Every finding on record at Brushy Creek Post Acute

Based on review of the facility policy, record review, and interviews, the facility neglected to provide services and care to Resident (R)1. Specifically, the facility failed to monitor and provide medications as ordered by the physician, resulting in R1 suffering a hypertensive crisis.On [DATE] at 11:30 AM, the State Agency (SA) determined that the facility's non-compliance with one or more federal health, safety, and/or quality regulations could cause psychosocial harm.On [DATE] at 1:15 PM, the survey team provided the Administrator with a copy of the Centers for Medicare and Medicaid Services (CMS) Immediate Jeopardy (IJ) Template, informing the facility IJ existed as of [DATE]. The IJ was related to 42 CFR 483.12 - Freedom from Abuse, Neglect, and Exploitation.On [DATE], the facility provided an acceptable IJ Removal Plan. On [DATE], the survey team validated the facility's corrective actions and determined the facility put forth due diligence in addressing the noncompliance. An extended survey was conducted in conjunction with the Complaint Survey for non-compliance at F600 constituting substandard quality of care.Findings include:Review of the facility's procedure copyrighted 2001, titled Blood Pressure, Measuring, stated, The purpose of this procedure is to measure the pressure exerted by the circulating volume of blood on the walls of the arteries, veins, and chambers of the heart. General Guidelines . 4. Hypertension is usually defined as blood pressure over 140/90 mm/hg (although the elderly often have persistent systolic readings from 140 to 160 mm/Hg. 5. Hypertension should be reported to the physician. If a resident has a hypertensive reading, staff should record several readings taken at different times of the day. Staff should note any pertinent medications and/or recent changes of condition when reporting to the physician.Review of R1's Face Sheet revealed R1 was admitted to the facility on [DATE] with diagnoses including, but not limited to, hypertensive crisis, likely acute Intracranial hemorrhage, left PCA occlusion, Dementia with word-finding difficulties, and ambulatory dysfunction.Review of R1's vital signs (VS) revealed on [DATE], at 19:56 [7:56 PM] BP [Blood Pressure] 192/103 HR [Heart rate] 73 Resp 21 O2 sat [Oxygen Saturation] 96% Temp [Temperature] 97.5 F [Fahrenheit].Review of R1's Medication Administration Record (MAR) revealed an order for AmLODIPine Besylate tablet 5 mg [milligrams], Give 1 tablet by mouth every 24 hours as needed for the SPB [Systolic Blood Pressure] greater than 160; start date [DATE] 0645PM, discharge date [DATE] at 0820 AM. Documentation did not reveal that a dose was given on [DATE] following R1's blood pressure reading of 192/103.Review of R1's Care Plan with a start date of [DATE] documented, Medication - Antihypertensive: Resident requires antihypertensive medication related to Hypertension. Further review of the Care Plan revealed the following approach: Observe for side effects of medication (i.e., bradycardia, dizziness, fatigue, bronchospasm, hypotension, edema, nausea, diarrhea, rash, etc.) and notify the physician promptly if observed.Review of R1's 2-hour rounds revealed on [DATE] at 22:45 [11:45 PM] the resident was in the chair. No other documentation noted. On [DATE] at 3:27 AM, R1 was on left side, and back. R1 expired at 03:20 AM.Review of R1's OnSite Healthcare & Wellness report of communication did not reveal a message of when R1's BP was taken.Review of BP machine revealed a sign attached stating vital signs to report temp above 100.4, heart rate (HR) below 50 or above 100, respiration below 14 or above 22, and BP systolic -below 90 or above 190. Diastolic below 40 or above 90.Review of progress notes on [DATE] at 4:13 AM by Registered Nurse (RN)1 revealed The resident was slumped over bathroom sink leaning forward with head over sink and legs were buckled with weight on vanity. No pulse, respiration effort. Do Not Resuscitate (DNR) confirmed. R1 placed in the wheelchair and transferred to bed. No acute findings. Postmortem care assisted with primary [Certified Nursing Assistant] CNA1. Called the resident daughter first on contact and left a voicemail to return a call. Called the son he was on his way to the facility. Primary nurse notified on call NP via live chat number.Review of late entry progress note on [DATE] at 6:37 AM revealed CNA1 found R1 cyanotic, no pulse, no respirations. R1 was warm, cyanotic no palpable [NAME]. RN1 notified. RN1 pronounced R1 at 03:20 AM.During an interview on [DATE] at 12:24 PM, LPN1, stated I was in another cottage. I was called by another CNA. She stated she was at the sink, standing and I think she is dead. When I arrived, I tried to get a pulse. I didn't get anything. I called the supervisor, and the supervisor came over and pronounced to her. I had to get a wheelchair cause she was upright standing. It was three employees who manually lifted her up and placed back in bed. She was a new admission. We got report that she could not get out of bed. She would not stay in bed. She was not evaluated by PT [Physical Therapy]. Depending on the time of the day, PT would come out to do an assessment or the next day. She was found over the sink standing up. LPN1 stated, The only report I received was R1 was a new admit who had a stroke and stays in bed most of the time. From the time she arrived to the time she expired, it wasn't eight hours. The oncoming nurse did not report any concerns with her BP.During a followup interview on [DATE] at 01:21 PM, LPN1 stated, The CNA did not tell me about the vital signs. If she doesn't tell me, I don't know. If I knew what R1's BP was I could have asked her to retake it. It was her first day off from orientation. The vital sign machine will tell you if the reading is inaccurate. The CNA did not text it to me. She has my phone number to call me. I had two cottages that night, sometimes three. I usually have one CNA with each cottage. The cottage I was sharing with another nurse.During an interview on [DATE] at 04:05 PM, Quality Assurance Nurse stated, We do not know which provider is working a specific night. We only use the on-call provider number.During an interview on [DATE] at 4:11 PM, the Director of Nursing (DON) stated, I found out the next morning when I reported to work. LPN1 came in to inform me what had happened.During a second interview on [DATE] at 4:13 PM, the DON stated, We have a cheat sheet on the vital sign (VS) machine on who to contact. I talked to CNA1 about that and told her she should have called LPN1. The day shift vital signs wasn't high. The reason it is not in the electronic medical record is the resident wasn't entered in the system, so it didn't transcribe over. Our expectation is if you are not sure on the readings of the vital signs, the CNAs should contact the nurse. LPN1 is saying one thing and the CNA is saying another. CNA1 should have contacted the nurse. The DON further stated, We are still in the process of investigating this incident. I am actually waiting for licensure to get back with me on their findings. I have reeducated the staff, the nurse and the CNA. F600 Correction/Removal PlanOn [DATE] at 12:36 PM, the Administrator notified the Medical Director of the Immediate JeopardyOn [DATE], the Director of Nursing and/or designee-initiated education for all staff on Abuse/Neglect police[sic] and procedures.Education will be concluded by [DATE]All staff (including any agency assigned staff) that have not completed education by end of day on [DATE] will not be permitted to work until education is completed. 3. On [DATE], the Director of Nursing and/or designee-initiated education to all nursing staff on procedure for follow up on abnormal vital signs.Education will be concluded by [DATE]All staff (including any agency assigned staff) that have not completed education by end of day on [DATE] will not be permitted to work until education is completed.On [DATE], the Director of Nursing and/or designee-initiated education to all CNAs related to reporting abnormal vital signs.Education will be concluded by [DATE]All staff (including any agency assigned staff) that have not completed education by end of day on [DATE] will not be permitted to work until education is completed.On [DATE] the Director of Nursing and/or designee initiated an audit on all residents MARS with anti-hypertensive and/or cardiovascular medications over the last 30 days to ensure meds were given as ordered.10 residents receiving cardiac medications will be audited weekly for 4 weeks and monthly for 2 months beginning on [DATE] to ensure medications given as ordered.On [DATE], the Director of Nursing and/or designee-initiated education with CNAs on facility policy and procedure for following checklist for taking resident vital signs.Education will be concluded by [DATE]All staff (including any agency assigned staff) that have not completed education by end of day on [DATE] will not be permitted to work until education is completed.On[DATE], the Director of Nursing and/or designee-initiated education with all licensed nurses on what meds available in Omnicell and how to pull meds from the Omnicell.Education will be concluded by [DATE]All staff (including any agency assigned staff) that have not completed education by end of day on [DATE] will not be permitted to work until education is completed.On [DATE], the Director of Nursing and/or designee-initiated education for all licensed nurses on entering residents into PCC timely upon admission.Education will be concluded by [DATE]All staff (including any agency assigned staff) that have not completed education by end of day on [DATE] will not be permitted to work until education is completed. Allegation of Compliance: [DATE]

Based on review of the facility policy, record review, and interviews, the facility failed to ensure that cardiopulmonary resuscitation (CPR) was initiated to Resident (R)1, Specifically, not responding in a timely manner and initiating CPR per the physician's order.On [DATE] at 11:30 AM, the State Agency (SA) determined that the facility's non-compliance with one or more federal health, safety, and/or quality regulations could cause psychosocial harm. On [DATE] at 1:15 PM, the survey team provided the Administrator with a copy of the CMS Immediate Jeopardy (IJ) Template, informing the facility IJ existed as of [DATE]. The IJ was related to 42 CFR 483.24-Quality of Life.On [DATE], the facility provided an acceptable IJ Removal Plan. On [DATE], the survey team validated the facility's corrective actions and determined the facility put forth due diligence in addressing the noncompliance. An extended survey was conducted in conjunction with the Complaint Survey for non-compliance at F678 constituting substandard quality of care. Findings include:Review of the facility's policy titled, Advance Directives, no revision or copyright date, revealed advanced directives will be respected in accordance with state law and facility policy. Policy . 8. If the resident indicates that he or she has not established advance directives, the facility staff will offer assistance in establishing advance directives. a. The resident will be given the option to accept or decline the assistance, and care will not be contingent on either decision. b. Nursing staff will document in the medical record the offer to assist and the resident's decision to accept or decline assistance . 13. If the resident or representative refuses treatment, the facility and care providers will: f. Offer pertinent alternative treatments; and g. Modify the care plan as appropriate, providing all other appropriate services (i.e., those that will allow him or her to maintain the highest practicable physical, mental and psychosocial well-being).Review of R1's Face Sheet revealed R1 was admitted to the facility on [DATE] with diagnoses including, but not limited to, hypertensive crisis, likely acute Intracranial hemorrhage, left PCA occlusion, Dementia with word-finding difficulties, and ambulatory dysfunction.Review of R1's face sheet does not reveal a code status.Review of R1's Medication Administration Record (MAR) revealed an order for full code with a discharge date [DATE] at 08:20 AM.Review of R1's Care Plan did not reveal code status.Review of a progress note dated [DATE] at 4:13 AM by Registered Nurse (RN)1, revealed The resident was slumped over bathroom sink leaning forward with head over sink and legs were buckled with weight on the vanity. No pulse, respiration effort. Do Not Resuscitate (DNR) confirmed. R1 placed in the wheelchair and transferred to bed. No acute findings. Postmortem care assisted with primary [Certified Nursing Assistant]CNA1. Called the resident daughter first on contact and left a voicemail to return a call. Called the son he was on his way to the facility. Primary nurse notified on call NP [Nurse Practitioner] via live chat number.Review of late entry progress note dated [DATE] at 6:37 AM revealed, CNA1 found R1 cyanotic, no pulse, no respirations. R1 was warm, cyanotic no palpable [NAME]. RN1 notified. RN1 pronounced R1 at 03:20 AM.During an interview on [DATE] at 02:18 PM, the Director of Nursing (DON) stated, We used what we had on file from the hospital. If the daughter were here, we would have updated the information received. We do not have DNR choices; that is a living will.During an interview on [DATE] at 10:08 AM, Licenses Practical Nurse (LPN)2, The orders are put in by the unit managers. When they are first admitted . We will refer to the computer of code status. Every cottage we keep a yellow binder with the demographics and code status. The orders are populated as soon as they are admitted . On admission, I talked to her and her daughter. R1 was oriented x2. She was able to hold a conversation. I got a history from my daughter. I performed my assessment. In report from the hospital and EMT's she did run high Blood Pressures (BP)'s. The daughter told me that had been the norm for her. I explain to the daughter it would be a full code until we have a signed DNR in the patient info book.Review of R1's Electronic Medical Record (EMR) did not reveal documentation related to the nurse discussing code options with the daughter.During an interview on [DATE] at 10:25 AM, the NP stated, I learned about the incident the next day. I ask the family about the Do Not Resuscitate (DNR), because sometimes they will change their minds. Then I will complete the standard form for Brushy Creek and have the physician sign. I think the facility honors the DNR from the hospital until we can see them. I think it is a standing order until we can see them. We have a standard DNR form. I have never seen the other form with the choices here at Brushy Creek. The medical administration order and the DNR form should be the same. Since I have been having problems entering the code status, I have the supervisor, Assistant Director of Nursing (ADON), or the nurses enter the code status. I reach out to the supervisor or ADON, or some nurses will enter the code status. Unfortunately, I am not able to enter the code status.During an interview on [DATE] at 10:31 AM, Director of Social Services (SS), stated, She came in around 6:30 PM and expired about 3 AM. We usually speak with the residents first. Depending on their Brief Interview for Mental Status (BIMS) score, we will then contact the family. We did not have the opportunity to speak with her or her family.During an interview on [DATE] at 10:55 AM, the DON stated, I do not think they rely on the ADON [Assistant Director of Nursing] to change the code status. My expectation was that we would have gone with what came from the hospital. Especially since the daughter was there and stating she was made a DNR at the hospital. What would have happened in a normal situation, the MD would have come in and made sure the DNR was continued and entered in PCC [Point Click Care] as a DNR. Then the NP would have written the order in and it would have popped over to the MAR. In an emergency situation, we need to make sure all nurses have the capability to enter code status in the MAR.During an interview on [DATE] at 11:07 AM, the Administrator stated, We are notified via Tiger Text. I have to go back to look at when it happened. We review code status and make sure that we did the right thing at our meetings. F678 Correction/Removal PlanOn [DATE] at 12:36 PM, the Administrator notified the Medical Director of Immediate Jeopardy.On [DATE], the Social Service Director initiated an audit on Code Status for all new admissions within the last 30 days. All code binders in all cottages audited to ensure they match orders in PCC.On [DATE], The Social Service Director initiated an audit on Code Status for all other residents and audited code binders in all cottages to ensure they match orders in PCC.New admission's code status and code books will be audited weekly for 4 weeks and monthly for 2 months beginning on [DATE].On [DATE], the Social Service Director initiated an audit on Advanced Directive to determine if conversations with resident and/or RR held at time of admissions for all new admissions within the last 30 days.New admissions will be audited weekly for 4 weeks and monthly for 2 months beginning on [DATE] to ensure education offered on Advance Directives and code status honored.On [DATE], education was provided by the Assistant Regional Director of Clinical Services and Regional [NAME] President of Operations to, Administrator, Director of Nursing, Assistant Director of Nursing, and Social Service Director on conversations with resident and/or RR for Advanced Directives upon admission.Education conducted as a review of facility policy and procedure in regard to Advanced Directives with resident and/or RR upon admission.On [DATE], education was initiated by Director of Nursing and/or designee to all licensed nurses related to education resident and/or RR on Advanced Directive and code status upon admission.Education will be concluded by [DATE]All staff (including any agency-assigned staff) that have not completed education by end of day on [DATE] will not be permitted to work until education is completed.On [DATE], the Director of Nursing and/or designee-initiated education for all nursing staff on Code Blue policy and procedures.Education will be concluded by [DATE]All staff (including any agency assigned staff) that have not completed education by end of day on [DATE] will not be permitted to work until education is completed.On [DATE], the Director of Nursing initiated an audit on Code Status accuracy and Advanced Directives on all resident Care PlansCare plans will be audited weekly for 4 weeks and monthly for 2 months beginning on [DATE] to ensure code status is accurate.Allegation of Compliance [DATE]

Based on observation, interview, record review, and facility policy review, the facility failed to ensure residents were free from unnecessary psychotropic medications for 3 (Residents (R)10, R51, and R127) of 6 residents reviewed for unnecessary medications in a total sample of 31. The facility failed to ensure adequate monitoring had occurred for R10's use of an antipsychotic medication. In addition, the facility failed to ensure psychotropic medications had a stop date in excess of 14 days. These failures placed the residents at risk of having unmet care needs and a decreased quality of life.Findings Include:Review of the facility policy titled, Psychotropic Medication Use, dated February 2025 revealed, . Residents do not receive psychotropic medications that are not clinically indicated and necessary to treat a specific condition documented in the medical record .When determining whether to initiate, modify, or discontinue medication therapy the interdisciplinary team conducts and documents and evaluation of the resident. The evaluation includes the residents: physical, behavioral, mental, and psychosocial status; comorbid conditions; expressions or indicators of distress; changes in functional status; resident complaints, behaviors, and symptoms .PRN [as needed] .For psychotropic medications that are NOT antipsychotics; If the prescriber or attending physician believes it is appropriate to extend the PRN order beyond 14 days, they will document the rationale for extending the use and include the duration for the PRN order .1. Review of the admission Record located in the Profile tab of the electronic medical record (EMR) revealed R10 was admitted to the facility on [DATE]. During her stay, R10 had diagnoses that included but was not limited to dementia without behavioral disturbance, psychotic disturbance, mood disturbance and delusional disorders, dated 11/18/22 and a diagnosis of schizoaffective disorder on 04/25/24.Review of the Order Summary located in the Orders tab of the EMR revealed, Aripiprazole 2 mg [milligram]. Give one tab every morning for schizoaffective disorder [a mix of hallucinations, delusions, and disorganized thinking], dated 05/04/24.Review of the 04/09/21 and revised on 09/05/24 Comprehensive Care Plan located in the Care Plan tab of the EMR revealed, Mood and Behavior: Resident exhibits the following mood or behavior issues, not using call light due to yelling out 'help me' I need to call 911, using remote as a phone, feels like she is falling out of bed related to a diagnosis of dementia, depression, paranoid, schizoaffective disorder.Review of the 02/28/25 Behavioral Nurse Practitioner (BNP) Visit Note revealed, Patient is a [AGE] year-old long-term resident at the facility .Patient reports she is feeling pretty good . Some confusion noted . Patient reports she is anxious to get out of the wheelchair, which makes her depressed . Sleep is good. Appetite is good . Denies auditory hallucinations . Patient says she sees 'little things' in her eyes. She says that the eye doctor told her they were floaters. Denies suicidal ideations. On 02/17/25 the patient's urinalysis and culture were positive . I did not notice any paranoia during today's visit. Staff reports that the patient has improved with the antibiotic regimen for the UTI [urinary tract infection] Hallucinations: By history denies today. Review of the February 2025, March 2025, April 2025, May 2025, June 2025, and July 2025 MAR (Medication Administration Record) for behaviors revealed no documented behaviors.Review of the quarterly Minimum Data Set (MDS) located in the MDS tab of the EMR with an Assessment Reference Date (ARD) of 10/08/25 revealed R10 had a Brief Interview of Mental Status (BIMS) score of 15 out of 15 which indicated R10 was cognitively intact, had no behaviors, and was administered an antipsychotic medication during the observation period.During an interview on 12/12/25 at 11:16 AM, Registered Nurse (RN)16 was asked if she had noticed any delusions or paranoia for R10. RN16 stated, Not that I have seen. She does get restless, but that is about all I see.During an interview on 12/12/25 at 11:27 AM, Certified Nurse Assistant (CNA)13 stated, She is very easy to work with. She is alert and can tell me what is going on with her. CNA13 was asked if R10 has times in which she sees things that are not there or hears things that are not in reality. CNA13 stated, No, not at all.During an interview on 12/12/25 at 12:27 PM, the Social Services Director (SSD) stated, We have our behavioral weekly meetings on Thursdays. R10 had not had any behaviors and has not been reviewed as nothing has changed.During an interview on 12/12/25 at 1:30 PM, R10 was asked if she has had any hallucinations such as seeing things that are not in reality. R10 stated, I used to way in the past, but not now. During an interview on 12/12/25 at 1:36 PM, the Director of Nursing (DON) stated, We have done education as the nurses' just put zeros [on the behavior documentation], because they are not acting out. We had an IDT [interdisciplinary team] meeting, and we discussed her antipsychotic and antidepressants, but she has not had any behaviors documented.2. Review of the admission Record located in the Profile tab of the EMR revealed that R51 was admitted to the facility on [DATE] with diagnoses including but not limited to Alzheimer's disease with agitation.Review of a significant change MDS located in the MDS tab of the EMR with and ARD of 09/02/25 revealed R51 was assessed by staff to be severely impaired in cognition, was on hospice care, and was administered an antianxiety medication during the observation period.Review of the Order Summary located in the Orders tab of the EMR revealed, Lorazepam (an antianxiety medication) 1 MG [milligram] every four hours PRN [as needed] for seizures, dated 11/04/25. There was no stop date documented.During an interview on 12/11/25 at 2:50 PM, the DON stated, I wasn't aware that the need for stop dates on hospice prescribed medications.3. A review of R127's EMR revealed the resident was last admitted to the facility on [DATE], following a hospital stay where he was treated for an infection. His diagnoses included but was not limited to: post-traumatic stress disorder (PTSD), major depressive disorder, and attention-deficit hyperactivity disorder (ADHD).A review of R127's order summary, found under the Orders tab, revealed R127 had two as needed (PRN) orders for Adderall beginning on 11/10/25: Adderall Oral Tablet 15 MG (Amphetamine-Dextroamphetamine) Give 1 tablet by mouth every 24 hours as needed for ADHD; and Adderall XR Oral Capsule Extended Release 24 Hour 20 MG (Amphetamine- Dextroamphetamine) Give 1 capsule by mouth every 24 hours as needed. Neither order had an end date. During an interview with the Director of Nursing (DON) on 12/11/25 at 1:19 PM, she was asked about R127's PRN Adderall orders and she stated that she did not believe the medication was a psychotropic and that any order not taken after 30 days was discontinued. The DON also provided a copy of a Progress Note, dated 11/12/25, that indicated that the resident requested to have the medication be PRN, as per the documentation, the resident does not need the medication daily. Review of www.pdr.net (Physicians' Desk Reference) listed Adderall as a central nervous system (CNS-brain and spinal cord) stimulant. A review of the Medication Administration Record (MAR), under the Orders tab, revealed the medication had not been administered since it was ordered, but the order was still active as of 12/12/25. An attempt was made to contact the Consultant Pharmacist but was not successful.

Based on observations, interviews, record review, and facility policy review, the facility failed to administer medications in a manner to prevent cross-contamination for 1 (Resident (R)36) and to implement Enhanced Barrier Precautions (EBP) for 2 residents (R115 and R105) in a total sample of 31. These failures placed the residents at risk for cross-contamination and/or worsening health concerns.Findings include:Review of the facility policy titled Enhanced Barrier Precautions dated December 2024 revealed, . Enhanced Barrier Precautions (EBPs) are utilized to prevent the spread of multi-drug-resistant organisms (MDROs) to residents . Indwelling medical devices include central lines, urinary catheters, feeding tubes, and tracheotomies .Examples of secretions or excretions include wound drainage, fecal incontinence or diarrhea, or other discharged from the body that cannot be contained and pose an increased potential for extensive environmental contamination and risk transmission of a pathogen .Review of the facility policy titled Administering Medications dated April 2019 revealed, . Staff follows established facility infection control procedures (e.g., handwashing, techniques, gloves, isolation procedures, etc.) for the administration of medications, as applicable .1. Review of the admission Record located in the Profile tab of the electronic medical record (EMR) revealed R36 was admitted to the facility on [DATE] with diagnoses including but not limited to a stroke and diabetes.During a medication pass observation on 12/11/25 at 7:59 AM, Registered Nurse (RN)7 was observed to use her fingers, without using hand hygiene, to obtain medications from a bottle and from medications cards. RN7 placed the medications into the medication cup for administration. At 8:05 AM, RN7 put on gloves (without hand hygiene) and obtained an insulin pen from the top drawer of the medication cart. At 8:07 AM, RN7 entered R36's room and administered the oral medications. RN7 was observed to have placed the insulin pen on R36's bed linens prior to and after administration.During an interview on 12/11/25 at 8:08 AM, RN7 stated, I am aware that I should have put the medication on the lid when dosing from the bottle and punch the medications from the card without using my fingers to pull them out, but I witnessed other nurses' when being trained as they were using their fingers to put medications in the cup. I guess I just followed along. RN7 was asked why she placed the resident's insulin pen on the bed linens prior to and after administration of the insulin before going back to the medication cart and placing the insulin pen in the drawer. RN7 acknowledged that practice could cause cross-contamination and was a break in infection control.During an interview on 12/11/25 at 9:15 AM, the Director of Nursing (DON) was informed of the medication pass with R36. The DON stated, That should have never happened.2. Review of the admission Record located in the Profile tab of the EMR revealed R115 was admitted to the facility on [DATE] with diagnoses including but not limited to sepsis (life-threatening response to an infection) due to Methicillin Susceptible Staphylococcus Aureus (MRSA-antibiotic resistant bacteria).Review of the Order Summary located in the Orders tab of the EMR revealed, Cefazolin [an antibiotic] 500 mg [milligrams] IV every eight hours.During an observation on 12/11/25 at 1:03 PM, RN1 was observed to administer the IV medication without wearing a gown. During an interview on 02/11/25 at 2:00 PM, RN1 was asked why she did not wear a gown, as the EBP precautions were posted on the door to R115's room. RN1 stated, I thought the EBP precautions were only used for his wound care. RN1 left the room, looked at the signage outside the door, and stated, I should have used a gown for the IV medications also.3. Review of the admission Record located in the Profile tab of the EMR revealed R105 was admitted to the facility on [DATE] with diagnoses including but not limited to, dementia and an open wound to the right lower leg and coccyx.Review of the 09/22/25 Order Summary located in the Orders tab of the EMR revealed, Enhanced Barrier Precautions related to wounds.Prior to observing wound care on 12/11/25 at 10:43 AM, with RN9 and Licensed Practical Nurse (LPN)2 stated that R105 had a bowel movement and needed to be cleaned up prior to providing wound care. LPN2 did not wear a gown during incontinent care. LPN2 was asked why she did not wear a gown for incontinent care for a resident on EBP precautions. LPN2 stated, I did not see the sign. RN9 and LPN2 then observed the EBP signage outside R105's door and confirmed that gowns were to be used for incontinent care. On 12/11/25 at 10:50 AM, the Staff Development Coordinator (SDC) approached this surveyor and stated, They [nurses] don't have to wear a gown when changing linens or providing care. EBP is only for wound care or if they had a PICC [Peripherally inserted central catheter-a long thin tube inserted into the vein] line or indwelling urinary catheter. The SDC further stated, Current CDC [Center for Disease Control and Prevention] guidelines do not require a gown for personal care. The SCD was asked then why the EBP signage indicated that staff need to wear gowns and gloves during personal care. The SDC did not answer.During an interview on 12/11/25 at 11:19 AM, the DON stated, The SDC came to me about the EBP guidelines and I told her yes, we do have to wear gowns while providing care.During an interview on 12/11/25 at 12:00 PM, the Infection Preventionist (IP) stated, It is gown and gloves for any care with residents who have EBP. It spells it out on the notice on the door.

Based on observations, record review, interviews, and facility policy review, the facility failed to assess the ability to manage and self-administer medications in 1 out of 5 residents, (Resident (R)13), reviewed for unnecessary medications out of a total sample of 31 residents. This failure increased the risk of medication errors for R13.Findings include:The facility's Self-Administration of Medications policy, with a revision date of February 2021, states, Residents have the right to self-administer medications if the interdisciplinary team has determined that it is clinically appropriate and safe for the resident to do so. The policy also confirms that the (MAR) should indicate if a dose is self-administered. Review of a Progress Note dated 05/25/23 in the electronic medical record (EMR) revealed R13 was admitted to the facility on [DATE], following a hospitalization for a left leg fracture and respiratory failure. The EMR Orders also revealed that the resident had a tracheostomy with no ventilator and required the use of a Percutaneous Endoscopic Gastrostomy (PEG) tube for nutrition and administration of medications. During an observation of medication administration, R13 was found to be self-administering his medications. The resident was observed on 12/11/25 at 11:00 AM crushing his own medications and administering them via his PEG tube. This was confirmed by Registered Nurse (RN)7.Review of R13's care plan revealed an area of focus related to Medication - Self-Administration Per the focus, R13 prefers to self-administer medication and is capable of doing so as assessed/determined by the IDT. Interventions for the focus were initiated on 04/20/24 and included: assessing cognitive ability, encouraging assistance from the nurse, periodic review, and physicians' order for specific medications for self-administration.A review of the Orders tab in the EMR revealed R13's December physician's orders included two orders that indicated self-administration: 1) Pro-Stat Oral Liquid, 30 milliliters (mL) twice daily and 2) Enteral Feed, 474mL twice daily with 120 mL water flush via PEG tube.During an interview on 12/11/25 at 4:10 PM, RN7 confirmed that she had been working at the facility for four months and since she started R13 had been self-administering all his medications. RN7 added that the resident was watched to confirm the medications were properly crushed and administered via the PEG tube most times. She also confirmed that she documented in the medication administration record (MAR) like any other administered medication. Review of the Assessment tab of the EMR revealed a Nursing - Self-Administration of Medication Observation dated 04/19/24. Under section A, Self-Determination it indicated that R13 did self-administer some Meds. The list of medications included: Sodium Chloride Inhalation Nebulization Solution 6%. The notice also advised how the medications would be stored and it indicated Resident Room. During an interview with the Director of Nursing (DON) on 12/12/25 at 8:39 AM, the DON stated that she was not aware that R13 was self-administering all his medications. She did confirm that she was aware of the nebulizer treatments and that the administering nurse should be providing visual oversight and documenting only what they witnessed.

Based on observations, record review, interviews, and document review, the facility failed to provide physician-ordered adaptive equipment for 1 resident, (Resident (R)16), out of the sample of 31 residents. The facility's failure to provide the adaptive utensils increased the risk that R16 would lose his independence in eating. Findings include:The facility provided a form titled Best Practice: Adaptive Feeding Equipment dated 12/20/23. Per the document, the process for getting adaptive equipment included a therapy referral, followed by an order if necessary. The nursing department confirmed the order and communicated it to the dietary department and appropriate nursing staff and updated the care plan. Once notified, the dietary department updated the tray card. A review of R16's Face Sheet, found under the Census tab of the electronic medical record (EMR), revealed the resident was admitted to the facility on [DATE], with diagnoses including but not limited to: encephalopathy (brain dysfunction), dysphagia (difficulty swallowing), and dementia. On 12/10/25 at 12:13 PM, R16 was observed in the dining room, seated in his wheelchair. There was an untouched meal tray on a table nearby. Certified Nurse Assistant (CNA)6 was interviewed on 12/10/25 at 12:19 PM and she confirmed that the meal did belong to R16. CNA6 added that R16 typically did not eat much of his provided meal, but that he will drink and request coffee throughout the day. The meal ticket for the R16 was requested, but CNA6 confirmed that it was not on the meal tray. Review of most the recent nutritional assessment, dated 11/21/25, revealed Nutrition/Goals/Monitoring and Evaluation: 87 yo [year old] feeding self, eating 50-100% of meals. Has adaptive feeding equipment to aid in self-feeding. Diet upgraded to mechanical soft from puree 11-21-25 per ST [speech therapy] . A review of R16's care plan, found under the Care Plan tab of the EMR, revealed that the resident is at risk for malnutrition due to abnormal labs.mechanically altered diet, poor intake. Interventions for this care plan focus included upgrading the resident's diet to mechanical soft, initiated 11/21/25 and adaptive feeding equipment initiated 11/17/25. A review of the R16's EMR, under the Orders tab, it revealed an order for Adaptive Feeding Equipment (Adaptive Utensil: built up handled utensils) to be provided during all meals to facilitate independence with self-feeding, with a start date of 11/19/25. The meal ticket was requested from the Dietary Manager (DM), who provided the ticket on 12/11/25 at 2:30 PM. The DM confirmed that the meal ticket did not indicate the resident had adaptive equipment and that the dietary staff was not aware of the order. He added that he did not have access to physician orders and that the therapy staff would have to inform the dietary department of updates. During an interview with the Rehabilitation Director, on 12/12/25 at 9:20 AM, he confirmed that the dietary department would not receive electronic notification of changes to diets or an addition of adaptive equipment. He added that they would typically hand deliver the changes to the dietary department. He was asked about the missing information for R16 and he stated that he could not explain it, but that someone missed the order and it did not make it to the dietary department.

Based on observation, interview, and record review, the facility failed to ensure the Daily Staff Posting contained the facility name, the actual hours of the nurses in each cottage, and whether or not the nurse was an RN (Registered Nurse) or LPN (Licensed Practical Nurse). This failure made visitors, families, and residents unaware of the current staffing levels in each cottage.Findings include:The facility had no written policy for staff posting.During an observation on 12/10/25 at 9:30 AM in Dogwood Cottage, the staff posting was observed on the wall in the day room. The staff posting did not show the name of the facility, had included one nurse and one CNA (Certified Nurse Assistant) on duty for both the 7:00 AM to 7:00 PM shift and the 7:00 PM to 7:00 AM shift. The posting did not include whether the nurse on duty was a Registered Nurse (RN) or a Licensed Practical Nurse (LPN).During an interview on 12/11/25 at 8:45 AM, Licensed Practical Nurse (LPN)15 was asked if she worked in her cottage for the entire shift. LPN15 stated, No, I am responsible for two cottages. The CNA is in this cottage for the whole shift. LPN15 was asked who was responsible for the Daily Staff Postings LPN15 stated, The nurse is. I put it up every morning. LPN15 was asked if you were not in this cottage from 7:00 AM to 7:00 PM then you are here only half the time. LPN15 stated, Yes. LPN 15 was asked if the 7:00 PM to 7:00 AM shift has one cottage. LPN15 stated, No, they sometimes have three cottages.During an interview on 12/11/25 at 9:12 AM, the Director of Nursing (DON) was told about the lack of information on the Daily Staff Postings. The DON acknowledged that the current Daily Staff Postings did not meet the regulatory requirements.

Based on observations, interviews, record review, and policy review, the facility failed to ensure that two Residents(R)93, and R107) of two residents sampled for restraints, were free from restraints. Specifically, R93 and R107 were observed seated in Broda chairs with chair alarms on, and with bed alarms situated on both of these beds. Additionally, there was no documentation that less restrictive methods were attempted. Continued use of the position alarms has the potential to cause a decline in physical functioning, including an increased dependance in activities of daily living (e.g., ability to walk), impaired muscle strength and balance, decline in range of motion, and risk for development of contractures. Findings include: Review of the facility's policy titled Restraint Policy dated 04/21, revealed, Policy Statement .restraints shall only be used to treat the resident's medical symptom(s) and never for discipline or staff convenience, or for the prevention of falls .Physical restraints are defined as any manual method, or physical, or mechanical device, material, or equipment attached or adjacent to the resident's body that the individual cannot remove easily .When the use of restraints is indicated, the least restrictive alternative will be used for the least amount of time necessary, and the ongoing re-evaluation for need for restraints will be documented .Restrained individuals shall be reviewed regularly to determine whether they are candidates for restraint reduction, less restrictive methods of restraints, or total restraint elimination. 1. Review of R93's undated Admission Record located in the EMR under the Profile tab, indicated the resident was admitted to the facility on [DATE], with diagnoses including dementia, muscle weakness, unsteadiness on feet, difficulty walking, and history of falling. Review of R93's quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 07/24/24, located in the EMR under the MDS tab with a Brief Interview of Mental Status (BIMS) score two out of 15, indicating the resident is severely cognitively impaired. Further review indicates resident was assessed as having chair and bed alarms. Review of R93's Physician Orders dated 02/14/24, located in the EMR under the Orders tab documented, Bed and chair alarms, check placement and function every shift and prn [as needed]. Review of R93's Care Plan dated 11/25/23 located in the EMR under the Care Plan tab documented, Falls: Resident is at risk for falls with or without injury related to antihypertensive medication, and history of falls. Interventions: .bed/chair alarms for poor safety awareness, check placement and function every shift and PRN. Observations on 10/29/24 at 2:30 PM and 10/31/24 at 12:30 PM, R93 was seated in a Broda wheelchair with a chair position alarm attached to the chair. During an interview on 10/31/24 at 1:39 PM, Registered Nurse (RN)2 was questioned concerning why R93 had position alarms located on his chair and bed. RN2 stated the resident is very impulsive and has had multiple falls. The alarms were put into place to prevent his falling. RN2 confirmed that there was no documentation in the EMR of the monitoring and assessment of the alarms. During an interview on 10/31/24 at 2:06 PM, the Nurse Practitioner (NP) was questioned why R93 had chair and bed alarms ordered. The NP responded that the resident has poor safety awareness, and has tried assorted sizes and shapes of wheelchairs, unsuccessfully. 2. Review of R107's undated Admission Record located in the EMR under the profile tab, indicated R107 was admitted to the facility on [DATE], with diagnoses including fracture of right humorous, muscle weakness, Parkinson's disease with dyskinesia with fluctuations, and dementia. Review of R107's admission MDS with an ARD of 10/10/24, located in the EMR under the MDS tab with BIMS score of seven out of 15, indicating the resident was severely cognitively impaired. The resident required substantial/maximal assistance for all mobility activities. Review of R107's Physician Orders dated 10/11/24, located in the EMR under the Orders tab revealed an order for bed/chair alarm to bed/chair at all times, every shift. Review of R107's Care Plan dated 10/07/24, located in the EMR under the Care Plan tab documented, Falls: Resident is at risk for falls with or without injury related to weakness, medications. Interventions: initiated 10/11/24 Bed/chair alarm every shift. Check positioning and functioning every shift. Observation's on 10/29/24 at 1:17 PM, and 10/31/24 at 1:32 PM, R107 was seated in a Broda wheelchair with a chair position alarm attached to chair. During an interview on 10/31/24 at 1:32 PM, RN2 was questioned why did R107 have a chair and bed position alarms in place. RN2 responded that R107 has Parkinsons and dementia, he gets very impulsive and tries to stand and falls. When asked if the resident has the ability to stand, RN2 stated, No. RN2 added the alarms are to help keep him from falling. RN2 confirmed that there was no documentation in the EMR of the monitoring and assessment of the alarms. During an interview on 10/31/24 at 2:02 PM, the NP was questioned on why R107 has the chair/bed alarms. The NP stated the resident has Parkinsons and dementia, he is very impulsive and has a complete lack of safety awareness. The resident is a fall risk and is not a candidate for removal of alarms. During an interview on 10/31/24 at 2:26 PM, the Director of Nursing (DON) was questioned concerning the use of the chair and bed alarms for R93 and R107. The DON responded that she expected the alarms to be care planned, the interventions and monitoring to be conducted and documented. The DON confirmed that there were no assessments, monitoring, or other interventions attempted related to the alarms. The DON stated that fall prevention was not a valid use for the alarms.

Based on record review, interview, and document review, the facility failed to revise the Preadmission Screening and Resident Review (PASARR) Level I for one of three residents (Resident (R) 34) reviewed for PASARR out of a sample of 29 residents when there was a new diagnosis of mental illness. This had the potential for a failure to identify what specialized or rehabilitative services the resident needed and whether placement in the facility was appropriate. Findings include: Review of R34's Profile tab of the electronic medical record (EMR) revealed she was admitted to the facility on [DATE] with diagnoses which included major depressive disorder, single episode, and generalized anxiety disorder. A new diagnosis of schizoaffective disorder was added on 09/01/23. Review of R34's PASARR Level 1 Screening Form, with review date of 03/25/24 and located in the Misc tab of the EMR, revealed mental illness diagnoses of anxiety and depression. Psychotropic medications listed included quetiapine 25 milligrams (mg) and Zoloft 50mg. Review of R34's Progress Notes tab of the EMR revealed a Nurse Practitioner (NP) Encounter note dated 06/16/23 where the NP ordered Abilify (aripiprazole- an antipsychotic medication) 2mg daily for delusions and paranoia. Review of NP Encounter note dated 09/01/23 stated to give aripiprazole 2mg daily for schizoaffective disorder. Review of the Orders tab of R34's EMR revealed an order for aripiprazole 2mg daily for schizoaffective disorder dated 09/01/23. Review of R34's Care Plan in the EMR under the Care Plan tab revealed a focus area initiated on 12/05/23 for antipsychotics. Review of R34's quarterly Minimum Data Set (MDS) with an Assessment Review Date (ARD) of 10/01/24, located in the MDS tab of the EMR, revealed Brief Interview for Mental Status (BIMS) score of 11 out of 15 which indicated moderate cognitive impairment. R34 had a diagnosis of schizophrenia (e.g., schizoaffective, and schizophreniform disorders) and received antipsychotic medication. Review of R34's EMR revealed there was no evidence of a new PASARR I screening after the facility added the schizoaffective disorder diagnosis. During an interview on 10/30/24 at 3:55 PM, the MDS Coordinator (MDSC) stated she entered the schizoaffective disorder diagnosis into the MDS when the NP documented it in a Progress Note. The MDSC reported she failed to inform the Social Services Director (SSD) who did the PASARRs of the new diagnosis and did not know if a new PASSAR screening was completed. During an interview on 10/30/24 at 4:34 PM, the SSD stated the facility was expected to complete a new PASARR Level I with a new diagnosis of schizoaffective disorder. The SSD was unable to locate a PASSAR completed by the facility which included the schizoaffective diagnosis. During an interview on 10/31/24 at 1:45 PM, the Director of Nursing (DON) stated she expected a new PASARR Level I to be completed when a resident had a new diagnosis of schizoaffective disorder. Review of the facility provided PASRR Training for Providers, dated 06/20/23, revealed, Referral to Level II for mental illness is not required for all applicants exhibiting behavior or adaptation problems. Only applicants who have or are suspected of having a serious mental illness must be referred to Level II. The checklist for mental illness indicators included diagnoses (confirmed or suspected): schizophrenia, . , and other mental disorder that may lead to a chronic disability ln cases where the individual is admitted to the nursing facility without the appropriate screening, the nursing facility will be responsible for completing the required screening and for arranging any specialized services or specialized rehabilitative services deemed necessary.

Based on interviews, record review, and policy review the facility failed to ensure for one Resident(R)295) of six residents sampled for accidents, maintained a safe, hazard free environment. Specifically, staff left a wooden chair next to the resident's bed and R295 supposedly hit her head on the arm of the chair, resulting in a laceration to her forehead that required sutures. Failure to ensure that residents have a safe and hazardous free environment could result in further accidents with injuries. Findings include: Review of R295's undated Admission Record located in the electronic medical record (EMR), under the Profile tab indicated the resident was admitted to the facility on [DATE], with diagnoses including Alzheimer's disease, difficulty in walking, and muscle weakness. Review of R295's admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 07/25/24 and the Brief Interview of Mental Status (BIMS) score was three out of 15, indicating the resident was severely cognitively impaired and was assessed as not exhibiting behaviors. The resident was wheelchair bound and dependent on staff for all activities of daily living (ADLs), including mobility in and out of bed. Further review of the MDS indicated the resident had sustained a fall with fracture within six months of admission to facility. Review of R295's Fall Risk assessment dated [DATE], located in the EMR under the Evaluation tab, indicated the resident's fall score was 32, indicating the resident was a high fall risk. The assessment indicated a score of 16-42 indicated high fall risk. Review of R295's Care Plan dated 05/16/24 and revised on 06/20/24 indicated, resident is at risk for falls with or without injury related to altered mental status, antihypertensive medication, antipsychotic medication, history of falls, and unsteady gait. Interventions included: keep bed in low position with brakes locked, keep call light within reach, keep personal items frequently used within reach, keep within supervised view as much as possible, safety devices as ordered: fall mat beside low bed when resident is in bed. Review of the Initial Report, dated 09/05/24 at 1:35 PM, revealed, Resident observed with a small left eyebrow laceration and hematoma. Resident was sent to the emergency room (ER) for evaluation and treatment. Resident returned to facility with six sutures to her left eyebrow. The 5-day investigation report, submitted by the Director of Nursing (DON) indicated, On the morning of September 5, 2024, Administrator, Assistant DON (ADON), and DON went into R295's room to evaluate her and her room. The resident was in bed. She was noted to have sutures intact to her left eyebrow. Her bed was in a low position with a fall mat beside her bed. There was a wooden chair at her bedside with the arm of the chair at the level of the blood, there was noted to be a small amount of blood on the right chair arm. CNA (Certified Nurse Aide) stated she used the chair to feed the resident if she is still in bed, and never thought it would be a potential problem. The wooden chair was removed from the room and a recliner was placed. During an interview on 10/31/24 at 11:33 AM, CNA2 stated that the night shift CNA (CNA1's name) noticed the bruise on R295. CNA2 was questioned concerning R295's mobility, and behaviors. CNA2 stated R295 could be combative at times and was a total assist. The resident spoke incoherently, and sometimes CNA2 fed R295 her meal in her room. During an interview on 10/31/24 at 11:57 AM, Registered Nurse (RN)1 was questioned about the incident with R295. RN1 stated that she was in another cottage, and just left there, approximately 9-9:30 AM. CNA1 stopped her and told her (R295's name) had blood all over her head and that she (CNA1) had called the supervisor and left a voice mail. RN1 stated that she entered F295's room and the resident was lying in bed with her head tilted a little bit. RN1 stated that she assessed her wound, called emergency medical services (EMS), and that a wooden chair was sitting in front of resident, facing the resident. RN1 stated R295 was not alert and oriented, was incomprehensible, and that she has never seen her get up. During an interview on 10/31/24 at 12:30 PM, CNA1 stated that she was making rounds, and when she entered the resident's room, she saw that R295 had blood all over her face, clothing, and sheet. She immediately called the supervisor, there was no answer, she left a voicemail and went to get the nurse. Stated she did not recall if there was a chair in the room or not. During an interview conducted on 10/31/24 at 3:21 PM, the DON stated she went to see the resident who was lying in bed and unable to tell her what had happened. There was a wooden chair right at the level of the bed. The DON stated that she started an investigation, interviewed staff and other residents. CNA1 told her she found the resident like that and that she had notified the supervisor. When asked why the chair was at the bedside, CNA1 told her it was used to feed the resident. The DON noticed a small amount of blood on the chair's arm. CNA1 told her she doesn't remember leaving the chair there. The DON reached the conclusion that the resident pulled the chair onto her causing the laceration to the eyebrow.

Based on interviews, record review, and policy reviews the facility failed to ensure that one Resident(R)93 of five residents sampled for unnecessary medications was monitored for behaviors, side effects and efficacy of an antipsychotic medication. The failure to monitor for adverse effects and efficacy does not ensure the safe administration and dosing of the resident's antipsychotic medications. Findings include: Review of the facility's policy titled Antipsychotic Medication Use dated 07/22 indicated, staff will observe, document, and report to the attending physician information regarding the effectiveness of any interventions, including antipsychotic medications. Nursing staff shall monitor for and report any of the following side effects and adverse consequences of antipsychotic medications to the attending physician: general/anticholinergic: constipation, blurred vision, dry mouth urinary retention, sedation. Cardiovascular: orthostatic hypotension, arrhythmias. Metabolic: increase in total cholesterol triglycerides, unstable or poorly controlled blood sugar, weight gain; or Neurologic: akathisia, dystonia, extrapyramidal effects, akinesia; or tardive dyskinesia, stroke, or TIA [Transient Ischemic Attack]. Review of R93's undated Admission Record located in the electronic medical record (EMR) under the Profile tab, indicated the resident was admitted to the facility on [DATE], with diagnoses including anxiety disorder, Parkinson's disease with dyskinesia, and dementia. Review of R93's Physician Orders dated 10/19/24, located in the EMR under the Orders tab, revealed an order for Quetiapine Fumarate (an antipsychotic medication) 25 milligram (mg) at bedtime for Parkinson's psychosis. Review of R93's October Medication Administration Record (MAR) and Treatment Administration Record (TAR) revealed there was no monitoring of behaviors, efficacy, or side effects related to the antipsychotic medication administered. During an interview on 10/31/24 at 1:37PM, Registered Nurse (RN)2 confirmed there was no documentation of the monitoring of behaviors, efficacy, or side effects for R93's use of antipsychotic medication, and that there should have been. During an interview on 10/31/24 at 2:20 PM, the Director of Nursing (DON) was questioned concerning what the expectation of staff was monitoring for behaviors, efficacy, and adverse reactions to antipsychotic usage. The DON responded that the orders for antipsychotic medications are to be flagged for behavioral monitoring and side effects. The DON stated it was missing during chart audits.

Based on review of facility policy, record review, interview, and observation, the facility failed to report, to the state agency, an allegation of sexual abuse involving Resident (R)1's and R2's, for 2 of 2 residents reviewed for abuse. Findings include: Review of the facility policy titled, Abuse, Neglect, Exploitation or Misappropriation- Report and Investigation last revised in August 2022, revealed, All reports of resident abuse . are reported to local, state, and federal agencies . Findings of all investigations are documented and reported. 1. c. Resident to resident altercations-Sexual Contact- Required to report immediately but no later than 2 hours- . Sexual activity or fondling where one of the resident's capacity to consent to sexual activity is unknown. Review of R1's Face Sheet revealed R1 was admitted to the facility on [DATE], with diagnoses including but not limited to: encephalopathy, hypertension, Type 2 Diabetes Mellitus, GERD, anxiety disorder, suicidal ideation, depression, and Dementia with behavior disturbances. Review of R1's Quarterly Minimum Data Sheet (MDS) with an Assessment Reference Date (ARD) of 04/30/24, revealed R1 had a Brief Interview for Mental Status (BIMS) score of 6 out of 15, indicating R1 was severely cognitively impaired. Review of R2's Face Sheet revealed R2 was admitted to the facility on [DATE], with diagnoses including but not limited to: atrial fibrillation, Type 2 Diabetes Mellitus, COPD, Chronic Kidney Disease, duodenitis without bleeding, and hypoglycemia. Review of R2's Quarterly MDS with an ARD of 03/19/24, revealed R2 had a BIMS score of 13 out of 15, indicating R2 was cognitively intact. During an interview on 05/30/24 at 11:16 AM, Certified Nursing Assistant (CNA)1 revealed on the night of the allegation, she knocked on R1's door to provide care but the door was blocked. CNA1 states she went to get the nurse because she could not get into the room. When the door was opened, both residents were disrobed and standing beside the bed. CNA1 further stated that R1 was upset, yelling, and crying, stating she did not mean to do it. During an interview on 05/30/24 at 11:40 AM, Registered Nurse (RN)1 revealed that when the door was open, she found both residents disrobed from the waist down. R2 was asked to leave the room and he became very upset and said he was not going anywhere, because R1 asked him to come into her room. RN1 states that she spoke to R1 after R2 left the room and R1 stated that R2 did not do anything wrong, and R1 asked him to come into the room. RN1 further stated that R1 was upset because she was embarrassed about the incident. RN1 states R2 was sent out to the ER because he became upset and non-compliant after being told he could not go back into the room. RN1 states that R2 did not have a history of inappropriateness towards any other resident. During an interview on 05/30/24 at 3:50 PM, the Nurse Practitioner (NP) revealed that he spoke with R1 the day after the incident. The NP states at first, R1 denied the allegation, but eventually stated, she initiated it, and she did not want that man to get into trouble because he did not do anything wrong. The NP stated that R1 asked R2 into her room because she wanted to be with someone and R2 was the only man that was ambulatory on the unit, so that's why she chose to invite him into her room. During an interview on 05/30/24 at 3:55 PM, the Assistant Director of Nursing (ADON) revealed R2 was more abrasive when trying to talk to about the allegation. R2 kept saying she invited me in. the ADON states the police were called to make a report, but did not file a report because R1 expressed it was consensual. During an interview on 05/30/24 at 4:50 PM, the Director of Nursing (DON) revealed that she did not report the incident to the state agency because the incident was consensual.

Based on review of facility policy, record review, interview, and observation, the facility failed to report, to the state agency, an allegation of sexual abuse involving Resident (R)1's and R2's, for 2 of 2 residents reviewed for abuse. Findings include: Review of the facility policy titled, Abuse, Neglect, Exploitation or Misappropriation- Report and Investigation last revised in August 2022, revealed, Findings of all investigations are documented and reported. 1. c. Resident to resident altercations-Sexual Contact- Required to report immediately but no later than 2 hours- . Sexual activity or fondling where one of the resident's capacity to consent to sexual activity is unknown. Investigating Allegations 1. All allegations are thoroughly investigated. The administrator initiates investigations . 7. The individual conducting the investigation as a minimum: a. Reviews the documentation and evidence. b. Reviews the resident's medical record to determine the resident's physical and cognitive status at the time of the incident and since the incident. l. Documents the investigation completely and thoroughly. Review of R1's Face Sheet revealed R1 was admitted to the facility on [DATE], with diagnoses including but not limited to: encephalopathy, hypertension, Type 2 Diabetes Mellitus, GERD, anxiety disorder, suicidal ideation, depression, and Dementia with behavior disturbances. Review of R1's Quarterly Minimum Data Sheet (MDS) with an Assessment Reference Date (ARD) of 04/30/24, revealed R1 had a Brief Interview for Mental Status (BIMS) score of 6 out of 15, indicating R1 was severely cognitively impaired. Review of R2's Face Sheet revealed R2 was admitted to the facility on [DATE], with diagnoses including but not limited to: atrial fibrillation, Type 2 Diabetes Mellitus, COPD, Chronic Kidney Disease, duodenitis without bleeding, and hypoglycemia. Review of R2's Quarterly MDS with an ARD of 03/19/24, revealed R2 had a BIMS score of 13 out of 15, indicating R2 was cognitively intact. During an interview on 05/30/24 at 11:40 AM, Registered Nurse (RN)1 revealed, she found both residents disrobed from the waist down. R2 was asked to leave the room and he became very upset and said he was not going anywhere, because R1 asked him to come into her room. RN1 states that she spoke to R1 after R2 left the room and R1 stated that R2 did not do anything wrong, and R1 asked him to come into the room. RN1 further stated that R1 was upset because she was embarrassed about the incident. RN1 states R2 was sent out to the ER because he became upset and non-compliant after being told he could not go back into the room. RN1 states that R2 did not have a history of inappropriateness towards any other resident. During an interview on 05/30/24 at 3:55 PM, the Assistant Director of Nursing (ADON) revealed R2 was more abrasive when trying to talk to about the allegation. R2 kept saying she invited me in. The ADON states the police were called to make a report, but did not file a report because R1 expressed it was consensual. During an interview on 05/30/24 at 4:50 PM, the Director of Nursing (DON) revealed that she did not report the incident to the state agency because the incident was consensual.

Based on observations, interviews, record review, and facility policy review, the facility failed to ensure a comfortable and homelike environment was provided for 3 (Resident (R)1, R2 and R3) of 3 sampled residents whose rooms and common areas were reviewed. Specifically, the facility failed to properly clean resident rooms and common areas and failed to follow their Homelike Environment policy. Findings include: Review of facility policy titled, Homelike Environment revised in 02/21 stated, Resident are provided with a safe, clean, comfortable and homelike environment . 2. The facility staff and management maximizes, to the extent possible, the characteristics of the facility that reflect a personalized, homelike setting. These characteristics include: a. clean, sanitary and orderly environment;. Review of a Face Sheet revealed R1 had diagnoses including but not limited to displaced Trimalleolar fracture of right lower leg, low back pain , generalized anxiety, sprain of unspecified ligament of left ankle. Review of admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 06/09/23 revealed there was no MDS data available. Review of a Face Sheet revealed R2 had diagnoses including but not limited to heart Failure, type 2 diabetes, muscle weakness, anxiety disorder, major depressive disorder. Review of a quarterly MDS dated [DATE] revealed the resident scored 15 on a Brief Interview for Mental Status (BIMS), indication the resident was cognitively intact. Review of a Face Sheet revealed R3 had diagnoses including but not limited to difficulty in walking, Pneumonia, Polyosteoarthritis, dysphagia, anxiety, unsteadiness on feet. Review of a quarterly MDS with an ARD of 05/24/23 revealed the resident scored 13 on a BIMS, indicating that the resident was cognitively intact. Observation on 06/15/23 at 9:55 AM of Crepe [NAME] cottage revealed dust and debris in the common area on various items. Observation on 06/15/23 at 9:59 AM, [NAME] Cottage revealed a dirty linen cart and trash cans with no bags in rooms [ROOM NUMBERS]. Copious amounts of dust and dirty was also observed in the common area on the counter and on other various items. Observation on 06/15/23 at 10:04 AM of Camelia Cottage revealed dirty line cart dusty counters and black around the corners of the floors in resident bathrooms and rooms. Observation on 06/15/23 at 10:08 AM of Dogwood Cottage revealed a dirty linen cart. Observation on 06/15/23 at 10:13 AM of the [NAME] Cottage revealed wet tissue in the shower drain in room [ROOM NUMBER]. Observation on 06/15/23 at 10:18 AM of Forsythia Cottage revealed no trash bags in the trash cans in multiple resident rooms. A empty and unused resident bed was observed sitting in the hall and dust was observed on the counter. Observation on 06/15/23 at 10:22 AM of the [NAME] Cottage revealed dirty linen carts and dust in the common area on several items, and trash bags missing from the cans. Observation on 06/15/23 at 10:26 AM of the Tea Olive Cottage revealed dirt crumbs and dust on the counter in the common area. Observation cottage on 06/15/23 at 10:30 AM of the Rhododendron Cottage revealed a dirty line cart with black stains on it and a dusty counter in the common area. Observation on 06/15/23 at 10:30 AM of the Lilac Cottage revealed resident rooms [ROOM NUMBERS] with no trash bag in the cans. Observation on 06/15/23 at 10:34 AM of the Magnolia Cottage revealed artificial flowers in the common area covered in dust and the counter covered with dust and debris. Observation on 06/15/23 at 10:39 AM the [NAME] Cottage revealed dust and debris in the common area on several items and equipment. Observation on 06/15/23 at 1:25 PM of room [ROOM NUMBER] located in the [NAME] Cottage revealed a loose sink faucet in the bathroom and a black substance on the floors, there was not a phone located in the room and there was damage to one wall exposing the white interior. There was a wet tissue paper roll sitting on the handrail. During an interview on 06/15/23 at 11:25 AM, R1 stated her room was not clean upon her arrival on the morning of 06/09/23, it did not have phone and the outlet located behind the bed was covered in soot from what appeared to be an previous electrical shortage. R1 stated that there was dust on her lamp shade and that the bathroom floors looked as if they had not been clean in a while. During an interview on 06/15/23 at 1:32 PM, the Environmental Supervisor (EVS) stated that she provide housekeepers with a daily and weekly task list. The EVS states her expectations are to sweep, mop, wipe all surfaces, and clean common areas daily. The EVS also stated that on Fridays they dust the cottages. EVS revealed that they only wash the cloth coverings on the linen carts if they have blood or other bodily fluids on them. During an interview on 06/15/23 at 3:15 PM, R2 stated that he reported the mold on his ceiling to CNAs and has reported it during resident council meetings. R2 reported that housekeeping does not always clean his room and sometimes the just dump the trash and that's all. During an interview on 06/15/23 at 5:15 PM, Certified Nursing Assistant (CNA) stated that housekeeping services at the facility could be better, she also noted that all staff members are responsible for taking out the trash in resident room and not just housekeeping. CNA stated that she was working the night that R1 was at the facility and don't remember if she saw housekeeping clean the resident's room. An attempt was made to interview Licensed Practical Nurse (LPN)1 with no success.

Based on review of facility policy, interview and record review, the facility failed to ensure 1 of 1 resident reviewed for medications was free of significant medication errors. Resident (R)2 was not administered medications as ordered that were prescribed by a physician. Findings include: Review of the facility's policy titled Documentation of Medication Administration with a revised date of April 2018 revealed The facility shall maintain a medication administration record to document all medications administered. Review of a Face Sheet revealed R2 had diagnoses including but not limited to heart Failure, type 2 diabetes, muscle weakness, anxiety disorder, major depressive disorder. Review of a quarterly MDS dated [DATE] revealed the resident scored 15 on a Brief Interview for Mental Status (BIMS), indicating the resident was cognitively intact. Review of R2's Medication Orders revealed R2 was prescribed Amoxicillin Capsule 500 mg on 05/06/23 with the directions to Give 4 capsule by mouth one time a day for dental procedure for 1 day with a start date of 05/09/23. Review of R2s Progress Note titled Infection Note dated 05/06/23 at 12:00 PM revealed resident continues on abt tx, no s/sx of any adverse reactions noted, resident is able to make needs known, resident also started on a amoxicillin today for 4 days r/t dentist appointment on may 9th, as a preventative. Review of R2's Progress Note dated 05/08/23 revealed Amoxicillin Oral Tablet 500 MG Give 4 tablet by mouth one time only for 4 TABLETS for prophylaxis before dental appt tuesday for 1 Day resident needs to take tomorrow Review of R2's Medication Administration Record revealed that on 05/06/23 at 1300 R2 was given 4 capsules of Amoxicillin 500 mg. Further review of R2's MAR revealed that on 05/09/23 R2 was not administered Amoxicillin 500 mg as ordered. During an interview on 06/15/23 at 3:15 PM, R2 reported not receiving his Amoxicillin correctly on multiple occasions. R2 reported that a nurse gave him 1 tablet of Amoxicillin on a Saturday and told him that is it what the doctor ordered. R2 stated he is ordered to receive 4 tablets, 1 hour before his dentist appt, and that over the course of 4 to 5 days he received 8 tablets and from that he had diarrhea for multiple days after. R2 also reported that he voiced his concerns of receiving the wrong medication from a nurse on night shift.

Based on review of the facility policy titled, Admission Assessment and Follow Up: Role of the Nurse, record reviews and interviews, the facility failed to accurately assess, upon admission Resident (R)1, in order to initiate a baseline care plan that included all the needs to give accurate, quality care for R1. Specifically the baseline care plan for R1 did not include isolation for Flu and the need for oxygen. The facility further failed to complete an accurate admission assessment to include Flu and the need for oxygen. Findings include: Review of the facility policy titled, Admission Assessment and Follow Up: Role of the Nurse, states, The purpose of this procedure is to gather information about the resident's physical, emotional, cognitive, and psychosocial condition upon admission for the purpose of managing the resident, initiating the care plan, and completing required assessment instruments, including the MDS (Minimum Data Set) assessment. Review on 04/11/2023 at 10:28 AM of the Baseline Care Plan for R1 included oxygen therapy, however it did not indicate the route of administration.The Admission assessment dated [DATE] revealed no indication of R1 requiring oxygen, no amount per nasal cannula and his need for oxygen. The Admission Assessment states under section F. Respiratory 1a. states no shortness of breath and 1b. no equipment. Review on 04/11/2023 at 11:45 AM of the hospital discharge orders dated 12/09/2022 revealed diagnoses of chronic obstructive disease, shortness of breath, and a pulmonary nodule. Further review of the discharge summary for R1, indicated a diagnosis of Flu. The orders also indicated that R1 had had surgery for a femoral fracture and during repair surgery he required oxygen at 4 liters per minute. He usually requires 2 liters per nasal cannula at night. Additional review of R1's baseline care plan did not indicate his active diagnosis of Flu or the need for isolation. During an interview on 04/11/23 at 12:08 PM with Licensed Practical Nurse (LPN)1, the nurse who received the R1 at time of admission, could not remember R1, the assessment nor the baseline care plan. However, LPN1 confirmed the findings.

Based on review of the facility policy titled, Medication Orders,resident discharge summary, medical record reviews, and interviews, the facility failed to ensure Resident (R)1 received ordered medication timely. Findings include: Based on review of the facility policy titled, Medication Orders, revealed, The purpose of this procedure is to establish uniform guidelines in the receiving and recording of medication orders. Under recording orders, #3 states, When recording orders for oxygen, specify the rate of the flow, route and rational. The facility failed to ensure physician ordered medications were administered for R1, a new admission in a timely manner. Review of the discharge summary from the hospital, R1 was to receive oxygen therapy for diagnoses including, but not limited to chronic obstructive pulmonary disease, shortness of breath and a pulmonary nodule. R1 had a diagnosis of Flu 2 (two) days prior to admission into the facility. Review of the Medication Administration Record (MAR) on 04/11/23 at 10:20 AM revealed R1 was admitted to the facility on [DATE] in the afternoon. The exact time of admission is not recorded. The MAR indicated that R1 did not receive his 5:00 PM, 9:00 PM, and 10:00 PM medications. He also had missed the 5:00 PM dose on 12/09/2022 and the 9:00 AM dose of Tamiflu on 12/10/2022 ordered to be given 2 times daily. The medications missed were Atorvastatin Calcium 40 milligrams (mgs) at bedtime on 12/09/22 and Melatonin 3 mgs at 9:00 PM on 12/09/2022. R1 had also missed Sinemet CR extended release 50-200 mg for Parkinson's Disease to be given at 9:00 PM and Trazodone HCI 50mg for Insomnia. He had missed Aspirin chewables 81 mg at 5:00 PM. Additional medications not received on 12/09/2022 included Acetaminophen 1000 mgs at 10:00 PM for mild pain and another dose of Carbidopa-Levodopa 25-100 mgs at 10:00 PM. During an interview on 04/11/2023 at 11:45 AM, the Director of Nursing stated that when residents come in the afternoon, the facility has no way of getting medications until the next day. She denied having a back up pharmacy. An interview on 04/11/2023 at 12:15 PM with the Nurse Consultant (NC) confirmed that the facility does have a backup pharmacy. The NC could not verify why the medications were not retrieved from the backup pharmacy.

Based on review of the facility policy titled, Isolation - Initiating Transmission - Based Precautions, the facility failed to ensure Resident (R)1, who was admitted with a diagnosis of Flu was placed on isolation at admission for 1 of 2 residents admitted with the Flu virus. Findings include: Based on the facility policy titled, Isolation - Initiating Transmission - Based Precautions, states as the policy statement, Transmission- Based Precautions are initiated when a resident develops signs and symptoms of a transmissible infection, arrives for admission with symptoms of an infection, or has a laboratory confirmed infection; and is at risk of transmitting the infection to other residents. Transmission -Based Precautions may include Contact Precautions, Droplet Precautions, or Airborne Precautions. The facility makes every effort to use the least restrictive approach to managing individuals, with potentially communicable infections. Transmission-Based Precautions are used only when the spread of infection cannot be reasonable prevented by less restrictive measures. Number 3 states under the Policy Interpretation and Implementation, : When Transmission-Based Precautions are implemented, the Infection Preventions (or designee): a. Clearly identified the type of precautions, the anticipated duration, the personal protective equipment (PPE) that must be used. d. states, Determines the appropriate notification on the room entrance door and on the front of the resident's chart. The signage informs the staff of the type of CDC precaution (s), instructions for use of PPE, and/or instructions to see a nurse before entering a room. R1 was not put on Transmission - Based Precautions for a diagnoses of the Flu upon admission. Review on 04/11/2023 at 10:50 AM of the Admission Assessment for R1 is checked for Standard Precautions, and no indications that R1 was placed on Transmission - Based Precautions upon admission. During an interview on 04/11/2023 at 12:15 PM, the Director of Nursing did agree and state that if a resident is admitted and has a diagnosis of Flu that should be placed on Transmission - Based Precautions at time of admission.

Based on policy review, record review, and interview, the facility failed to ensure 4 of 4 residents and/or their representatives (Resident (R) 13, R32, R114, and R134) reviewed for an emergent discharge to the hospital out of a total sample of 30 were provided with a written notice transfer notice that included all required information. The facility's transfer notice forms did not include information on how to appeal, if desired. In addition, although transfer forms prepared by the facility were provided to Emergency Medical Services (EMS) and the hospital where the resident was being transferred, the facility failed to assure that both the resident and their representative also received the forms. This failure has the potential to affect the resident and/or their Resident Representative (RR) in not having the knowledge of where and why a resident was transferred, and/or how to appeal the transfer, if desired. Findings include: Review of the facility policy titled Transfer or Discharge, Emergency, revised 08/2018, revealed, Policy Statement: Emergency transfers or discharges may be necessary to protect the health and/or well-being of the resident(s) . 4. Should it become necessary to make an emergency transfer or discharge to a hospital or other related institution, our facility will implement the following procedures . d. Prepare a transfer form to send with the resident; e. Notify the representative (sponsor) or other family member. On 09/14/22 at 12:50 PM, the Administrator also provided a page from the admission packet that stated, (8) Termination of Agreement, Discharge and Transfer .The notice will set forth the reason for the transfer or discharge and the effective date of the transfer or discharge. The notice will also set forth Resident's rights to a hearing to appeal the Facility's decision to discharge or transfer Resident. 1. Review of R13's Admission Record from the electronic medical record (EMR) showed a facility admitted [DATE] with medical diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] Interview with R13's RR (RR13) on 09/13/22 at 12:14 PM revealed that R13 was sent to the hospital in June for a [CONDITION(S)] after a fall in the facility. Review of the EMR Progress Notes tab revealed that, Effective Date: 06/06/22 07:06 [7:06 AM] Type: Health Status Note: Resident was walking in living room area when she lost balance and fell near the book shelf. Notified [management] and will notify [RR13]. Review of the EMR Census tab confirmed R13 was on Hospital Leave effective 06/08/22. Further review of the EMR revealed a Late Entry: Effective Date: 06/15/22 14:52 [2:52 PM] Type: Skin/Wound Note which showed the resident was readmitted to the facility after repair of a [CONDITION(S)] Review of the resident's record revealed no evidence that a written notice, with all required information, was provided to both the resident and their representative at the time of the transfer to the hospital. In response to a request for evidence that a written notice was provided to all required parties at the time of transfer, the Director of Nursing (DON) provided a SNF/NF [Skilled Nursing Facility/Nursing Facility] to Hospital Transfer Form, dated 06/07/22. Review of this form revealed that it was a communication form between the facility and receiving hospital, which included the location to which R13 was being sent, the reason and date of transfer, and other information, including the resident's functional status, vital signs, skin/wound issues, medications, devices, immunizations, risk alerts, and property sent to the hospital with the resident. Review of this form revealed that it did not include any information on how to appeal the transfer. During a follow-up conversation on 09/14/22 at 9:10 AM, RR13 confirmed that the facility did not provide a written transfer notice to them at the time the resident was sent to the hospital, stating, No, I didn't get anything in writing. They [facility] called me, told me she had a fall and had swelling in the leg. The mobile x-ray found a fracture, facility called and asked which hospital I preferred to send her to. Interview on 09/14/22 at 12:15 PM with Licensed Practical Nurse (LPN) 1 revealed that, in addition to the hospital transfer form provided by the DON, the facility also utilized another form, titled, Transfer/Discharge Notice. Review of a blank copy of this form referenced by LPN1 revealed that it also failed to include information on how to appeal a transfer or discharge. LPN1 stated that two copies of each form (the 'SNF/NF To Hospital Transfer Form' and the 'Transfer/Discharge Notice were made and placed in two packets - one for the hospital, and one for EMS. When asked about the provision of a written transfer notice to the resident and their RR, LPN1 stated One [packet with the form] may be given to the resident but it's for the hospital. When asked if the transfer form she filled out was copied for the resident and RR, LPN1 stated, No, one goes to the EMS packet and one to the hospital packet. The family may sign it if they are at the bedside, but one goes to EMS and one to the hospital. They [the resident and RR] don't get a copy. Although the forms referenced above may have been sent to the hospital with the resident, the DON was unable to provide evidence that a written transfer notice, with all required information, was also provided to the RR at the time the resident was transferred to the hospital. 2. Review of R32's EMR Admission Record showed a facility admitted [DATE] and a readmitted [DATE]. Per a quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 07/26/22, the resident had moderate cognitive impairment, based on a Brief Interview for Mental Status (BIMS) score of 11/15. During an interview on 09/12/22 at 12:46 PM, R32 stated he had been sent to the hospital when the facility ran out of his [CONDITION(S)] medicine about two months ago. When asked if he had received a written notice of transfer, R32 responded, No, nothing in writing. Review of R32's EMR Progress Notes revealed, 7/11/2022 07:53 [7:53 AM] Nurses Note Note Text: Pt. is out to [name] hospital via stretcher by EMS [emergency medical services] r/t [related to] ongoing [CONDITION(S)] activity. [RR] has been notified and requested him to be sent to [name] ER. Further review of the EMR progress notes did not reveal any documentation of the provision of a written transfer notice to either the resident or RR. In response to a request for evidence that the resident and their representative were both provided a written transfer notice which contained all required information, the DON provided a SNF/NF to Hospital Transfer Form, dated 07/11/22. The form noted where R32 was being sent, the reason, and date, as well as the resident's functional status, belongings sent, vital signs, skin/wound issues, medications, devices, immunizations, and risk alerts. This form failed to include the resident's appeal rights. Further review of the form which the facility provided to the hospital revealed no evidence that the form which was to be sent to the hospital was also provided to the resident, and their representative, as required by the regulation. Review of the documentation provided by the DON revealed that it did not include the Transfer/Discharge Notice form referenced above. During an interview on 09/14/22 at 10:53 AM, the DON stated, There are two packets, one has 'SNF/NF to Hospital' transfer form, med list and face sheet and is given to EMS for the hospital. The second has a handwritten form [transfer notice] and that should be copied put into first envelope so both packets have the same things. When asked when/if the RR is provided a written transfer notice and how it is provided, the DON stated, the RR is not sent a copy of the notice. The Regional Director of Clinical Services (RDCS), who was also present during the interview, added, Medical records was saying they notify [the RR], but it is only by telephone. In an interview on 09/14/22 at 12:06 PM, Unit Manager (UM) 1 stated, I called the wife. The transfer discharge notice goes with him [the resident]. When asked how/if the RR received a written copy of the transfer notice, UM1 replied She [the RR] can get a copy when she comes in or she can get a copy when she goes to see him in the hospital. UM1 stated the SNF/NF Transfer to Hospital form goes to the hospital but confirmed no one at the facility was sending the RR anything in writing. The DON, who was also present during this interview, stated that, When social services does discharges, they educate about appeal process, but it's not on this form. 3. Review of R114's closed record review for hospitalization revealed an 09/10/22 Health Status Note in the EMR Progress Notes tab indicating the Nurse Practitioner ordered the resident sent to the hospital for evaluation and treatment due to elevated creatinine levels. In response to a request for evidence that the resident and the RR were provided a written transfer notice with all required information, the DON provided a SNF/NF to Hospital Transfer Form, dated 09/10/22, that stated where R114 was being sent, the reason and date, as well as functional status, belongings sent, vital signs, skin/wound issues, medications, devices, immunizations, and risk alerts. The form failed to include any information about the resident's right to appeal the transfer. Review of the documentation provided by the DON revealed that it did not include the Transfer/Discharge Notice form referenced above. During an interview on 09/14/22 at 12:15 PM regarding the transfer, LPN1 stated, I was looking thru the [resident's] labs and the creatinine was 7.3 acute renal failure. I called the NP [name] and received an order to send out immediately. The wife was at the bedside. When asked about transfer paperwork provided, LPN1 responded, There are two copies of each, the face sheet, the MAR [medication administration record], the transfer form and the form with the bed hold information that I sign. There are two packets, one for the hospital. When asked if the other packet was for the resident, LPN1 continued Well, I gave it to the wife to give to the hospital. The two packets, one is for EMS and one is for the hospital. Asked to clarify if any paperwork was given to the resident or RR, LPN1 clarified, One may be given to the resident but it's for the hospital. When asked if the transfer form she filled out was copied for the resident and RR, LPN1 stated, No, one goes to the EMS packet and one to the hospital packet. The family may sign it if they are at the bedside, but one goes to EMS and one to the hospital. They [the resident and RR] don't get a copy. Interview with R114's RR on 09/14/22 12:24 PM confirmed she was not provided a written transfer notice with all required information. RR114 stated the facility gave her an envelope when the resident was sent out to the hospital; however, she was told to give the envelope to the hospital, adding I didn't get anything to keep. RR114 then double checked, looking in her bag and confirmed there was nothing. 4. Review of R134's Transfer/Discharge Report in the EMR Profile tab, showed an admitted [DATE] with medical diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of R134's EMR Prog Note [Progress Notes] tab revealed that on 04/16/22 at 10:36 AM, a note that the resident called for help. enter room pt [patient] was leaning on right side unable to stand. Pt had increased confusion unable to make needs known. all sx [symptoms] noted are a change from her baseline. notified supervisor, family and MD [doctor]. Review of a SNF to Hospital Transfer Form revealed that in response to the change in condition, the resident was transferred to the hospital. Further review of R134's EMR Prog Note and Misc [Miscellaneous] tabs revealed no evidence that either the resident and/or their RR were provided a written notice of transfer, with all required information including appeal rights, at the time the resident was sent to the hospital on 04/16/22. A phone interview was conducted on 09/13/22 at 8:25 PM with R134's family member (FM134), who stated that they received a call between 10:00 AM or 11:00 AM on 04/16/22 from the RR (another family member), stating that a hospital had called about R134 needing a blood transfusion. Per FM134, the RR was not sure who had called him, or where R134 was currently located. When asked if R134's RR had received a written transfer notice, which included where R314 was transferred to and why, FM134 responded No, only the one call [RR] received asking for permission for the blood transfusion. Interview on 09/14/22 at 6:17 PM with the DON revealed there is a form signed at the time the resident is sent out it which talks about the transfer notice, bed hold rights, and other information which is sent with the resident to the hospital. In the situation with R134, the DON stated that verbal notice was given to the husband (RR) and then a copy of the transfer form was sent with the patient to be given to the hospital, and EMS also received a copy of the paperwork. The DON stated, It's like a two for one form. When asked about the written transfer notice required by regulation to be provided to the resident and the resident representative, the DON stated, I am aware there must be ink on the paper and we make every effort to do. The types of efforts include if they are here and the patient is cognitively enough, if not the verbal [notification] show more of a good faith effort, or nursing notes types up.

Based on interview, record review, and review of facility policy, the facility failed to ensure 4 of 4residents (Resident (R) 13, R32, R114, and R134) reviewed for hospitalization and/or their Resident Representative (RR) received a written bed hold notice upon emergent transfer to the hospital. This failure had the potential to contribute to possible denial of re-admission following a hospitalization for residents transferred emergently to the hospital. Findings include: 1. Review of R13's Admission Record from the electronic medical record (EMR) revealed a facility admitted [DATE]. Review of a SNF/NF [Skilled Nursing Facility/Nursing Facility] to Hospital Transfer Form, dated 06/07/22, revealed R13 was being sent to the hospital. Review of the EMR Census Tab revealed R13 was on Hospital Leave effective 06/08/22. Further review of the EMR revealed no evidence of the provision of a written bed hold notice to either the resident or RR at the time of this transfer. In response to a request for evidence that a written bed hold policy was provided to R13 or her RR, the facility provided a signed copy of an 03/29/21 Brushycreek [sic] Post Acute Nursing Home Agreement. Review of this form revealed that Page 10 included the Facility Bed Hold Policy. However, although the Director of Nursing (DON) provided evidence that the resident and RR received a copy of the bed hold policy at the time of admission in 2021, no evidence was provided that a copy of the bed hold notice was also provided at the time of the resident's transfer to the hospital in 06/2022. During an interview on 09/14/22 at 9:10 AM regarding receipt of a written bed hold policy at the time of the 06/2022 transfer, RR13 stated, I didn't have any idea they had the option of holding a bed after the 10 days. RR13 confirmed they did not receive written documentation of the facility's bed hold policy at the time that R13 was transferred to the hospital in 06/2022. 2. Review of R32's EMR Admission Record showed a facility admitted [DATE] and a readmitted [DATE]. Review of a quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 07/26/22, revealed the resident had moderate cognitive impairment, based on a Brief Interview for Mental Status (BIMS) score of 11/15. During an interview on 09/12/22 at 12:46 PM, R32 stated he had been sent to the hospital about two months ago when the facility ran out of his [CONDITION(S)] medicine. When asked if he had received a written bed hold policy at that time, R32 stated he did not remember receiving anything in writing about a bed hold. Review of R32's EMR Progress Notes revealed, 7/11/2022 07:53 [7:53 AM] Nurses Note Note Text: Pt. is out to [name] hospital via stretcher by EMS [emergency medical services] r/t [related to] ongoing [CONDITION(S)] activity. [RR] has been notified and requested him to be sent to [name] ER. In response to a request for evidence that a written bed hold policy was provided to R32 and his RR, the facility provided an 01/31/20 signed copy of a Brushycreek [sic] Post Acute Nursing Home Agreement which included bed hold information on page 10. Although the DON provided evidence that a copy of the bed hold notice was provided at the time of admission in 2020, the DON was unable to provide evidence that a written copy of the bed hold notice was also provided, per the regulation, to both the resident and their RR at the time of the 07/11/22 transfer to the hospital. During an interview on 09/14/22 at 10:53 AM regarding written bed hold policy provision, the Regional Director of Clinical Services (RDCS) stated, Just reading the regulation for [bed hold policies] where the admission bed hold notice is not enough. 3. During a closed record review for hospitalization , review of R114's EMR Admission Record showed an admitted [DATE]. Further review of the EMR Progress Notes tab revealed an 09/10/22 Health Status Note that the resident was being sent out to the hospital for evaluation and treatment due to elevated creatinine levels. In response to a request for documentation a written bed hold policy was provided to R13 or her RR, the facility provided a signed copy of an 08/30/22 Brushycreek [sic] Post Acute Nursing Home Agreement which included the bed hold policy. Although the DON provided evidence that a copy of the bed hold notice was provided at the time of admission in 2022, the DON was unable to provide evidence that a written copy of the bed hold notice was also provided, per the regulation, to both the resident and their RR at the time of the 09/10/22 transfer to the hospital. During an interview on 09/14/22 at 12:15 PM, Licensed Practical Nurse (LPN) 1 stated there were two copies of various forms completed at the time of transfer, including, the form with the bed hold information that I sign. There are two packets, one for the hospital. When asked if the other packet was for the resident, LPN1 continued Well I gave it to the wife to give to the hospital. The two packets, one is for EMS, and one is for the hospital. Asked to clarify if any paperwork was given to the resident or RR, LPN1 clarified, One may be given to the resident but it's for the hospital. When asked if the form she filled out was copied for the resident and RR, LPN1 stated, No, one goes to the EMS packet and one to the hospital packet. The family may sign it if they are at the bedside, but one goes to EMS and one to the hospital, they [resident and RR] don't get a copy. Interview with R114's RR on 09/14/22 12:24 PM, confirmed she was given an envelope at the time of the transfer, but was told to give it to the hospital. RR114 denied being given written information about the facility's bed hold notice at the time of the resident's transfer, stating, I didn't get anything to keep. RR114 then double checked, looking in her bag and confirmed there was nothing. In an interview on 09/14/22 at 10:08 AM regarding written bed hold notices upon emergent discharge, Unit Manager (UM) 2 stated, No, they get that in the packet they sign on admission. UM2 verified that a bed hold notice is not provided at the time a resident is transferred emergently. 4. Review of R134's Transfer/Discharge Report (a report with demographic and limited medical information) from the EMR Profile tab, showed an admitted [DATE] with medical diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of R134's EMR Prog Note [Progress Notes] tab showed a note on 04/16/22 at 10:36 AM that the resident had a change from her baseline, and staff notified the supervisor, family, and physician. Per a SNF /NF to Hospital Transfer Form, the resident was transferred to the hospital on 04/16/22 in response to this change in condition. Further review of R134's EMR in the Documents tab under the section, Admissions Packet, revealed a copy of a Bed Hold Notification form that was completed upon admission on 04/12/22. No other documentation was found in the EMR regarding written information about the facility's bed hold policies also being provided to R134 or his representative upon his transfer to the hospital on 04/16/22. During a phone interview on 09/13/22 at 8:25 PM with a family member (FM134), she stated that she received a call between 10:00 AM or 11:00 AM on 04/16/22, from the RR (a different family member) stating a hospital had called about R134 needing a blood transfusion. When asked if R134's RR had received written information about the facility's bed hold policy at the time the resident was transferred to the hospital, FM134 No, only the one call [RR] received asking for permission for the blood transfusion. Interview on 09/14/22 06:17 PM with the DON revealed that at admission, the Social Worker and whoever does the admission talks about bed hold and what the possible outcomes will be, such as if you are sent home and what might happen and if they need home health etc . Also, during admission discussion are held about the bed holds. In the situation with R134, the DON stated that verbal information (not a written notice) was provided to the husband (RR) at the time of the transfer to the hospital. The DON stated, I am aware there must be ink on the paper and we make every effort to do. The types of efforts include if they are here and the patient is cognitively enough, if not the verbal show more of a good faith effort, or nursing notes types up. The DON confirmed that a written bed hold notice was not sent to the RR at the time of the resident's transfer to the hospital stating that, Forms are not mailed, the original forms are sent with the resident, to the hospital.

Based on record review and interview the facility failed to ensure that a resident does not develop pressure sores unless the individual's clinical condition demonstrates that they were unavoidable. Resident #1 developed a Stage 2 pressure ulcer to the sacrum when the resident's air mattress was unplugged and deflated. There was no documentation of when the air mattress was found deflated or that the nurse assessed the resident at the time of the discovery. There was no order for treatment for [REDACTED]. One of one resident's reviewed for pressure ulcer. The findings included: Review of Resident #1's medical record revealed a Wound Care Progress Note dated 11/6/14 at 12:07 that indicated "Elder now with Stage 2 FA PU (pressure ulcer) to sacrococcygeal area 10 cm (centimeters) x 5 cm. Butterfly with irregularity. Wound bed beefy red - small amount of bleeding with cleansing. Edges are flat. Is on air mattress. Air mattress found unplugged Tuesday night on 3rd shift...". The RN Clinical Nurse Specialist stated the Tuesday night was on 11/4/14 during the 11:00 PM - 7:00 AM shift. Review of Resident #1's Nurse's Notes dated 11/4/14 revealed no documentation related to the resident's air mattress being found unplugged. There was no documentation of when the air mattress was found deflated or that the nurse assessed the resident's skin at the time of the incident. A Nurse's Note dated 11/4/14 at 10:02 AM indicated the RN Clinical Nurse Specialist completed a brief assessment of Resident #1 after the nurse's report. The RN Clinical Nurse Specialist noted [MEDICAL CONDITION] to the inner aspect of the right eye. In an interview with the surveyor on 2/10/15 at approximately 4:12 PM, the RN Clinical Nurse Specialist stated that s/he examined Resident #1 related to concerns of [MEDICAL CONDITION] and the resident's level of response. The RN Clinical Nurse Specialist did not assess the resident related to the air mattress being found unplugged. Review of Resident #1's Nurses Notes dated 11/5/14 at 2:44 PM indicated "....while adls (activities of daily living) provided this AM elder buttocks observed to be bleeding. supervisor called and came to assess. Area cleansed and duoderm placed....". Review of the facility's Incident Report dated 11/5/14 indicated it was completed by LPN(Licensed Practical Nurse) #1 the 7:00 AM- 3:00 PM nurse for Resident #1. The event occurrence date was noted as 11/5/14. The event detail indicated "It was reported to me that elders air mattress was found unplugged on the 11-7 shift and that elder's matress(sic) was completely flat leaving elder laying on metal bed frame. Bed was plugged back in and matress re-inflated. When 1st shift provided AM care elders buttocks observed to be bleeding. Nursing supervisor called and came to asses elder. Cleaned with wound cleanser and thin duoderm placed." Contributing factors were noted as "bed was pushed against the wall which pulled the plug out of the socket. Bed has been moved away from the wall. Oncoming staff notified to make sure bed does not get pushed all the way against wall and to be sure air mattress does not become unplugged." The Incident Report included the question was the use of a device or appliance involved in the development of the pressure ulcer. The report indicated yes the air mattress was involved in the development of the resident's pressure ulcer. The Incident Report indicated the physician, supervisor and nurse were notified of the incident. Review of Resident #1's Physician orders [REDACTED]. Resident #1 was sent out to the hospital 11/7/14 and returned to the facility on [DATE]. Resident #1's readmission orders [REDACTED]. Review of Resident #1's November 2014 Treatment Administration Record (TAR) revealed there was no treatment documented as administered for the Stage 2 pressure ulcer to the sacrum between 11/4/14 and 11/14/14. Further review of the November 2014 TAR revealed an order dated 11/13/14 for duoderm to bilateral Stage 2 after cleansing. In an interview with the surveyor on 2/10/15 at approximately 3:35 PM, the Nurse Manager stated that Resident #1's bed was found unplugged by the resident's son. The resident's CNA had changed the location of the outlet used for the air mattress so that it was visible by the time the Nurse Manager had gone to look into what happened. The Nurse Manger stated that previously the air mattress was plugged into an outlet behind the resident's nightstand. The Nurse Manager stated it was determined that the bed was moved while providing care and felt that was how the mattress became unplugged. The Nurse Manager was asked if any education was provided to the staff or if an investigation was completed. The Nurse Manager responded that there were no additional follow up after the CNA had changed the outlet used. In an interview with the surveyor on 2/10/15 at approximately 5:00 PM, the DON (Director of Nursing) stated that the information related to when Resident #1's air mattress was found unplugged may have been on the rounding log. The DON stated that the rounding log is not part of the resident's permanent medical record. The DON stated that the nurse should have documented on the incident and completed a body audit. The DON stated Resident #1 had a lot of skin integrity issues. At approximately 5:25 PM, the DON stated that rounding logs are only kept for 30 days and could not provide the log from 11/4/14. The DON also stated that the treatment to Resident #1's pressure ulcer was based on protocol and should have been placed on the resident's TAR. Review of the facility's Pressure Ulcer Prevention/Skin Tear Protocol revealed pressure ulcer prevention interventions and treatment of [REDACTED].