant medications with the corresponding physician orders on 07/26/2025. She said all medications were present except one medication that would have been needed that evening and was not in the emergency kit. She said she called the pharmacy and it was delivered as a high priority and was available at time of administration. During an interview on 07/28/2025 at 10:17 AM MA K said she received in-services on abuse, neglect, change of condition, missing medications, reporting to the DON, notifying the physician regarding changes and medications not being available. She said they had to make sure medications were available in house and not just mark the MAR as unavailable and go on to the next resident. She said she would report it to her charge nurse if something was not available and they could possibly get it for her out of the emergency kit. She said if she finished a medication card she checked her cart for an extra card and if not in her cart she would go immediately to let the charge nurse know about the medication. She said she was able to re-order medications on her computer. During an interview on 07/28/2025 at 10:20 AM MA L said she was shadowing MA K and had started work last week. She said she received in-services on abuse, neglect, change of condition, missing medications, reporting to the DON, notifying the physician regarding changes and medications not being available. During an interview on 07/28/2025 at 10:25 AM MA M said she received 5 or 6 in-services on Saturday and 2 more that morning and they included abuse, neglect, change of condition, missing medications, reporting to the DON, notifying the physician regarding changes and medications not being available. She said they were told to report unavailable meds to the charge nurse, ADON or DON so they could re-order it or possibly get it from the emergency kit. During an interview on 07/28/2025 at 10:30 AM with LVN N said she received in-services on abuse, neglect, change of condition, missing medications, reporting to the DON, notifying the physician regarding changes and medications not being available. During an interview on 07/28/2025 at 10:35 AM MA O said she received in-services and they included abuse, neglect, change of condition, missing medications, reporting to the DON, notifying the physician regarding changes and medications not being available. She said they were told to report unavailable meds to the charge nurse, ADON or DON so they could re-order it or possibly get it from the emergency kit. During multiple interviews on 07/28/2025 with general staff from the day shift (6AM-6PM) (Housekeeper P, Housekeeper Q, Housekeeper R, Dietary Manager T, Housekeeping Supervisor U, DA W, [NAME] X, DA FF) from 1:04 PM-1:47 PM indicated they said they had been trained on abuse and neglect and change of condition. They said they were given examples of how to identify a change of condition and report it to the charge nurse. They said the abuse coordinator was the administrator and was who they reported to. During multiple interviews on 07/28/2025 with nurses, CNAs, and Mas from both shifts (6AM-6PM and 6PM-6AM) (CNA S, CNA V, CNA Y, NA Z, HA AA, CNA BB, CNA DD, CNA EE, RN GG, MA HH, MA JJ, LVN KK, RN LL, LVN MM, MA NN, MA OO) from 1:08 PM-2:15 PM indicated they said they had been trained on abuse and neglect, change of condition, medication administration, notification of the physician, DON and responsible parties of changes and/or missed medications, ordering of medications and unavailability of medications.Review of Resident #1's electronic MAR dated July 2025 indicated the following:Lacosamide Oral Solution 10 mg/ml Give 20 ml via G-tube two times a day for epilepsy was marked as given at 6:00 PM on 07/26/2025 and 12:00 AM and 6:00 AM on 07/27/2025.Review of Resident #1's electronic MAR dated July 2025 indicated the following:Levetiracetam 100 mg/ml Give 15 ml via G-tube twice a day. The 9:00 PM dose on 07/25/2025 was marked as given and the 9:00 AM dose was marked as given on 07/26/2025. Review of Resident #1's electronic MAR dated July 2025 indicated the following:Topiramate 100 mg tablet Give one via G-tube two times a day was marked as given two times on 07/25/2025 and two times on 07/26/2025.Review of Resident #1's electronic MAR dated July 2025 indicated the following:Valproic Acid 250 mg/5 ml Give 10 ml via G-tube three times a day for epilepsy was marked as given at 10:00 PM on 07/26/2025 and 9:00 AM, 3:00 PM on 07/27/2025 were marked as given. On 07/28/2025 at 12:54 PM, the Administrator was informed of the Immediate Jeopardy and provided the IJ template. The non-compliance was identified as past non-compliance. The Immediate Jeopardy began on 07/22/2025 and ended on 07/26/2025. The facility had corrected the noncompliance before the survey began.

Based on observations, interviews and record review the facility failed to ensure a resident environment remained as free of accident hazards as is possible for 1 of 3 residents reviewed for accidents (Resident #1) Resident #1 asked for hot water, MA A heated the water in the microware and did not place a lid on the cup. Resident #1 spilled the water and received a burn on her leg. The facility failed to have measures in place to prevent residents from burns. The noncompliance was identified as Immediate Jeopardy PNC (past non-compliance). The IJ (Immediate Jeopardy) began on 9/1/24 and ended on 9/10/24. The facility had corrected the noncompliance before the survey began. This failure could place resident at risk of suffering, injuries, and hospitalization. Findings included: Record review of Resident #1's face sheet dated 7/11/25 indicated she was a [AGE] year-old female admitted to the facility on [DATE]. Her diagnoses were Cervical disc disorder with myelopathy (compressed cervical spine with a potential for problems with fine motor skills, balance, and walking). Record review of Resident #1's quarterly MDS dated [DATE] indicated a BIMS score of 12 (moderate cognitive impairment). Resident #1 had functional limited range of motion on one side of the upper extremity. The assessment indicated that for eating, Resident #1 required substantial to maximal assist, with the helper providing more than half the effort. Record review of Resident #1's care plan dated 9/1/24 indicated she was at risk for burns due to hot liquids. Some of the interventions were coffee and other hot liquids should not be served if over 140-degree, the resident was to use a cup with a lid, and use dominate hand for drinking. Record review of Resident #1's nursing notes dated 9/1/24 indicated the following:*at 10:40 a.m. indicated the resident notified staff of spilling chicken broth in her lap. The skin assessment completed at that time had findings of a scald marks measuring 15 cm long and 1 cm wide at the widest point. Vaseline was applied to the area, and the resident denied pain at this time. The responsible party and the physician were notified. *At 11:41 a.m. indicated the physician gave an order for Silvadene cream to be applied two times daily to the right medial thig until resolved. *At 1:25 p.m. indicated reassessed burn to the right medial thigh *At 1:00 p.m. indicated A blister was noted to be forming to the superior portion of the original scald mark measuring 1.5 cm x 0.9cm. Record review of Resident #1's first hot liquid assessment dated [DATE] indicated she had a loss of mobility /reduced movement to the upper extremities. Resident #1 could not consume hot liquids without interventions. She required lids on cups to reduce the potential for burns with coffee or hot liquids. Record Review of a facility Provider Investigation Report indicated on 9/1/24 around 10:50 a.m. Resident #1 asked MA A for some hot water for some chicken broth. The aide provided the hot water, and the resident spilled her chicken broth in her lap. Record review of a written statement from MA A indicated on 9/1/24 Resident #1 requested hot water. The MA said she heated the water in the microwave and took it back to Resident #1's room. She said the resident put a cube of stock in the cup and stirred it up and took a sip. The MA said she exited the room, and a short time later Resident #1 came to the nurse's station with and empty cup stating she had spilled the hot liquid on her thighs. MA A said at that time Resident #1 said she usually had a lid on her cups to prevent spills. The MA said she had not known Resident #1 used lids for her cups. Record review of a written statement from RN B indicated on 9/1/24 at about 10:50 a.m. Resident #1 wheeled herself to the nursing station. Resident #1 said she spilled chicken broth in her lap. A skin assessment was done at that time and the burn was found to the right medial thigh measuring 15 cm x 1 cm. The resident stated when she picked up the mug with the broth in it the mug slipped from her fingers and spilled on her lap and on the floor. The resident stated she did not have a lid for her mug. The physician was notified and ordered Silvadene ointment twice a day until resolved. At 1:00 p.m. the resident was reassessed and had a blister measuring 1.5 cm x 0.9 cm noted to the superior portion of the burn. Aides and CNAs were instructed this resident needed a lid on all cups of hot liquids. During an interview on 6/30/25 at 10:30 a.m. Resident #1 said a long time ago, she spilled hot water on her lap, and it burned her leg. She said the cup just slipped and the cup of hot water spilled onto her lap. She said she could not feel it at the time but told the nurse. She said she asked the MA to bring her some hot water to make her broth. She said the MA heated the water in the microwave and brought it to her. She said since then, the facility had removed the microwaves, and they cannot use them anymore. During an interview on 7/10/25 at 12:22 p.m. the Regional Compliance Nurse said their company took over the facility 7/01/24. She said when they first took over the building there were microwaves available throughout the building. She said after the incident with Resident #1 they removed all the microwaves from nutrition rooms. They placed only one microwave in the medication room for the nurses to provide hot food and liquids to the residents. She said there as a thermometer in the medication room and all staff were educated on the temperature being at 140 or below. She said the nurses were the only ones that could heat up liquids or food for residents. The Regional Compliance Nurse said on 9/1/24 they had conducted audits of all residents at risk for hot liquids, completed hot liquid assessments, and care plan updates for at risk residents. Record review of an in- service dated 9/1/24 indicated MA A had a one-on-one in service and all staff including dietary staff on hot liquids. The in service indicated hot liquids should not be served if above 140 degrees. Lids are to be placed to prevent hot liquid from spilling. Record review of the facility Self-Reporting Protocol /Ad Hoc QAPI- Hot Liquid Burn dated 9/1/24 indicated the following:* Reported intake into the state agency. * Notified the physician to determine if any new orders were need. *The facility competed hot liquid assessments in PCC for all residents who drink coffee, or hot liquids. * Care planned any resident at risk for hot liquid burns. *The facility indicated they ensured any special dietary interventions were on the tray cards of applicable residents. * In- serviced nursing staff, and dietary staff to follow any interventions for residents requiring hot liquid interventions. * In- serviced all staff that a charge nurse or dietary staff member are the only employee that can heat up liquid in the microwave for residents. All liquid temperature at 140 degrees or below before serving. *The facility initiated a monitoring system to ensure interventions for those at risk was care planned and interventions were in place, for four weeks. Record review of hot liquid temperature monitoring indicated the Dietary Manager at least 5 times a week will ensure any dietary initiated interventions for those at risk for hot liquids are in place and care planned. Monitoring indicated The Dietary Manager and the DON would ask at least 10 staff per week how liquids should be warmed up if requested by a resident and what temperatures hot liquids should be prior to making accessible or serving residents. The monitoring sheets included dates from 9/4/24 through 9/10/24. During an interview on 7/11/25 at 11:15 a.m. the Regional Compliance Nurse said the monitoring was completed for the four weeks. She said the missing sheets had likely been misplaced due to a significant staff turnover they had changed Administrators at least two times since then and the DON is also relatively new. Therefore, the sheet could have been lost during transitions. Record review of care plans and hot liquid assessments for Resident #1, sampled Residents #4, #5 and #6 indicated they were completed with interventions in place. Interviews were conducted with facility employees as follows: 7/10/25*at 8:50 a.m. CNA E worked 6a to 6p*at 9:00 a.m. MA F worked 7a to 7p*at 9:03 a.m. LVN G worked form 5:45 a.m. to 6p*at 9:20 a.m. CNA H worked from 6a to 6p*at 9:24 a.m. ADON/LVN I- said she worked various hours and shifts*at 9:30 a.m. MA J worked 7 a to 7p*at 9:35 a.m. RN K worked 6a to 6p*at 9:45 a.m. CNA L worked 6a to 6 p*at 10:17 a.m. LVN M worked 6a to 6 p*at 10:30 a.m. ADON/LVN O said she worked various hours and shifts7/11/25* at 4:17 a.m. RN P worked from 6p to 6a* at 4:29 a.m. LVN Q worked from 6p to 6a* at 4:36 a.m. CNA R worked from 6p to 6a* at 9:55 a.m. RN T worked 6a to 6p CNAs and MAs said they were aware that only nurses or dietary staff could heat up liquids. They said anytime a resident asked for hot water or food the nurse was informed. They were also aware the liquids were to be at 140 degrees or less. Nurses said there was only one microwave, and it was in the medication room. They were responsible for heating resident liquids. They said there was a thermometer in the medication room next to the microwave. They were to check the temperatures to make sure it was 140 degrees or less. They said the residents that needed lids with their hot liquids were identified and had those lids were in place. They had extra lids if needed. Observation of the facility on 7/11/15 at 11:15 a.m. showed there was a microware in the employee break room that had a keypad entry. The only other microware noted in the facility was in the medication room. There was a thermometer noted next to it. The noncompliance was identified as Immediate Jeopardy PNC (past non-compliance). The IJ (Immediate Jeopardy) began on 9/1/24 and ended on 9/2/24. The facility had corrected the noncompliance before the survey began.

Based on interview, and record review the facility failed to ensure residents were free from significant medication errors for 1 of 3 residents reviewed for medications (Resident #2). The facility failed to follow their policy on medication administration resulting in a significant medication error. *Resident #2 was readmitted [DATE] and had an order on 12/22/24 for Eliquis to be held until 12/27/24- the order did not have a restart date. *Resident #2 had an order on 12/23/24 to hold Eliquis for 4 days and restart the medication on 12/27/24. *The facility did not resume Resident #2's Eliquis medication and he was sent to the hospital on 1/26/25 with DVT and pulmonary embolism. The noncompliance was identified as Immediate Jeopardy PNC (past non-compliance). The IJ (Immediate Jeopardy) began on 1/26/25 and ended on 2/28/25. The facility had corrected the noncompliance before the survey began. This failure could jeopardized resident heath and could have been terminal. Findings Included: Record review of Resident#2's face sheet dated 1/28/25 indicated he was an [AGE] year-old male admitted to the facility 2/13/23. He had diagnoses of Hemorrhage of anus and rectum, history of pulmonary embolism, and chronic embolism and thrombosis of deep veins of left lower extremity. Record review of Resident #2's quarterly MDS dated [DATE] indicated a BIMS score of 13(cognitively intact). His functional limitation in range of motion indicated he had impairment on both sides of his lower extremities and used a wheelchair for mobility. Record review of Resident #2's care plan dated 7/2/24 indicted a focus area of anticoagulant(Eliquis-mediation used to prevent and treat blood clots in the blood vessels and the heart) therapy. An intervention was to monitor, document and report to the physician, signs and symptoms of anticoagulant complications. Record review of Resident #2's computerized physician an order dated 6/28/24 indicated an order for Eliquis 5mg to give one tablet by mouth two times a day related to personal history of pulmonary embolism. Record review of Resident #2's nursing notes dated 12/20/24 at 3:21 a.m. indicated he was transferred to the hospital. Record review of Resident #2's nursing notes dated 12/21/24 indicated the following: *at 4:32 a.m. indicated Resident #2 returned to the facility. *At 4:54 p.m. the report from the hospital nurse indicated Resident #2 was schedule for a polyp removal and to hold Eliquis for 6 days. *At 8:00 p.m. indicated to hold the Eliquis until 12/27/24. Record review of Resident #2's physician orders indicated an order dated 12/22/24 indicated to place the medication on hold on 12/27/24 with no duration or start date. Record review of Resident #2's physician order dated 12/23/24 indicated place the Eliquis on hold from 12/23/24 with a duration of 4 days and restart on 12/27/24. Record review of Resident #2's December 2024 MAR revealed Eliquis oral table 5mg by mouth two times a day. The MAR indicated on 12/20/24 the resident was hospitalized and from 12/21/24 the medication was on hold through 12/31/24. Record review of Resident #2's MAR for January 2025 revealed Eliquis oral table 5mg by mouth two times daily was not administered and was on hold until 1/29/25. During an interview on 7/11/25 at 9:15 a.m. the Regional Compliance Nurse said the two orders for Resident #2's Eliquis canceled each other out. She said the facility computer system would automatically rerestart medications that were on hold. However, the order written on 12/23/24 said to restart the medications on 12/27/24 and that order ended on 12/27/24 at 12:00 a.m. She said the 12/22/24 order placed the Eliquis on hold starting 12/27/24 and began on 12/27/24 at 12:00 a.m. That was why the medication were placed on hold indefinitely. The Regional Compliance Nurse said the 12/22/24 order did not indicate a duration or a restart date. Record review of Resident #2's hospital records dated 1/26/25 indicated he was admitted with diagnosis of noncompliant with Eliquis. Resident #2 presented to the hospital with syncope, he was found to have symptomatic acute pulmonary embolism with right ventricular strain and right DVT requiring mechanical thrombectomy (surgical intervention to remove blood clots) and transition to Eliquis. Record review of the facility Self-Reporting Protocol /Ad Hoc QAPI- Neglect- Medication Error Resulting in Harm. indicated the following:* conducted an audit to determine if any other residents were affected. *An abuse and neglect in-service for all staff to include failure to administer medications as ordered by the physician can be considered neglect. *Staff were in serviced on notification of a change in condition to include reporting change of condition to the nurse. *An in-service was conducted on following MD orders for all nurses to include how to place a medication on hold and add stop/start dates to the physician orders. *An in-service was conducted on Medication Administration policy to include the ensure medications were given correctly. *A medication error policy in-service was conducted with Mas and all nurses to include notification of the physician. *An in service was conducted on medication reconciliation for all nurses to include medication review upon admission and readmission to reduce the incidence of medication errors. *The facility initiated a monitoring system to monitor orders to ensure they were transcribed correctly, physician orders were followed, for at least 4 weeks. The medical director signed the protocol. Record review of an in service dated 1/26/25 indicated nurses and MAs were in serviced on medication administrator to verify the medication and liable to the MAR, always follow the 5 rights of medication administration, right drug, dose, resident, time and route. If the medication is showing that is in on hold, investigate and verify why the medication was being held. The Medication Administration policy was attached. The staff were also in serviced on the facility Medication Error Policy. Record review of an in service dated 1/26/25 indicated staff were in serviced on abuse and neglect. The in service indicated failure to administer medications as order by the physician can be considered neglect. Record review of an in service dated 1/26/25 indicated all staff were in serviced on notification of change in condition. The in service indicated a nurse is to be notified anytime a change in condition is notice. The charge nurse will then be responsible for assessing the resident and notifying the physician and responsible party. This will be documented on the SBAR. Record review of an in service dated 1/26/25 indicated nurses were in serviced on the Medication Reconciliation Process which involved reconciling and comparing medication orders at each stage of the resident stay in the facility to resolve any discrepancies. Medication reviews should occur upon admission or readmission to reduce the incidence of medication errors. The in service indicated that was to be documented in the drug regimen review. Record review of an in service dated 1/26/25 indicated nurses were in serviced on following physician orders to verify the order that was received was correct and to contact the physician for any clarification. When orders were received a progress note or SBAR should be completed along with the notification of the responsible party. Review of the attached policy on Physician's Orders indicted the purpose was to monitor and ensure the accuracy and completeness of the medication orders, treatments orders, and ADL order for each resident. The orders were to be reviewed for accuracy if written orders, telephone orders, or verbal orders. Record review indicated the facility had audited orders on hold and anticoagulants and all medications completed on 1/28/25. Record review of the facility medication error monitoring indicated it began on 1/27/25 ended 2/28/25. The medication administration error monitoring indicated at least 5 times a week all new admissions and readmission from previous days to ensue all orders are transcribed in the system and that all ordered medications were available. The DON or designee would interview a least 4 nurses and medication aides each week and ask them what they would do if medication were not available or what to do regarding medications for any residents returning to the facility. Interviews conducted with facility employees as follows:7/10/25 * at 8:50 a.m. CNA E worked 6a to 6p* at 9:00 a.m. MA F worked 7a to 7p* at 9:03 a.m. LVN G worked form 5:45 a.m. to 6p* at 9:20 a.m. CNA H worked from 6a to 6p* at 9:24 a.m. ADON/LVN I- said she worked various hours and shifts* at 9:30 a.m. MA J worked 7 a to 7p* at 9:35 a.m. RN K worked 6a to 6p* at 9:45 a.m. CNA L worked 6a to 6 p* at 10:17 a.m. LVN M worked 6a to 6 p* at 10:30 a.m. ADON/LVN O said she worked various hours and shifts7/11/25* at 4:17 a.m. RN P worked from 6p to 6a* at 4:29 a.m. LVN Q worked from 6p to 6a* at 4:36 a.m. CNA R worked from 6p to 6a* at 9:55 a.m. RN T worked 6a to 6p Interviews with staff revealed they were knowledgeable about the in services that were provided. Interviews with nurses revealed they were familiar on how to put medications on hold, with durations, and restart dates for residents with appointments or readmissions. They said if they had admissions or readmissions they would reconcile the medications with the physician orders, contact the facility physician for clarification on medications. The nurses said if they noted a change in condition or were informed of a change in condition of a resident they would assess. The CNAs said if they noted a change in the condition of a resident, they would notify the nurse and document on the required form. The MAs said if they had any medication questions they would notify the nurse for clarification. If they noted a medication on hold for longer than the usual 3 to 5 days, they would ask questions for clarification. The noncompliance was identified as Immediate Jeopardy PNC (past non-compliance). The IJ (Immediate Jeopardy) began on 1/26/25 and ended on 1/28/25. The facility had corrected the noncompliance before the survey began.

Based on interview and record review the facility failed to ensure the resident was oriented with a planned, safe and orderly discharge for 1 of 5 residents reviewed for discharge (Resident #3). Resident # 3 was discharged to the hospital, the facility refused to take him back due to nonpayment. Resident # 3 resided at the hospital for over 30 days until the hospital was able to find placement. This Failure could place residents at risk of not permitting a safe and orderly dischargeFindings included: During an interview on 6/30/25 at 11:42 a.m. the Administrator said there were no records for Resident #3 in their computer system, because he was discharged out of the system prior to their change of ownership on 7/1/24. She said she had to go to the hospital after she started working at the facility because the facility had been blacklisted and the hospital would not refer any residents to them. She said the hospital was upset because the former owners had dumped Resident #3 and refused to take him back. She said she would request Resident # 3's records from the prior facility owners. Record review of Resident # 3's face sheet indicated he was an [AGE] year-old male admitted to the facility on [DATE]. He had diagnoses of anxiety disorder, paralysis affecting the right dominant side, adjustment disorder, diabetes, right leg above the knee amputation, need for personal care assistance, age related cognitive decline, and housing instability, housed with risk of homelessness. Record review of Resident #3's discharge MDS dated [DATE] indicated it was an unplanned discharge to a short-term general hospital with a discharge date of 6/10/24. Record review of a 30-day notice dated 12/29/23 indicated Resident # 3 had failed after reasonable notice to pay under Medicare of Medicaid to stay at the facility. His effective date of discharge was 1/29/24. Record review of Resident #3's petition for Eviction indicated the grounds for eviction was unpaid rent as of December 2023 amounting to $18,330.00. The notice to vacate was hand delivered. The notice was filed at the county court on 3/26/24. Record review of Resident #3's nursing notes dated 6/10/24 at 1:25 a.m. indicated the resident complained of shortness of breath with oxygen status fluctuating between 90 to 92. He was sent to the hospital. Record review of social services notes dated 6/11/15 at 11:00 a.m. indicated Resident #3 was discharged and would not return per eviction notice served on 4/18/24 for nonpayment. His family was notified to pick up his belonging, and Adult Protective Services was notified. Record review of Resident #3's nursing notes from 5/30/24 until discharge on [DATE] did not indicate any discharge actions in place. Record review of Resident # 3's hospital records indicated he was admitted to the hospital on [DATE] due to shortness of breath. Record Review of the hospital Social Worker note dated 7/19/24 indicated they had made approximately 35 referrals for Resident # 3's discharge with 12 referrals being denied out right and 26 pending during his admission. The records indicated the facility his admitting facility refused to take him back. Resident #3 was discharged from the hospital on 7/19/24 to another facility. During an interview on 7/9/25 at 10:24 a.m. the Social Worker said she worked at the facility for two years. She said she had been trying to get Resident #3 discharged from the facility due to nonpayment prior to 6/10/24. The Social Worker said he did not want to go anywhere and did not want to provide any financial paperwork to apply for Medicaid. The Social Worker said Resident # 3 was getting some kind of money, he had Medicaid but lost in 2023 because he was overcompensated. She said he paid $12, 000 for a van that he could not drive, she said he could not walk. She said the facility had given him a 30-day discharge notice at one time, but they could not get him to leave. The Social Worker said the former owners of the facility had taken him to court and gotten an eviction notice. She said she had never seen an eviction notice at a nursing facility before. The Social Worker said they had given him the eviction notice back in April of 2024 and she thought Resident #3 had gone over the time of his eviction. The Social Worker said she thought they contacted the Deputy, but no one came to evict Resident # 3. She said Resident # 3 had gone to the hospital 6/10/24 and the hospital called and said he needed to come back. She said the former Administrator talked to the hospital and told them the facility was not taking Resident #3 back. She said the hospital was upset and pulled out their Medical Director, NP, and the hospital stopped sending them admissions. She said Resident #3 had to stay in the hospital for over 30 days because the hospital could not find placement for him. She said she called the family to come and get his things, but it took them over a week to come and get Resident # 3's things after he was discharged from the facility on 6/10/25. During an interview on 7/9/25 at 11:15 a.m. the Ombudsman said she was not aware of Resident 3's discharge and was not involved. During an interview on 7/11/25 at 8:50 a.m. the Administrator and Regional Compliance Nurse said they had not put any corrective measures in place regarding Resident # 3's discharge. They said he was gone prior to their company taking over the facility. They said they did not know anything about the dumping of Resident #3. He said the former Administrator told them back in October of 2024 Resident # 3 was discharged . They said after the hospital removed their doctor, and NP. They said were not getting any admission referrals from the hospital they investigated the matter. They said it was not their policy to dump residents and would not have discharged Resident # 3 in that fashion. Record review of the facility Resident Rights policy last revised 11/28/16 indicated the resident had a right to dignified existence, self-determination, communication. The facility must provide equal access to quality care regardless of diagnosis, severity of condition or payment source. A facility must establish and maintain identical polices and practice regarding transfer, discharge, and the provision of services under the State plan for all residents regardless of the payment source.

Based on observations, interviews, and record review, the facility failed to ensure necessary treatment and services, consistent with professional standards of practice, to promote healing and prevent new pressure injuries from developing was provided for 1 of 4 residents reviewed for pressure injuries (Resident #3). The facility failed to ensure Resident #3 did not develop a stage II pressure injury to the right heel on 3/25/25 and a stage III pressure injury to the right buttock on 4/8/25 that were not present on her admission to the facility. The facility did not ensure Resident #3 was repositioned to effectively alleviate pressure to right buttock on 4/4/25 and 4/5/25. The facility did not ensure Resident #3 was repositioned to effectively alleviate pressure to the right heel on 4/4/25 and 4/5/25. These failures could place residents at risk for new development or worsening of existing pressure injuries, pain, and decreased quality of life. Findings included: Record review of the face sheet dated 4/4/25 indicated Resident #3 was [AGE] years old and admitted to the facility on [DATE] with diagnoses including aftercare following joint replacement surgery, pressure ulcer of the sacral region, pressure injury of the left heel, type II diabetes, and presence of right artificial hip joint. Record review of the admission MDS dated [DATE] indicated Resident #3 usually made herself understood and understood others. The MDS indicated Resident #3 had no cognitive impairment, (BIMS score of 13). The MDS indicated Resident #3 had no behavior of refusing care. The MDS indicated Resident #3 had functional limitation of range of motion to both the extremities of the upper and lower body. The MDS indicated Resident #3 was dependent on staff for repositioning (rolling left and right from her back while in bed; the ability to move from sitting on the side of the bed to lying flat on the bed; and the ability to sit on the side of the side of the bed from laying flat on the bed). The MDS indicated Resident #3 was always incontinent of bowel and bladder. The MDS indicated Resident #3 was at risk for pressure injury and indicated she had 1 unstageable pressure injury presenting as a deep tissue injury (DTI, pressure injury where the underlying tissue, including muscles and subcutaneous tissue, is damaged, but the skin surface may remain intact) that was present on admission and 1 unstageable pressure injury, unstageable due to slough ( type of non-viable [dead] tissue that accumulates in a wound. Usually yellowish, grayish, or brownish in color and, often with a stringy or wet consistency) or eschar (type of non-viable tissue covering the wound bed, usually tan, brown, or black in color with a dry, thick, leathery consistency) also present on admission. The MDS indicated Resident #3 received the following skin and ulcer/Injury treatments; pressure reducing device for her bed, pressure ulcer/injury care. Record review of Resident #3's the care plan revised on 4/4/25 indicated she had the following identified pressure injuries; Stage II pressure injury ( a stage II pressure injury has partial thickness loss of dermis presenting as a shallow open ulcer with a red or pink wound bed, without slough or bruising. A stage II pressure injury may also present as an intact or open blister) to the right buttock; a stage II pressure injury to the left buttock; and a stage II pressure injury to the right heel. The care plan interventions included to follow facility policies and protocols for the prevention/treatment of skin breakdown. The care plan also indicated Resident #3 needed assistance to turn/reposition every two hours. The care plan stated Resident #3 was resistant to repositioning. Record review of the physician wound care note dated 3/14/25 indicated Resident #3 had a resolved (healed) sacral DTI and an unstageable DTI to the right heel measuring 0.4 cm in length x 0.5 cm in width. The physician wound care note recommended interventions included; float heels in bed, off load wound, and reposition per facility protocol. Record review of the physician wound care note dated 3/21/25 indicated Resident #3 had an unstageable DTI to the right heel measuring 0.6 cm in length x 0.7 cm in width. The physician wound care note recommended interventions included; float heels in bed, off load wound, and reposition per facility protocol. Record review of the physician wound care note dated 3/25/25 indicated Resident #3 had an unstageable DTI to the right heel measuring 1.2 cm in length x 2.2 cm in width. The physician wound care note recommended interventions included; float heels in bed, off load wound, and reposition per facility protocol. Record review of the physician wound care note dated 4/1/25 indicated Resident #3 had an unstageable DTI to the right heel measuring 1.0 cm in length x 0.5 in width. The physician wound care note recommended interventions included; float heels in bed, off load wound, and reposition per facility protocol. Record review of Resident #3's nursing skin assessment on 4/3/25 indicated she had a pressure injury measuring 1.3 x1.2 x0.2 to the right buttock and was described as an open area. During an interview and observation on 4/4/25 at 10:10 am Resident #3 was laid in a semi- [NAME] (reclined position at approximately a 30- to- 45- degree angle) in her bed. Resident #3 had a wedge positioned to the lower back of the left side. Her buttock was on the surface of the mattress. Both her right and left heels laid on the surface of the mattress. Resident #3 said she could only barely lift her heels from the bed without assistance. Resident #3 tried to demonstrate to the state surveyor lifting the left then right heel off the surface of the bed. Resident #3 slightly elevated the left heel approximately 1 cm off the surface of the mattress. Resident #3 did not effectively raise the right heel from the surface of the mattress. Resident #3 said she could not turn side to side by herself in the bed. Resident #3 indicated no one had attempted to move her in the bed yet today. During an interview and observation on 4/4/25 at 12:40 p.m., Resident #3 remained in the semi- [NAME] (reclined position at approximately a 30- to- 45- degree angle) in her bed. Resident #3 had a wedge positioned to the lower back of the left side. Her buttock was on the surface of the mattress. Both her right and left heels laid on the surface of the mattress . During an interview on 4/4/25 at 2:13 pm CNA E indicated she regularly worked the hall Resident #3 resided on. CNA E said she rounded on residents every 2 hours. CNA E was asked what care she provided during those rounds. CNA E did not mention repositioning or alleviating pressure areas of dependent residents. During an interview and observation on 4/4/25 at 2:30 p.m., Resident #3's family member was sitting in Resident #3's room. Resident #3 remained in the semi- [NAME] (reclined position at approximately a 30-to-45-degree angle) in her bed. Resident #3 had a wedge positioned to the lower back of the left side. Her buttock was on the surface of the mattress. Resident #3 had a very small wedge under the right ankle. Resident #3's heel laid on the surface of the mattress. Resident #3's family member said she had placed that wedge under Resident #3's ankle to try to get her heel off of the bed. Resident #3's family member said she had a wound to the right heel. Resident #3's family member said she brought the wedge to the facility because the facility staff were not raising her heels off of the bed and she thought bringing the wedge would help. Resident #3's family member stated she came regularly to the facility to see Resident #3 and stayed for several hours at a time and never would see the facility staff reposition Resident #3 . Resident #3's family member said she voiced her concerns regarding Resident #3 needing to be repositioned to alleviate pressure to her buttock and heels but could not provide names of staff or specific dates and times. During an observation on 4/5/25 at 7:40 a.m., Resident #3 laid in her bed. Resident #3 had a wedge positioned to the lower back of the left side. Her buttock was on the surface of the mattress. A pillow was under her calves but both her right and left heels laid on the surface of the mattress . During an interview and observation on 4/5/25 at 10:00 a.m., Resident #3 laid in in her bed. Resident #3 had a wedge positioned to the lower back of the left side. Her buttock was on the surface of the mattress. A pillow was under her calves but both her right and left heels laid on the surface of the mattress. Resident #3 indicated no staff had attempted to reposition her. During an observation on 4/8/25 at 12:15 p.m., Resident #3 was assessed by the LVN F and the wound care physician. The wound to Resident # 3's right heel was bright red with a dry blister. The wound care physician said the right heel wound was a stage II pressure injury. Resident #3 was rolled to the left lateral side while in her bed. Resident #3 had red open area to the right buttock. The wound care physician said the wound was a stage III pressure injury. Resident #3 also had an additional area to the buttock measuring 0.7 cm in length x 0.1 cm in width below the stage III pressure area. The wound care physician stated the intact discolored skin below the stage III pressure injury was a DTI. During an interview on 4/8/25 at 12:25 p.m., LVN F said it was very important to ensure Resident #3's buttock and heels were positioned to alleviate pressure from those areas in order to promote wound healing and prevent deterioration of, and/ or the development of new pressure wounds. LVN F said residents should be repositioned every 2 hours by nursing staff (CNAs and nurses). During an interview on 4/8/25 at 1:00 p.m., the DON said nursing staff (CNAs and nurses) should ensure repositioning was attempted every 2 hours in order to prevent pressure injuries from getting worse as well as prevent the development of new pressure injuries. During an interview on 4/8/25 at 1:10 p.m., the Administrator said it was important for residents to be repositioned to prevent the development of pressure injuries. Record review of the facility policy and procedure titled Pressure Injury: Prevention, Assessment and Treatment revised 8/12/16, stated, Procedure: Nursing personnel will continually aim to maintain the skin integrity, tone, turgor and circulation to prevent breakdown, injury and infection . (6.) Nursing Action/Rationale: Prevention: The nurse can assist in the prevention of pressure injuries by performing the following nursing interventions .Add any interventions to care plan. (1.) Determine resident' s skill tolerance to pressure and develop a turning schedule; residents should be turned every two (2) hours or more often if necessary and notify the Treatment Nurse/designee of any potential problems. (2.) Do the blanching test by pressing the finger into a reddened area, a normal blood supply to the reddened area is seen when the area blanches white and then turns pink again. If the area remains red, a pressure sore is impending due to impaired circulation, keep resident off the area for 24 hours and then repeat the test .(5.) Maintain body alignment with support for body parts; pillows, cradles, pads, heel/elbow protectors, and mattresses can be used to help relieve pressure .

Based on observations, interviews, and record review, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 1 of 4 staff (CNA C) observed for infection control. The facility failed to ensure CNA C changed gloves and performed hand hygiene while performing incontinent care on Resident #1. This failure could place residents and staff at risk for cross-contamination, spread of infection, and could potentially affect all others in the building. Findings included: 1. During an observation on 4/5/25 at 8:33 a.m. CNA C entered Resident #1's room without performing hand hygiene. CNA C stopped at Resident #1's roommate's bed, laid gloves on the bed, and adjusted something on the bed rail. CNA C picked up the gloves, did not perform hand hygiene, and put the clean gloves on. CNA C went to the Resident #1's chest and removed a clean gown and socks. CNA C assisted Resident #1 out of bed. Resident #1's gown was observed to be wet up to the middle of her back. CNA C did not remove her gloves or perform hand hygiene. CNA C pushed Resident #1 in her wheelchair to the bathroom. CNA C did not change gloves or perform hand hygiene and left the bathroom to get wipes. CNA C removed Resident #1's wet brief and took off her gown. CNA C did not change gloves or perform hand hygiene. CNA C moved Resident #1's clean clothes off the wheelchair and retrieved a clean brief out of storage drawer in bathroom. CNA C dried the urine off Resident #1 and did not change gloves or perform hand hygiene. CNA C put a clean gown on Resident #1, used clean wipes to wipe Resident #1's bottom, took her own glasses off her face, and continued to wipe Resident #1's bottom using clean wipes. CNA C put a clean brief on Resident #1, removed her gloves, and did not perform hand hygiene. CNA C left the room to get barrier cream, returned to the bathroom, put on clean gloves, and applied barrier cream to Resident #1's bottom. CNA C did not change gloves or perform hand hygiene. CNA C pulled up Resident #1's brief and assisted her to the wheelchair. CNA C removed her gloves and did not perform hand hygiene. CNA C pushed Resident #1 in the wheelchair back to her side of the room. CNA C put on gloves, bagged up the wet linens and clothing, removed her gloves, and did not perform hand hygiene. During an interview on 4/5/25 at 10:14 a.m. CNA C said hand hygiene should be performed after removing gloves and before putting on clean gloves. CNA C said gloves should be changed when going from dirty to clean, after applying cream, if gloves were visibly soiled, and when changing tasks. CNA C said she should have changed her gloves and performed hand hygiene after several steps when providing care for Resident #1. CNA C said she should not have used the gloves she set on Resident #1' roommate's bed when providing Resident #1's care. CNA C said the importance of proper glove changes and hand hygiene was to prevent the spread of bacteria and contamination. During an interview on 4/7/25 at 11:29 am the DON said hand hygiene should be performed when entering and exiting a resident room, between glove changes, and when going from clean to dirty. The DON said the importance of proper glove changes and hand hygiene was to prevent infections and the spread of bacteria. Record review of the facility's Fundamentals of Infection Control Precautions last revised 3/2024 indicated, A variety of infection control measures are used for decreasing the risk of transmission of microorganisms in the facility. The measures make up the fundamentals of the infection control precautions. Hand Hygiene continues to be the primary means of preventing the transmission of infection. The following is a list of some situations that require hand hygiene: .Before and after assisting a resident with personal care .Before and after assisting a resident with toileting .After contact with a resident's mucous membranes or bodily fluids or excretions .After removing gloves or aprons .Consistent use by staff of proper hand hygiene practices and techniques is critical to preventing the spread of infections .Gloves are worn for three important reasons: To provide a protective barrier and prevent cross contamination of the hands when touching blood, body fluids, secretions, excretions, mucous membranes, and nonintact skin. The wearing of gloves in specific circumstances will reduce the risk of exposures to blood borne pathogens and is mandatory for all employees .wearing gloves does not replace the need for hand washing because gloves may have small inapparent defects or be torn during use, and hands can become contaminated during removal of gloves. Failure to change gloves between resident contacts is an infection control hazard.

Based on interviews, and record review, the facility failed to develop and implement a comprehensive person-centered care plan to meet each resident's medical needs for 1 of 6 residents (Resident #2) reviewed for comprehensive resident centered care plan. The facility failed to ensure Resident #2 was not care planned for a secured unit when the facility did not have a secured unit. This failure could place the residents at increased risk of not having their individual needs met and a decreased quality of life. Findings Included: 1. Record review of the face sheet dated 4/5/25 indicated Resident #2 admitted to the facility on [DATE] with diagnoses including second cervical vertebrae (the second vertebrae in the spinal column, located in the neck region) with routine healing, surgical aftercare, seizures, hypertension (elevate blood pressure), and shortness of breath. Record review of the MDS dated [DATE] indicated Resident #2 understood others and was understood by others. The MDS indicated Resident #2 had a BIMS score of 15 and was cognitively intact. Record review of the care plan revised 2/27/25 indicated Resident #2 resided in the Secure Care Unit, related to diagnosis of dementia (or related diagnosis) and risk for elopement. During an interview on 4/5/25 at 6:54 a.m. the Regional Nurse said the facility did not have a secured unit. The Regional Nurse said the facility did not have any residents that required a secured unit at this time. During an interview on 4/7/25 at 11:29 am the DON said she was ultimately responsible for ensuring care plans were correct. The DON said the facility did not have a secure unit in the facility. The DON she was not aware of any residents that had a care plan to be in a secured unit. The DON said secured units being care planned was not something she had looked at on the care plans as the facility did not have a secured unit. The DON said the importance of the care plans being accurate were so the facility staff knew how to take care of the residents. Record review of the facility's undated Comprehensive Care Planning policy indicated, The facility will develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment .

Based on observations, interviews, and record review, in accordance with State and Federal laws, the facility failed to store all drugs and biologicals in locked compartments under proper temperature controls and permitted only authorized personnel to have access to the keys on 3 of 7 medication carts reviewed for labeling and storage of medication. The facility did not ensure the medication cart on hall 200 and 2 medication carts on hall 300 were secured and unable to be accessed by unauthorized personnel. This failure could place residents at risk for not receiving drugs and biologicals as needed or a drug diversion. Findings included: 1. During an observation on 4/5/25 at 5:08 a.m. the medication cart on the 200 Hall was in the middle of the hallway unlocked with the keys lying on top of the cart and no staff nearby. During an interview on 4/5/25 at 5:10 a.m. LVN A said she was the nurse for the 200 Hall. LVN A said she did not always leave her medication cart unlocked with the keys on top of the cart. LVN A said a CNA had called her into a resident room to assist with a mechanical lift transfer (uses specialized equipment to safely lift and move individuals who cannot safely bear weight) and she walked away from the medication cart leaving it unlocked and the keys lying on top of the cart. LVN A said the importance of ensuring the medication carts were locked and the keys were secure was to keep the medications and the residents safe. 2. During an observation on 4/5/25 at 5:12 a.m. the medication cart on the 300 Hall was unlocked. RN B walked by the unlocked cart and did not lock the cart. 3. During an observation on 4/5/25 at 5:13 a.m. The second medication cart on the 300 Hall was unlocked. A staff member walked past the cart and did not lock the cart. During an interview on 4/5/25 at 5:14 a.m. RN B said she was the nurse for the 300 Hall. RN B said she did not always leave her medication carts unlocked. RN B said she had gone to get trash bags and had just finished passing her morning medications. RN B said the importance of ensuring medication carts were locked was so the residents could not get into the medications and take something not prescribed to them. During an interview on 4/7/25 at 11:29 am the DON said she expected the nurses and the MAs to keep their medication carts locked at all times unless they were pulling medications from the cart. The DON said the importance of keeping the medication cart locked was to prevent drug diversion and to prevent residents from getting in the cart and possibly taking the incorrect medications. Record review of the facility's Storage of Medication policy dated 2003 indicated, Medications and biologicals are stored safely, securely, and properly following manufacturer's recommendations or those of the supplier. The medication supply is accessible only to licensed nursing personnel, pharmacy personnel, or staff members lawfully authorized to administer medications .Medication rooms, carts, and medication supplies are locked and attended by persons with authorized access.

Based on observations, interviews, and record review, the facility failed to ensure a resident who was unable to carry out activities of daily living received the necessary services to maintain grooming and personal hygiene were provided for 1 of 7 (Resident #1) residents reviewed for ADLs. The facility failed to ensure Resident #1 received incontinent care for an episode of urine incontinence on 4/5/25. These failures could place residents at risk of not receiving services/care and decreased quality of life. Findings Included: 1. Record review of the face sheet dated 4/7/25 indicated Resident #1 was admitted to the facility on [DATE] with diagnoses including overactive bladder, urinary incontinence, muscle weakness, unsteadiness on feet, and difficulty walking. Record review of the quarterly MDS dated [DATE] indicated Resident #1 understood others and was understood by others. The MDS indicated Resident #1 had a BIMS score of 11 and was moderately cognitively impaired. The MDS indicated Resident #1 required substantial/maximum assistance with toileting. The MDS indicated Resident #1 required partial/moderate assistance with transfers. The MDS indicated Resident #1 was occasionally incontinent of urine and frequently incontinent of bowel. Record review of the care plan updated 1/29/25 indicated Resident #1 had ADL self-care performance deficit with interventions including supervision with toileting as needed. During an interview on 4/4/25 at 10:42 a.m. Resident #1 said she was always waiting to get changed. Resident #1 said today was the first time in a while she had breakfast and was not wet from urine. During an interview and observation on 4/5/25 at 8:28 a.m. Resident #1's breakfast tray was sitting on her bedside table. Resident #1 said she was wet all over from an incontinent episode. Resident #1's nightgown was observed being wet in the front. During an observation on 4/5/25 at 8:33 a.m. CNA C assisted Resident #1 out of bed. Resident #1's gown was observed to be wet up to the middle of her back. During an interview on 4/5/25 at 8:49 a.m. CNA C said she did rounds at approximately 6:00 a.m.-6:15 a.m. to check on the residents and ensure they were ok and not on the floor. CNA C said after her first round, she got the residents up who needed to be up for breakfast. CNA C said then she would start her first round before the breakfast trays came out. CNA C said the last time she had checked on Resident #1 was between 6:00 a.m. and 6:15 a.m. CNA C said she had the back half of the hall today and she did not check to see if Resident #1 was wet. During an interview on 4/5/25 at 8:54 a.m. NA D said she did rounds every 2 hours. NA D said when she made rounds, she ensured people were dry, and comfortably positioned. NA D said she did not check to see if Resident #1 was wet when she checked on Resident #1's roommate. NA D said she did not check on Resident #1 because Resident #1 got up and went to the bathroom on her own. During an interview on 4/7/25 at 11:29 am the DON said she expected residents to be checked for incontinent episodes by staff even if the resident was only occasionally incontinent. The DON said the importance of staff checking residents for incontinent episodes was to aide in preventing skin breakdown, for the residents' comfort, and for infection prevention. During an interview on 4/7/25 at 11:45 a.m. the Divisional Director said the facility did not have a specific policy regarding incontinent care. Record review of the facility's Skin Integrity Management dated 2003 indicated, .Skin should be cleansed at the time of soiling and at routine intervals. The frequency of skin cleansing should be individualized according to need and/or resident preference .

Based on interview and record review, the facility failed to ensure residents receive treatment and care in accordance with professional standards of practice and the comprehensive person-centered care plan for 1 of 7 (Resident #1) residents reviewed for quality of care. The facility failed to perform neurological assessments following an incident report dated 1/9/25 indicating Resident #1 had a fall and hit her head resulting in her being hospitalized with a subdural hematoma. The facility failed to recognize a change in Resident #1's level of consciousness resulting in the family requesting for Resident #1 to be sent to the hospital and Resident #1 being admitted to the hospital with a diagnosis of a subdural hematoma. The failures resulted in an identification of an Immediate Jeopardy (IJ) at 11:00 a.m. on 1/23/25. While the IJ was removed on 1/24/25, the facility remained out of compliance with a scope identified as isolated due to the facility's need to complete in-service training and evaluate the effectiveness of the corrective systems. These failures could result in residents with falls not being monitored appropriately or residents a change in condition not being recognized leading to further resident decline, residents not receiving timely treatment, and death. Findings Included: 1. Record review of the face sheet dated 1/22/25 indicated Resident #1 was a [AGE] year-old female admitted to the facility on [DATE] with diagnoses including dementia, anxiety, hemiplegia (muscle weakness or partial paralysis on one side of the body), cerebral infarction (ischemic stroke), and chronic kidney disease (longstanding disease of the kidneys leading to renal failure). Record review of the MDS dated [DATE] indicated Resident #1 usually understood others and was usually understood by others. The MDS indicated Resident #1 had a BIMS of 11 and was moderately cognitively intact. The MDS indicated Resident #1 required substantial/maximum assistance with toileting, bathing, and transfers. Record review of the care plan revised 12/15/24 indicated Resident #1 was at risk for falls related to actual continuous falls with a goal of the resident will not sustain serious injury through the review date. Record review of the incident report for Resident #1 date 1/9/25 indicated, This RN found resident on the floor laying on her right her right side and head against the wall. Resident stated, I was trying to walk to the bathroom and fell . vital signs and neuro assessment done due to resident stating she hit her head on the wall, range of motion intact without pain . Record review of the nursing progress note for Resident #1 dated 1/12/25 written by LVN A indicated, family is requesting resident go to ER due to change in [level of consciousness . Record review of the hospital records dated 1/14/25 indicated Resident #1 was admitted to the hospital on 1/12/25 with diagnoses including subacute subdural hematoma (brain bleed), metabolic encephalopathy (brain disorder that occurs when there is an imbalance of chemicals in the blood), probably secondary to subacute subdural hematoma vs urinary tract infection, and urinary tract infection. During an interview on 1/22/25 at 1:39 p.m. the Regional Compliance Nurse said the facility did not have neuro assessments for Resident #1's fall on 1/9/25. The Regional Compliance Nurse said the nurse who entered the incident report did so incorrectly and the EMR system did not generate for neuro assessments to be completed. The Regional Compliance Nurse said RN B no longer was employed at the facility. The Regional Compliance Nurse said RN B quit after they were questioning her regarding Resident #1's fall on 1/9/25. The Regional Compliance Nurse said RN B was confused about the process of entering the incident report, at first claimed Resident #1 fell , then said it was another resident, and then corrected herself again stating Resident #1 was the resident who had fell . The Regional Compliance Nurse said CNA C was working with RN B on 1/9/25 and was questioned regarding the fall. The Regional Compliance Nurse said CNA C said Resident #1 had a fall and she assisted RN B in getting Resident #1 off the floor. During an interview on 1/22/25 at 2:06 p.m. RN B said she had not been employed at the facility since 1/17/25. RN B said she had resigned from the facility. RN B said she had worked on 1/9/25. RN B said she had a resident fall on 1/9/25. RN B said she thought it was Resident #1. RN B said Resident #1 was in the doorway lying on her right side and Resident #1 stuck out in her mind because she was not aware Resident #1 could move. During an interview on 1/22/25 at 2:12 p.m. the DON said the incident on 1/9/25 was confusing. The DON said she had called RN B regarding the fall. The DON said RN B at first said Resident #1 fell , then said it was the resident across the hall from Resident #1, and then said no, it was Resident #1. During an interview attempt on 1/22/25 at 2:53 p.m. CNA C did not answer the phone and a voicemail was left for her. During an interview on 1/23/25 at 10:10 am the DON said she expected nurses to perform neurological assessments after any head injury, any fall where the resident hit their head or may have hit their head, when a resident had a change in condition not related to their diagnosis that would indicated a neurological issue such as change in behavior or speech. The DON said neurological checks were performed every 15 minutes for an hour, every 30 minutes for an hour, every hour for two hours, every 2 hours for four hours, and then every shift for 48 hours to total 72 hours. During an interview on 1/23/25 at 5:04 p.m. LVN D said she had worked on 1/11/25 and 1/12/25. LVN D said she had assisted in taking care of Resident #1 on 1/11/25. LVN D said she was being trained by LVN A on 1/12/25. LVN D said she had noticed Resident #1 was not responding to her on 1/12/25 the same way she had been on 1/11/25. LVN D said she told LVN A she believed Resident #1 had a change in condition as she was not responding the same way or talking as much. LVN D said LVN A told her Resident #1 did that sometimes and they did not worry about it. LVN D said later in the day on 1/12/25 Resident #1's family came in and were concerned about her change in condition and not happy it had not been addressed. LVN D said Resident #1's family requested she be sent to the hospital. LVN D said at that time Resident #1 was sent to the hospital for evaluation. During an interview attempt on 1/24/25 at 12:05 pm LVN A did not answer the phone and the surveyor was unable to leave a message. Record review of the facility's Neurologic Checks policy last revised May 2016 indicated, Neurologic checks are a combination of objective observations and measurements done to evaluate neurologic status. The results of the checks assist to determine nervous system damage and/or deterioration. The caregiver will identify changes indicating progressive improvement or deterioration in neurologic status. The resident will be free from energy. Procedure 1. Perform handwashing 2. Explain the procedure to the resident based on the ability of the resident to understand the procedure. 3. Become familiar with general physical assessment and history of neurological disorders and conditions affecting mental status. 4. Assess vital signs .5. Asses best eye response .6. Assess best verbal response .7. Assess best motor response .8. Use penlight to check response of pupils to light .9. Check grip of the hand and ability to squeeze hand. Compare grip strength in both hands. 10. Frequency of checks after initial neuro check: every 15 minutes times four, every 30 minutes times two, one-hour times two, every two hours times two, then every shift times 48 hours. 11. All deterioration in neurologic status will be immediately reported to the physician. The nurse will document assessment and the time of physician notification in the clinical record. The Administrator was notified on 1/23/25 at 11:22 a.m. that an Immediate Jeopardy situation was identified due to the above failure. The Administrator was provided the Immediate Jeopardy template on 1/23/25 at 11:27 a.m. The facility's Plan of Removal was accepted on 1/23/25 at 2:41 p.m. and included: Plan of Removal On 1/23/25 Resident #1 had a head to toe and neurological assessment completed by the charge nurse. No change in condition noted. Completed 1/23/25. As of 1/23/25 Resident #1's nurse from 1/9/25 is no longer employed with the facility. As of 1/23/25 a neurological assessment was completed on all residents that had an unwitnessed fall or hit their heads within the last 30 days. No changes in condition were identified. This was completed on 1/23/25. The Administrator, DON, ADON, or designee will review all falls during the morning clinical meeting to ensure that all neuro assessments have been completed for all unwitnessed falls or residents who hit their heads. This will start 1/23/25 and continue indefinitely. The Medical Director was notified of the immediate jeopardy on 1/23/25. An ADHOC QAPI was completed on 1/23/25 with medical director and interdisciplinary team to discuss the immediate jeopardy and plan of removal. The Compliance Nurse in-serviced the Administrator, DON, and ADON 1:1 on the following topics below. This was completed on 1/23/25. o Abuse and Neglect Policy- failure to complete neurological assessment on residents that suffer an unwitnessed fall or hit their head could be considered neglect. o Fall Prevention Policy- to include neurological assessment for unwitnessed falls or resident who it their head. o Neurological Assessment Policy. o Incident reporting - how and when to complete an incident report with the post assessments to include fall notes and neuro assessments. o Notification of Change in Condition Policy to physician and responsible part for any change in condition. o Documentation - to include User Defined Assessments (UDA), progress notes, 24-hour report, etc. and follow-up for incidents and post incident assessments. The following in-services were initiated by the Regional Compliance nurse, Administrator, DON, and ADON on 1/23/25. Any staff member not present or in-serviced on 1/23/25 will not be allowed to assume their duties until in-serviced. All new hires will be in-serviced during orientation. All PRN staff will in-serviced prior to start of their next shift. All agency staff will in-serviced prior to their assignment. All Staff o Abuse and Neglect- failure to complete neurological on residents that suffer an unwitnessed fall could be considered neglect. o Notification of Change in Condition Policy report to a charge nurse for any resident that suffers a fall or change in condition immediately. Licensed Nurses: o Abuse and Neglect Policy- failure to complete neurological on residents that suffer an unwitnessed fall could be considered neglect o Fall Prevention Policy- to include neurological assessment for unwitnessed falls or resident who it their head. o Incident reporting - how and when to complete an incident report with the post assessments to include fall notes and neuro assessments. o Neuros Assessment Policy o Notification of Change in Condition Policy to physician and responsible part for any change in condition. o Documentation - to include UDAs, progress notes, 24-hour report, incident reports, and post incident assessments. On 1/24/25 the surveyor confirmed the facility implemented their plan of removal sufficiently to remove the Immediate Jeopardy (IJ) by: Record review on 1/23/24 of Resident #1's neurologic assessment. Record review of 14 out of 18 residents with unwitnessed falls or that hit their heads in the past 30 days neurologic assessments indicated all neurological exams did not indicate any change in the residents' current condition. Record review of the sign-in sheet for the ADHOC QAPI meeting dated 1/23/25 indicated the facility had a QAPI meeting regarding the above failure. Record review of an undated Payroll Input/Personnel Action Form indicated RN B's last date worked at the facility was 1/15/25. The Payroll Input/Personnel Action Form indicated RN B quit/walked of the job on 1/16/25. During interviews with licensed nurse (the Treatment Nurse, ADON E, LVN F, LVN G, LVN H, RN J, RN K, and LVN D) on 1/23/25 and 1/24/25 between 7:15 a.m. and 4:04 p.m. staff were able to name all types of abuse including physical, verbal, sexual, misappropriation of property, and neglect. Staff interviewed said in the case of reported abuse they would notify the abuse coordinator immediately. Staff interviewed said the abuse coordinator was the Administrator. Staff interviewed said if a resident had a change in condition including a fall the physician should be notified immediately. Staff interviewed said in the event of an unwitnessed fall the resident should be assessed and neuro checks initiated, the physician should be notified, and an incident report should be accessed through the risk management tab in the electronic medical records and completed. Staff interviewed said accessing the incident report through the risk management tab resulted in all necessary UDAs including neuro checks being automatically populated. Staff interviewed said all assessments should be documented in the electronic medical record and all changes in condition, medication, etc. should be documented on the 24-hour report. Staff interviewed said neurological assessments consisted of assessing vital signs, assessing best eye response, assessing best verbal response, assessing best motor response, using a penlight to check response of pupils to light, and checking grip of the hand and ability to squeeze hand including comparing grip strength in both hands. Staff interviewed said frequency of neurologic assessment should be as follows: after initial neuro check: every 15 minutes times four, every 30 minutes times two, one-hour times two, every two hours times two, then every shift times 48 hours. During interviews with staff (CNA M, CNA N, CNA P, CNA R, CNA S, CNA T, CNA V, the Admissions Director, Housekeeper W, and the Social Worker) on 1/24/25 between 10:21 a.m. and 10:45 a.m. staff were able to name all types of abuse including physical, verbal, sexual, misappropriation of property, and neglect. Staff interviewed said in the case of reported abuse they would notify the abuse coordinator immediately. Staff interviewed said the abuse coordinator was the Administrator. Staff said if they noticed a change in condition in a resident, they would report it to the nurse immediately and fill out a Stop and Watch Form (a form used by the facility uses to determine what type of change in condition was observed, who the resident was, who reported the change in condition, and who the change of condition was reported to. On 1/24/25 at 10:45 a.m., the Administrator was informed the IJ was removed; however, the facility remained out of compliance the facility remained out of compliance with a scope identified as isolated due to the facility's need to complete in-service training and evaluate the effectiveness of the corrective systems.

Based on observation, interview, and record review, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 2 of 4 staff (CNA M and CNA X) observed for infection control. The facility failed to ensure CNA M performed hand hygiene between glove changes. The facility failed to ensure CNA M changed her gloves and performed hand hygiene after picking barrier cream up off the floor and continuing incontinent care. The facility failed to ensure CNA M did not touch Resident #2's face or swab her mouth after performing incontinent care, not changing gloves, and picking up the trash bag containing the dirty brief and wipes. The facility failed to ensure CNA X used each disposable wipe only once while providing incontinent care. The facility failed to ensure CNA X did not put the dirty brief, wipes, and gloves at the end of Resident #3's bed on top of the sheets while performing incontinent care. The facility failed to ensure CNA X changed gloves and performed hand hygiene after touching the dirty diaper and wipes and then applying barrier cream to Resident #3's vaginal area. These failures could place residents and staff at risk for cross-contamination, spread of infection and could potentially affect all others in the building. Findings Include: 1. During an observation on 1/23/25 at 2:00 p.m. CNA M perform incontinent care on Resident #2. CNA M performed hand hygiene and donned gloves. CNA M gathered a clean brief and wipes. CNA M unfastened and rolled down Resident #2's wet brief, did not change gloves or perform hand hygiene. CNA M cleaned Resident #2's vaginal area with disposable wipes. CNA M rolled Resident #2 to her side, removed the dirty brief, did not change gloves or perform hand hygiene, and cleansed Resident #2's bottom with clean wipes. CNA M retrieved barrier cream from Resident #2's dresser, applied cream to her bottom, then dropped the cream tube in the floor. CNA M removed her gloves, retrieved a clean pair of gloves from Resident #2's dresser drawer, did not perform hand hygiene, picked the barrier cream up off the floor, and donned the clean gloves. CNA M put a clean brief on Resident #2, did not change gloves or perform hand hygiene, adjusted the bed position, touched Resident #2's face with her gloved hand, moved the trash bag containing the dirty brief and wipes, and then swabbed Resident #2's mouth with a moistened sponge swab. CNA M removed her gloves, picked up the trash, exited the room, disposed of the trash, and then performed hand hygiene. During an interview on 1/23/25 at 2:12 p.m. CNA M said hand hygiene should be performed before and after performing care on a resident. CNA M said if something was picked up off the floor hand hygiene should be performed prior to resuming care. CNA M said she did pick up the barrier cream off the floor and did not perform hand hygiene afterwards. CNA M said she did not perform hand hygiene because she was not thinking and was nervous being observed by the surveyor. CNA M said gloves should be changed when they were visibly dirty. CNA M said the importance of proper hand hygiene and changing gloves was infection control. 2. During an observation on 1/24/25 at 10:51 a.m. CNA X performed incontinent care on Resident #3. CNA X provided privacy and explained the procedure prior to beginning incontinent care. CNA X removed tissues from around Resident #3's colostomy bag (a waterproof pouch that collects fecal waste from the body after a surgical procedure called a colostomy). The tissues were observed to have a small amount of brown substance on them. CNA X opened the wet brief. CNA X wiped between the vaginal area and leg with the same wipe twice. CNA X wiped Resident #3's vaginal area with the same wipe 3 times. CNA X wiped Resident #3's vaginal area twice with another wipe. CNA X wrapped the dirty tissues and dirty wipes into the dirty brief and placed the dirty brief on the end of Resident #3's bed. CNA X did not change her gloves or perform hand hygiene. CNA X applied barrier cream to Resident #3's bottom, touched the dirty brief with her gloved hand, and then applied barrier cream to her vaginal area. CNA X put a clean brief on Resident #3, removed her gloves, placed the dirty gloves next to the dirty brief on the end of the bed, and washed her hands. CNA X donned clean gloves and put the dirty brief and dirty gloves in a trash bag to remove from the room. During an interview on 1/24/25 at 11:05 a.m. CNA X said she did not notice if the tissues she removed from around Resident #3's colostomy bag were dirty or not. CNA X said wipes were not supposed to be used more than once. CNA X said she did not know why she used the wipes more than once while providing incontinent care. CNA X the importance of only using each wipe once was to prevent the spread of dirty substances to clean areas. CNA X said hand hygiene should be performed before and after providing care. CNA X said the importance of proper hand hygiene was to prevent spreading germs. CNA X said a dirty brief or dirty gloves should not be left on a resident's bed during care. CNA X said she did not know why she left the dirty brief or dirty gloves on the bed. During an interview on 1/24/25 at 12:26 p.m. the Regional Compliance Nurse said the facility did not have incontinent care or CNA checkoffs for CNA M or CNA X. During an interview on 1/24/25 at 12:38 p.m. the Regional Compliance Nurse said during incontinent care she expected staff to change their gloves and perform hand hygiene when going from dirty to clean. The Regional Compliance Nurse said disposable wipes were not designed to be used more than once during incontinent care. The Regional Compliance Nurse said she expected dirty briefs, dirty wipes, and dirty gloves to be placed in a trash bag and not a resident's bed. The Regional Compliance Nurse said the importance of proper hand hygiene, ensuring dirty supplies were put in a trash bag, and only utilizing disposable wipes once was to prevent cross contamination and for infection control. Record review of facility's Fundamentals of Infection Control Policy dated 2019 indicated, A variety of infection control measures are used for decreasing the risk of transmission of microorganisms in the facility. These measures make up the fundamentals of infection and control precautions. 1. Hand Hygiene: Hand hygiene continues to be the primary means of preventing the transmission of infection. The following list is a list of some situations that require hand hygiene: .Before and after assisting a resident with personal care .Upon and after coming in contact with a resident's intact skin .Before and after assisting a resident with toileting .After contact with a resident's mucous membranes and body fluids or excretions. After handling soiled or used linens, dressing, bedpans, catheters, and urinals .After removing gloves or aprons .Consistent use by staff of proper hygienic practices and techniques is critical to preventing the spread of infections .Gloves are worn for three importance reasons. 1. To provide protective barrier and prevent gross contamination of the hands when touching blood, body fluids, secretions, excretions, mucous membranes, and on intact skin .2. To reduce the likelihood that microorganisms present on the hands of personnel will be transmitted to residents during invasive or other resident care procedures that involve touching a resident's mucous membranes or nonintact skin. 3. To reduce the likelihood that hands of personnel contaminated with microorganisms from a resident or a fomite can transmit these microorganisms to another resident; in the situation, gloves must be changed between resident contacts, and hands washed after gloves are removed. Wearing gloves does not replace the need for hand washing because gloves may have small inapparent defects or be torn during use, and hands can become contaminated during removal of gloves .

Based on observation, interview, and record review, the facility failed to ensure a resident who was unable to carry out activities of daily living received the necessary services to maintain grooming and personal hygiene were provided for 2 of 7 (Resident #1 and Resident #4) residents reviewed for ADL's. The facility did not ensure Resident #4 was cleaned up after having a liquid yellow substance covering his mouth, gown, sheets, and blanket. The facility did not provide scheduled showers for Resident #1 and Resident #4. These failures could place residents at risk of not receiving services/care, embarrassment, and decreased quality of life. Findings Include: 1. Record review of the face sheet dated 1/22/25 indicated Resident #4 was aa [AGE] year-old male, readmitted to the facility on [DATE] with diagnosis including age-related cognitive decline, dementia. Guillain-Barre Syndrome (a condition in which the body's immune system attacks the nerves and can cause weakness, numbness, or paralysis), and need for assistance with personal care. Record review of the MDS dated [DATE] indicated Resident #4 was usually understood by others and usually understood others. The MDS indicated Resident #4 had a BIMS of 13 and was cognitively intact. The MDS indicated Resident #4 was dependent for toileting, bathing, and personal care. Record review of the care plan last revised 11/05/24 indicated Resident #4 had an ADL self-care deficit with interventions including staff assistance of one for bathing, personal hygiene, and oral care. Record review of the Documentation Survey Report dated 1/22/25 indicated Resident #4 was scheduled to receive his showers on Mondays, Wednesdays, and Fridays. Record review of Resident #4's shower records indicated: November 2024 he was scheduled for 13 showers and received 8. December 2024 he was scheduled for 13 showers and received 8. During an observation on 1/22/25 at 10:23 a.m. Resident #4 was lying in bed. Resident #4 was observed to have a liquid yellow substance all over his sheets, blankets, gown, and mouth. Resident #4's breakfast tray was sitting on bedside table out of reach of the resident and untouched. During an observation on 1/22/25 at 10:47 a.m. Resident #4 had a liquid yellow substance on his mouth, sheets, gown, and blanket. Breakfast tray was not on his bedside table. 2. Record review of the face sheet dated 1/22/25 indicated Resident #1 was a [AGE] year-old female admitted to the facility on [DATE] with diagnoses including dementia, anxiety, hemiplegia (muscle weakness or partial paralysis on one side of the body), cerebral infarction (ischemic stroke), and chronic kidney disease (longstanding disease of the kidneys leading to renal failure). Record review of the MDS dated [DATE] indicated Resident #1 usually understood others and was usually understood by others. The MDS indicated Resident #1 had a BIMS of 11 and was moderately cognitively intact. The MDS indicated Resident #1 required substantial/maximum assistance with toileting, bathing, and personal hygiene. Record review of the care plan revised 12/15/24 indicated Resident #1 had an ADL self-care deficit with interventions including staff assistance of one for bathing. Record review of a nursing progress note for Resident #1 indicated she was readmitted to the facility on [DATE]. Record review of the Documentation Survey Report dated 1/22/25 indicated Resident #1 was scheduled to receive her showers on Tuesday, Thursdays, and Saturdays. Record review of Resident #1's shower records indicated: January 2025 from January 1-January 12 there are no records of her receiving a shower and from her readmission on January 17-January 22 there were no records of her receiving a shower. During an interview on 1/24/25 at 12:15 pm CNA M said the CNAs were responsible for giving the residents their showers/bed baths and the nurses were responsible for ensuring the CNAs gave the showers/bed baths. CNA M said residents were scheduled for showers/bed baths 3 times a week. CNA M said if a CNA saw a resident was visibly dirty or had spilled something on themselves the CNA should clean the resident up immediately. CNA M said if a resident refused their shower/bed bath they should be reapproached at a later time, the refusal should be documented, and the nurse should be notified. CNA M said the importance of the residents getting cleaned up and receiving their showers/bed baths was for personal hygiene, to make them feel better about themselves, and for infection control. During an interview on 1/24/25 at 12:17 p.m. CNA X said the CNAs were responsible for giving the residents their showers/bed baths. CNA X said residents received showers every other day and as requested. CNA X said if a resident was found dirty or had a yellow liquid substance all over them they should be cleaned up immediately. CNA X said if a resident refused their shower/bed bath they should be reapproached at a later time and the nurse should be notified. CNA X said the importance of ensuring residents received their showers and were cleaned up when need was for hygiene and to better assess for skin issues. During an interview on 1/24/25 at 12:29 p.m. LVN Y said any nursing staff was responsible for giving the residents their showers including nurses and CNAs. LVN Y said the residents were scheduled for showers 3 times a week and received them as needed too. LVN Y said if a resident refused a shower the CNA should notify the nurse, the resident should be reapproached, and if the resident still refused the family and physician should be notified. LVN Y said if a resident was found with a liquid yellow substance all over them the CNA should report it to the nurse as it could be vomit and then clean the resident up. LVN Y said if meal trays were being picked up and a resident was dirty or covered with a liquid substance the resident should be cleaned up before the meal tray was removed. LVN Y said the importance of ensuring residents were cleaned in a timely manner and received their showers was to prevent skin issues. During an interview on 1/24/25 at 12:38 p.m. the Regional Compliance Nurse said she expected residents to receive showers 3 times a week unless they refused. The Regional Compliance Nurse said the CNAs were responsible for giving the showers and the charge nurses were responsible for verifying the showers were given. The Regional Compliance Nurse said if a shower was refused it should be documented. The Regional Compliance Nurse said if a resident was found by a CNA covered in a liquid yellow substance she expected the CNA to report it to the nurse so the nurse could assess the resident and then clean the resident up. The Regional Compliance Nurse said the importance of ensuring residents were clean and received their showers was quality of life. During an interview on 1/24/25 at 1:05 p.m. the Administrator said she expected residents to receive showers 3 times a week and as needed. The Administrator said the importance of residents receiving their showers was for infection control, so the resident feels better, and for respect. Record review of the facility's Bath, Tub/Shower policy dated 2003 indicated, Bathing by tub or shower is done to remove soil, dead epithelial cells, microorganisms from the skin, and body odor to promote comfort, cleanliness, circulation, and relaxation .The aging skin becomes dry, wrinkled, thinner, and blemished with various aging spots over time and is easily affected by environmental temperature and humidity, sun exposure, soaps, and clothing fabrics. The frequency and type of bathing depends on resident preference, skin condition, tolerance, and energy levels. Although a daily bath or shower is preferred and necessary for some, the aging skin can be maintained by bathing every two days or with partial bathing as needed .

Based on interview and record review the facility failed to consult with the resident's physician when there was a significant change in the resident's physical and mental status that is, a deterioration in health, mental, or psychosocial status in either life-threatening conditions or clinical complications for 1 of 6 (Resident #1) residents reviewed for notification of change. 1. The facility failed to consult with the physician when Resident #1 who was taking Eliquis (blood thinner) and Aspirin (blood thinner) fell and sustained a hematoma to the back of her head. 2. The facility failed to follow their policy on physician notification when the resident had a change of conditions including decreased blood pressure of ,d+[DATE] (normal blood pressure is ,d+[DATE]), increased restlessness, confusion, and hallucinations following her fall on [DATE] at 3:01 a.m. resulting in the Resident #1 being sent to the emergency roiagnom on [DATE] at 4:42 p.m. This failure resulted in an identification of an Immediate Jeopardy (IJ) on [DATE] at 4:30 p.m. While the IJ was removed on [DATE], the facility remained out of compliance at actual harm that is not immediate jeopardy with a scope identified as isolated due to the facility's need to complete in-service training and evaluate the effectiveness of the corrective systems. This failure could place residents at risk for not receiving care and services to meet resident needs. Findings Include: 1. Record review of the face sheet dated [DATE] indicated Resident #1 was admitted to the facility on [DATE] with diagnoses including dementia, peripheral vascular disease (narrowing of the blood vessels situated away from the heart or brain), unsteadiness on feet, abnormalities of gait and mobility, long term use of anticoagulants (blood thinners), and hypertension. Record review of the physician orders dated [DATE] indicated Resident #1 had an order for Aspirin 81mg daily starting [DATE] for occlusion of unspecified carotid artery (major blood vessel that supplies blood to the brain). The physician orders indicated Resident #1 had an order for Eliquis 2.5mg twice a day starting [DATE] for atrial fibrillation (irregular, often rapid heart rate that commonly causes poor blood flow). Record review of the MDS dated [DATE] indicated Resident #1 sometimes understood others and was sometimes understood by others. The MDS indicated Resident #1 had a BIMS of 00 and was severely cognitively impaired. The MDS indicated Resident #1 required extensive assistance with bed mobility, transferring, toileting, locomotion on and off the unit, and walking. The MDS indicated Resident #1 used a wheelchair for mobility. Record review of the baseline care plan dated [DATE] indicated Resident #1 was non-ambulatory with interventions including provide assistance with transfers, encourage/remind use of assistive devices with ambulation, bed in low position, and keep call light in reach. The care plan indicated Resident #1 was on anticoagulants with interventions including observe for signs and symptoms of bleeding. Record review of the fall risk assessment dated [DATE] indicated Resident #1 had no risk for falls. Record review of nursing progress noted dated [DATE] at 3:01 a.m. indicated Resident #1 was found lying on the floor on right lateral side in close proximity to the bed. The progress note indicated Resident #1 had a closed, raised area to the back of her head. The progress noted indicated an ice pack was applied to the back of Resident #1's head. The progress note indicated neurological checks were initiated, education was provided on call light use, and bed was in lowest position. The progress note indicated there was an addendum in [DATE] a 1:06 a.m. indicating Resident #1 family, physician, and the ADON had been notified of the fall. Record review of the Neurological Assessment Flow sheet dated [DATE] between 6:00 a.m.- 6:00 p.m. indicated Resident #1 had a blood pressure of ,d+[DATE] (normal range for an adult is ,d+[DATE]). Record review of the nursing notes for Resident #1 dated [DATE] between 6:00 a.m. and 6:00 p.m. indicated there was no documentation to indicate Resident #1's physician was notified when Resident #1 had a blood pressure of ,d+[DATE], was restless, confused, and hallucinating, or was consulted when the physician inquired if the resident was anticoagulants. Record review of a nursing progress noted dated [DATE] at 1:33 p.m. indicated Resident #1 was restless, confused, and hallucinating. Record review of a nursing progress note dated [DATE] at 4:42 p.m. indicated Resident #1 was transferred to the emergency room due to fall from [DATE], the hematoma to the back of her head, and changes in level of consciousness. Record review of a nursing progress note dated [DATE] at 5:39 p.m. written by the DON indicated the physician and nurse practitioner were updated on Resident #1's change in neurologic status post fall. The progress note indicated the physician and nurse practitioner agreed with Resident #1's transfer to the emergency room . Record review of the intake revealed the complaint was called into the state agency on [DATE] by the complainant indicated the Resident #1 a fall on [DATE] and was not notified until [DATE] at 8:00 a.m. The complaint indicated Resident #1 was more confused than usual on [DATE] when the complainant visited and requested Resident #1 be sent to the emergency room for evaluation. The complaint indicated Resident #1 had a fractured rib as well as the injury to the back of her head. Record review of Resident #1's inpatient hospice medical records dated [DATE] indicated she was admitted to the hospice facility from the hospital with diagnoses including senile degeneration of the brain and dementia. The hospice medical record indicated Resident #1 was comatose on admission. The hospice medical record indicated Resident #1 had rib fractures. Record review of Resident #1's inpatient hospice medical records dated [DATE] indicated Resident #1 expired on [DATE] at 7:18 p.m. During an interview on [DATE] at 2:09 p.m. the Nurse Practitioner said she had not been notified of Resident #1's fall on [DATE]. The Nurse Practitioner said if she had been notified of Resident #1's fall she would have given orders to transfer to the emergency room for evaluation. The Nurse Practitioner said she would recommend all residents that have a fall with head injury, especially those taking anticoagulants, should be sent to the emergency room for evaluation. During an interview on [DATE] at 3:10 p.m. the Physician said anyone over [AGE] years old and taking blood thinners who had a fall with head injury would require a cat scan. The Physician said he had received a message on [DATE] notifying him of Resident #1's fall. The physician was not able to provide the time he received the message. The Physician said he had sent a message back asking if Resident #1 was on any blood thinners. The Physician said he never received a response regarding Resident #1's medication orders. The Physician was unaware of the times of the messages. The Physician said he was later informed of Resident #1 being sent to the emergency room . During an interview on [DATE] at 3:48 p.m. the DON said the nurse on duty at the time of Resident #1's fall was no longer an employee at the facility due to taking a job in another city. During an interview on [DATE] at 3:49 p.m. the ADON said he did not remember the incident with Resident #1. The ADON said he did not remember being notified of Resident #1's fall. The ADON said if a fall was reported to him with a resident having a raised area to their head he would advise the nursing staff to send them to the emergency room . The ADON said if a resident had a fall with head injury and was taking anticoagulants he would expect them to be sent to the emergency room immediately, and then notifications be made. Record review of the facility's Fall-Clinical Protocol policy revised [DATE] indicated, The physician will help identify individuals with a history of falls and risk factor for falling .In addition, the nurse shall assess and document/report the following .Recent injury, especially fracture or head injury .All current medication .The staff, with the physician's guidance, will follow up on any fall with associated injury until the resident is stable and delayed complications such as late fracture or subdural hematoma have been ruled out or resolved . Record review of the facility's Change in a Resident's Condition or Status policy revised [DATE] indicated, .The nurse will notify the resident's Attending Physician or physician on call when there has been a(an): accident or incident involving the resident .significant change in the resident's physical/emotional/mental condition .Prior to notifying the Physician or healthcare provider, the nurse will make detailed observations and gather relevant and pertinent information for the provider . The Administrator was notified on [DATE] at 4:45 p.m. that an Immediate Jeopardy situation was identified due to the above failure. The Administrator was provided the Immediate Jeopardy template on [DATE] at 4:52 p.m. The facility's Plan of Removal was accepted on [DATE] at 11:05 a.m. and included: Notified Medical Directors of Immediate Jeopardy by the DON. The Administrator and DON initiated in-services for all licensed nurses that educated on Policy of Change in Resident's Condition or Status; Provider notification - notifying provider of anticoagulant medication, dose, and frequency in the setting of unwitnessed falls or falls with head involvement. [DATE] Added in-servicing for all staff to include Interact 4.0 Stop and Watch Early Warning Tool. In addition, for licensed staff added on [DATE] In-servicing Interact 4.0 Change in Condition - When to Report to the MD/NP/PA forms that include Vital Signs, Lab Tests and Diagnostic Procedures, Signs and Symptoms A's, Sign and Symptoms B's, Signs and Symptoms C's, Signs and Symptoms D's, Signs and Symptoms E, F, G's, Signs and Symptoms H, I's, Signs and Symptoms L, M, N's, Signs and Symptoms P, R's, Signs and Symptoms S's, Signs and Symptoms T, U, V's, Signs and Symptoms W's. Added in-servicing for all licensed staff to utilize the Interact 4.0 SBAR Communication form as a reference to guide their assessments of residents and communication to providers. Also added in-services for licensed staff regarding Interact 4.0 Care Path for Acute Mental Status Change, interact 4.0 Care Path for Fall and Interact 4.0 Care Path for Change in Behavior. Initiated review for provider notification if unwitnessed fall or fall involving head in the setting of anticoagulant use in past 30 days. In-services will be completed by [DATE] and any clinical staff who have not been present by this time for in-servicing will be in-serviced before they care for residents. The Director of Nursing, the Assistant Director of Nursing and the treatment nurse-initiated chart reviews for appropriate assessment and notification if unwitnessed fall or fall involving head in the setting of anticoagulant use in past 30 days. These chart reviews are occurring by the Director of Nursing, if a resident is identified who has experienced an unwitnessed fall or fall involving their head and are on anticoagulant(s) in the absence of appropriate assessment and notifications the resident will be assessed for any changes in level of consciousness or significant variation in vital signs or resident's condition the provider will be updated with this information for further recommendations. This task will be completed by [DATE]. The Director of Nursing, the Assistant Director of Nursing and the treatment nurse Initiated assessments of any residents who have had an unwitnessed fall or fall involving head in past 30 days who are still in the facility for change of level of consciousness and will discuss with Provider team for any changes in treatment plan. This task will be completed [DATE]. On [DATE] the surveyor confirmed the facility implemented their plan of removal sufficiently to remove the Immediate Jeopardy (IJ) by: Verifying the Medical Director and Nurse Practitioner had been informed of the Immediate Jeopardy. Interviews of Licensed Nurses (LVN A, LVN B, LVN C, LVN D, LVN E, LVN F, LVN G, LVN H, ADON, RN J) were performed. During the interviews all licensed nurses were able to correctly identify when to notify the physician of a resident's change in condition including falls with head injuries and informing the physician of all medication the residents were taking when notifying changes in condition. Interviews of Staff (LVN A, LVN B, LVN C, LVN D, LVN E, LVN F, LVN G, LVN H, ADON, RN J, Front Door Receptionist K, Housekeeper L, CNA M, CNA N, CNA P, DOR, Dietary Aide R, Dietary Aide S, CNA T, Dietary Aide U, Housekeeper V, OT W, CNA X, CNA Y, CNA Z) were performed. During the interviews all staff were able to correctly identify changes in condition of a resident and who to report the changes to. Record review of audits performed by the Administrator, DON and Treatment Nurse of resident fall assessment, falls witnessed and unwitnessed over the past 30 days, and physician notification were completed. On [DATE] at 4:08 p.m., the Administrator was informed the IJ was removed; however, the facility remained out of compliance at actual harm with a scope identified as isolated due to the facility's need to complete in-service training and evaluate the effectiveness of the corrective systems.

Based on interview and record review the facility failed to ensure that residents receive treatment and care in accordance with professional standards of practice for 1 of 6 (Resident #1) residents reviewed for quality of care. 1. The facility failed to intervene when Resident #1, who was on anticoagulants fell , hit her head resulting in a raise area on her head. The resident experienced a change in condition which include low blood pressure and hallucinating. The resident was not sent to the hospital until 3 hours after the change when the family had her sent out. 2. The facility failed to consult with the physician of the resident orders for Eliquis (blood thinner) and Aspirin (blood thinner) when reporting the fall. This failure resulted in an identification of an Immediate Jeopardy (IJ) on [DATE] at 4:30 p.m. While the IJ was removed on [DATE], the facility remained out of compliance at actual harm that is not immediate jeopardy with a scope identified as isolated due to the facility's need to complete in-service training and evaluate the effectiveness of the corrective systems. These failures could place residents at risk of harm or death related to not receiving proper care or death following a fall with head injury while taking anticoagulation medication (blood thinners). Findings Include: 1. Record review of the face sheet dated [DATE] indicated Resident #1 was admitted to the facility on [DATE] with diagnoses including dementia, peripheral vascular disease (narrowing of the blood vessels situated away from the heart or brain), unsteadiness on feet, abnormalities of gait and mobility, long term use of anticoagulants (blood thinners), and hypertension. Record review of the physician orders dated [DATE] indicated Resident #1 had an order for Aspirin 81mg daily starting [DATE] for occlusion of unspecified carotid artery (major blood vessel that supplies blood to the brain). The physician orders indicated Resident #1 had an order for Eliquis 2.5mg twice a day starting [DATE] for atrial fibrillation (irregular, often rapid heart rate that commonly causes poor blood flow). Record review of the MDS dated [DATE] indicated Resident #1 sometimes understood others and was sometimes understood by others. The MDS indicated Resident #1 had a BIMS of 00 and was severely cognitively impaired. The MDS indicated Resident #1 required extensive assistance with bed mobility, transferring, toileting, locomotion on and off the unit, and walking. The MDS indicated Resident #1 used a wheelchair for mobility. Record review of the baseline care plan dated [DATE] indicated Resident #1 was non-ambulatory with interventions including provide assistance with transfers, encourage/remind use of assistive devices with ambulation, bed in low position, and keep call light in reach. The care plan indicated Resident #1 was on anticoagulants with interventions including observe for signs and symptoms of bleeding. Record review of the fall risk assessment dated [DATE] indicated Resident #1 had no risk for falls. Record review of nursing progress noted dated [DATE] at 3:01 a.m. indicated Resident #1 was found lying on the floor on right lateral side in close proximity to the bed. The progress note indicated Resident #1 had a closed, raised area to the back of her head. The progress noted indicated an ice pack was applied to the back of Resident #1's head. The progress note indicated neurological checks were initiated, education was provided on call light use, and bed was in lowest position. The progress note indicated there was an addendum in [DATE] a 1:06 a.m. indicating Resident #1 family, physician, and the ADON had been notified of the fall. Record review of the Neurological Assessment Flow sheet dated [DATE] between 6:00 a.m.-6:00 p.m. indicated Resident #1 had a blood pressure of ,d+[DATE] (normal range for an adult is ,d+[DATE]). Record review of the nursing notes for Resident #1 dated [DATE] between 6:00 a.m. and 6:00 p.m. indicated there was no documentation to indicate Resident #1's physician was notified when Resident #1 had a blood pressure of ,d+[DATE], was restless, confused, and hallucinating, or was consulted when the physician inquired if the resident was anticoagulants. Record review of a nursing progress noted dated [DATE] at 1:33 p.m. indicated Resident #1 was restless, confused, and hallucinating. Record review of a nursing progress note dated [DATE] at 4:42 p.m. indicated Resident #1 was transferred to the emergency room due to fall from [DATE], the hematoma to the back of her head, and changes in level of consciousness. Record review of a nursing progress note dated [DATE] at 5:39 p.m. written by the DON indicated the physician and nurse practitioner were updated on Resident #1's change in neurologic status post fall. The progress note indicated the physician and nurse practitioner agreed with Resident #1's transfer to the emergency room . Record review of the intake revealed the complaint was called into the state agency on [DATE] by the complainant indicated the Resident #1 a fall on [DATE] and was not notified until [DATE] at 8:00 a.m. The complaint indicated Resident #1 was more confused than usual on [DATE] when the complainant visited and requested Resident #1 be sent to the emergency room for evaluation. The complaint indicated Resident #1 had a fractured rib as well as the injury to the back of her head. Record review of Resident #1's inpatient hospice medical records dated [DATE] indicated she was admitted to the hospice facility from the hospital with diagnoses including senile degeneration of the brain and dementia. The hospice medical record indicated Resident #1 was comatose on admission. The hospice medical record indicated Resident #1 had rib fractures. Record review of Resident #1's inpatient hospice medical records dated [DATE] indicated Resident #1 expired on [DATE] at 7:18 p.m. During an interview on [DATE] at 2:09 p.m. the Nurse Practitioner said she had not been notified of Resident #1's fall on [DATE]. The Nurse Practitioner said if she had been notified of Resident #1's fall she would have given orders to transfer to the emergency room for evaluation. The Nurse Practitioner said she would recommend all residents that have a fall with head injury, especially those taking anticoagulants, should be sent to the emergency room for evaluation. During an interview on [DATE] at 3:10 p.m. the Physician said anyone over [AGE] years old and taking blood thinners who had a fall with head injury would require a cat scan. The Physician said he had received a message on [DATE] notifying him of Resident #1's fall. The physician was not able to provide the time he received the message. The Physician said he had sent a message back asking if Resident #1 was on any blood thinners. The Physician said he never received a response regarding Resident #1's medication orders. The Physician was unaware of the times of the messages. The Physician said he was later informed of Resident #1 being sent to the emergency room . During an interview on [DATE] at 3:48 p.m. the DON said the nurse on duty at the time of Resident #1's fall was no longer an employee at the facility due to taking a job in another city. During an interview on [DATE] at 3:49 p.m. the ADON said he did not remember the incident with Resident #1. The ADON said he did not remember being notified of Resident #1's fall. The ADON said if a fall was reported to him with a resident having a raised area to their head he would advise the nursing staff to send them to the emergency room . The ADON said if a resident had a fall with head injury and was taking anticoagulants he would expect them to be sent to the emergency room immediately, and then notifications be made. Record review of the facility's Fall-Clinical Protocol policy revised [DATE] indicated, The physician will help identify individuals with a history of falls and risk factor for falling .In addition, the nurse shall assess and document/report the following .Recent injury, especially fracture or head injury .All current medication .The staff, with the physician's guidance, will follow up on any fall with associated injury until the resident is stable and delayed complications such as late fracture or subdural hematoma have been ruled out or resolved . Record review of the facility's Change in a Resident's Condition or Status policy revised [DATE] indicated, .The nurse will notify the resident's Attending Physician or physician on call when there has been a(an): accident or incident involving the resident .significant change in the resident's physical/emotional/mental condition .Prior to notifying the Physician or healthcare provider, the nurse will make detailed observations and gather relevant and pertinent information for the provider . Record review of https://premierneurologycenter.com/blog/blood-thinners-head-injuries-what-you-need-to-know/#:~:text=%3D%3EIf%20you%20are%20taking%20a,seek%20medical%20attention%20right%20away which specifically says in the conclusion If you are taking a blood thinner, it is important to be aware of the risk associated with head injuries. If you experience a bump, blow, or jolt to the head, it is important to seek medical attention right away. Even if you do not feel any symptoms after the injury, it is still important to be evaluated by a doctor. If you are taking an older blood thinner such as .aspirin in addition to a blood thinner, it is especially important to seek medical attention right away if you experience a head injury since the risk of delayed hemorrhage is higher in patients taking these medications. The Administrator was notified on [DATE] at 4:45 p.m. that an Immediate Jeopardy situation was identified due to the above failure. The Administrator was provided the Immediate Jeopardy template on [DATE] at 4:52 p.m. The facility's Plan of Removal was accepted on [DATE] at 11:20 a.m. and included: Notified Medical Directors of the Immediate Jeopardy in writing on [DATE] at 10:42 p.m Administrator and Director of Nursing initiated in-services for all licensed nurses that educated on Policy of Change in Resident's Condition or Status; Provider notification - notifying provider of anticoagulant medication, dose, and frequency in the setting of unwitnessed falls or falls with head involvement. [DATE] Added in-servicing for all staff to include Interact 4.0 Stop and Watch Early Warning Tool. In addition, for licensed staff added on [DATE] In-servicing Interact 4.0 Change in Condition - When to Report to the MD/NP/PA forms that include Vital Signs, Lab Tests and Diagnostic Procedures, Signs and Symptoms A's, Sign and Symptoms B's, Signs and Symptoms C's, Signs and Symptoms D's, Signs and Symptoms E, F, G's, Signs and Symptoms H, I's, Signs and Symptoms L, M, N's, Signs and Symptoms P, R's, Signs and Symptoms S's, Signs and Symptoms T, U, V's, Signs and Symptoms W's. Added in-servicing for all licensed staff to utilize the Interact 4.0 SBAR Communication form as a reference to guide their assessments of residents and communication to providers. Also added in-services for licensed staff regarding Interact 4.0 Care Path for Acute Mental Status Change, interact 4.0 Care Path for Fall and Interact 4.0 Care Path for Change in Behavior. In-services will be completed by [DATE] and any clinical staff who have not been present by this time for in-servicing will be in-serviced before they care for residents. The Director of Nursing, the Assistant Director of Nursing and the treatment nurse-initiated chart reviews for appropriate assessment and notification if unwitnessed fall or fall involving head in the setting of anticoagulant use in past 30 days. These chart reviews are occurring by the Director of Nursing, if a resident is identified who has experienced an unwitnessed fall or fall involving their head and are on anticoagulant(s) in the absence of appropriate assessment and notifications the resident will be assessed for any changes in level of consciousness or significant variation in vital signs or resident's condition the provider will be updated with this information for further recommendations. This task will be completed by [DATE]. Reviewed policy for Falls - Clinical Protocol for any necessary changes. It was determined to move 2g., i., j., #3. Physician was changed to Provider team to include NPs and PAs, reviewed inserted for collaboration sections of the policy and stand and go portions of the document changed to orthostatic vitals of blood pressures and pulse in the setting of residents who may not be able to stand. Director of Nursing, Assistant Director of Nursing and treatment nurse-initiated assessments of any residents who have had an unwitnessed fall or fall involving head in past 30 days who are still in the facility for change of level of consciousness. Any concerns to be discussed with Provider team for further instruction. This task to be completed [DATE] In daily clinical meetings IDT will discuss and review incidents to monitor for appropriate identification of risk for serious adverse outcome. Although this has been a process, greater focus on falls with risk for serious adverse outcome is a focal point starting [DATE]. The Director of Nursing (or designee Nursing Manager if Director of Nursing is not available) will report this to the Administrator during daily Leadership meeting. On [DATE] the surveyor confirmed the facility implemented their plan of removal sufficiently to remove the Immediate Jeopardy (IJ) by: Verifying the Medical Director and Nurse Practitioner had been informed of the Immediate Jeopardy. Interviews of Licensed Nurses (LVN A, LVN B, LVN C, LVN D, LVN E, LVN F, LVN G, LVN H, ADON, RN J) were performed. During the interviews all licensed nurses were able to correctly identify when to notify the physician of a resident's change in condition including falls with head injuries and informing the physician of all medication the residents were taking when notifying changes in condition. Interviews of Staff (LVN A, LVN B, LVN C, LVN D, LVN E, LVN F, LVN G, LVN H, ADON, RN J, Front Door Receptionist K, Housekeeper L, CNA M, CNA N, CNA P, DOR, Dietary Aide R, Dietary Aide S, CNA T, Dietary Aide U, Housekeeper V, OT W, CNA X, CNA Y, CNA Z) were performed. During the interviews all staff were able to correctly identify changes in condition of a resident and who to report the changes to. Record review of audits performed by the Administrator, DON and Treatment Nurse of resident fall assessment, falls witnessed and unwitnessed over the past 30 days, and physician notification were completed. Record review of the facility's Change in Condition and Falls-Clinical Protocol policies confirmed the updated language from Physician to Provider Team. On [DATE] at 4:08 p.m., the Administrator was informed the IJ was removed; however, the facility remained out of compliance at actual harm with a scope identified as isolated due to the facility's need to complete in-service training and evaluate the effectiveness of the corrective systems.