Every finding on record at Bluestone Health and Rehabilitation

Based on record review, observation, and staff interview, the facility failed to ensure precautions were taken for resident's when the smoking assessment and the resident's care plan indicated a need for the resident to wear a smoking apron for safety when smoking. This was true for one (1) of three (3) residents reviewed during the complaint survey process. Resident Identifier: #7. Facility Census: 54. Findings Included: a) Resident #7 A record review, completed on 06/17/26 at 8:50 PM, revealed Resident #7 had a smoking safety evaluation that was dated 05/08/26. The evaluation noted the resident was safe to smoke with a smoking apron and supervision.During an observation on 06/18/26 at 8:50 AM, Resident #7 was brought to the smoking area. Resident #7 was permitted to begin smoking with no smoking apron. At 8:53 AM, the Corporate RN #100 verified the active smoking evaluation indicated that a smoking apron was necessary for the resident's safety. At 8:55 AM, CNA #50 verified a smoking apron was not used for Resident #7.

Based upon record review, staff interviews, resident interview, and observation, the facility failed to maintain a resident environment as free from accident hazards as possible. This was true for three (3) of the three residents reviewed during the long term care survey process. The facility's failure to thoroughly review circumstances and change the processes for deliveries to residents created a risk of serious harm related to residents ordering over-the-counter medications known to be abused as well as THC gummies and offering them to other residents. Resident identifiers: #27, #54, #57 #5 and #42. Facility census: 57. Findings included: a) During an Interview with an anonymous resident the following was reported: On 4/03/26, two female residents purchased cannabis gummies and had them delivered via Door Dash. The anonymous resident reported that the two female residents offered her a gummy, which she refused. She went on to report both female residents were sent out to the hospital after one of the residents was noticeably impaired. These residents were later identified as Resident #5 and #42. Record review completed on 04/21/26 of the facilities reportable and grievance logs revealed no investigation was completed for Resident #5 and Resident #42 regarding changes in condition due to cannabis gummies being brought into the facility and offered to other residents. The surveyor reviewed a change in condition dated 04/03/26 stating Resident #5 was sent to the local ER for further evaluation and a toxicology screen. The signs and symptoms the resident was displaying included altered mental status and suspicion of substance abuse. Resting pulse was noted as greater than 100 at 105 also. A review of a nursing progress note dated 04/03/26 at 2:00 PM labeled as a late entry revealed the following: Resident was educated on facility policies regarding not being allowed to have OTC medications or CBD products in the room; the resident voiced understanding and agreement. A nursing note dated 04/03/26 at 1:10 PM stated CNA approached this nurse and informed me that Resident #42 had informed her that this resident had given her two gummies and that she consumed one and it tasted bad, so she threw the other one away in her trash can. CNA removed the gummy from Resident #42's trash can and gave it to this nurse. A square red gummy with sugar coating was observed. I then went to speak with this resident, and she was observed lying on her bed with eyes reddened and voiced CO 'feeling tired'. VS then obtained; 108/84, 98.1, 16, 105, 95% off RA. I asked resident what type of gummy she consumed and she stated, 'pot gummies' and pointed towards a wooden box on her bedside table. I asked resident if I could look in the box and she stated, 'yes go ahead'. I opened the wooden box and observed several loose squared red gummies with sugar coating on them, three vape pens, one suspected CBD vape pen, a bottle of Benadryl, and several Imodium tablets in store foil packaging. Resident then informed this nurse that she purchased the gummies and CBD vape pen from door dash. I then asked resident if I could remove the items and she consented. Administrator, DON, and physician was notified. The wooden box with all belongings was released to administrator. New orders received per FNP to send resident out to local ER for further evaluation due to suspicion of substance abuse and obtain a toxicology screen. Resident made aware and in agreement with new order. 1:20 PM- (name of emergency medical transport) notified for transport 1:25 PM- Report called to (name of hospital) ER nurse 1:45 PM- (name of local emergency medical transport) on site x2 attendees to transport resident to local ER. All transfer paperwork was sent with resident. Resident #42 was on the following medications and possible side effects taking medications with Cannabis gummies Prozac (Fluoxetine) 40 MG: Major interaction. Prozac can increase THC levels, causing increased drowsiness, worsening depression, cognitive impairment, or mania. Buspar (Buspirone) 7.5 MG: Potential for serotonin syndrome (confusion, muscle twitching, rapid heart rate) when combined with other serotonergic agents and cannabis. Keppra (Levetiracetam) 750 MG: Increased risk of drowsiness, dizziness, confusion, and difficulty concentrating. Prazosin 1 MG: Potential for increased dizziness or fainting due to additive blood-pressure-lowering effects. A note dated 04/03/26 at 2:27 PM stated, LPN #69 came and notified me that two residents (#42 and #5) consumed unknown substance like gummies. I immediately went to assess this resident while the LPN #29 was notifying the DON, administrator, and Dr. Resident #42 eyes were very red and stated she feels paranoid. Vitals 115/76, 108, 18, 97.9, 92% RA. Resident told this Nurse that she received Two Gummies from (resident #5). She stated the Gummies tasted bad, so she threw the gummy in the trash. The CNA #58, took the Gummy out of the trash and took it to the nurse station. Resident #42 also told this nurse that another resident (#15), knew about the Gummies. This Nurse went and spoke to Resident #15 and the resident stated that Resident #5 came into her room and told her that she has Gummies and THC pens. Resident #5 told Resident #14 that she was going to give resident #42 two gummies. Resident #15 also stated that Resident #5 wrote a letter to a worker, Restorative aide #46 letters and she still had the letter on her bed, and I can have the letter if I want it. Nurse went to the room and got the letter and gave it to the administrator. Nurse did not read the letter. LPN #24 and LPN #69 were on our way to check on (resident #5 ) when we noticed a man from Door Dash knocking on the door. The man gave the nurse the bag and exited the facility quickly. It was a pack of cigarettes with a receipt with two CBD purchases on the receipt. The facility administration (administrator and director of nursing) had no evidence that a thorough investigation into this matter had been completed. Because only a limited action was taken following the incident on 04/03/26 the facility administration was presented with an Immediate Jeopardy template on 04/21/26 at 6:00 PM. The failure to identify a situation where residents were susceptible to drug abuse from other residents created an immediate jeopardy situation. On 04/21/26 at approximately 8:45 PM, the facility presented the following Plan of Correction: 1. Corrective Action for Residents Affected Resident #5 and Resident #42 were immediately assessed on 04/03/2026 for any adverse effects related to ingestion of suspected cannabis gummies. Nursing assessments, vital signs monitoring, and physician notifications were completed. Residents were transferred to the hospital as indicated and monitored upon return with no ongoing adverse effects identified. Anonymous Resident #1 was interviewed and confirmed no ingestion occurred. The resident remained safe with no identified concerns. The facility immediately initiated an abuse investigation on 04/21/2026 and reported the allegation in accordance with regulatory guidelines. The facility ensured that all required notifications were completed. 2. Identification of Other Residents with Potential to be Affected On 04/21/2026, the facility started conducting a comprehensive room-to-room audit of all residents, that either they or their responsible party consent too, to identify the presence of non- prescribed medications, suspected cannabis and/or CBD products, or unauthorized substances. The facility is attempting to interview all residents regarding knowledge of any residents sharing or giving each other over-the-counter medications or other non-prescribed substances or anyone offering non-prescribed substances to them or ingesting any non-prescribed or over-the-counter medications or substances. The facility has started and is conducting interviews with all staff regarding knowledge of residents sharing or giving over-the-counter medications, or health or pharmaceutical products; noticed any situations where staff or resident may have exchanged non-prescription products outside of the standard process; and any challenges or concerns seen related to residents accessing or using non-prescription products safely. All residents are being assessed for signs and symptoms of impairment or changes in condition. A retrospective review of incident reports, 24-hour reports, and grievance logs is being completed for the previous 30 days to ensure no additional unreported or uninvestigated incidents existed in violation of F600, F609, and F610 requirements. 3. Systemic Changes to Prevent Recurrence The facility implemented the following systemic changes to address compliance with F600, F609, and F610: External deliveries by DoorDash will be inspected by staff upon delivery, in accordance with Federal Regulation 557, Respect, Dignity/Right to have Personal Property and follow guidelines on how to search residents' deliveries with consent. Residents will be re-educated on the facility's expectations regarding safety, including the prohibition of non-prescribed medications and substances within the facility, and the importance of not sharing or accepting medications or items from other residents. All staff will be re-educated on 04/21/2026 or prior to their next scheduled shift on the following: Abuse prevention and resident-to-resident abuse (F600) Mandatory reporting requirements, including timelines and immediate reporting expectations (F609) Investigation requirements, including documentation, interviews, and follow-through (F610) Identification of impairment and prohibition of non-prescribed medications and substances New hires will receive this education during orientation, and ongoing education will be reinforced through monthly in-services and QAPI review. 4. Monitoring to Ensure Compliance The facility implemented the following monitoring systems: The Administrator and/or designee will audit all reportable events and grievances daily for two (2) weeks, then weekly for four (4) weeks, and monthly thereafter to ensure compliance with F609 reporting requirements. The Director of Nursing (DON) or designee will audit all abuse investigations weekly for four (4) weeks, then monthly for two (2) months to ensure investigations are completed timely and thoroughly in accordance with F610 requirements. The facility will conduct weekly audits of delivery logs and contraband checks for four (4) weeks, then monthly for two (2) months. Findings will be reviewed through the QAPI program, and corrective actions will be implemented as needed to ensure sustained compliance. c) The State Agency accepted the Plan of Correction on 04/21/26 at 9:07 PM. d) Education and Post Tests Staff Interviews Have you ever observed residents sharing or giving each other over-the-counter medications, or health or pharmaceutical products? Have you you noticed any situations where staff or residents may have exchanged non-prescription products outside of the standard process? Are there any challenges or concerns you've seen related to residents accessing or using non-prescription products safely? Recognizing Substance Use in Long-Term Care Quick Reference For Clinical Staff Why It Matters- Substance use in older adults is often under- recognized, Signs may mimic dementia, delirium or depression, Early recognition improves safety and outcomes. Common Substances in Long Term Care- Alcohol, Prescription medications (opioids, benzodiazepines, sleep aides), Over- the-counter misuse (sleep/cough products). General Warning Signs- Falls, unsteady gait, slurred speech, New or worsening confusion or memory changes, Mood swings, agitation, withdrawal, Decline in ADL's or therapy participation. Substance-Specific Clues- Alcohol: odor, flushed face, tremors, unexplained injuries. Opioids: excessive drowsiness, pinpoint pupils, slow breathing. Benzodiazepines/Sedative: confusion, falls, daytime sleepiness. Higher-Risk Residents- Chronic pain or anxiety/depression, Cognitive impairment, History of substance use, Polypharmacy or recent life transitions. What Staff Should Do- Observe and compare to baseline, Document objectively and factually, Report concerns through proper channels. Escalate Immediately If- Unresponsiveness or respiratory depression, Suspected overdose, Sudden severe confusion or repeated unexplained falls. Remember- Substance use is a medical issue, not a moral one. Use dignity, respect and teamwork. DoorDash Delivery Protocol To help ensure the safety and well-being of all residents, the facility will no longer allow DoorDash services to deliver items directly to residents. All deliveries must be received by facility staff before being given to the resident. Facility staff will inspect these deliveries with resident consent. Facility staff will respect the resident tights to refuse inspection. This process helps us confirm that items are appropriate, safe, and in compliance. Residents are encouraged to plan accordingly and understand that this protocol is in place to protect their health and maintain a safe living environment for everyone. Medication Safety For your safety, residents are not permitted to share prescribed medications, non-prescribed (over-the-counter) medications, or other substances with others. Medications are ordered specifically for each individual and may be harmful if taken by someone for whom they were not intended. Residents should also not accept medication or other substances if it is offered by another resident, even if it seems harmless. If you feel unwell or believe you need medication, please notify staff so they can assist you appropriately and safely. The IJ was abated on 04/22/26 at 4:28 PM. b) Resident #27 Resident #27 has capacity to make own medical decisions. Progress notes from the resident's medical record documented the following: 02/18/2026 12:40*Nursing NoteNote Text: The Administrator, with the DON [Director of Nursing] and UM [Unit Manager] present, spoke with resident regarding staff reports that they had witnessed her having a vape in her room that she refused to allow the nurse to secure per policy. She initially denied having a vape at all and then she admitted to having had one that was now empty. Administrator asked where she got the vape and resident stated, I'm not going to tell you where I got it. She then stated she threw it away. The Administrator attempted to clarify when and where it was discarded. She said today, in the trash barrels in the hallway. She would not elaborate on the time she discarded the vape. UM went immediately to attempt to locate the discarded vape without success. Resident was educated verbally by the Administrator on the dangers of using a vape in a room with an oxygen concentrator present and turned on and further educated her on the smoking policy to include that all smoking paraphernalia must be turned into the nurses to be stored until scheduled smoke times, and finally that vaping is not permitted inside the facility. Resident voiced understanding and agreed to follow the policy. 02/18/2026 12:21*Communication with ResidentNote Text: This NHA knocked on resident's door and asked to enter. This NHA was accompanied by the DON. This NHA entered the resident's room to address concerns regarding the presence of a vape device and/or smoking paraphernalia within the resident's room. The resident admitted to having a vape device in her possession and keeping the vape in her room.The resident had previously been educated by this NHA on 12/26/25 regarding the facility smoking policy, which states that all smoking paraphernalia must be stored in a secure location accessible to staff. Residents are not permitted to keep smoking paraphernalia on their person or within their room. Smoking items may only be utilized during designated smoking times, under staff supervision, and in theapproved smoking area. At that time, the resident verbalized understanding of the policy.During this encounter, the resident was re-educated on the facility smoking policy and the associated safety risks of vaping or smoking within the facility. Additional education was provided regarding the significant fire and safety hazards related to vaping or smoking in proximity to oxygen equipment. The resident currently has an oxygen concentrator in her room and prefers to leave the concentrator running continuously, even when not actively in use, per her preference.The resident verbalized understanding of the education provided. The resident declined to disclose how the vape device was obtained and refused this NHA's request to inspect drawers or personal storage areas to verify removal of the device from the room. The resident was unable to clearly state where or how the vape device had been disposed of prior to this NHA's discussion with resident. 02/18/2026 11:49*Behavior NotePlease describe the behavior demonstrated:: Knocked on resident's door for medication pass. Resident didn't answer. This nurse poked her head in the door and observed resident resting in her bed with eyes closed and audible snoring observed with a vape in her hand. Resident asked if she would give this nurse vape. Resident stated No and tucked vape into clear plastic tote bag.How often did this behavior occur/last: 1xDescribe any interventions attempted:: Attempted to educate resident on smoking and vaping policy. Resident continued to refuse to give this nurse vape. DON and Administrator notified.Effectiveness of Interventions:: The resident's care plan with an initiationdate of 09/08/25 included that they smoked cigarettes. The resident had the following physician orders: -Oxygen Therapy: Oxygen 3 liters via Nasal Cannula continuously. May be removed for transports, shower, and activities of interest.every shiftOther Active 3/29/2026 A quarterly smoking assessment was last conducted on 03/10/26, and was not marked for vaping. According to the Medical University of South Carolina, vaping while using supplemental oxygen is extremely dangerous and can cause severe fires, explosions, facial burns, and death. Oxygen supports combustion, making even small sparks from a vape's heating element, or a battery failure, ignite the enriched oxygen atmosphere, clothing, or the nasal cannula instantly. During the period of the survey, it was still not known whether the resident had vape pens in her possession, and resident refused a room search. This possible serious fire hazard was reviewed with RN Consultant #87 on 04/29/2026 at 12:22 PM. RN Consultant indicated she would be taking care of this immediately. b) Resident #54 An observation on 04/14/26 at 1:00 PM, Resident #54 was observed lying in his bed with the right fall mat leaned along the wall behind the headboard. Record review completed on 04/14/26 showed the care plan had an intervention stating Fall matts to bilateral sides of bed while resident is in the bed During an interview with LPN #65 on 04/14/26 at 1:05 PM who confirmed floor matt was not in place and statedI'll get that down now they just laid Resident #54 down c) Resident #57 During a check for fall prevention measures on 04/23/26 at 9:15AM, Resident #57 was observed lying in his bed with the bed not in the low position. A review of the care plan for Resident #57 includes the following: RISK FOR FALLS: the resident is at riskfor falls related to: muscle weakness,cognitive impairment, incontinence,psychoactive medication use, recenthospitalizations, visual impairment; historyof traumatic brain injury and multiple CVAswith deficits. Bed in lowest positionDate Initiated: 12/05/2025 It was confirmed in an interview with Registered Nurse Consultant #86 that Resident #57's bed was not in lowest position with resident in the bed at 04/23/26 at 9:21 AM.

Based on resident interview and record review the facility failed to protect two (2) residents from neglect by failing to provide care timely incontinence care Resident #1 and failing to provide the correct texture of food for Resident #3. Resident identiifers: #1, and #3. Resident #1 sustained actual physical harm from this action. Facility Census 57. Findings Included: Findings include: a) Resident #1 A policy titled Abuse includes a definition for neglect that reads: neglect is the failure of the facility, its employees or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish, or emotional distress. During the initial interview with Resident #1 on 04/20/26 at 1:55 PM, he stated he had been left overnight without having his brief changed and had been experiencing diarrhea. Resident #1 stated he requested to be changed. Resident #1 stated that when they did change his brief the next morning, the bowel movement had to be picked off and his bottom all the way to the front was sore. In an interview with Nurse Aide (NA) #25 via telephone at 12:50 PM on 04/21/26, she stated she changed Resident #1 on Saturday, 04/18/26 before she left for the day. She stated she went back on Sunday, 04/19/26 to assist his aide and Resident #1 stated he had not been changed since CNA #25 did it the day before. Resident #1 stated he had asked the night shift aides to change him, but they came in, changed his roommate and left. NA #25 states Resident #1 was raw and his skin was bad! CNA #25 stated she reported the issue to Licensed Practical Nurse (LPN) #69 immediately. In an interview with CNA #58 via telephone on 04/21/26 at 1:25PM. She stated she went in to change a wet and soiled brief on Sunday morning. Resident #1 stated he had not been changed all night. He stated he had asked the aides that came in to change his roommate, but the aide said they would come back. However the aide left and did not return. CNA #58 states his skin was pretty bad and raw and red. CNA #58 stated she showed LPN #69 immediately, who then notified Registered Nurse (RN) #63. An order written on 04/19/26 reads as follows: Wound Care: Cleanse excoriation to sacrum and scrotum with soap and water, allow to dry then apply barrier cream Shift until resolvedevery shift for wound healing. The active date/time on the order was 04/19/26 at 6:00 PM. The last skin assessments in the Electronic Medical Record (EMR) are from 04/08/26 and 04/15/26 which show no skin issues to the sacrum or scrotum. A record review of the reportables and grievances does not include this situation. In an interview with Administrator on 04/22/26 at approximately 12:00PM, she confirmed that this situation would be neglect if it is accurate. b) Resident #3 A review of the progress notes dated 04/26/26 for Resident #3 reads: Resident was given grilled cheese on dinner tray. Her diet order is for mechanical soft. Resident ate some of the grilled cheese before the Nurse Aide (NA) noticed and she coughed a few times and then was fine. NA took the tray and got her another one that she could eat without problem. Lumina contacted and spoke with [the provider] and she ordered to document situation and if there were any further coughing or congestion episodes to call back. The diet orders for Resident #2 include mechanical soft texture (a diet that consists of foods that are moist, soft-textured and easily formed into a bolus). The Diet and Nutrition Care Manual for a mechanical soft diet lists grilled sandwiches as foods to avoid. An interview with nurse consultant #87 on 04/29/26 at 1:30PM confirmed this incident occurred according to the documentation and was not reported.

Based on record reviews and staff interviews the facility failed to develop and implement a person centered comprehensive care plan regarding activities for residents #37,#29,#25,#8,#1,#2, and accidents hazards for resident #54,#57 and Positioning and mobility for residents #7 and #18. These failed practices had the potential to affect more than a minimal number of residents residing in the Long Term Care Facility. Resident Identifier: #37,#29,#25,#8,#1,#2,#57 #7 and #18 Facility census: 57 Findings Included: a) Resident #37 Record review completed on 04/23/26 revealed the following Activities-Resident Preferences Evaluation Section A Daily Preferences Question nine (9) Daily preferences note Resident stated he likes to play cards and checkers. Resident enjoys taking showers in the evening. Section B Activity Preferences question two (2)a Preferred music genre(s): Early listening, Ethnic/Heritage, Jazz, Modern/Current. Further record review of Resident37's Care Plan revealed to not be person centered no mentioning of preferences such as Cards, checkers or types of music the resident prefers to listen to are in the residents plan of care. During an interview on 04/27/26 at approximately 3:00 PM with the Activity Director while Registered Nurse Coordinator # 87 present. the activity director confirmed care plans were not person centered and set individualized goals. b) Resident #29 Record review completed on 04/23/26 revealed the following; Activities-Resident Preferences Evaluation review revealed the following: Resident #29 enjoyed judge shows, criminal discovery shows, Martyr Mystery, and criminal documentaries. Resident enjoys going on outings with her son. Section B Activity Preferences question two (2)a Preferred music genre(s): Rock and country. Question nine(9) Activity Preference Note: Resident prefers not to participate in group activities at this time. Resident enjoys participating in one-on-one activities with activity staff and self-directed activities. Section B Activity Preferences question two (2)a Preferred music genre(s): Rock and county. Further review of Resident #29's care plan revealed no mention of one-on-one activities, preferred TV shows, or the type of music resident #29 enjoyed. During an interview, on 04/27/26 at approximately 3:00 PM, with the Activity Director while Registered Nurse Coordinator # 87 present the Activity Director confirmed that care plans were not person centered and lacked individualized goals. c) Resident #25 Record review completed on 04/23/26 revealed the following; Activities-Resident Preferences Evaluation~ Section A Daily Preferences Question nine (9) Daily preferences note: Resident prefers to rest throughout the day. Residents enjoy social visits Resident enjoys going on outings with her son. ~ Section B Activity Preferences question two (2)a Preferred music genre(s): Rock and county.Question nine(9) Activity Preference Note: Resident prefers not to participate in group activities at this time. Resident enjoys participating in one-on-one activities with activity staff and self directed activities. is all marked as preferences Further record review of resident #25's care plan showed no preferences for one on one activities by staff, TV shows or type of music Resident #25 prefers. During an interview on 04/27/26 at approximately 3:00 PM with the Activity Director while Registered Nurse Coordinator # 87 present. The activity director confirmed care plans were not person centered and set individualized goals. d) Resident #8 Activities. Record review completed on 04/23/26 revealed the following; Activities-Resident Preferences Evaluation~ Section A Daily Preferences Question nine (9) Daily preferences note: Resident prefer to stay in bed and not participate in Out of Room (OOR) or group activities at this time. Residents go out Monday, Wednesday, and Friday for dialysis. Resident enjoys talking on her cell phone to family and friends. ~ Section B Activity Preferences question two (2)a Preferred music genre(s): inspirational/Religious, Jazz, Modern/Current.Question nine(9) Activity Preference Note: Resident does not participate in OOR activities at this time. Resident actively participates in self directed activities of interests is all marked as preferences Further record review of Resident #8's care plan shows no preferences for music. During an interview on 04/27/26 at approximately 3:00 PM with the Activity Director while Registered Nurse Coordinator # 87 present. the activity director confirmed care plans were not person centered and set individualized goals. e) Resident #1 Record review completed on 04/23/26 revealed the following; Activities-Resident Preferences Evaluation~ Section A Daily Preferences Question nine (9) Daily preferences note: Residents prefer to stay in bed and sleep most days. Other times when Resident #1 is up, he enjoys sitting in the hallways talking with other residents and staff that goes by. ~ Section B Activity Preferences question two (2)a Prefered music genre(s): Country and Modern/Current.Question nine(9) Activity Preference Note: Resident participates in self directed activities of interests, Resident prefers not to participate in group activities at this time. Residents at times will allow a one on one activity of his choice. Further review of Resident #1's care plan revealed personal specific goals to be set for the one on one visits. During an interview on 04/27/26 at approximately 3:00 PM with the Activity Director while Registered Nurse Coordinator # 87 present. The activity director confirmed care plans were not person centered and set individualized goals. f) Resident # 54 Accidents During a check for fall prevention measures on 04/14/26 at 1:00 PM, Resident #57 was observed lying in his bed with the right fall mat leaned along the wall behind the headboard. Record review completed on 04/14/26 showed the care plan had an intervention stating Fall matts to bilateral sides of bed while resident is in the bed During an interview with LPN #65 on 04/14/26 at 1:05 PM who confirmed floor matt was not in place and statedI'll get that down now they just laid Resident #54 down

Based upon record review, observation, and staff interview, the facility failed to post accurate nurse staffing data in a prominent location viewable by staff and visitors. This was found to be true for 22 days of 23 days of staffing reviewed during the long term care survey process. Facility census: 57.Findings included: a) The surveyor attempted to find the daily nursing staffing data sheet upon entrance to the facility on [DATE], and could not find it. Upon asking where it was posted, the Director of Nursing took me to the nurse's station where the posting was located on the wall near the nurses station. The surveyor requested nursing staffing data sheets and time punch detail sheets for staff for the following days:-04/25/26-04/19/26-04/18/26-03/29/26-03/28/26-02/15/26-02/14/26-12/27/25-12/26/25-12/24/25-11/29/25-11/28/25-11/27/25-11/01/25-10/31/25-10/30/25-10/11/25-10/10/25-10/09/25-10/08/25-10/07/25-10/06/25-10/05/25A review of the posted nurse staffing sheets found the following inaccuracies:-Inaccurate dates were posted nurse staffing sheets on the following dates:10/5/25 actual date, 10/5/26 was date listed on the posting04/18/26 actual date, 4/18/25 was date listed on posting04/19/26 actual date, 04/19/25 was date listed on posting During an observation on 04/28/26 at 12:02 AM, the staffing numbers for the night shift on the daily nurse staffing sheet documented two (2) Licensed Practical Nurses (LPN), three (3) Nurse Aides (NA) and zero (0) Registered Nurses (RN) working. A visual count confirmed one (1) LPN, 0 RN, and 2 NA. Nurse Aide #5 was sleeping on duty upon arrival to the facility. Nurse Aide #10 was in the breakroom with a makeshift office set up using a table, laptop, battery charger, and large rolling briefcase. Later, the surveyor learned one NA was sitting 1:1 with a resident, leaving two NAs to cover the 56 other residents in the facility. During an interview with LPN #36, when asked about another LPN working per the posted daily nurse staffing sheet, he replied the other LPN is pregnant and called in sick. When asked if this would cause some work to not be completed, he responded that if he worked hard, they would get it all done. During an interview with the Regional Director of Operations (RDO) on 04/28/26 at 12:35 AM, the surveyor reviewed the staffing sheet discrepancy, and the findings: one NA was sleeping, and the other was conducting business on his laptop. Other inaccuracies found were:-04/25/26 Unable to discern actual number of NAs working on day and evening shifts, as changes were made on top of writing-04/19/26 Total hours worked were wrong on staffing sheet, 165.5 were posted, versus 156.8 actual hours worked.-04/18/26 Total hours worked were wrong on staffing sheet. 150.5 was posted, versus168.08 actual hours worked.-03/29/26 Total hours worked were wrong on staffing sheet. 159 was posted, versus167.6 actual hours worked.-03/28/26 Total hours worked were wrong on staffing sheet. 142.5 was posted, versus150.33 actual hours worked.-02/14/26 Total hours worked were wrong on staffing sheet. 127.5 was posted, versus 124.66 actual hours worked.-12/27/25 Total hours worked were wrong on staffing sheet. 162 was posted, versus 180.36 actual hours worked.-12/26/25 Total hours worked were wrong on staffing sheet. 155.5 was posted versus168.8 actual hours worked.-12/24/25 Total hours worked were wrong on staffing sheet. 181.5 was posted, versus 191.98 actual hours worked.-11/29/25 Total hours worked were wrong on staffing sheet. 146.75 was posted, versus 157.2 actual hours worked.-11/28/25 Total hours worked were wrong on staffing sheet. 158.75 was posted, versus 170.2 actual hours worked.-11/27/25 Corrections made on top of actual hours and number of staff, so it is not clear which numbers are correct.-11/01/25 Total hours worked were wrong on staffing sheet. 151 was total based on staffing sheet, actual actuals were 164.25.-10/31/25 Total hours worked were posted as 155.62. Adding the hours on the nurse staffing sheet, you get 147.5. Using time detail report, total hours worked were actually 167.33.-10/30/25 It is unclear as to the number of Nurse Aides working on 1st shift. Total hours worked were 143 versus actual hours worked being 178.98.-10/11/25 Total hours worked were wrong on staffing sheet. 129 hours was posted, versus 160.31 actual hours worked.-10/10/25 Total hours worked were wrong on staffing sheet. 158 hours was posted, versus 175.05 actual hours worked.-10/09/25 Total hours worked were wrong on staffing sheet. 158.75 was posted, versus 205.97 actual hours worked.-10/08/25 Total hours worked were wrong on staffing sheet. 158.25 was posted, versus 176.71 actual hours worked.-10/07/25 Total hours worked were wrong on staffing sheet. 146 was posted versus 160.62 actual hours worked.-10/06/25 Total hours worked were wrong on staffing sheet. 135 was posted versus 144.69 actual hours worked.-10/05/25 Actual number of NAs working on 1st shift is posted as three (3,) when according to punch detail report there were four (4). Total hours worked were wrong on staffing sheet. 154,5 was posted versus 168.12 actual hours worked. Samples of the descrepancies were reviewed with RN Consultant on 04/28/26 mid afternoon.

Based on record review, resident interviews, staff interviews, observations, the facility administration failed to effectively operate the facility in a manner that ensured residents attained or maintained their highest practicable physical, mental, and psychosocial well-being. The facility failed to provide administrative oversight to ensure adequate staffing, resident protection systems, abuse/neglect reporting and investigation, and a person-centered activity program were implemented and monitored. These systemic failures resulted in repeat deficient practices and had the potential to affect all residents residing in the facility. Facility census: 57.Findings include:Review of staffing schedules, punch detail reports, and Hours Per Patient Day (HPPD) calculations revealed the facility failed to maintain minimum staffing levels on 2 of 23 reviewed days.On 04/25/26, the HPPD was calculated at 1.99 using posted staffing data and 2.59 using punch detail sheets.On 02/14/26, the HPPD was calculated at 2.19 using staffing data sheets and 2.14 using punch detail sheets, below the minimum required 2.25 HPPD.Review of the CASPER report revealed the facility triggered for low weekend staffing during Quarter 1 of 2026.During an interview on 04/20/26 at 1:55 PM, Resident #1 stated he had been left overnight in a soiled brief while experiencing diarrhea despite requesting assistance from staff. Resident #1 stated when staff changed him the following morning, his bottom was sore all the way up to the front.During a telephone interview on 04/21/26 at 12:50 PM, CNA #25 stated she had changed Resident #1 on 04/18/26 prior to leaving work and returned the following day to assist another aide. CNA #25 stated Resident #1 reported he had not been changed overnight despite requesting assistance from night shift aides. CNA #25 stated Resident #1 was raw and his skin was bad.During an interview on 04/21/26 at 1:25 PM, CNA #58 stated Resident #1 reported staff changed his roommate during the night but did not return to change him. CNA #58 stated the resident's skin was pretty bad and raw and red.Review of the medical record revealed a wound care order dated 04/19/26 for excoriation to the sacrum and scrotum; however, no skin assessment had been completed prior to the order. Previous skin assessments dated 04/08/26 and 04/15/26 documented no skin issues.These findings demonstrated that the facility failed to provide adequate administrative oversight, which meant sufficient staffing and monitoring systems were not in place to prevent neglect and ensure resident care needs were met.Facility policy titled Abuse defined neglect as failure of the facility or its staff to provide goods and services necessary to avoid physical harm, pain, mental anguish, or emotional distress. The policy further required allegations involving abuse, neglect, exploitation, or mistreatment to be reported timely to the administrator and appropriate state agencies.Review of facility reportable and grievance logs revealed no investigation was initiated regarding Resident #1 being left overnight in a soiled brief resulting in excoriation and skin breakdown.During an interview on 04/22/26 at approximately 12:00 PM, the Administrator confirmed the incident involving Resident #1 was not reported to the state agency.Further review revealed the facility also failed to report a crime involving cannabis gummies brought into the facility and offered to other residents to the state agency, and failed to thoroughly investigate reasonable suspicion of that crime.During an interview, Anonymous Resident #1 reported that on 04/03/26 two residents purchased cannabis gummies through DoorDash and offered them to other residents. The resident reported both residents were later sent to the hospital after one became noticeably impaired.Review of facility reportable and grievance logs revealed no investigation had been completed for Resident #5 and Resident #42 regarding changes in condition related to cannabis gummies being brought into the facility and offered to residents.Review of nursing documentation dated 04/03/26 revealed Resident #5 exhibited altered mental status, reddened eyes, lethargy, and an elevated pulse of 105 after consuming a pot gummy. Documentation revealed staff discovered additional gummies and vape pens in the resident's room, and the resident required transfer to the emergency department for evaluation and toxicology screening.These findings demonstrated that facility administration failed to ensure systems were in place for reporting, investigating, and responding to allegations of neglect, abuse, and significant changes in resident condition.Based on resident interviews, Resident Council review, observations, record review, and staff interviews, the facility failed to provide an ongoing activity program that met the interests and psychosocial needs of residents.During the Resident Council meeting on 04/14/26, residents voiced concerns regarding repetitive and non-age-appropriate activities, lack of evening activities, and limited meaningful engagement. Residents reported activities primarily consisted of bingo, cartoons, coloring, and children's games.Record review of activity calendars from January through April 2026 revealed repetitive programming including cartoons, [NAME] Says, Hungry Hippos, poster making, and Connect Four. The calendars also included a daily smoking break labeled Puff Masters and Pioneers as a scheduled activity.Review further revealed minimal evening programming after 3:00 PM and no structured sensory programming for low-functioning residents.Observation on 04/21/26 at 7:00 PM and again at 8:00 PM revealed residents sitting in hallways and the television room without staff interaction or organized activities.During an interview on 04/27/26, the Activity Director stated there was no specific list of residents requiring sensory stimulation programming and stated room visits were conducted during one-on-one visits.

Based on record review and staff interviews the facility failed to maintain a complete accurate medical record for resident #54 regarding Nothing by Mouth (NPO) Resident #63's skin assessments, Resident#18's NPO orders, and Resident #63's POST form. These were random opportunities of discovery during the Long-Term care survey process and has the potential to affect more than a minimal number of residents residing in the facility. Resident identifier: #54, #63, #18 Facility census: 57 a) Resident #54 Record review of orders completed on 04/13/26 revealed the following intervention in the care plan may give all medications and liquids via gastrostomy tube r/t resident is NPO Further record review revealed the following orders; Lorazepam oral concentrate 2 MG/ML Give .25 ML by mouth three times a day Neomycin sulfate oral tablet 500 MG give two tablets by mouth two times a day During an interview with LPN #65 when asked about giving medications to Resident #54 by mouth she stated No he gets all of his medicine by g-tube and confirmed the order was not correct and stated I will call and get those clarified now.' b) Resident #18 Resident has orders for nil per os (NPO) diet, texture and consistency, meaning nothing by mouth. During a record review on 04/23/26, there is an order for Neurontin: give one (1) capsule by mouth three (3) times a day and an order for Zanaflex: give two (2) [milligrams] mg by mouth four (4) times a day. In an interview with LPN #69 at 4:10PM on 04/27/26, she stated she has not given Resident #18 anything by mouth throughout this month. She stated the documentation that she signed showing Resident #18 received medication by mouth on the Medication Administration Record (MAR) was incorrect. In an interview with Director of Nursing on 04/28/26 at 1:30PM, it was confirmed that Resident #18 is to have nothing by mouth and she had two (2) medications ordered by mouth and documentation that it was being administered by mouth. c) Resident #2 During an interview with Resident #2 on 04/23/26 at 9:10AM, he stated he had not been out of bed for about two (2) months, since his back surgery. In an interview with Nurse Aide (CNA) #4 at 11:30AM on 04/23/26, she stated Resident #2 has not been up since his surgery. She stated that using the Hoyer lift hurts his knee, and although they attempted to convince him to get up, he refused. In an interview with Registered Nurse Unit Manager (RNUM) #63 at 11:30AM on 04/23/26 she stated Resident #2 has not been up since his surgery that she has witnessed. A review of Chair/Bed-to-Chair Transfer tasks for Resident #2 notes that Resident #2 required substantial/maximum assist or was dependent with transfers on the following dates: -04/01/26 -04/02/26 -04/08/26 -04/09/26 -04/10/26 -04/11/26 -04/12/26 -04/15/26 -04/15/26 -04/20/26 A review of sit to stand tasks for Resident #2 notes that he required substantial/maximum assist or was dependent with these transfers on the following dates: -04/02/26 -04/10/26 -04/16/26 -04/20/26 A review of toilet transfer tasks notes that Resident #2 was dependent with toilet transfers on the following dates: -04/07/26 -04/10/26 -04/11/26 -04/16/26 -04/20/26 A review of the task labeled wheel 50 feet with two turns, show that Resident #2 was dependent and using a manual wheelchair on the following dates: -04/01/26 -04/02/26 -04/08/26 -04/09/26 -04/10/26 -04/11/26 -04/15/26 -04/16/26 -04/20/26 The five (5) day Minimum Data Set (MDS) dated [DATE] for Resident #2 has sit to stand and toilet transfers labeled as inapplicable, and chair/bed-to-chair transfers labeled as not attempted due to medical conditions or safety concerns. The question regarding the use of a wheelchair is marked no. An interview with Director of Nursing on 04/28/26 at 1:30PM confirmed incorrect documentation regarding Resident #2's transfers.

Based on resident interviews, Resident Council review, record review, observations, and staff interviews, the facility failed to provide an ongoing, person-centered activity program that met the interests and needs of the resident population, including providing age-appropriate activities, evening programming, and individualized/sensory activities for low-functioning residents.This deficient practice had the potential to affect all residents residing in the facility by failing to promote psychosocial well-being, meaningful engagement, and quality of life. Resident identifier; #48,#19,#25,#8,#1,#2,#3,#37,#45,#23 Facility Census; 57 Findings include:a) Resident Council Concerns and Resident InterviewsDuring an initial interview on 04/20/26 at 12:50 PM, Resident #2 stated the activity staff hardly ever come into his room for activities.During the Resident Council meeting held on 04/14/26 at 11:00 AM, Residents #48, #19, #23, #3, #37, and #45 voiced concerns regarding the facility's activity program. Residents expressed a desire for more age-appropriate programming, stating that current activities primarily consist of bingo with candy prizes, cartoons, and coloring. While some residents reported enjoying crafts, they indicated a preference for more adult-oriented group activities, including music and interactive programming.Resident #37 stated, The activities here are elementary, and further reported there are no consistent evening activities, with only occasional movie nights offered. Resident #25 stated, Yeah, we get offered coloring and cartoons, and indicated that requests for evening activities had been discussed in prior Resident Council meetings a month or two ago, with no implementation noted. b) Activity Programming ReviewRecord review completed on 04/27/26 of the facility's activity calendars from January 2026 through April 2026 revealed repetitive activities that were not age-appropriate for the adult resident population. Examples include:January: Connect Four, poster making, cartoons, Hungry HipposFebruary: Cartoons, [NAME] Says, Connect FourMarch: Cartoons, [NAME] Says, Connect FourAdditionally, the calendar included a daily scheduled activity titled Puff Masters and Pioneers from 1:00 PM to 1:30 PM, which was identified as a facility-designated smoking break rather than a structured activity.Review further revealed limited activity offerings after 3:00 PM, typically consisting of only one (1) to two (2) activities, such as an evening movie or a group session titled Singing with [NAME].A request was made for a list of residents requiring sensory stimulation programming for low-functioning residents. The Activity Director (AD) stated, I don't have a particular list of residents who require sensory stimulation activities; we just do room visits when we complete one-on-ones. No additional documentation or structured sensory programming was provided for review.Review of resident care plans indicated they were not consistently person-centered or reflective of individual preferences and needs as identified in the comprehensive assessments. c) ObservationObservation conducted on 04/21/26 at 7:00 PM revealed residents seated in the hallway and television room without staff interaction or structured activities.Continued observation at 8:00 PM on the same date showed residents remained in the television room without engagement or staff-led programming.Observations indicated that no organized activities were provided after 4:00 PM unless self-directed by residents. d) Staff InterviewsOn 04/14/26 at 4:00 PM, residents were observed sitting in the hallway doorway and television room. Licensed Practical Nurse (LPN) #65 was asked whether evening activities were offered and stated, Not that I am aware of. Some residents watch TV; however, I am normally only here until 6:00 PM.During an interview on 04/27/26 at approximately 3:00 PM, the Activity Director (AD) stated, I base my activities on what they want through Resident Council. When asked specifically about evening activities, the AD stated, We talk about it in Resident Council; they are fine with it.

Based on record review and staff interview, the facility failed to update the Pre-admission Screening and Resident Review (PASARR) when a diagnoses of Post Traumatic Stress Disorder (PTSD), was added for Resident #5. This was true for one (1) of four (4) residents reviewed for PASARR. Resident identifier: #5. Facility census: 57. Findings included: Findings included: a) Resident #5 On 04/27/26 at 2:46 PM a review of the medical record found that a PASARR had been completed on 11/17/26 for Resident #5. Resident #5 was transferred from another facility on 11/17/26. A diagnosis of PTSD was added on 11/21/26. This PASARR was not updated to reflect the PTSD diagnosis. The Registered Nurse (RN) #85 confirmed this on 04/28/26 at approximately 10:45 AM.

Based on observation, staff interview, staff postings review and resident interview the facility failed to ensurse sufficient nursing staff across all shifts and units to meet the needs of depdendent residents. Resident identifiers: #1. Facility census: 57. a) Findings included:During the resident council meeting on 04/22/25, the residents voiced concerns of call lights are answered sometimes after 1-3 hours. Residents stated that staff would say they would be right back, but they never returned or came back hours later claiming they had been outside smoking with a resident. -04/20/26 Resident #8 stated, Sometimes it takes a while to get help.-04/20/26 at 12:39 PM, Resident #2 stated, Night shift takes forever to answer a call light.-04/20/26 at 1:43 PM, Resident #25 stated, It takes an hour to answer the call light. I have to go to the bathroom a lot because of my meds.-04/21/26 at 10:33 AM, Resident #27 stated, I frequently wait 45 minutes or more to get changed. At the 4:00 PM smoke break, all the Nurse Aides and one nurse accompany the residents outdoors to smoke, leaving one nurse to cover the entire floor. After 5:00 PM, they won't even bother to answer call lights, you are forced to wait until day shift comes on. If you need to be changed during meal tray pass, they will tell you to wait until they are through with passing trays.-04/20/26 at 9:36 PM, Resident #5 stated, They need more help. A record review of the following days was completed. This involved using the posted daily nurse staffing sheet along with the detail punch time sheets for each staff member to match the posted daily nurse staffing sheet, and calculating the Hours Per Patient Day (HPPD). -On 04/25/26, the HPPD was calculated at 1.99 using posted staffing data and 2.59 using punch detail sheets.On 02/14/26, the HPPD was calculated at 2.19 using staffing data sheets and 2.14 using punch detail sheets, below the minimum required 2.25 HPPD. These findings were reviewed with RN Consultant #87 on 04/29/26 late afternoon. b) Resident #1 A policy titled Abuse includes a definition for neglect that reads: neglect is the failure of the facility, its employees or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish, or emotional distress. During the initial interview with Resident #1 on 04/20/26 at 1:55 PM, he stated he had been left overnight without having his brief changed and had been experiencing diarrhea. Resident #1 stated he requested to be changed. Resident #1 stated that when they did change his brief the next morning, the bowel movement had to be picked off and his bottom all the way to the front was sore. In an interview with Nurse Aide (NA) #25 via telephone at 12:50 PM on 04/21/26, she stated she changed Resident #1 on Saturday, 04/18/26 before she left for the day. She stated she went back on Sunday, 04/19/26 to assist his aide and Resident #1 stated he had not been changed since CNA #25 did it the day before. Resident #1 stated he had asked the night shift aides to change him, but they came in, changed his roommate and left. NA #25 states Resident #1 was raw and his skin was bad! CNA #25 stated she reported the issue to Licensed Practical Nurse (LPN) #69 immediately. In an interview with CNA #58 via telephone on 04/21/26 at 1:25PM. She stated she went in to change a wet and soiled brief on Sunday morning. Resident #1 stated he had not been changed all night. He stated he had asked the aides that came in to change his roommate, but the aide said they would come back. However the aide left and did not return. CNA #58 states his skin was pretty bad and raw and red. CNA #58 stated she showed LPN #69 immediately, who then notified Registered Nurse (RN) #63.An order written on 04/19/26 reads as follows: Wound Care: Cleanse excoriation to sacrum and scrotum with soap and water, allow to dry then apply barrier cream Shift until resolvedevery shift for wound healing. The active date/time on the order was 04/19/26 at 6:00 PM.The last skin assessments in the Electronic Medical Record (EMR) are from 04/08/26 and 04/15/26 which show no skin issues to the sacrum or scrotum.A record review of the reportables and grievances does not include this situation.In an interview with Administrator on 04/22/26 at approximately 12:00PM, she confirmed that this situation would be neglect if it is accurate.c) During an observation on 04/28/26 at 12:02 AM, the staffing numbers for the night shift on the daily nurse staffing sheet documented two (2) Licensed Practical Nurses (LPN), three (3) Nurse Aides (NA) and zero (0) Registered Nurses (RN) working. A visual count confirmed one (1) LPN, 0 RN, and 2 NA. Nurse Aide #5 was sleeping on duty upon arrival to the facility. Nurse Aide #10 was in the breakroom with a makeshift office set up using a table, laptop, battery charger, and large rolling briefcase. Later, the surveyor learned one NA was sitting 1:1 with a resident, leaving two NAs to cover the 56 other residents in the facility. During an interview with LPN #36, when asked about another LPN working per the posted daily nurse staffing sheet, he replied the other LPN is pregnant and called in sick. When asked if this would cause some work to not be completed, he responded that if he worked hard, they would get it all done. During an interview with the Regional Director of Operations (RDO) on 04/28/26 at 12:35 AM, the surveyor reviewed the staffing sheet discrepancy, and the findings: one NA was sleeping, and the other was conducting business on his laptop. Review of the CASPER report also revealed the facility triggered for low weekend staffing during Quarter 1 of 2026.

Based on observation and resident and staff interviews, the facility failed to provide meals that were palatable and attractive. This had the potential to affect all residents receiving nutrition from the kitchen. Resident identifiers: #2, #35 and #27. Census: 57Findings include: a) Resident #2 During initial interviews on 04/20/26 at 12:55PM, Resident #2 stated that the food is terrible. b) Resident #35 On 04/21/26 1:47 PM Resident #35 stated the food is sometimes cold and it does not taste good A sample tray with hamburger and french fries was brought to state surveyors on 04/28/26. The hamburger was not apealing to they eye, the French Fries were mushy and pale, the hamburger lacked seasoning and left a tasted not desired after eating, On 04/28/26 at 1:00 PM Registered Nurse Consultant #87 confirmed the meal looked unappetizing. c) Resident # 27 During initial interviews on 04/21/26 at 10:35 AM, Resident #27 stated, The food is terrible. It is so bad, that I order all of my food in. This should not have to be the way it is, since I already pay once for it.

Based on observations and staff interview the facility failed to ensure pans were dry before stacking rusulting in Wet nesting a dangerous practice of stacking or storing washed, wet items (like bowls, plates, or pots) together before they are fully dry. This trapped moisture creates a dark, low-air environment that allows bacteria to grow rapidly this failed practice had the potential to affect more than a minimal number of residents residing in the long termcare facility. Facility censuse:57During the initial tour of the kitchen on 04/20/26 with the Dietary Manager, two (2) metal pans and one clear plastic serving container was observed on the shelf stacked and wet. The Dietary Manager pulled them and stated, I'll take care of these now. On 04/21/26 at 10:00 AM during a follow-up kitchen tour, another metal pan was observed wet on the shelf. The Dietary Manager confirmed the pan was wet and removed it.

Based upon record review and staff interview, the facility failed to notify the ombudsman and resident/resident representative of the resident's transfer and provide information on the bed hold notification. This was found to be true for two (2) of two (2) residents reviewed during the long term care survey process. Resident identifiers: #62, #27. Facility census: 57. Findings included: a) Resident #62 Resident #62 was admitted to the facility on [DATE]. Resident was transferred to (name of local Hospital) on 03/10/26 after being found unresponsive. The resident did not have capacity to make their own medical decisions. The progress notes from the resident's medical record pertaining to this day included the following: 3/10/2026 04:40*Nursing NoteNote Text: Resident had anormal v/s [vital signs] and lethargic, right arm swollen, legs and feet swollen called NP [Nurse Practitioner] [first and last name of Nurse Practitioner] stated to send her to the [name of acute care facility] ER [Emergency Room]ambulance is here to transfer her outto the ER 3/10/2026 09:18*Nursing NoteNote Text: Called [name of acute care facility] for update. Spoke with [first name of staff] in ER. Stated, Resident will be admitted to ICU at [name of acute care facility] when bed comes available with Dx [diagnosis] of UTI [Urinary Tract Infection], Septic Shock, Respiratory Failure, bil plueral effusion and lung mass. MPOA [Medical Power of Attorney] aware. 3/11/2026 06:51 Orders - Administration NoteNote Text: Resident admitted to [acute care facility] A review of the documentation for the acute transfer found that the facility representative signed the bed hold notice, however, there was no documentation to support the verbal notification, such as a second signature or verification that the bed hold notice had been mailed to the resident's representative for signature. Additionally, the bed hold notice included the bed hold policy as well as a list of resources available for contacting if the resident was dissatisfied with their transfer/discharge. The surveyor requested verification that the Long Term Care Ombudsman was notified of the transfer. The facility could not produce this documentation. b) Resident #27 Resident #27 has the capacity to make their own medical decisions. The resident's medical record documents the resident was transferred to an acute care facility on 12/28/25, returning to the long-term care facility on 01/05/26. The progress notes in the medical record on the transfer date included the following: 12/28/2025 13:29*Nursing NoteNote Text: LPN came to this nurse and stated resident had slurred speech and was lethargic. Upon assessment, resident noted to be laying in the bed and unable to keep eyes open. Upper extremities noted to be twitching intermittently. Skin noted to be pallor. B/P [Blood Pressure] 58/47. Unable to obtain pulse and O2 D/T [due to] resident being uncooperative. Resident able to awake long enough to respond Yes to going out to the ER after this nurse asked if she would go. Resident very disoriented. [Name of EMS] attendees X 2 arrived via stretcher for transport to [name of acute care facility]. All appropriate paperwork sent with attendees. Report called in to [name of acute care facility] ER. Physician, UM [unit manager], and DON notified. A review of the acute transfer form and paperwork provided by the facility found the ombudsman was not notified of the transfer. The transfer paperwork and findings for both residents were reviewed with the Director of Nursing (DON) at 04/23/2026 9:54 AM. She acknowledged it. This was also reviewed with the NHA (Nursing Home Administrator) on 04/23/26 at 10:58 AM.

Based on record review and staff interviews, the facility failed to ensure Resident #3 received food in the form to meet her needs. This was a random opportunity for discovery during the Long-Term Care Survey Process. Census: 57 Resident identifier: #3Findings include: a) Resident #3 A review of the progress notes dated 04/26/26 for Resident #3 reads, Resident was given grilled cheese on dinner tray. Her diet order is for mechanical soft. Resident ate some of the grilled cheese before the [Certified Nurse Aid] CNA noticed and she coughed a few times and then was fine. CNA took the tray and got her another one that she could eat without problem. Lumina contacted and spoke with [the provider] and she ordered to document situation and if there were any further coughing or congestion episodes to call back. The diet orders for Resident #2 include mechanical soft texture (this diet consists of foods that are moist, soft-textured and easily formed into a bolus).The Diet and Nutrition Care Manual for a mechanical soft diet lists grilled sandwiches as foods to avoid. An interview with Registered Nurse Consultant #87 on 04/29/26 at 1:30PM confirmed Resident #3 is ordered a mechanical soft diet and that a grilled cheese sandwich is not on that diet.

Based on resident interview and record review the facility failed to report a resident allegation of neglect involving not having a brief changed and an instance where a resident was given the wrong consistency of food. The facility also failed to report the reasonable suspicion of a crime where a resident brought in THC gummies and distributed them to other residents. Resident identifiers: #3 and #1. Facility census: 57. Findings Included: a) Resident #1 A policy titled, Abuse includes a definition for neglect that reads, neglect is the failure of the facility, its employees or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish, or emotional distress.The policy also reads, the organization will maintain systems to ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, are reported immediately, but not later than [two] 2 hours after allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury, to the administrator of the facility, or his or her designee, and to other officials (including to the State Survey Agency and adult protective services where state law provides for jurisdiction in long-term care facilities) in accordance with State law through established procedures. During the initial interview with Resident #1 on 04/20/26 at 1:55 PM, he stated staff left him overnight without changing his brief and that he had been experiencing diarrhea. Resident #1 states he requested to be changed. Resident #1 stated that when they did change his brief the next morning, his bottom was sore all the way up to the front. In a telephone interview with Nurse Aide (NA) #25 at 12:50PM on 04/21/26, she stated she changed Resident #1 on Saturday, 04/18/26 before she left for the day. She stated she returned on Sunday, 04/19/26 to assist his aide. Resident #1 stated he had not been changed since CNA #25 did it the day before. Resident #1 stated he had asked the night shift aides to change him, but they came in, changed his roommate and left. CNA #25 states Resident #1 was raw and his skin was bad! NA #25 stated she reported the issue to Licensed Practical Nurse (LPN) #69 immediately. In an interview with CNA #58 via telephone on 04/21/26 at 1:25PM, she stated she went in to change a wet and soiled brief on Sunday morning. Resident #1 stated he had not been changed all night. He stated he asked the aides who came in to change his roommate, but they said they would come back. However, the aides left and did not return. CNA #58 states his skin was pretty bad and raw and red. CNA #58 stated she showed LPN #69 immediately, who then notified Registered Nurse (RN) #63. An order written on 04/19/26 reads as follows: Wound Care: Cleanse excoriation to sacrum and scrotum with soap and water, allow to dry then apply barrier cream. Continue until resolved every shift for wound healing. This order was dated 04/19/26 at 6:00 PM. The last skin assessments in the Electronic Medical Record (EMR) are from 04/08/26 and 04/15/26 which show no skin issues to the sacrum or scrotum.A record review of the reportables and grievances did not include this situation.In an interview with the Administrator on 04/22/26 at approximately 12:00 PM, she confirmed that this situation was not reported to the state office.b) Resident #3 A review of the progress notes dated 04/26/26 for Resident #3 reads: Resident was given grilled cheese on dinner tray. Her diet order is for mechanical soft. Resident ate some of the grilled cheese before the Nurse Aide (NA) noticed and she coughed a few times and then was fine. NA took the tray and got her another one that she could eat without problem. Lumina contacted and spoke with [the provider] and she ordered to document situation and if there were any further coughing or congestion episodes to call back. The diet orders for Resident #2 include mechanical soft texture (a diet that consists of foods that are moist, soft-textured and easily formed into a bolus). The Diet and Nutrition Care Manual for a mechanical soft diet lists grilled sandwiches as foods to avoid. An interview with nurse consultant #87 on 04/29/26 at 1:30PM confirmed this incident occurred according to the documentation and was not reported. c) During an Interview with an anonymous resident the following was reported: On 4/03/26, two female residents purchased cannabis gummies and had them delivered via Door Dash. The anonymous resident reported that the two female residents offered her a gummy, which she refused. She went on to report both female residents were sent out to the hospital after one of the residents was noticeably impaired. These residents were later identified as Resident #5 and #42. Record review completed on 04/21/26 of the facilities reportable and grievance logs revealed no investigation was completed for Resident #5 and Resident #42 regarding changes in condition due to cannabis gummies being brought into the facility and offered to other residents. The surveyor reviewed a change in condition dated 04/03/26 stating Resident #5 was sent to the local ER for further evaluation and a toxicology screen. The signs and symptoms the resident was displaying included altered mental status and suspicion of substance abuse. Resting pulse was noted as greater than 100 at 105 also. A review of a nursing progress note dated 04/03/26 at 2:00 PM labeled as a late entry revealed the following: Resident was educated on facility policies regarding not being allowed to have OTC medications or CBD products in the room; the resident voiced understanding and agreement.A nursing note dated 04/03/26 at 1:10 PM stated CNA approached this nurse and informed me that Resident #42 had informed her that this resident had given her two gummies and that she consumed one and it tasted bad, so she threw the other one away in her trash can. CNA removed the gummy from Resident #42's trash can and gave it to this nurse. A square red gummy with sugar coating was observed. I then went to speak with this resident, and she was observed lying on her bed with eyes reddened and voiced CO 'feeling tired'. VS then obtained; 108/84, 98.1, 16, 105, 95% off RA. I asked resident what type of gummy she consumed and she stated, 'pot gummies' and pointed towards a wooden box on her bedside table. I asked resident if I could look in the box and she stated, 'yes go ahead'. I opened the wooden box and observed several loose squared red gummies with sugar coating on them, three vape pens, one suspected CBD vape pen, a bottle of Benadryl, and several Imodium tablets in store foil packaging. Resident then informed this nurse that she purchased the gummies and CBD vape pen from door dash. I then asked resident if I could remove the items and she consented. Administrator, DON, and physician was notified. The wooden box with all belongings was released to administrator. New orders received per FNP to send resident out to local ER for further evaluation due to suspicion of substance abuse and obtain a toxicology screen. Resident made aware and in agreement with new order.1:20 PM- (name of emergency medical transport) notified for transport1:25 PM- Report called to (name of hospital) ER nurse1:45 PM- (name of local emergency medical transport) on site x2 attendees to transport resident to local ER. All transfer paperwork was sent with resident.Resident #42 was on the following medications and possible side effects taking medications with Cannabis gummiesProzac (Fluoxetine) 40 MG: Major interaction. Prozac can increase THC levels, causing increased drowsiness, worsening depression, cognitive impairment, or mania.Buspar (Buspirone) 7.5 MG: Potential for serotonin syndrome (confusion, muscle twitching, rapid heart rate) when combined with other serotonergic agents and cannabis.Keppra (Levetiracetam) 750 MG: Increased risk of drowsiness, dizziness, confusion, and difficulty concentrating.Prazosin 1 MG: Potential for increased dizziness or fainting due to additive blood-pressure-lowering effects.A note dated 04/03/26 at 2:27 PM stated, LPN #69 came and notified me that two residents (#42 and #5) consumed unknown substance like gummies. I immediately went to assess this resident while the LPN #29 was notifying the DON, administrator, and Dr. Resident #42 eyes were very red and stated she feels paranoid. Vitals 115/76, 108, 18, 97.9, 92% RA. Resident told this Nurse that she received Two Gummies from (resident #5). She stated the Gummies tasted bad, so she threw the gummy in the trash. The CNA #58, took the Gummy out of the trash and took it to the nurse station. Resident #42 also told this nurse that another resident (#15), knew about the Gummies. This Nurse went and spoke to Resident #15 and the resident stated that Resident #5 came into her room and told her that she has Gummies and THC pens. Resident #5 told Resident #14 that she was going to give resident #42 two gummies. Resident #15 also stated that Resident #5 wrote a letter to a worker, Restorative aide #46 letters and she still had the letter on her bed, and I can have the letter if I want it. Nurse went to the room and got the letter and gave it to the administrator. Nurse did not read the letter. LPN #24 and LPN #69 were on our way to check on (resident #5 ) when we noticed a man from Door Dash knocking on the door. The man gave the nurse the bag and exited the facility quickly. It was a pack of cigarettes with a receipt with two CBD purchases on the receipt. The facility administration (administrator and director of nursing) had no evidence that this reasonable suspicion of a crime had been reported to the state survey agency or that a thorough investigation into this matter had been completed. d) Resident #22An interview with Resident #22's daughter was conducted on 04/28/26 at 10:00 AM. The daughter reported she arrived at the facility on 04/07/26 at 6:50 AM, and followed a nurse aide to her room who reported the resident was vomiting throughout the night. When they entered the room, the daughter noticed the resident was wearing the same brief she had on when the daughter left the previous evening, which she had dated for 5:00 PM. Daughter reported the brief was soaked, her mother's health had declined and she asked the nurse to send her to the hospital. She also expressed recent dissatisfaction with care regarding sheet changes and incontinence care, stating she had several conversations with the Director of Nursing. She also reported filing a grievance on this date stating she told staff during the care plan meeting, as well as the Director of Nursing, that her mother had not been changed since the previous day. On 04/28/26 at approximately 4:00 PM, an interview was conducted with the Director of Nursing (DON) and Registered Nurse Consultant #8. They reported that the incident was not classified as abuse/neglect because the facility did not consider the brief to be wet. They would have only changed it if it was wet and would have only reported the incident if they found it to be abuse/neglect. DON did speak with the daughter on 04/07/26; however, the facility could not find any paperwork, grievances, or resolutions for the allegations reported.

Based on observations and staff interview the facility failed to ensure call light was within reach of Resident #54. This was a random opportunity for discovery. Resident identifier: #54 Facility census: 57Findings Include: a) Resident #54On 04/22/26 at 2:10 PM the surveyor observed Resident #54 in a geri chair beside his bed. The call light was hanging off the back of the headboard, out of reach.During an interview on 04/22/26 2:30 PM with Nurse Aide (NA) #30 this surveyor asked where his call light was, NA#30 stated, We normally hook it to his shirt but he can point and tell us what he needs,it should be within reach to get our attention. An interview with the Director of Nursing (DON) on 4/23/26 at approximately 11:00 AM confirmed that the call light should be within resident's reach.

Based on observation, record review and staff interview, the facility failed to recognize standards of practice that address the identified limitations in ability to perform activities of daily living (ADL) to ensure Resident #57 received assistance with meals. This was true for one (1) of four (4) sampled for nutrition during the Long-Term Care Survey Process. Census: 57 Resident identifier: #57Findings include: a) Resident #57 The surveyor watched the lunch service on 04/22/26. Resident #57 was served his tray at 12:02 PM. Resident was observed falling asleep periodically during this meal. He finished his meal at 1:27 PM, and staff picked up the tray after he ate 51-75% of the meal. Staff provided no cueing during this time nor offered to reheat his meal. In an interview with Occupational Therapy Assistant (OTA) #20 on 04/23/26 at approximately 3:30 PM, she stated she had dinner with Resident #57 on 04/22/26. She stated she spent 30 minutes in the room and provided cueing for Resident #57 to finish approximately 50% of his meal. In an interview with CNA #4 on 04/28/26 at 11:51 AM, she stated Resident #57 takes a long time to finish his meals. She stated aides must leave his tray after picking up the rest of the trays because he eats so slowly. A review of Resident #57's weights shows he weighed 176 pounds on 02/02/26. On 04/06/26, Resident #57 weighed 170 pounds. This calculates to a 3.41% weight loss in three (3) months. On 12/04/25, Resident #57 weighed 185 pounds. This calculates to an 8.82% weight loss over five (5) months. A risk review note dated 04/01/26 shows a five (5) percent weight loss over 30 days. The interventions are to provide the diet as ordered, a Registered Dietician (RD) consult as needed, record meal percentage intake, and record weights as ordered. The orders for Resident #57 include giving one four (4) ounce serving of fortified pudding in the afternoon. The care plan for Resident #57 includes providing set up only for meals. It was confirmed in an interview with Director of Nursing (DON) at 1:25 PM on 04/28/26 that Resident #57 does not receive any assistance with his meals and that he has experienced weight loss.

Based on record review, staff and resident interview, the facility failed to ensure a resident's right to receive written notice, including reason for change, before resident's room or roommate is changed. Resident identifiers: #45, and #25. Facility census: 57. Findings included: a) Resident #45 On 04/20/26 at 1:59 PM, Resident #45 reported she was not notified that her room was being moved until the facility came to move her room on 03/05/26 and was never notified in writing. On 04/23/26 at approximately 12:30 PM, during an interview, the Social Worker reported she notified Resident #45 verbally prior to changing her room that she would be moving that day to another room because this room was needed for isolation on 03/05/26. She reported she did not notify Roommate #25 that she was getting a roommate and did not notify either party in writing. Review of document titled Hill Valley Healthcare Room Change/Roommate Assignment revealed the following: Specific Procedures/Guidance2. Prior to changing a room or roommate assignment all parties involved in the change/assignment (e.g., residents and their representatives will be given advance notice of such change.)3. Advance notice of a roommate change will include why the change is being made and any information that will assist the roommate in becoming acquainted with his or her new roommate. b) Resident #25During an interview with Resident #25 on 04/20/26 at 1:30 PM the resident reported that she was not notified she was getting a roommate. She was unaware until her new roommate was moved into her room. On 04/23/26 at approximately 12:30 PM, during an interview, the Social Worker reported that she verbally notified Resident #45 verbally prior to changing her room. She explained that the room change was necessary for an isolation on 03/05/26. She reported she did not notify Roommate #25 that she was getting a roommate and did not notify either party in writing. Review of document titled Hill Valley Healthcare Room Change/Roommate Assignment revealed the following: Specific Procedures/Guidance2. Prior to changing a room or roommate assignment all parties involved in the change/assignment (e.g., residents and their representatives will be given advance notice of such change.)3. Advance notice of a roommate change will include why the change is being made and any information that will assist the roommate in becoming acquainted with his or her new roommate.

Based on resident interview and record review the facility failed to identify and thoroughly investigate allegations of neglect which included two (2) residents not receiving timely incontinence care and a resident receiving the incorrect texture of food. Resident identifiers: #1, #3 and #22. Facility Census 57. Findings Included: Findings include: a) Resident #1 A policy titled, Abuse includes a definition for neglect that reads: Neglect is the failure of the facility, its employees or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish, or emotional distress. This policy also states, Designated staff will immediately review and investigate all allegations or observations of abuse. The results of all investigations are to be communicated to the administrator or his or her designated representative and to other officials in accordance with State law, including to the State Survey Agency, within [five] 5 working days of the incident. During the initial interview with Resident #1 on 04/20/26 at 1:55 PM, he stated staff left him overnight without changing his brief and that he had been experiencing diarrhea. Resident #1 states he requested to be changed. Resident #1 states when they did change his brief the next morning, his bottom was sore all the up to the front. In an interview with Certified Nurse Aide (CNA) #25 via telephone at 12:50PM on 04/21/26, she stated she changed Resident #1 on Saturday, 04/18/26 before she left for the day. States she went back on Sunday, 04/19/26 to assist his aide and Resident #1 stated he had not been changed since CNA #25 did it the day before. Resident #1 stated he had asked the night shift aides to change him, but they came in, changed his roommate and left. CNA #25 states Resident #1 was raw and his skin was bad! CNA #25 stated she reported the issue to Licensed Practical Nurse (LPN) #69 immediately. In an interview with CNA #58 via telephone on 04/21/26 at 1:25PM. She stated she went in to change a wet and soiled brief on Sunday morning. Resident #1 stated he had not been changed all night. He stated he asked the aides that came in to change his roommate, but they said they would come back. However, the aides left and did not return. CNA #58 states his skin was pretty bad and raw and red. CNA #58 stated she showed LPN #69 immediately, who then notified Registered Nurse (RN) #63. An order written on 04/19/26 at 6:00 PM reads as follows: Wound Care: Cleanse excoriation to the sacrum and scrotum with soap and water, allow to dry then apply barrier cream every shift until resolved for wound healing. The last skin assessments in the Electronic Medical Record (EMR) are on 04/08/26 and 04/15/26 which show no skin issues to sacrum or scrotum. A record review of the reportables and grievances do not include this situation. In an interview with the Administrator on 04/22/26 at approximately 12:00 PM, she confirmed that this situation was not reported or thoroughly investigated. b) Resident #22 An interview with Resident #22's daughter was conducted on 04/28/26 at 10:00 AM. The daughter reported she arrived at the facility on 04/07/26 at 6:50 AM, and followed a nurse aide to her room who reported the resident was vomiting throughout the night. When they entered the room, the daughter noticed the resident was wearing the same brief she had on when the daughter left the previous evening, which she had dated for 5:00 PM. Daughter reported the brief was soaked, her mother's health had declined and she asked the nurse to send her to the hospital. She also expressed recent dissatisfaction with care regarding sheet changes and incontinence care, stating she had several conversations with the Director of Nursing. She also reported filing a grievance on this date stating she told staff during the care plan meeting, as well as the Director of Nursing, that her mother had not been changed since the previous day. On 04/28/26 at approximately 4:00 PM, an interview was conducted with the Director of Nursing (DON) and Registered Nurse Consultant #8. They reported that the incident was not classified as abuse/neglect because the facility did not consider the brief to be wet. They would have only changed it if it was wet and would have only reported the incident if they found it to be abuse/neglect. DON did speak with the daughter on 04/07/26; however, the facility could not find any paperwork, grievances, or resolutions for the allegations reported. c) Resident #3 A review of the progress notes dated 04/26/26 for Resident #3 reads: Resident was given grilled cheese on dinner tray. Her diet order is for mechanical soft. Resident ate some of the grilled cheese before the Nurse Aide (NA) noticed and she coughed a few times and then was fine. NA took the tray and got her another one that she could eat without problem. Lumina contacted and spoke with [the provider] and she ordered to document situation and if there were any further coughing or congestion episodes to call back. The diet orders for Resident #2 include mechanical soft texture (a diet that consists of foods that are moist, soft-textured and easily formed into a bolus). The Diet and Nutrition Care Manual for a mechanical soft diet lists grilled sandwiches as foods to avoid. An interview with nurse consultant #87 on 04/29/26 at 1:30PM confirmed this incident occurred according to the documentation and was not reported.

Based on observation, resident interview and staff interview, the facility failed to allow a resident and/or their responsible party to exercise his or her right to file an anonymous grievance for facility and follow grievance policy on a grievance completed for another resident. Resident identifier: #22. Facility census: 57. a) Resident Council Resident Council meeting was held on 04/21/2026 at 11:00 AM with a group of 11 (eleven) residents who reported they had no method to anonymously file a grievance. Residents reported they did not want to report complaints for fear of retaliation. They felt concerns brought up in the resident council were not taken seriously. An interview with the Social Worker on 04/21/26 at 6:39 PM revealed there was no method for an anonymous grievance. She reported residents and family members had to ask a nurse or department head for a grievance form.Review of the Facility policy titled Grievances/Complaints states that residents and their representatives have the right to file grievances, either orally or in writing, with facility staff or the agency designated to hear grievances (e.g., the State Ombudsman). The Administrator and staff will make prompt efforts to resolve grievances to the satisfaction of the resident and/or representative.

Based on record review, resident representative interview, and staff interview the facility failed to ensure a resident who entered the facility without a pressure ulcer did not develop an avoidable pressure ulcer during their stay. In addition the facility failed to identify and treat the pressure ulcer once it was developed. Resident #59 entered the facility without a pressure ulcer she was discharged back to her previous living arrangement and with in hours the nurse who worked for the behavioral health company discovered multiple wounds which required her to be sent to the hospital once discovered. The facility documentation mentioned no wounds and no treatments for the wounds were ever ordered. This resulted in actual harm for Resident #59. This was true for one (1) of three (3) residents reviewed for pressure ulcers during a complaint survey. Resident Identifiers: #59. Facility Census: 58. Findings include: a) Resident #59 On 04/24/24 the State Agency (SA) received a complaint from another state agency which read as follows: The client was in the care of (Name of this Facility), (Address of this facility) 01/18/2024 to 2/7/2024. The client returned to her residence (Name of Local Behavioral Health Home and address of home) on 02/07/24. On this date the staff Nurse, (Name of Registered Nurse (RN) at the Behavioral Health Company), completed a body assessment on client at the (Name of Behavioral Health Company) home. Multiple pressure wounds and bruising in various stages were observed during the assessment. This led to a referral being submitted to Centralized Intake on 2/7/2024. This also led to the client being admitted to (Name of local acute care hospital) due to the wounds on 2/7/2024. The admissions report was completed by (First and Last Name of physician), DO at (Name of Local acute care hospital). (Name of County) DOHS Adult Protective Unit received a referral regarding client that stated, It is reported that (First Name of Resident #59) was in care at (The Name of this facility) nursing home for rehabilitation and 24-hour care. She returned to her group home on [DATE]. After returning home, multiple pressure wounds, at various stages were observed. There was a very large bruise on her abdomen and flank area. (First Name of Resident #59) could not communicate where the bruises came from. It is believed the wounds and bruises occurred at (The Name of this Facility) nursing home. The situation was not documented or expressed to follow up workers. It is reported that (First Name of Resident #59) has dementia and needs total assistance with ADL (Activities of Daily Living)s. She is not able to get up and move around. (First Name of Resident #59) is an IDD waiver. (First Name of Resident #59) was taken by EMS to (Name of Local Acute Care hospital) and was admitted . Assigned Worker interviewed staff at (Name of this facility) where all documentation provided to this worker denies that client had any wounds during her stay and care at the facility. The worker received statements, reports, and photos from (Name of Local Behavioral Health Company) staff that documented wounds on client approximately 2 hours after client was discharged from (Name of this facility) and returned to her (Name of local Behavioral Health Care) Home. Worker spoke with (Name of Local Acute care hospital)Social Worker, (First and Last Name of Hospital Social Worker), on several occasions and received reports and photos of the wounds on the client when client was admitted on [DATE]. A teleconference was held with Dr. (First and Last Name of Physician) on 3/15/2024 where worker questioned the possibility that the wounds found on client could have developed in a two-hour period. With the information and photos provided to Dr. (Last name of Physician) he concluded that it was not possible that the wounds on the client could have occurred in a two-hour period, and they must have occurred while client was in the care of (Name of this Facility). He concluded this specifically because the wounds were in various stages and that there was a chronic lack of skin care. On 02/10/25 Resident #59's medical record from the facility was reviewed. The record void of any documentation related to wounds. A Braden scale for predicting pressure risk was completed on the following days resulting in the following scores: -- 01/18/24 - 16 which indicates the resident was at risk for developing pressure ulcers. -- 01/26/24 - 16 which indicated the resident was at risk for developing pressure ulcers. --02/03/24 - 16 which indicated the resident was at risk for developing pressure ulcers. A review of Resident #59's care plan found the following pertaining to skin integrity: Focus Statement 'I have potential for impairment to skin integrity r/t incontinent episodes, dementia. This focus statement was added to the care plan on 01/19/24, and was canceled on 02/21/24 after the residents discharge. The goal associated with this focus statement read: I will have intact skin, free of redness, blisters or discoloration through review date. This goal was initiated on 01/19/24 with a target date of 04/25/24. This goal was canceled on the same date as the focus statement. Interventions related to his goal included: -- Administer medications, supplements and treatments as ordered. Monitor/document for side effects and effectiveness. -- Barrier cream as ordered/indicated. -- Follow facility policies/protocol for routine skin monitoring. Report any changes to MD/NP. -- Follow facility policies/protocols for the prevention/treatment of skin breakdown. -- Provide peri-care with any incontinent episodes All interventions were initiated on 01/19/24 and canceled on 02/21/24. The care plan also indicated the following related to ADL assistance required by Resident #59: -- BED MOBILITY: The resident uses extensive assistance X2 staff with turning and repositioning in bed. This was added to the care plan on 01/18/24. -- DRESSING: The resident is totally dependent on staff for dressing. This was added to the care plan on 01/18/24. -- TOILET USE: The resident is totally dependent on staff for toilet use. This was added to the care plan on 01/18/24. -- TRANSFER: The resident uses extensive assistance x 2 with transferring. This was added to the care plan on 01/18/24. -- BATHING/SHOWERING: The resident is totally dependent on staff to provide (SP bath/shower as necessary. This was added to there care plan on 01/18/24. Further review of the record found no indication the facility was turning repositioning the resident every 2 hours. The Director of Nursing (DON) stated this was just a standard of care and would not need to be documented. Review of the residents bathing record found during her stay she received five (5) bed baths with the last one being on 02/06/24, six (6) showers with the last one being on 02/03/24, and eight (8) partial baths with the last one being on 02/05/24. A review of the facility's policy titled, Pressure Injury Prevention and Management found the following: .Preventative Measures 1. Preventative interventions will be implemented based on the pressure ulcer/injury risk assessment, other related factors, and resident preferences. Such interventions may include: a. Education to the resident/resident representative on risks associated with pressure ulcer/injury. b. Frequent encouragement and assistance with turning, repositioning, shift of weight etc. c. Use of pressure reducing/relieving support surfaces or devices that assist with pressure redistribution and tissue load. d. Range of motion as tolerated. e. Management of contractors to minimize pressure. f. Assistance with personal hygiene and ADLs, including appropriate fitting clothing and shoes. g. Assistance with incontinence care, and application of moisture barrier ointments to protect skin from contact with urine and/or feces. h. Application of moisturizing lotions to intact skin. i. Encouragement and assistance for adequate nutrition and hydration consistent with prescribers orders, including administration of nutritional supplements. Identification 1. Staff will be encouraged to promptly report any observation of a change in the resident's skin integrity. 2. Weekly Skin observations will be conducted by a licensed nurse and findings will be documented in the resident's medical record. 3. Observations of new pressure ulcer/injury will be: a. Reported to the physician/practitioner for further evaluation and treatment. b. Referred to the designated wound nurse as appropriate . Further review of Resident #59's medical record found the following weekly skin observation: -- 01/18/24 - This observation was completed by Licensed Practical Nurse (LPN) #59 and indicated the resident had no bruises, open wounds, surgical incisions, skin tears, reddened areas or other skin conditions noted. This was the skin observation completed on admission. -- 01/22/24- This observation was completed by Registered Nurse (RN) #14 and indicated the resident had no bruises, open wounds, surgical incisions, skin tears, reddened areas or other skin conditions noted. -- 01/29/24- This observation was completed by LPN #15 and indicated the resident had no bruises, open wounds, surgical incisions, skin tears, reddened areas or other skin conditions noted. -- 02/05/24- This observation was completed by RN #14 and indicated the resident had no bruises, open wounds, surgical incisions, skin tears, reddened areas or other skin conditions noted. This was the last weekly skin prior to Resident #59's discharge on [DATE]. A review of Resident #59's minimum data set (MDS) with an assessment reference date (ARD) of 01/25/24 indicated the resident had zero (0) unhealed pressure ulcers/injuries. A review of Resident #59's discharge MDS with an ARD of 02/07/24 indicated the resident had zero (0) unhealed pressure ulcers/injuries. A review of the physicians orders for Resident #59 from the time of admission until the time discharge found no orders related to pressure ulcer treatment and/or prevention. A review of Resident #59's Discharge summary completed by LPN #13 indicated the resident had no special treatment including wound care ordered. This assessment also indicated the resident needed assistance with transfers, toileting, bathing, and medication management. Further review of the record found a progress note dated 02/07/24 at 11:23 AM which indicated the resident left the facility at 12:40 PM accompanied by (Name of Local Behavioral) transport via wheel chair van. During a review of the statements provided by another state agency it was found the RN for the local behavioral health company completed a body assessment at 4:08 PM on 02/07/24 along with an LPN from the same company and found the following skin issues: Bruises noted on bilateral arms and one bruise noted on the right hand where the thumb and index finger meet. A few scratches noted across her abdomen. A large bruise noted on the left abdominal and flank area. Area noted on the bottom of her right heel , boggy (abnormal tissue texture that feel spongy or mushy. A boggy heel can indicate a heel pressure injury.) feeling, and half is dark in color and the other part is whitish yellow in color. Area noted to left outer ankle, skin is open and center is dark red and black in color. Pitting Edema is noted to bilateral lower extremities up to the knees. Her brief was removed, and she had a small soft BM (bowel movement) While cleaning her up, a clump of something whiteish yellow in color came out from her inner labia area, and then she began to urinate after it was cleared away. Several areas noted to her buttocks that are soft, fluid filled, and dark red and black in color. There is open area to skin right above the anus with serosanguineous drainage. The facility filed a reportable incident related to this on 02/15/24. They investigated and determined it to be unsubstantiated due to the resident being discharged from the facility. They noted statements from staff and record review saw no indication the resident had pressure ulcers. The former Nursing Home Administrator (NHA) noted she had her admissions coordinator review a referral for the resident which they received on 02/12/24 and it had no mention of pressure ulcers. Therefore she had unsubstantiated the allegation of the resident developing the Pressure ulcers at the facility. The SA requested the hospital medical record for Resident #59 for the hospital stay beginning on 02/07/24. The records were reviewed and found the following facts: -- Resident #59 presented to the emergency department at 6:01 pm from they behavioral health company's community home. -- An MDM (medical decision making) Narrative found the following, MDM Narrative: This patient is [AGE] year-old female who presents with multiple skin wounds secondary to pressure related source. Differential includes cellulitis, deep tissue abscess, rhabdomyolysis, metabolic abnormality given the lack of mobility. Patient was initially ordered IV fluid, in addition to treatment for the possibility of radiographic pneumonia. She is unable to participate in history, however does appear dehydrated. Once the patient's workup returned, she was found to have significant hypernatremia. Given this, the case was discussed with hospitalist team for admission evaluation. -- A history and physical dated 02/07/24 contained the following, Information Obtained from: caregiver Chief Complaint: wounds HPI: (First and last Name of Resident #59) is a (age redacted to maintain confidentiality), [NAME] female who was recently discharged from the (Name of this facility) and admitted to (Name of local behavioral health company) group home. She was sent here for developing wounds on the sacrum and heels. It was reported that patient is requiring too much care to be cared for in a group home and would do better in a nursing home setting. Skin: General: Skin is warm and dry. Coloration: Skin is pale. Findings: Lesion present. Comments: For full wound physical exam and assessment please see pictures put in system by staff today.Assessment/Plan: Active Hospital Problems Diagnosis -- Primary Problem: Hypernatremia -- Dehydration -- Decubitus skin ulcer -- A review of the hospitalist progress notes dated 02/08/24 contained the following: Subjective: Pt was admitted on [DATE] after presenting to the ER from (Name of behavioral health company) group home for wounds of the sacrum and heels. It was reported that the group home cannot take care of her and she will be need placement. Apparently she was just released from the (Name of this nursing home) nursing home. Her sodium was very elevated at 171 and BUN 81. She is dehydrated. She has D5W at 75. Nephrology consulted. -- A wound care note dated 02/09/24 contained the following information: 'Wound #1 Coccyx Removed old dsg from the wound. Stage/Type: Deep Tissue Injury Length (cm): 4.6 Width (cm):7 Depth (cm): Wound Bed: Purple, blistery Wound Edges: attached Surrounding tissue: superficial opening at base. Wound #2 Right dorsal foot at heel Removed old dsg from the wound. Stage/Type: Deep Tissue injury Length (cm):9.3 Width (cm):4.7 Wound Bed: dark purple, blister like Drainage: none Drainage amount: none Wound Edges: attached Surrounding tissue: intact During an interview with the Director of Nursing (DON) on the morning of 02/12/25 She was asked to review the photos of the wounds from the hospital. She indicated, That was a blister caused by friction. You can tell where it had been filled and busted. She stated, I can't speak to what might have happened after she left here. The DON was then referred back to the facility's policy titled Pressure Injury Prevention and Management which contained the following definition for a deep tissue injury, Persistent non-blanchable deep red, maroon, or purple discoloration. Intact or non-intact skin with localized area of persistent non-blanchable deep red, maroon or purple discoloration, or epidermal separation revealing a dark wound bed or blood filled blister. Pain and temperature change often precede skin color changes. Discoloration may appear differently in darkly pigmented skin. The injury results from intense and/or prolonged pressure or shear forces at the bone muscle interface. The wound may evolve rapidly to reveal the actual extent of tissue injury or may resolve without tissue loss . The DON then agreed the wounds pictured were pressure injuries. She did not agree they were developed at this facility. When advised what Dr. (Name of Physician named in complaint) had said about the wounds she remained silent.

Based on record review, staff interview, and resident interview, the facility failed to provide services that are necessary to avoid emotional distress by transferring Resident #29 from the bed to a wheelchair via the mechanical lift on shower days, despite the resident being fearful of the lift. Multiple staff confirmed the resident would cry and scream. As soon as the transfer was complete, the resident would stop crying. This has resulted in psychosocial harm as evidenced by the mental anguish suffered by the resident while in the lift. The mental anguish was evidenced by the resident crying and yelling while in the lift. This has happened on multiple occasions and is not an isolated incident. This failed practice was true for (1) one of (3) three residents reviewed for abuse and neglect during the Long-Term Care Survey Process. Resident identifier: #29. Facility Census 58. Findings Included: a) Resident #29 During the initial interview, on 01/07/25 at 1:35 PM, Resident #29 stated, I am afraid of the lift. I don't like being in it. They put me in it on shower days. I fell with one of the lifts one time. Now I am afraid. A record review on 01/08/24 at 11:00 AM, of the Brief Interview for Mental Status (BIMS) completed on 10/28/24, revealed that Resident #29 had a BIMS score of 15. This indicates cognition is intact. Further record review of the care plan for Resident #29 revealed no interventions or behaviors noted related to lift transfers on shower days. During an interview, on 01/09/25 at 11:30 AM, Nurse Aide (NA) #68 stated, She cries and hollers in the lift for showers. When we put her on the shower chair she calms down and then screams and hollers when we put her back in the lift to put her back in bed. During an interview, on 01/09/25 at 12:05 PM, NA #47 stated, She screams and cries in the lift. She is scared. During an interview, on 01/09/25 at 12:30 PM, Licensed Practical Nurse (LPN) # 75 stated, She screams when it is shower day. I am not sure what it is related to. During an interview, on 01/09/25 at 12:40 PM, Registered Nurse Supervisor (RNS) # 45 stated, I can hear her sometimes hollering when she is in the lift. They have not tried anything different with her since I have been here. I have been here for 3 months. During an interview on 01/09/25 at 12:42 PM, The Director of Nursing (DON) stated, I was not aware of the situation. I will check into it and get back to you. During an interview on 01/09/25 at 12:46 PM, Resident #29 stated, I would rather take bed baths if it meant I did not have to get up in the lift. I am afraid of being in it. A record review on 01/09/25 at 1:30 PM, revealed a Behavior Observation Monthly Summary dated 10/06/2024, under B (Behaviors and Side Effects), question (1) one (Behaviors that triggered psychoactive use/non-pharmacological interventions), Resident #29 is marked for the following behaviors: Cursing, Resists Activities of Daily Living (ADL) care, screaming, crying, Anxiety/agitation, and grabbing. Under question 1a reads as follows: Resident has episodes of refusing care, becoming anxious before ADLs are performed. Further record review revealed, (3) more Behavior Observation Monthly Summary dated 11/06/24, 12/06/24, and 01/07/25, under B (Behaviors and Side Effects), question (1) one (Behaviors that triggered psychoactive use/non-pharmacological interventions), Resident #29 is marked for the following behaviors: Cursing, Resists Activities of Daily Living (ADL) care, screaming, crying, Anxiety/agitation, and grabbing. A record review, on 01/09/25 at 1:45 PM, of the shower task for Resident #29 for the months of 10/2024,11/2024, and 12/2024 revealed that Resident #29 was to have showers on Sunday day shift, and Wednesday evening shift. Within the (3) three-month time Resident #29 had 23 showers documented. Further record review revealed that no interventions have been put in place to minimize the emotional distress with the mechanical lift and that Resident #29 diagnoses that include Mild Intellectual Disabilities, Cognitive Communication Deficit, Major Depressive Disorder, and anxiety disorder. During an interview on 01/09/25 at 2:00 PM, The Administrator stated, We will report this and investigate it. b) Reportable interviews A review of the facilities reportable on 01/13/25 at 12:05 PM, dated 01/09/25 revealed staff statements that read as typed below: b1.) Statement from DON: While therapy was completing a screen, I spoke with (Resident #29 name) about her transfers in and out of bed. She stated that she was afraid of falling and that made her not like the lift, shower chair or shower bed. I asked if she was afraid of the mechanical lift, shower bed or shower chair. She said, ' No, I don't like it. When asked if staff had ever forced her to do anything she said, Well no! When asked if she didn't want to go to the shower, was she offered a bed bath and she said, yes. The last I asked her was if she was willing to use the lift to get out of bed and she said she didn't like it but she would do it. I clarified with her to say, even though you don't like the lift, are you willing to use the lift to get out of bed and she said, Yes. b2.) Statement from Corporate Registered Nurse (CRN) # 77: On 01/09/25 at approximately (14:30) 2:30, I observed DON, discussing transfers in and out of bed. She stated that she was afraid of falling and she didn't like the lift, shower bed, or shower chair. She denied being afraid of the shower bed, shower chair or lift. She denied staff making her do anything. She denied staff making her do anything she didn't want to do. When asked if she was offered a bed bath when she didn't want showered she said yes. When asked if she was willing to use the lift to get in and out of bed she said she would but didn't like it.' b3.) Statement from NA #16: The resident will have behaviors starting at different times on her shower days. Sometimes as soon as our shift starts. Sometimes later in the shift. I have never heard the resident say she didn't want to shower or that she didn't want on the lift. The resident will continue to yell and have behaviors during the transfer, through the entire shower and while putting the resident back in bed. After she is back in bed the behaviors stop. Yesterday the ambulance came to take the resident's roommate to a doctor appointment. As soon as the resident saw the stretcher she started having behaviors and yelling, even after explaining . (This was all of the statement the SA received.) b4.) Statement from NA #66: I have worked with (Resident #29 name) and I have showered her. She screams, Mommy, Mommy. I try to calm her down and tell her everything is okay. We need to wash up and get cleaned but she has never told me she is scared or anything to that matter. b5.) Statement from NA #57 I have showered (Resident #29 name) on many occasions with little encouragement. She will let us give her a shower. She has never said that she is scared of the lift. It just makes her a little nervous. b6.) Statement from NA #4 I have given (Resident #29 name) shower before and she screams. When given words of encouragement she takes a shower. She has never said she was afraid to get on the Hoyer lift. b7.) Statement from Occupational Therapy Assistant (OTA) # 23: When (Resident #29 name) came to the facility she was able to complete stand/pivot transfers with maximum assistance x 2. At that time she consistently refused to participate in transfers to get out of bed even with encouragement with therapy. (Resident #29 named) would present with behaviors of yelling and screaming profanity when encouraged to transfer. Currently (Resident #29 named is unable to transfer unless using a mechanical lift due to refusal to attempt the task and anxiety. b8.)Statement from NA #68: I ( NA #68 name ), has encountered (Resident #29 name) behaviors when she is in the lift going to shower chair and behaviors going to shower room and during shower. Also behaviors when putting back in bed. She has not refused. She rolls when she's getting ready to shower. To my knowledge she has never said she was afraid. b9.) Statement from NA #58: (Resident #29 name) has behaviors any time she up out of her bed. Doesn't have to be the lift. (Resident #29 name) turns for you to allow you to do care. Never refuses care or lift, just yells , screams and acts out every time she gets up out of bed. Never told me she was scared to use lift just has behaviors when its time to use the lift, shower chair, hallways and lift anytime she is out of her bed. b10.) Statement from RNS #45: (Resident #29 name) fusses when she gets into the lift, in the hallway and in the shower room. Resident has not refused care. Resident has not stated that she is afraid of the lift. Residents' behaviors are not consistent. She has behaviors when she is in the shower chair in the hallway and in the shower room. I have never known resident to have behaviors while in the bed. b11.) Statement from NA #61: When I give (Resident #29 name) a shower, she doesn't refuse the lift. She will cooperate by rolling over to get the lift pad under her. Once we begin to lift her in the air she will cry and fuss at us. It continues on in the shower bed, out in the hallway and in the shower, just anytime she's out of her bed. I believe her behaviors aren't consistent only when she is out of bed. She has never said that she was afraid of the lift. Only that she doesn't like it, but she will cooperate with us. b12.) Statement from NA #28: (Resident #29 name) has never told me that she's afraid of the lift. She shows behaviors anytime she is out of the bed, whether it's in the lift, the shower bed in the shower room. Her behavior is also not consistent. She'll go from yelling to laughing with us before she gets out of the bed. She cooperates and rolls and lets us put the lift pad under her. She has also never refuses a shower and if she did I would report it to the nurse and give her bed bath. b13.) Statement from NA #48: I have gave (Resident #29 name) a shower before and she has her days she will go and not fuss and she also has days she fusses and doesn't want to go and I leave her alone and offer her a bed bath if nothing else. She has said she doesn't like the lift but has said she was scared of being in the lift. She also has her days she screams in shower chair and shower room and lift. The nurse notified of behavior and she refuses to go to shower. b14.) Statement from NA #47 I have given (Resident #29 name) a shower before and she usually cusses, and calls names. She also has regular conversations during the time of getting her up for the shower. She can go from yelling, cussing and screaming to smiling and talking nice, no matter if she is in the shower chair or lift. She has never said she wasn't getting in the shower chair or lift, but has stated she doesn't like it. If she was to refuse I would let the nurse know and give her a bed bath. b15.) Statement from NA #73 I (NA #73 name) have gave (Resident #29 name) showers on her shower days (Saturday) morning. (Resident #29 name) never tells me or the other CNA'S no. She gets real fussy and starts yelling. We try to encourage her by telling her we will make it quick. She doesn't say nothing and I report it to the nurse. Her behaviors be on and off when she is in the lift and in the shower room. 51554

Based on observation, medical record reviews and staff interviews, the facility failed to deploy staff to provide the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being, consistent with the resident's comprehensive assessment and plan of care for all residents residing on third (3rd) floor. Failure to deploy licensed nurses (RN's and/or LPN's) to provide initial and ongoing assessments of the clinical needs of the residents including any acute changes in condition, such as cardiac/respiratory failure, choking, hemorrhaging, poor glycemic control, onset of [CONDITION(S)], behavioral emergencies, or falls resulting in head injuries or fractures, and failure to deploy staff to provide ongoing monitoring and supervision of staff to assure the implementation of the care plan as written. This deficient practice put the 6 out of 9 residents on third (3rd) floor at risk for serious injury, serious harm, serious impairment, or death. Resident identifiers: #13, #15, #31, #23, #2 and #8. Facility Census: 39. The state agency determined these failures placed Residents #13, #15, #31, #23, #2 and #8. in an immediate jeopardy situation due to the lack of deployment of adequate license nurses (RN's and/or LPN's) to assess and treat any acute changes in condition, such as cardiac/respiratory failure, choking, hemorrhaging, poor glycemic control, onset of [CONDITION(S)], behavioral emergencies, or falls resulting in head injuries or fractures. The state agency notified the Nursing Home Administrator of the immediate jeopardy at 7:27 PM on [DATE]. The facility submitted an abatement plan of correction (APOC) at 8:27 PM on [DATE]. The state agency requested changes and an additional APOC was submitted at 8:53 PM on [DATE]. At 8:58 PM on [DATE], the APOC was accepted by the state agency. The state agency verified the APOC was implemented, and the immediate jeopardy was abated at [DATE] at 9:41 PM. Once the immediate jeopardy was abated, deficient practices remained, and the scope and severity were decreased from a K to an E. Date/time IJ was called at 7:27 PM on [DATE]. Date IJ started on [DATE]. Date Abatement POC approved at 8:53 PM on [DATE]. Date/time IJ was abated at 9:41 PM on [DATE]. The plan of correction stated as follows: --The facility failed to deploy staff to provide the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being, consistent with the resident's comprehensive assessment and plan of care for all residents residing on third (3rd) floor. --Social Worker (SW) to contact residents and their families to inform of room moves to occur tonight. --Residents on third floor will be moved to the first floor immediately. --RN will be staffed on the 3rd floor until all residents are moved. --No residents will be placed on 3rd floor unless facility has adequate staffing. Findings included: a) Review of the Licensed nurse staffing schedule Review of the assignment sheet for [DATE] found the building has three (3) floors: First floor had nineteen (19) residents; second floor had eleven (11) residents, and third floor had nine (9) residents. First floor had a licensed nurse full time; the second and third floor had one (1) nurse who is responsible for all care and services provided to both second and third floors. A review of the licensed nurse, nursing schedule provided by the facility from [DATE] to [DATE] found the following: 1. Review of the nurse schedule for [DATE] to [DATE] from 6:00 AM to 6:00 PM On the following days the facility had 2 nurses scheduled to work all three (3) floors from 6:00 AM to 6:00 PM: [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], and [DATE]. On [DATE] the facility scheduled 2 nurses to work all three floors from 6:00 AM to 6:00 PM. A third nurse was scheduled to work from 2:00 PM to 10:00 PM. On the following days the facility had one (1) nurse scheduled to work all three (3) floors from 6:00 AM to 6:00 PM: [DATE], [DATE], and [DATE]. Between [DATE] through [DATE], there were 38 days out of 41 days were the facility only had 2 licensed nurses working to cover residents living on 3 floors of the nursing facility from 6:00 AM to 6:00 PM. In addition, the other 3 days in the review period only had 1 licensed nurse scheduled to work all 3 floors from 6:00 AM to 6:00 PM. No more than one Nurse Aide was present on the 3rd floor during the survey. 2. Review of the nurse schedule for [DATE] to [DATE] from 6:00 PM to 6:00 AM On the following days the facility had 2 nurses scheduled to work all three (3) floors from 6:00 PM to 6:00 AM: [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], and [DATE]. On [DATE] the facility scheduled 2 nurses to work all three floors from 6:00 AM to 6:00 PM. A third nurse was scheduled to work from 2:00 PM to 10:00 PM. On the following days the facility had one (1) nurse scheduled to work all three (3) floors from 6:00 PM to 6:00 AM: [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], and [DATE]. The nursing schedule for the 3rd floor provided by the facility reflected no nurses were scheduled to work from 6:00 PM to 6:00 AM on [DATE]. Between [DATE] through [DATE], there were 39 days out of 41 days were the facility only had 2, 1 or no licensed nurses working to cover residents living on 3 floors of the nursing facility from 6:00 PM to 6:00 AM. A nursing schedule for the remaining days in [DATE] was requested but never provided; however, observations proved similar staffing patterns continued through [DATE]. An interview with the nursing home administrator on [DATE] at 7:27 PM confirmed residents were moved to the third floor on [DATE]. As of [DATE] the facility had residents residing on all three (3) floors of the facility. Surveyors could not ascertain the actual staffing levels for the 3rd floor as the facility could not produce assignment sheets or the entire schedule. During the interview with the administrator, she was unable to answer the question about the schedule. No more than one Nurse Aide was present on the 3rd floor during the survey. b) Emergency Crash Cart Observation on [DATE] at 9:30 AM of the emergency cart (crash cart) used for choking and emergency first aid as well as CPR was unable to be opened; no license nurse (RN/LPN) was on the floor to verify the contents of the cart. (A crash cart is used to provide treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] . The emergency crash cart was located on the 3rd floor next to the nurse's station. Observations on third floor on [DATE] from 11:15 AM to 11:50 AM revealed no licensed nurse (RN and/or LPN) was present for 35 minutes. From 11:53 AM to 12:05 PM there was no licensed nurse (RN/LPN) was on the third floor for 12 minutes. At 12:30 PM the nurse left the third floor via the elevator. At 12:25 PM on [DATE], it was determined the crash cart was unable to be accessed due to the lack of knowledge by staff on how to open the cart. LPN #90 did not know how to unlock the emergency crash cart. This was confirmed by the Director of Nursing (DON) on [DATE] at 1:20 PM. The observed timeline for getting the emergency crash cart open on [DATE] found: --11:50 am LPN #90 came to the floor and surveyor asked her to unlock the emergency crash cart. She was unable to open the cart and stated, I think the keys to this cart is downstairs on second floor. --11:53 am LPN #90 left the floor to get keys. --12:05 pm LPN #90 returned to floor and met with Hospice personnel evaluating Resident #13 for about 5 minutes and at 12:10 pm attempted to get in the crash cart to no avail. --12:10 pm LPN called on the phone to have the DON to come and assist her in opening the emergency crash cart. --12:22 pm NA #83 stated she thought there was a button to push or slide on the drawers. At this time LPN #90 and the surveyor were able to open the drawers. --From 11:15 am till 12:22 pm the facility was unable to access the emergency cart. The crash (emergency) cart supplies are PPE, gloves, gown, face masks, non-rebreather mask, nasal cannula, venti-masks. First aid- alcohol swabs, abdominal pads, band aids, Coban wrap, normal saline, gauze, bodily fluid spill kit, Sani-cloths, bio-hazard bags, and red biohazard bags, Ambu- bag and suction machine and tubing. This is the only source of supplies located on third floor. Six (6) of nine (9) residents on the 3rd floor are Full Code Residents #2, #23, #13, #15, #8 and #31. If an emergency arises and no licensed nurses are on the floor, nurse aides must go to the nurses' room to call for assistance. The licensed nurse must reach the floor by elevator or two flights of stairs. This failure created an immediate jeopardy situation for all residents on the 3rd floor, and also for those who may require treatment from the crash cart. c) Resident #8 Review of the care plan revealed the following problems Resident #8 was care planned for: --Full code status --One occurrence of behavior of touching another female resident in private areas --History of verbally abusive/aggressive behavior, including cursing towards others. --Resident will curse and yell at another resident that wanders by his room or if they go into his room by mistake --Resident feels he must fight for his life and is unable to be redirected at times. --Resident has had behaviors becoming physically aggressive, including punching EMT staff. --Resident has actual behavior problem: Resident has exhibited sexually inappropriate such as trying to grab and touch female staff and one instance of this behavior towards another resident. --Potential for injury falls related to general weakness and declining gait. --Inability to maintain health state independently related to muscle weakness and chronic fatigue. --Bathing requires the assistance of 1 person, he likes to do his own daily care, and prefers showers 3 days a week. --Resident requires the assistance of 1 person for dressing. --Resident is continent of bladder/bowel, uses bathroom, uses bathroom/urinal independently. Review of the current quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of [DATE] gave the following information: --BIMS (Brief Interview for Mental Status) of 15 which indicated cognitively intact. --Independent for all activities of daily living (ADL) except for walking in corridor which did not occur during the quarter. --Required set up assistance for dressing, eating, and personal hygiene. --Required supervision of one for bathing. Observation of Resident #8 in hallway on first floor in his wheelchair on [DATE] at 1:00 PM found him yelling at Resident #14, who has been noted to wander in the hallways throughout the survey. The staff redirected Resident #8 away from Resident #14 and told Resident #8 that Resident #14 was permitted in the hallway. Resident #8 was moved from first floor to third floor on [DATE], to room [ROOM NUMBER] after having an episode of inappropriate touching of Resident #16 on [DATE]. Resident #8 was to be on every fifteen (15) minute checks after the inappropriate touching of Resident #16. Multiple observations on [DATE] at 9:35 AM, [DATE] at 11:15 AM to 12:30 PM, [DATE] at 2:20 PM found Resident #8 was mobile and freely moving about the third floor without any staff supervision. The facility failed to provide evidence Resident #8 was being checked every 15 minutes. Due to the facility's failure to provide adequate nursing staffing on the third floor, this placed Resident #8 and other residents in his environment at immediate jeopardy due to: --Resident #8 was has a full code status, and not having sufficient nursing staff available to call the code and immediately start CPR. --Resident #8 was potentially a risk to other residents due to his history of sexually inappropriate behavior and the one recent incident of being sexually inappropriate with another resident. --Resident #8 had physically aggressive behaviors that have resulted in him punching an EMS worker. --Resident #8 is care planned for fall risk due to general weakness and declining gait. If the resident were to fall, the lack of nursing would delay identification of the fall and the need for immediate medical assistance. -Resident #8 has wandering behavior and is on 15 minute checks. There was no evidence in the documentation or in observations that these checks were occurring. d) Resident #2 Review of the care plan included the following problems: --The resident had actual/history of/potential for behavior(s): refusing to take medications at times. --She can become frustrated and yell at staff. --She frequently states she wants to leave facility. --Resident is forgetful and will at times ask for a different meal to eat and when brought to her, she will state that she never asked for that. --She will keep food containers and food items that are on her tray such as milk, syrup containers, etc. ----- Behaviors maybe related to dementia/other diagnoses/issues. --Actual behavior problem was wandering related to dementia with mental behavioral disorders. --Inability to maintain health state independently related to personal history of other mental and behavioral disorders with a history of convulsions --Potential for injury falls related to dementia with general weakness and history of convulsions. Also, will throw self in floor. --Potential for [CONDITION(S)] activity. diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] --Resident not to have knives on meal trays. Review of the most recent Quarterly MDS with ARD [DATE] gave the following information: --BIMS score of 11 which indicated the resident is moderately cognitively impaired. --Independent for all ADLs except locomotion off unit occurred only once or twice and required limited assistance of one person for personal hygiene. --For bathing required supervision. --Occasionally incontinent of urine and bowel. Due to the facility's failure to provide adequate nursing staffing on the third floor, this place Resident #2 at immediate jeopardy due to: --Resident #2 was has a full code status, and not having sufficient nursing staff available to call the code and immediately start CPR. --Resident #2 was also care planned for fall risk and history. If the resident were to fall, the lack of nursing would delay identification of the fall and the need for immediate medical assistance. Her history of convulsions also placed her at a higher risk of falling. e) Resident #15 Review of the care plan included the following problems: --Inability to maintain health state independently related to multiple [CONDITION(S)] and [CONDITION(S)]. --At risk for falls related to [CONDITION(S)] and [CONDITION(S)] ([CONDITION(S)]). --At risk for skin integrity alterations related to bilateral food drop, [CONDITION(S)] to left non dominant side with decreased mobility. Review of a comprehensive MDS with an ARD of [DATE] gave the following information: --BIMS score of 6 which indicated the resident was severely cognitively impaired. --Required extensive assistance for bed mobility, transfer, dressing, toilet use, and personal hygiene. --Required two (2) person physical assist for bed mobility. Required physical help of one person in part of bathing activity. --Occasionally incontinent of urine and frequently incontinent of bowel. --Experienced one (1) fall with no injury in the last 3 months. Due to the facility's failure to provide adequate nursing staffing on the third floor, this place Resident #15 at immediate jeopardy due to: --Resident #15 was has a full code status, and not having sufficient nursing staff available to call the code and immediately start CPR. --Resident #15 was also care planned for fall risk and history. If the resident were to fall, the lack of nursing would delay identification of the fall and the need for immediate medical assistance. g) Resident #13 On [DATE] at 2:20 PM, Resident #13 was observed lying in bed with a nasal cannula (an oxygen delivery device). Resident #13's oxygen concentrator was observed on [DATE] at 2:20 PM to be running at a rate of three (3) liters per minute. There was no licensed nurse available to verify the oxygen flow rate. Employee #83, a Nurse Aide (NA), verified the oxygen was running at 3 liters per minute. A review of Resident #13's physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . On [DATE] at 3:41 PM, the DON verified Resident #13's oxygen concentrator was set on three (3) liters per minute and she confirmed the oxygen order was for two (2) liters per minute. Review of the care plan for Resident #13 found the following problems: --Resident has behaviors that include screaming, cursing, or throwing items during activities, often occurs when resident doesn't win a game or contest; also, episodes of throwing items in hall or at staff if she becomes angry or upset. --Impaired expressive or receptive communication related to a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] --Resident may miss part of message. Resident at times misinterprets other resident's communication and behaviors which causes resident to act out verbally along with becoming physically threatening. --Resident is on anti-psychotic medication for behaviors. History of gradual dose reduction failures due to behaviors starting again or increasing. --Resident has a BIMS score of 11 score which indicated the Resident is moderately cognitively impaired --Resident requires extensive assist of one person with bathing, dressing, bed mobility, transfers, and toileting. Due to the facility's failure to provide adequate nursing staffing on the third floor, this place Resident #13 at immediate jeopardy due to: --Resident #13 was has a full code status, and not having sufficient nursing staff available to call the code and immediately start CPR. h) Resident #31 Review of the care plan for Resident #31 included the following problems: --Inability to maintain health state independently related to weakness and history of [CONDITION(S)]. --Resident has a potential for injury falls related to muscle weakness, difficulty walking requires one assist. --Resident noted to have a fall on [DATE], slid from bed while attempting to transfer. Resident had been educated on calling for assistance for transfers. Resident moved closer to nursing station. Review of the comprehensive MDS with an ARD of [DATE] found the following: --Resident #31 had a BIMS score of 6 which indicated severe cognitive impairment --Required extensive assistance with one-person physical assist for dressing, toilet use, and personal hygiene. --Required limited assistance with one-person physical assistance for bed mobility and transfer. --Resident is always continent. Due to the facility's failure to provide adequate nursing staffing on the third floor, this place Resident #31 at immediate jeopardy due to: --Resident #31 was has a full code status, and not having sufficient nursing staff available to call the code and immediately start CPR. --Resident #31 was at risk and care planned for falls. As a result he was moved closer to the nurses station, however, the lack of nursing did not increase his level of safety from falling. If the resident were to fall, the lack of nursing would delay identification of the fall and the need for immediate medical assistance. i) Resident #23 Review of the care plan found the following problems: --The resident had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] . --She stated that she wants staff to die, called them names, stated they were demons which is related to a psychotic disorder with hallucinations. --The resident's behaviors occur at least once a week, especially when she is asked if she wants to get a shower or if she is asked to get out of bed. --Resident has a history of stating she wanted to harm herself with a soda can. Resident has stated she wanted to harm herself because she wanted to leave the facility. --Inability of maintain health state independently related to decreased mobility. --History of falls prior to admission related to muscle weakness and debility. Review of the recent quarterly MDS with an ARD of [DATE] gave the following information: --Resident has a BIMS score of 15 which indicated the resident was cognitively intact. --Required extensive assistance with one-person physical assist for bed mobility, dressing, and personal hygiene. --Required extensive assistance with two or more persons physical assist for transfer and toilet use. --Required total dependence with assistance of one person for locomotion on unit. --Required physical assistance of one person for bathing. --Frequently incontinent of urine and stool. Due to the facility's failure to provide adequate nursing staffing on the third floor, this place Resident #23 at immediate jeopardy due to: --Resident #23 was has a full code status, and not having sufficient nursing staff available to call the code and immediately start CPR. --Resident #23 had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] . She was care planned for not having knives on meal trays and to make sure she did not keep items from her food tray. --Resident #23 had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] . If the resident were to fall, the lack of nursing would delay identification of the fall and the need for immediate medical assistance.

Based on record review and staff interview, the facility failed to ensure residents received treatment and care in accordance with professional standards of practice. The facility failed to follow physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . This failed practice had the potential to affect four (4) of six (6) residents receiving insulin medications. Resident identifiers: #10, #22, #29, #5. Facility census: 39. The state agency determined these failures placed Residents #10, #22, #29, #5 in an immediate jeopardy situation due to potential complications from [CONDITION(S)] or [CONDITION(S)] resulting from failure to follow the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The facility submitted an abatement plan of correction (APOC) at 7:35 PM on 08/24/21. The state agency requested changes and an additional APOC was submitted at 7:52 PM on 08/24/21. At 8:50 PM on 08/24/21, the APOC was accepted by the state agency. The state agency verified the APOC was implemented, and the immediate jeopardy was abated at 08/30/21 at 2:00 PM. Once the immediate jeopardy was abated, deficient practices remained, and the scope and severity were decreased from a K to an E. Date/time IJ was called at 6:08PM on 08/24/21. Date IJ started on 07/17/21. Date Abatement POC approved at 8:50 PM on 08/24/21. Date/time IJ was abated at 2:00 PM on 08/30/21 The plan of correction stated as follows, the facility's failure to follow the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] --The Quality Assurance Registered Nurse (QA RN) will review all diabetic orders and all finger sticks for accuracy. This will be completed 8/24/21. --Education on diabetic management and following physician ordered parameters prior to administering insulin to be provided to all licensed nurses by 8/27/20 by QA RN or designee. --QA RN or designee will review all finger sticks and insulin administrations for accuracy daily x 30 days, then weekly thereafter. --Practitioner will review medications and finger sticks on 8/25/2021 then monthly thereafter for all residents receiving insulin. A deficient practice remained when the facility failed to follow physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The facility also failed to follow medication orders. This was a random opportunity for discovery that had the potential to affect one (1) of 20 residents reviewed during the long-term care survey process. Additionally, the facility failed to obtain a discharge order from the physician for one (1) of three (3) residents reviewed for the care area of hospitalization . Resident identifiers: #42, #15, #43. Facility census: 39. Findings included: a) Resident #10 Review of Resident #10's physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #10's Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . On the following dates and times, Resident #10's MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] --08/02/21 at 7:00 AM, for fingerstick blood glucose of 110 --08/04/21 at 11:00 AM, for fingerstick blood glucose of 121 --08/09/21 at 7:00 AM, for fingerstick blood glucose of 124 --08/13/21 at 5:00 PM, for fingerstick blood glucose of 122 --08/14/21 at 5:00 PM, for fingerstick blood glucose of 137 --08/15/21 at 5:00 PM, for fingerstick blood glucose of 130 --08/13/21 at 5:00 PM, for fingerstick blood glucose of 108 On 08/10/21 at 11:00 AM, Resident #10's insulin was held for fingerstick blood glucose of 148, despite the parameters to give. On 08/24/21 at 10:01 AM, the above findings were reviewed with the Director of Nursing (DON). The DON had no additional information regarding the matter. The failure to follow the physician parameters for holding or giving insulin placed this resident at immediate jeopardy for [CONDITION(S)] and [CONDITION(S)] events. The immediate risk of low blood sugar ([CONDITION(S)]) can lead to severe confusion and disorientation, seizures, loss of consciousness, coma, even death. The immediate risk of [CONDITION(S)] (high blood sugar) can cause long-term complications, including problems in the extremities (hands and feet), bone and joint problems, nerve damage, [CONDITION(S)], kidney failure, and cardiovascular disease. b) Resident #22 Review of Resident #22's physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] --[MEDICATION(S)] Insulin, 5 units subcutaneously at 7:00 AM (with no parameters), ordered 7/14/21 --[MEDICATION(S)] Insulin, 8 units subcutaneously at 11:00 AM and 5:00 PM, hold for fingerstick blood glucose less than 140, ordered 07/14/21 --[MEDICATION(S)] Insulin, 20 units subcutaneously at bedtime (with no parameters), ordered 03/10/21 Resident #22's MAR from 07/26/21 to present was reviewed. At 7:00 AM on the following dates, Resident #22's insulin was held despite no parameters to do so. --07/27/21 for fingerstick blood glucose of 104 --07/29/21 for fingerstick blood glucose of 103 --07/30/21 for fingerstick blood glucose of 125 --07/31/21 for fingerstick blood glucose of 73 --08/01/21 for fingerstick blood glucose of 86 --08/06/21 for fingerstick blood glucose of 62 --08/07/21 for fingerstick blood glucose of 115 --08/08/21 for fingerstick blood glucose of 98 --08/12/21 for fingerstick blood glucose of 92 --08/13/21 for b fingerstick blood glucose of 106 --08/14/21 for fingerstick blood glucose of 98 --08/15/21 for fingerstick blood glucose of 88 --08/18/21 for fingerstick blood glucose of 101 --08/19/21 for fingerstick blood glucose of 72 --08/20/21 for fingerstick blood glucose of 113 --08/22/21 for fingerstick blood glucose of 102 On the following dates and times, Resident #22's MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] --07/28/21 at 5:00 PM, for fingerstick blood glucose of 126 --08/20/21 at 5:00 PM, for fingerstick blood glucose at 117 On 08/24/21 at 2:53 PM, the above findings were reviewed with the DON. The DON confirmed Resident #22 did not have an order to hold the 7:00 AM insulin dose for blood glucose level less than 140. The DON also confirmed Resident #22 received insulin the other two (2) times when the resident's blood glucose was less than 140. The failure to follow the physician parameters for holding or giving insulin placed this resident at immediate jeopardy for [CONDITION(S)] and [CONDITION(S)] events. The immediate risk of low blood sugar ([CONDITION(S)]) can lead to severe confusion and disorientation, seizures, loss of consciousness, coma, even death. The immediate risk of [CONDITION(S)] (high blood sugar) can cause long-term complications, including problems in the extremities (hands and feet), bone and joint problems, nerve damage, [CONDITION(S)], kidney failure, and cardiovascular disease. c) Resident # 29 Resident #29 was admitted on [DATE] with an order for [MEDICAL RECORD OR PHYSICIAN ORDER] administer: 10 units; subcutaneous. Hold if blood sugar is less than 110. On the following dates and times, Resident # 29's MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] On 07/17/2021 at 4:15 PM, the blood sugar was 83 and Resident # 29 received 10 units of [MEDICATION(S)] (insulin) and should have been held. On 07/24/2021 at 5:25 PM, Resident # 29 was given [MEDICATION(S)] (insulin) 10 units when her blood sugar was 103 and should have been held. On 08/23/2021 at 6:30 PM Resident # 29 was given [MEDICATION(S)] (insulin) 10 units when her blood sugar was 109 and should have been held. Resident #29's blood sugars were not obtained on the following days: 07/21/21, 07/25/21, 07/26/21, 07/27/21, 07/28/21, 07/29/21, 07/30/21, 07/31/21, 08/01/21. The resident received [MEDICATION(S)] 10 units on every occasion mentioned above even through the blood sugars were not obtained. During an interview on 08/24/2021 at 6:30 PM, the Director of Nursing (DON) confirmed the staff failed to follow the physicians' orders to check the blood sugar before administering the insulin and to hold if below 110. She stated, she has no idea why it was not done. The failure to follow the physician parameters for holding or giving insulin placed this resident at immediate jeopardy for [CONDITION(S)] and [CONDITION(S)] events. The immediate risk of low blood sugar ([CONDITION(S)]) can lead to severe confusion and disorientation, seizures, loss of consciousness, coma, even death. The immediate risk of [CONDITION(S)] (high blood sugar) can cause long-term complications, including problems in the extremities (hands and feet), bone and joint problems, nerve damage, [CONDITION(S)], kidney failure, and cardiovascular disease. d) Resident #5 Review of Resident #5's medical record found a physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . No order for fingersticks was found. Review of the August 2021, Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . On the following dates and times the [MEDICATION(S)] 10 units was held on three (3) occasions without an order and no physician notification: 08/05/21 at 5pm- fingerstick was 68 08/06/21 at 5 PM - fingerstick was 76 08/14/21 at 5 PM- fingerstick was 84 On 08/24/21 at 3:30 PM, the above findings were reviewed with the DON. The DON confirmed Resident #5 did not have an order to obtain fingersticks and he did not have an order to hold the [MEDICATION(S)] on 08/05/21, 08/06/21 and 08/14/21. The failure to follow the physician parameters for holding or giving insulin placed this resident at immediate jeopardy for [CONDITION(S)] and [CONDITION(S)] events. The immediate risk of low blood sugar ([CONDITION(S)]) can lead to severe confusion and disorientation, seizures, loss of consciousness, coma, even death. The immediate risk of [CONDITION(S)] (high blood sugar) can cause long-term complications, including problems in the extremities (hands and feet), bone and joint problems, nerve damage, [CONDITION(S)], kidney failure, and cardiovascular disease. e) Resident #42 Review of Resident #42's medical records revealed an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . Abnormal [MEDICATION(S)] levels may indicate kidney or liver problems or malnutrition. [MEDICATION(S)] is a medication given for seizures, and levels are monitored to ensure a therapeutic, but not toxic, medication level has been obtained. Resident #42's electronic health record (EHR) contained no results for [MEDICATION(S)] and [MEDICATION(S)] levels performed on 08/02/21. During an interview on 08/25/21 at 1:06 PM, the Director of Nursing (DON) confirmed laboratory testing for [MEDICATION(S)] and [MEDICATION(S)] levels had not been performed on 08/02/21 as ordered by the physician. No further information was provided through the completion of the survey. f) Resident #15 Review of Resident #15s electronic medical records found an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . Further review found handwritten prescriptions dated 04/14/21 through 08/01/21, by Resident #15's attending physician for [MEDICATION(S)] Extended-Release (ER) 15 milligrams (mg) three times daily. Dispense #90 tablets. An interview with the Director of Nursing on 08/30/21 at 1:30 PM, verified the handwritten prescription by Resident #15's attending physician were for [MEDICATION(S)] three times a day although the electronic medical records was for twice daily. She confirmed the electronic medical record was inaccurate. g) Resident #43 A medical record review on 08/30/21 for Resident #43, revealed no order had been obtained to discharge the resident to a local hospital for treatment on 08/09/21 at 1:02 PM. Resident #43 had exhibited behaviors, which the staff was unable to manage so he was transferred to a emergency room for evaluation. In an interview with the Nursing Home Administrator (NHA) on 08/30/21 at 3:10 PM, she reported she was unable to locate the order to transfer Resident #43 to the local hospital for treatment on 08/09/21.

Based on observation, medical record reviews and staff interviews, the facility failed to provide the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being, consistent with the resident's comprehensive assessment and plan of care for all residents residing on third (3rd) floor. Failure to deploy licensed nurses (RN's and/or LPN's) to provide initial and ongoing assessments of the clinical needs of the residents including any acute changes in condition, such as cardiac/respiratory failure, choking, hemorrhaging, poor glycemic control, onset of [CONDITION(S)], behavioral emergencies, or falls resulting in head injuries or fractures, and failure to deploy staff to provide ongoing monitoring and supervision of staff to assure the implementation of the care plan as written. This deficient practice put the 6 out of 9 residents on third (3rd) floor at risk for serious injury, serious harm, serious impairment, or death. Resident identifiers: #13, #15, #31, #23, #2 and #8. Facility Census: 39. The state agency determined these failures placed Residents #13, #15, #31, #23, #2 and #8. in an immediate jeopardy situation due to the lack of deployment of adequate license nurses (RN's and/or LPN's) to assess and treat any acute changes in condition, such as cardiac/respiratory failure, choking, hemorrhaging, poor glycemic control, onset of [CONDITION(S)], behavioral emergencies, or falls resulting in head injuries or fractures. The state agency notified the Nursing Home Administrator of the immediate jeopardy at 7:27 PM on [DATE]. The facility submitted an abatement plan of correction (APOC) at 8:27 PM on [DATE]. The state agency requested changes and an additional APOC was submitted at 8:53 PM on [DATE]. At 8:58 PM on [DATE], the APOC was accepted by the state agency. The state agency verified the APOC was implemented, and the immediate jeopardy was abated at [DATE] at 9:41 PM. Once the immediate jeopardy was abated, deficient practices remained, and the scope and severity were decreased from a K to an E. Date/time IJ was called at 7:27 PM on [DATE]. Date IJ started on [DATE]. Date Abatement POC approved at 8:53 PM on [DATE]. Date/time IJ was abated at 9:41 PM on [DATE] The plan of correction stated as follows: --The facility failed to deploy staff to provide the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being, consistent with the resident's comprehensive assessment and plan of care for all residents residing on third (3rd) floor. --Social Worker (SW) to contact residents and their families to inform of room moves to occur tonight. --Residents on third floor will be moved to the first floor immediately. --RN will be staffed on the 3rd floor until all residents are moved. --No residents will be placed on 3rd floor unless facility has adequate staffing. Findings included: a) Review of the Licensed nurse staffing schedule Review of the assignment sheet for [DATE] found the building has three (3) floors: First floor had nineteen (19) residents; second floor had eleven (11) residents, and third floor had nine (9) residents. First floor had a licensed nurse full time; the second and third floor had one (1) nurse who is responsible for all care and services provided to both second and third floors. A review of the licensed nurse, nursing schedule provided by the facility from [DATE] to [DATE] found the following: 1. Review of the nurse schedule for [DATE] to [DATE] from 6:00 AM to 6:00 PM On the following days the facility had 2 nurses scheduled to work all three (3) floors from 6:00 AM to 6:00 PM: [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], and [DATE]. On [DATE] the facility scheduled 2 nurses to work all three floors from 6:00 AM to 6:00 PM. A third nurse was scheduled to work from 2:00 PM to 10:00 PM. On the following days the facility had one (1) nurse scheduled to work all three (3) floors from 6:00 AM to 6:00 PM: [DATE], [DATE], and [DATE]. Between [DATE] through [DATE], there were 38 days out of 41 days were the facility only had 2 licensed nurses working to cover residents living on 3 floors of the nursing facility from 6:00 AM to 6:00 PM. In addition, the other 3 days in the review period only had 1 licensed nurse scheduled to work all 3 floors from 6:00 AM to 6:00 PM. No more than one Nurse Aide was present on the 3rd floor during the survey. 2. Review of the nurse schedule for [DATE] to [DATE] from 6:00 PM to 6:00 AM On the following days the facility had 2 nurses scheduled to work all three (3) floors from 6:00 PM to 6:00 AM: [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], and [DATE]. On [DATE] the facility scheduled 2 nurses to work all three floors from 6:00 AM to 6:00 PM. A third nurse was scheduled to work from 2:00 PM to 10:00 PM. On the following days the facility had one (1) nurse scheduled to work all three (3) floors from 6:00 PM to 6:00 AM: [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], and [DATE]. The nursing schedule for the 3rd floor provided by the facility reflected no nurses were scheduled to work from 6:00 PM to 6:00 AM on [DATE]. Between [DATE] through [DATE], there were 39 days out of 41 days were the facility only had 2, 1 or no licensed nurses working to cover residents living on 3 floors of the nursing facility from 6:00 PM to 6:00 AM. A nursing schedule for the remaining days in [DATE] was requested but never provided; however, observations proved similar staffing patterns continued through [DATE]. An interview with the nursing home administrator on [DATE] at 7:27 PM confirmed residents were moved to the third floor on [DATE]. As of [DATE] the facility had residents residing on all three (3) floors of the facility. Surveyors could not ascertain the actual staffing levels for the 3rd floor as the facility could not produce assignment sheets or the entire schedule. During the interview with the administrator, she was unable to answer the question about the schedule. No more than one Nurse Aide was present on the 3rd floor during the survey. b) Emergency Crash Cart Observation on [DATE] at 9:30 AM of the emergency cart (crash cart) used for choking and emergency first aid as well as CPR was unable to be opened; no license nurse (RN/LPN) was on the floor to verify the contents of the cart. (A crash cart is used to provide treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] . The emergency crash cart was located on the 3rd floor next to the nurse's station. Observations on third floor on [DATE] from 11:15 AM to 11:50 AM revealed no licensed nurse (RN and/or LPN) was present for 35 minutes. From 11:53 AM to 12:05 PM there was no licensed nurse (RN/LPN) was on the third floor for 12 minutes. At 12:30 PM the nurse left the third floor via the elevator. At 12:25 PM on [DATE], it was determined the crash cart was unable to be accessed due to the lack of knowledge by staff on how to open the cart. LPN #90 did not know how to unlock the emergency crash cart. This was confirmed by the Director of Nursing (DON) on [DATE] at 1:20 PM. The observed timeline for getting the emergency crash cart open on [DATE] found: --11:50 am LPN #90 came to the floor and surveyor asked her to unlock the emergency crash cart. She was unable to open the cart and stated, I think the keys to this cart is downstairs on second floor. --11:53 am LPN #90 left the floor to get keys. --12:05 pm LPN #90 returned to floor and met with Hospice personnel evaluating Resident #13 for about 5 minutes and at 12:10 pm attempted to get in the crash cart to no avail. --12:10 pm LPN called on the phone to have the DON to come and assist her in opening the emergency crash cart. --12:22 pm NA #83 stated she thought there was a button to push or slide on the drawers. At this time LPN #90 and the surveyor were able to open the drawers. --From 11:15 am till 12:22 pm the facility was unable to access the emergency cart. The crash (emergency) cart supplies are PPE, gloves, gown, face masks, non-rebreather mask, nasal cannula, venti-masks. First aid- alcohol swabs, abdominal pads, band aids, Coban wrap, normal saline, gauze, bodily fluid spill kit, Sani-cloths, bio-hazard bags, and red biohazard bags, Ambu- bag and suction machine and tubing. This is the only source of supplies located on third floor. Six (6) of nine (9) residents on the 3rd floor are Full Code Residents #2, #23, #13, #15, #8 and #31. If an emergency arises and no licensed nurses are on the floor, nurse aides must go to the nurses' room to call for assistance. The licensed nurse must reach the floor by elevator or two flights of stairs. This failure created an immediate jeopardy situation for all residents on the 3rd floor, and also for those who may require treatment from the crash cart. c) Resident #8 Review of the care plan revealed the following problems Resident #8 was care planned for: --Full code status --One occurrence of behavior of touching another female resident in private areas --History of verbally abusive/aggressive behavior, including cursing towards others. --Resident will curse and yell at another resident that wanders by his room or if they go into his room by mistake --Resident feels he must fight for his life and is unable to be redirected at times. --Resident has had behaviors becoming physically aggressive, including punching EMT staff. --Resident has actual behavior problem: Resident has exhibited sexually inappropriate such as trying to grab and touch female staff and one instance of this behavior towards another resident. --Potential for injury falls related to general weakness and declining gait. --Inability to maintain health state independently related to muscle weakness and chronic fatigue. --Bathing requires the assistance of 1 person, he likes to do his own daily care, and prefers showers 3 days a week. --Resident requires the assistance of 1 person for dressing. --Resident is continent of bladder/bowel, uses bathroom, uses bathroom/urinal independently. Review of the current quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of [DATE] gave the following information: --BIMS (Brief Interview for Mental Status) of 15 which indicated cognitively intact. --Independent for all activities of daily living (ADL) except for walking in corridor which did not occur during the quarter. --Required set up assistance for dressing, eating, and personal hygiene. --Required supervision of one for bathing. Observation of Resident #8 in hallway on first floor in his wheelchair on [DATE] at 1:00 PM found him yelling at Resident #14, who has been noted to wander in the hallways throughout the survey. The staff redirected Resident #8 away from Resident #14 and told Resident #8 that Resident #14 was permitted in the hallway. Resident #8 was moved from first floor to third floor on [DATE], to room [ROOM NUMBER] after having an episode of inappropriate touching of Resident #16 on [DATE]. Resident #8 was to be on every fifteen (15) minute checks after the inappropriate touching of Resident #16. Multiple observations on [DATE] at 9:35 AM, [DATE] at 11:15 AM to 12:30 PM, [DATE] at 2:20 PM found Resident #8 was mobile and freely moving about the third floor without any staff supervision. The facility failed to provide evidence Resident #8 was being checked every 15 minutes. Due to the facility's failure to provide adequate nursing staffing on the third floor, this placed Resident #8 and other residents in his environment at immediate jeopardy due to: --Resident #8 was has a full code status, and not having sufficient nursing staff available to call the code and immediately start CPR. --Resident #8 was potentially a risk to other residents due to his history of sexually inappropriate behavior and the one recent incident of being sexually inappropriate with another resident. --Resident #8 had physically aggressive behaviors that have resulted in him punching an EMS worker. --Resident #8 is care planned for fall risk due to general weakness and declining gait. If the resident were to fall, the lack of nursing would delay identification of the fall and the need for immediate medical assistance. -Resident #8 has wandering behavior and is on 15 minute checks. There was no evidence in the documentation or in observations that these checks were occurring. d) Resident #2 Review of the care plan included the following problems: --The resident had actual/history of/potential for behavior(s): refusing to take medications at times. --She can become frustrated and yell at staff. --She frequently states she wants to leave facility. --Resident is forgetful and will at times ask for a different meal to eat and when brought to her, she will state that she never asked for that. --She will keep food containers and food items that are on her tray such as milk, syrup containers, etc. ----- Behaviors maybe related to dementia/other diagnoses/issues. --Actual behavior problem was wandering related to dementia with mental behavioral disorders. --Inability to maintain health state independently related to personal history of other mental and behavioral disorders with a history of convulsions --Potential for injury falls related to dementia with general weakness and history of convulsions. Also, will throw self in floor. --Potential for [CONDITION(S)] activity. diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] --Resident not to have knives on meal trays. Review of the most recent Quarterly MDS with ARD [DATE] gave the following information: --BIMS score of 11 which indicated the resident is moderately cognitively impaired. --Independent for all ADLs except locomotion off unit occurred only once or twice and required limited assistance of one person for personal hygiene. --For bathing required supervision. --Occasionally incontinent of urine and bowel. Due to the facility's failure to provide adequate nursing staffing on the third floor, this place Resident #2 at immediate jeopardy due to: --Resident #2 was has a full code status, and not having sufficient nursing staff available to call the code and immediately start CPR. --Resident #2 was also care planned for fall risk and history. If the resident were to fall, the lack of nursing would delay identification of the fall and the need for immediate medical assistance. Her history of convulsions also placed her at a higher risk of falling. e) Resident #15 Review of the care plan included the following problems: --Inability to maintain health state independently related to multiple [CONDITION(S)] and [CONDITION(S)]. --At risk for falls related to [CONDITION(S)] and [CONDITION(S)] ([CONDITION(S)]). --At risk for skin integrity alterations related to bilateral food drop, [CONDITION(S)] to left non dominant side with decreased mobility. Review of a comprehensive MDS with an ARD of [DATE] gave the following information: --BIMS score of 6 which indicated the resident was severely cognitively impaired. --Required extensive assistance for bed mobility, transfer, dressing, toilet use, and personal hygiene. --Required two (2) person physical assist for bed mobility. Required physical help of one person in part of bathing activity. --Occasionally incontinent of urine and frequently incontinent of bowel. --Experienced one (1) fall with no injury in the last 3 months. Due to the facility's failure to provide adequate nursing staffing on the third floor, this place Resident #15 at immediate jeopardy due to: --Resident #15 was has a full code status, and not having sufficient nursing staff available to call the code and immediately start CPR. --Resident #15 was also care planned for fall risk and history. If the resident were to fall, the lack of nursing would delay identification of the fall and the need for immediate medical assistance. g) Resident #13 On [DATE] at 2:20 PM, Resident #13 was observed lying in bed with a nasal cannula (an oxygen delivery device). Resident #13's oxygen concentrator was observed on [DATE] at 2:20 PM to be running at a rate of three (3) liters per minute. There was no licensed nurse available to verify the oxygen flow rate. Employee #83, a Nurse Aide (NA), verified the oxygen was running at 3 liters per minute. A review of Resident #13's physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . On [DATE] at 3:41 PM, the DON verified Resident #13's oxygen concentrator was set on three (3) liters per minute and she confirmed the oxygen order was for two (2) liters per minute. Review of the care plan for Resident #13 found the following problems: --Resident has behaviors that include screaming, cursing, or throwing items during activities, often occurs when resident doesn't win a game or contest; also, episodes of throwing items in hall or at staff if she becomes angry or upset. --Impaired expressive or receptive communication related to a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] --Resident may miss part of message. Resident at times misinterprets other resident's communication and behaviors which causes resident to act out verbally along with becoming physically threatening. --Resident is on anti-psychotic medication for behaviors. History of gradual dose reduction failures due to behaviors starting again or increasing. --Resident has a BIMS score of 11 score which indicated the Resident is moderately cognitively impaired --Resident requires extensive assist of one person with bathing, dressing, bed mobility, transfers, and toileting. Due to the facility's failure to provide adequate nursing staffing on the third floor, this place Resident #13 at immediate jeopardy due to: --Resident #13 was has a full code status, and not having sufficient nursing staff available to call the code and immediately start CPR. h) Resident #31 Review of the care plan for Resident #31 included the following problems: --Inability to maintain health state independently related to weakness and history of [CONDITION(S)]. --Resident has a potential for injury falls related to muscle weakness, difficulty walking requires one assist. --Resident noted to have a fall on [DATE], slid from bed while attempting to transfer. Resident had been educated on calling for assistance for transfers. Resident moved closer to nursing station. Review of the comprehensive MDS with an ARD of [DATE] found the following: --Resident #31 had a BIMS score of 6 which indicated severe cognitive impairment --Required extensive assistance with one-person physical assist for dressing, toilet use, and personal hygiene. --Required limited assistance with one-person physical assistance for bed mobility and transfer. --Resident is always continent. Due to the facility's failure to provide adequate nursing staffing on the third floor, this place Resident #31 at immediate jeopardy due to: --Resident #31 was has a full code status, and not having sufficient nursing staff available to call the code and immediately start CPR. --Resident #31 was at risk and care planned for falls. As a result he was moved closer to the nurses station, however, the lack of nursing did not increase his level of safety from falling. If the resident were to fall, the lack of nursing would delay identification of the fall and the need for immediate medical assistance. i) Resident #23 Review of the care plan found the following problems: --The resident had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] . --She stated that she wants staff to die, called them names, stated they were demons which is related to a psychotic disorder with hallucinations. --The resident's behaviors occur at least once a week, especially when she is asked if she wants to get a shower or if she is asked to get out of bed. --Resident has a history of stating she wanted to harm herself with a soda can. Resident has stated she wanted to harm herself because she wanted to leave the facility. --Inability of maintain health state independently related to decreased mobility. --History of falls prior to admission related to muscle weakness and debility. Review of the recent quarterly MDS with an ARD of [DATE] gave the following information: --Resident has a BIMS score of 15 which indicated the resident was cognitively intact. --Required extensive assistance with one-person physical assist for bed mobility, dressing, and personal hygiene. --Required extensive assistance with two or more persons physical assist for transfer and toilet use. --Required total dependence with assistance of one person for locomotion on unit. --Required physical assistance of one person for bathing. --Frequently incontinent of urine and stool. Due to the facility's failure to provide adequate nursing staffing on the third floor, this place Resident #23 at immediate jeopardy due to: --Resident #23 was has a full code status, and not having sufficient nursing staff available to call the code and immediately start CPR. --Resident #23 had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] . She was care planned for not having knives on meal trays and to make sure she did not keep items from her food tray. --Resident #23 had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] . If the resident were to fall, the lack of nursing would delay identification of the fall and the need for immediate medical assistance.

Based on record review and staff interview the facility failed to ensure that residents receive treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices. The facility failed to administer Resident #12's and Resident #56's sliding scale insulin in accordance with the physician's orders [REDACTED].#12's blood sugar was recorded as 57. Resident #12 did not receive her sliding scale insulin coverage on 76 occasions when her blood sugar was in excess of 200 which required sliding scale coverage. This was during the time frame of 10/08/18 through current. Also on 01/25/19 the residents blood sugar was 57 and there was no evidence the facility implemented the hypoglycemic protocol. Resident #56 did not receive her sliding scale coverage on four (4) occasions when her blood sugar was in excess of 201 which required sliding scale coverage. This was from 02/09/19 through current. It was determined by the state agency (SA) that these failures place Resident #12 and Resident #56 at an immediate risk for serious harm and/or death placing Resident #12 and Resident #56 in an immediate jeopardy situation. At 12:30 p.m. on 04/09/19 the Nursing Home Administrator (NHA) and Director of Nursing (DON) was notified of the immediate jeopardy. The facility submitted a plan of correction (P[NAME]) at 1:29 p.m. on 04/09/19. The SA requested changes and new P[NAME] was submitted at 2:00 p.m The SA again requested changes and the final P[NAME] was submitted at 2:19 p.m. and was accepted by the SA at 2:27 p.m. The SA observed for implementation of the P[NAME] and determined it had been implemented. The IJ was abated at 4:50 p.m. on 04/09/19. This was true for two (2) of two (2) residents who receive sliding scale insulin coverage. After the IJ was abated a deficient practice remained therefore the scope and severity was decreased from a K to E. A deficient practice remained for Resident #35 the facility failed to ensure that the physician had provided orders for medications prior to them being administered. Finally, for Resident #54 the facility failed to respond an implement a smoking cessation program when the resident had requested one be implemented. These were all random opportunities for discovery. Resident identifiers: #12, #56, #35, and #54. Facility Census: 57. Findings included: a) Resident #12 1. Sliding Scale Insulin A review of Resident #12's medical record at 8:00 a.m. on 04/09/19 found the following physician orders: -- Order dated 10/08/18 [MEDICATION NAME] R Regular Insulin per sliding scale. 200 - 249 give 2 units, 250 - 299 give 4 units, 300 - 349 give 6 units, 350 - 400 give 8 units. BS (Blood Sugar) greater than 400 call physician. This ordered was an as needed order. -- Order dated 10/24/18 Accu Check twice daily at 6:00 a.m. and 6:00 p.m. Further review of the record found on the following occasions when Resident #12's blood sugar was elevated and she should have received sliding scale coverage and she did not: --10/08/18 - 6:01 p.m. blood sugar was 211. --10/08/18 - 8:02 p.m. blood sugar was 204. --10/10/18 - 1:11 p.m. blood sugar was 321. --10/11/18 - 8:03 a.m. blood sugar was 334. --10/11/18 - 12:09 p.m. blood sugar was 289. --10/12/18 - 8:17 a.m. blood sugar was 319. --10/12/18 - 4:27 p.m. blood sugar was 317. --10/12/18 - 8:13 p.m. blood sugar was 288. --10/14/18 - 2:58 p.m. blood sugar was 398. --10/16/18 - 8:03 a.m. blood sugar was 337. --10/16/18 - 5:10 p.m. blood sugar was 282. --10/16/18 - 8:19 p.m. blood sugar was 318. --10/21/18 - 7:49 p.m. blood sugar was 365. --10/22/18 - 8:45 p.m. blood sugar was 311. --10/23/18 - 8:46 p.m. blood sugar was 392. --10/24/18 - 4:47 a.m. blood sugar was 226. --10/24/18 - 9:46 a.m. blood sugar was 372. --10/24/18 - 6:09 p.m. blood sugar was 331. --10/26/18 - 5:37 p.m. blood sugar was 203. --10/29/18 - 5:07 a.m. blood sugar was 230. --10/30/18 - 5:44 a.m. blood sugar was 223. --10/31/18 - 5:34 p.m. blood sugar was 379. --11/02/18 - 5:52 p.m. blood sugar was 324. --11/05/18 - 9:09 p.m. blood sugar was 232. --11/12/18 - 5:54 a.m. blood sugar was 230. --11/12/18 - 8:00 p.m. blood sugar was 286. --11/13/18 - 5:24 p.m. blood sugar was 313. --11/14/18 - 5:06 a.m. blood sugar was 233. --11/16/18 - 5:27 a.m. blood sugar was 342. --11/17/18 - 5:04 a.m. blood sugar was 226. --11/17/18 - 5:25 p.m. blood sugar was 222. --11/19/18 - 5:05 a.m. blood sugar was 203. --11/20/18 - 5:46 p.m. blood sugar was 270. --11/21/18 - 5:24 p.m. blood sugar was 360. --11/23/18 - 5:03 p.m. blood sugar was 284. --11/24/18 - 5:13 p.m. blood sugar was 240. --11/25/18 - 5:13 a.m. blood sugar was 221. --11/26/18 - 5:53 p.m. blood sugar was 290. --11/28/18 - 5:01 p.m. blood sugar was 266. --11/30/18 - 5:30 a.m. blood sugar was 268. --11/30/18 - 5:01 p.m. blood sugar was 232. --12/03/18 - 5:09 p.m. blood sugar was 400. --12/07/18 - 5:14 p.m. blood sugar was 261. --12/09/18 - 5:07 a.m. blood sugar was 279. --12/09/18 - 5:35 p.m. blood sugar was 262. --12/15/18 - 6:01 a.m. blood sugar was 238. --12/19/18 - 5:12 p.m. blood sugar was 331. --12/22/18 - 5:42 p.m. blood sugar was 284. --12/23/18 - 5:57 p.m. blood sugar was 252. --12/25/18 - 6:05 a.m. blood sugar was 213. --12/26/18 - 5:15 a.m. blood sugar was 239. --12/27/18 - 9:43 a.m. blood sugar was 240. --12/27/18 - 5:15 p.m. blood sugar was 214. --12/28/18 - 5:45 a.m. blood sugar was 208. --12/31/18 - 5:16 p.m. blood sugar was 271. --01/01/19 - 5:34 a.m. blood sugar was 214. --01/03/19 - 7:19 p.m. blood sugar was 244. --01/04/19 - 5:06 a.m. blood sugar was 234. --01/05/19 - 5:10 p.m. blood sugar was 232. --01/06/19 - 5:00 p.m. blood sugar was 208. --01/11/19 - 5:05 p.m. blood sugar was 219. --01/13/19 - 5:28 p.m. blood sugar was 217. --01/19/19 - 5:08 p.m. blood sugar was 245. --01/23/19 - 5:24 p.m. blood sugar was 250. --01/25/19 - 5:38 p.m. blood sugar was 245. --01/26/19 - 5:45 a.m. blood sugar was 226. --01/31/19 - 5:34 p.m. blood sugar was 236. --02/06/19 - 5:24 a.m. blood sugar was 205. --02/19/19 - 5:16 p.m. blood sugar was 200. --02/24/19 - 6:38 p.m. blood sugar was 200. --03/07/19 - 5:00 a.m. blood sugar was 274. --03/11/19 - 6:18 p.m. blood sugar was 210. --03/12/19 - 5:04 a.m. blood sugar was 209. --03/26/19 - 5:07 a.m. blood sugar was 244. --04/02/19 - 5:09 p.m. blood sugar was 203. --04/07/19 - 5:46 a.m. blood sugar was 302. --04/08/19 - 5:06 a.m. blood sugar was 221. Review of the Medication Administration Record (MAR) found Resident #12 did not receive any sliding scale insulin on the above mentioned dates. An interview with the Director of Nursing (DON) at 11:00 a.m. on 04/09/19 confirmed Resident #12's insulin was not administered in accordance with the sliding scale insulin order. She stated that it should be recorded on the MAR when it is administered and it was not documented that it was given so it appears it was not administered. 2. Diabetic Protocol (Hypoglycemic Incident) A review of Resident #12's medical record at 8:00 a.m. on 04/09/19 found Resident #12's blood sugar was only 57. A review of the facility's Diabetic Protocol found the following, .If Glucose less than 60: If Resident is conscious, cooperative, and able to take fluids by mouth: -- Administer *(1) one full tube of glucose paste per package directions. Repeat glucose in 15 minutes. If glucose still less than 60, and resident remains stable as above repeat administration with another full tube of glucose paste (MONTH) give a total of 3 glucose pastes following same protocol before notifying physician. Recheck glucose in 15 minutes. If glucose greater than 60 with resident stable, notify physician on next facility round. Hold Scheduled insulin and oral hypoglycemic's until glucose greater than 200. Monitor glucose every 30 minutes time four (4), then every hour for two hours Further review of the medical record found no evidence the hypoglycemic protocol was ever implemented. An interview with the DON at 11:00 a.m. on 04/09/19 confirmed the hypoglycemic protocol was not implemented when the residents blood sugar was less than 60. b) Resident #56 A review of Resident #56's medical record at 10:00 a.m. on 04/09/19 found the following physician orders: -- Order Dated 04/28/18 which read Blood Sugar checks once a day at 7:00 p.m. This was an active order at the time of this review. -- Order dated 03/23/18 which read [MEDICATION NAME] R per sliding scale coverage if blood sugar is 201 - 250 give 4 units, 251 - 300 give 6 units, 301 - 350 give 8 units, 351 - 400 give 10 units, 401 - 450 give 14 units, 451 - 500 give 20 units, if blood sugar is greater than 500 call doctor. Further review of the record found on the following occasions when Resident #56's blood sugar was elevated and she should have received sliding scale coverage and she did not: -- 02/27/19 - 7:50 p.m. blood sugar was 278. -- 03/29/19 - 9:11 p.m. blood sugar was 235. -- 04/01/19 - 9:19 p.m. blood sugar was 236. -- 04/03/19 - 8:56 p.m. blood sugar was 231. An interview with the Director of Nursing (DON) at 11:00 a.m. on 04/09/19 confirmed Resident #56's insulin was not administered in accordance with the sliding scale insulin order. She stated that it should be recorded on the MAR when it is administered and it was not documented that it was given so it appears it was not administered. c) Facility's Plan of Correction The facility's plan of correction read as follows: 4-9-19 Physician order [REDACTED].#56 and #12 and to monitor glucose checks BID for 14 days, if less than 250mg/dL then decrease to 3 times a week. All licensed nursing staff in the building beginning 4-9-19, will be educated regarding use of Diabetic Protocol, followed by education provided during shift change to all incoming licensed nursing personnel and will continue until all licensed personnel have been educated. Daily audit for four weeks, then a weekly audit four weeks, followed by a random audit to be reviewed in morning meeting and in facility Quality Assurance meetings on any resident receiving sliding scale insulins. d) Resident #35 Review of the medical record found the resident was admitted to the facility on [DATE]. On 03/25/19, the resident returned to the facility from an outpatient procedure with the urologist. The facility had orders to hold the resident's Aspirin (ASA) and Eliquis 7 days prior to the procedure. The medication was held as directed. When the resident returned to the facility, the physician wrote hand written orders for, (MONTH) resume ASA and Eliquis when urine output is clear. Record review found a nurses note dated 03/25/2019 at 5:11 PM. Resident returned from (name of hospital/name of physician) at approximately 4:45 p.m. via (name of ambulance) wheelchair van without incident. Returned with two scripts. Keflex 500 mg one capsule PO (my mouth) Q (every) 8 hrs (hours) x 5 days. [MEDICATION NAME] 10 mg one tab PO QHS. Return appt. (appointment) Monday, (MONTH) 27, 2019 at 10:30 a.m. (MONTH) resume all meds except for anticoagulant medication, may resume that after urine clears up. A second nurses note dated 03/26/19 at 12:55 PM, .Resident had only voided once since returning from (name of hospital) as of medication pass time this AM. Urine is now clear and can resume ASA and Eliquis tomorrow. Review of the medication administration record found the medication was resumed. On 04/10/19 at 9:20 AM, the Director of Nursing (DON) was asked if a nurse can prescribe a medication without calling the physician for orders? The DON said the nurse would have looked at the resident's urine before resuming the medication. The DON could not find any evidence the physician was contacted and told by the nurse the urine was clear so the physician could order the medications ASA and Eliquis to be resumed. The DON was unable to verify how the nurse determined the urine was clear. The Resident's minimum data set (MDS) with an Assessment Reference Date (ARD) of 03/11/19 noted the resident was frequently incontinent of urine. e) R54 During a medical record review on 04/08/19 for R54 revealed the care plan had an approach to encourage resident to stop smoking and offer smoking-cessation assistance as desired, consult physician for nicotine patch/gum or other medication as needed. Further review of the Observation Book for the physician had a note on 01/02/19 for R54: Patient has agreed to try and quit smoking would like to start with low dose Nicotine Patch and decrease smoking gradually. In an interview with the director of nursing (DON) on 04/10/19 at 1:20 PM, she was unable to locate any evidence that R54 had been offered any smoking-cessation assistance to help her to decrease smoking.

Based on observation, record review, resident interview and staff interview, the facility failed to ensure Resident #33 was free from neglect. Resident #33 went 9 and 16 days without a shower. This failed practice had the potential to affect a limited number of residents. Resident identifiers: #33. Facility census: 57. Findings included: a) Resident #48 During an interview on 04/08/19 at 12:04 PM, Resident #48 stated he made a complaint in (MONTH) (YEAR) of a nurse aide talking to him abrasively. He stated he asked the Social Worker to please report her to the state. The resident said the Social Worker told him it would just be her word against his and would not do any good. After reviewing the Grievance and Concerns, there was one completed on 10/25/18 by the Social Worker. The 10/25/18 Grievance and Concern form noted the Resident reported not getting help to go to bed as he wanted because the NA could not get anyone to help her. The Grievance and Concern form noted the following: --The NA came in his room three times and turned off his call light. --The first time was at 3:30 PM. The NA said, it will be a little while and then 15 minutes later at 3:45 PM she said, What did I tell you? We will get to you when we can. --Resident stated that his buttock was getting sore (He did have pressure ulcers on his buttock). --At 4:00 PM, the NA came in his room again and turned off his call light and stated, I told you I had to get help and the other NA had to take the smokers out and she can't make it happen any faster. --It was 4:10 PM when he got to lay down. He told the Social Worker that the attitude of the NA was what bothered him the most. --He also stated that was not the only time that Nurse Aide was verbally abrasive towards him. --The Social Worker wrote a statement that the NA denied being abrasive and would be more careful about the way she speaks to him and other residents. A review of records revealed there was not a reportable completed by the facility for the allegation of verbal/mental abuse and neglect to the required state agencies. During an interview on 04/10/19 at 2:50 PM, the Person In Charge (whom was also the Social Worker) stated that she did not do any type of a reportable concerning this matter. She went on to say that the NA no longer works here. No further information was provided prior to exit. b) Resident #33 During an interview on 04/08/19 at 12:47 PM, Resident #33 stated she went two weeks without a shower. Resident # 33 also stated that she did not refuse a shower during this time. A review of the shower log Resident # 33 did not receive a shower from 2/11/19 to 02/20/19 which was nine (9) days between showers, she also did not receive a shower from 02/22/19 to 03/09/19 which was 16 days without a shower. During an interview on 04/10/19 at 12:34 PM, DoN was asked to verify the Resident went nine (9) and then 16 days without a shower. Her response was, I thought you said a week not two weeks. No other shower records were provided before the end of the survey.

I. Based on medical record review, review of hospital records, staff interview, and review of the facility's corrective actions after discovery, the facility failed to ensure physician's orders were followed regarding obtaining weekly [MEDICATION NAME] Time and International Normalized Ratio (PT/INR) for a resident receiving two (2) anticoagulants. The facility discontinued one anticoagulant, [MEDICATION NAME] without confirmation of the results of the PT/INR. The physician assessed the resident during this time period and failed to recognize lab orders were not completed as ordered. The failure to monitor and identify serious adverse reactions due to the failure to collect the ordered PT/INRs resulted in a critically elevated INR which lead to the resident's hospitalization . The resident expired within twenty-four hours of admission to the hospital. Resident identifier: #55. Facility census: 54. This deficient practice was determined to constitute past non-compliance, as it occurred after the last standard survey and before the start of this complaint investigation on [DATE]. The facility administrator was informed of the past non-compliance on [DATE] at 3:45 p.m. Findings include: a) Resident #55 Medical record review found the resident was transferred from the facility to an area hospital on [DATE]. According to facility records, the resident was transferred due to a decline in mental status. The resident was admitted to the area hospital on [DATE]. Review of the hospital's discharge summary, dated [DATE], found the resident was treated for [REDACTED]. The resident returned to the facility on [DATE] with new orders to receive two (2) anticoagulants: [MEDICATION NAME] 5 mg. by mouth, daily and [MEDICATION NAME] 65 g. (grams), subcutaneous, every 12 hours, stop on [DATE] or once the INR is between ,[DATE]. The admitting physician's orders directed a PT/INR be obtained weekly. The physician completed the resident's history and physical on [DATE] and noted the resident was receiving [MEDICATION NAME] 5 mg. daily and [MEDICATION NAME] 65 mg. every 12 hours pending stabilization of her [MEDICATION NAME]. On [DATE], the physician documented he saw the resident at the facility for an acute visit. "The resident's daughter approached the desk today indicating that her mother was having persistent dry cough." A chest x-ray was ordered. At the time of this physician's visit, three ([DATE], [DATE], and [DATE]) of the ordered PT/INRs had not been obtained. There was no documentation the physician was aware the PT/INR's had not been obtained as ordered. Review of the Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. The facility did not obtain the PT/INR as directed by the physician. There was no evidence the physician was aware the facility had discontinued the [MEDICATION NAME]. Further review of the medical record found the first PT/INR would have been due on [DATE]. Additional PT/INRs should have been completed on the following Mondays: [DATE], [DATE], [DATE], and [DATE]. The administrator, Employee #47, was interviewed on [DATE] at 1:00 p.m. She verified all weekly labs were obtained on Mondays. At that time, the administrator verified the PT/INRs were not obtained as ordered, and she verified the facility discontinued the [MEDICATION NAME] without confirming the INR was between 2.0 and 3.0. According to the medical record, on [DATE], the physician was notified of dried blood in the resident's brief, no active bleeding was noted. A urinalysis with culture and sensitivity (UA/C&S) was ordered but never obtained. On [DATE] at 1:00 p.m., the administrator confirmed the UA/C&S was never obtained as ordered by the physician. A nurse's note, dated [DATE], revealed the ". . . resident was experiencing bright red blood in brief and a nose bleed. . . ." The physician was contacted and a new order was written to "Hold [MEDICATION NAME] until Labs seen by (name of physician)." At 10:00 a.m. on [DATE], the family was advised of the resident's change in condition, but the family did not want the resident sent to the hospital. Results of the first PT/INR, obtained by the facility on [DATE] at 11:50 a.m., found the PT was 76.0 and the INR was greater than 8.0. An interview with the facility's contracted laboratory supervisor, on [DATE] at 10:00 a.m., found the laboratory could only guarantee the accuracy of the INR results to be greater than eight (8). According to the target range on the laboratory report, the PT should have been between 10.1 - 11.6 and the INR should have been between 2.0 and 3.0. The result of the lab testing was reported to the facility by the laboratory on [DATE] at 2:51 p.m. On Wednesday [DATE] at 3:05 p.m. the physician ordered, "Discontinued the [MEDICATION NAME] 5 mg. Start Vitamin K, one (1) 5 mg (milligrams) by mouth, daily. Dx. (diagnosis) elevated PT/INR. Obtain PT/INR on Friday." The facility immediately contacted the pharmacy to obtain the Vitamin K. The facility was notified by the pharmacy, at 4:00 p.m. on [DATE], Vitamin K was not available for immediate delivery. At 4:45 p.m. on [DATE], the pharmacy notified the facility the Vitamin K was not available from five (5) back up pharmacies and it could take 3.5 hours to get the medication to the facility. The nurse on duty spoke with family members at 7:40 p.m. on [DATE]. The nurse once again asked for permission to send the resident to the hospital. At that time the family agreed. The resident was discharged to the hospital at 8:00 p.m. on [DATE]. (The vitamin K arrived at the facility at 9:00 p.m. on [DATE], after the resident was discharged .) The hospital was visited on [DATE], where it was found the resident's INR had been greater than 15 when she was admitted on [DATE]. The hospital documents indicated she had been brought in as she had increased bleeding from her nose and she was not responding normally. The emergency room physician noted she was bleeding a large amount from her vagina. He ordered a catheter be inserted. A very large amount of bright red blood was seen in the urine draining from the resident ' s bladder. It was also noted the resident ' s right arm was still bleeding from the site where blood had been drawn six (6) hours earlier. A central line was discussed, but the physician wanted a surgeon to do the insertion because of the bleeding. The resident ' s daughter decided she only wanted her mother kept comfortable. The resident was place on hospice in the hospital. The resident expired at the hospital on [DATE], at approximately 12:05 p.m. Review of the current care plan, on [DATE], found the care plan was not updated to include the change in the resident's condition and the new physician's orders when the resident returned from the hospital on [DATE]. Employee #1, the care plan coordinator, was interviewed on [DATE] at 3:49 p.m. She verified she failed to update the existing care plan to include the use of [MEDICATION NAME] and the weekly PT/INRs when the resident returned from the hospital. Review of the physician's hospital discharge summary, dictated on [DATE], found the following: "...In June of 2012 because of her overall decline, the Resident was moved from Assisted Living to the Health Care area. There, she seemed to do well for a brief interval. Late in her course the Resident began experiencing episodes of some vaginal bleeding. The Resident had been on [MEDICATION NAME] with a weekly order for PT/INR but the Resident had gone for an interval of about four weeks with no PT/INR being obtained. When these were finally obtained in conjunction with additional laboratory studies the Resident was found to have an INR greater than 8. At that point, she was also found to have a degree of azotemia with an increase in her BUN. Interestingly, her hemoglobin was stable at 12 grams. She did have an increased white count. The Resident had an order given for PO (by mouth) [MEDICATION NAME] 5 mg. daily, as the family at that point declined hospital transfer, but because of the development through the day of recurrent bleeding and lethargy the Resident was transported from the facility to the emergency room at (name of area hospital.) The Resident apparently declined and ultimately expired there." Final Diagnosis: [REDACTED]. 1. [MEDICATION NAME] Induced [MEDICATION NAME] (abnormally low levels of [MEDICATION NAME] in the blood, characterized by poor clot formation, longer bleeding times, and a potential for hemorrhage) 2. [MEDICAL CONDITION] 3. [MEDICAL CONDITION] Reflux Disease 4. [MEDICAL CONDITION] 5. Essential Hypertension 6. [MEDICAL CONDITION] 7. [MEDICAL CONDITION]. II. Due to the finding of past non-compliance related to care regarding residents who received blood thinners, the medical records for six (6) additional residents who were ordered [MEDICATION NAME] were reviewed. This included Residents #9, #12, #11, #19, #40 and #43. Lab work, as ordered, was obtained for each of these residents, except Resident #40. a) Resident #40 Medical record review found the resident was admitted to the facility on [DATE]. The physician ordered [MEDICATION NAME] 5 mg., by mouth daily, for a [DIAGNOSES REDACTED]. Further orders required a [MEDICATION NAME] Time/International Normalized Ratio (PT/INR) to be completed weekly to ensure the [MEDICATION NAME] dosage was within therapeutic ranges. On [DATE], the physician ordered electrolytes, blood urea nitrogen (BUN), and Creatinine to be obtained monthly for a [DIAGNOSES REDACTED]. The administrator, when interviewed on [DATE], stated the facility obtained labs on Mondays. Review of the medical record found the facility failed to obtain a PT/INR on the following seven (7) Mondays in [DATE] and [DATE] : [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE]. On [DATE] at 1:00 p.m., the administrator confirmed the PT/INRs were not obtained on the above dates, as ordered by the physician. A PT / INR was obtained on [DATE]. The INR was 2.3, within the normal range. b) The facility pharmacist also failed to recognize the PT/INRs were not completed as ordered when he completed his monthly drug regimen reviews on [DATE] and [DATE]. Both pharmacy reviews reported no irregularities. c) The facility physician saw Resident #40 on [DATE] and again on [DATE]. There was no evidence the physician recognized the PT/INR's were not completed as ordered. d) Based on review of the facility's [DATE] corrective actions, which included an internal investigation of a resident's untimely death. The investigation resulted in a review of all orders to ensure all lab orders were completed as ordered, adding a line on the medication administration records which required the results of PT/INRs be documented each time the test was ordered, adding a bright pink sticker to the chart to indicate the resident was at risk for bleeding, education of all LPNs and RNs which included the new facility protocol for notification of the physician if a lab was not completed, new lab protocols, and critical thinking in the presence of bleeding and signs and symptoms to look for. All nursing staff were educated between [DATE] and [DATE], on the implementation of the new policy and procedures to ensure all orders were transcribed and carried out. The facility implemented disciplinary actions for the nurses involved. A monitoring system was established to ensure completion of all lab orders in a timely manner. The facility identified and corrected the deficits in care related to Resident #55 and Resident #40, and implemented corrective actions to prevent reoccurrence as of ,[DATE]-,[DATE]. The sample was expanded and records were review to ascertain the corrective actions were effective. No additional deficient practices were identified. Therefore, this citation constitutes past noncompliance with the requirements at 483.25 - Quality of Care. .

Based on resident interview, medical record review, observation, and staff interview, the facility failed to assure one (1) of forty-five (45) Stage II sample residents received the care and services necessary for an effective pain management program, resulting in actual harm to this resident due to untreated pain. Resident identifier: #85. Facility census: 50. Findings include: a) Resident #85 During an interview with Resident #85, she was asked (as part of the Stage I survey protocol) if she was experiencing any pain. Resident #85 stated she had pain in her legs and that they don't give her pain pills anymore. She stated she used to get a pain pill when she first got up and a pain pill when she went to bed. She stated she was in a wheelchair because of "my legs hurting so bad". Resident #85 triggered in the Stage II sample due to experiencing pain. A review of her medical record found she was prescribed [MEDICATION NAME] 5/500 mg every four (4) hours as needed (PRN) for pain. She was further ordered to be observed or questioned for pain every four (4) hours while awake. Review of the Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. The resident was visited in her room at 8:30 a.m. on 09/21/11. Observation found she was rubbing her left leg. When asked by this surveyor if she was experiencing any pain, Resident #85 stated, "Yes, my legs." and continued rubbing her left leg. When asked how much pain she was having on a scale of "1" to "10" (with "1" being, "Oh, it doesn't hurt much" and "10" being, "OH MY GOD THAT HURTS!"), the resident stated her pain was a "10". When asked if her nurse had asked her if she was having any pain when she received her medications this morning, Resident #85 stated the nurse did not ask her anything about having pain. An immediate review of the resident's MAR, on 09/21/11 at 8:34 a.m., found the licensed practical nurse (LPN - Employee #53) had documented having observed or questioned the resident for pain at 8:00 a.m. on 09/21/11. It was further noted that this nurse had already documented asking the resident about pain at 12:00 p.m. on 09/21/11. Employee #53 was then asked about her documentation of observing or questioning the resident about pain during the morning medication pass at 8:00 a.m. The nurse stated she asks her residents about pain but may have forgotten to ask Resident #85. When asked why she had already documented having assessed the resident for pain at 12:00 p.m., she stated that all those lines got her confused. The director of nursing (DON - Employee #44) was immediately informed, at 8:35 a.m. on 09/21/11, of the resident's complaints of pain and the LPN's failure to assess the resident for pain. She was also informed that the nurse had already documented assessing the resident for pain at 12:00 p.m. on 09/21/11. She agreed that this was a problem. .