Every finding on record at Calibre Post Acute, LLC

Based on observation, record review, and interview, the facility failed to ensure care plan revisions and care plan meeting requirements occurred for 3 (R #9, R #19, and R #61) of 9 (R #4, R #7, R #8, R #9, R #10, R #11, R #19, R #61, and R #91) residents when staff failed to: 1. Ensure the IDT members participated in a care plan meeting within 7 days of the completion of the admission MDS assessment for R #19. 2. Revise the care plan with the most current resident information for R #9 and R #61. These deficient practices could likely result in the care plan not being updated with the most current resident conditions and appropriate interventions, staff being unaware of changes in care provided, and residents not receiving the care related to changes in their health status or healthcare decisions. The findings are: Timing R #19 A. Record review of R #19's admission Record (no date) revealed R #19 was admitted to the facility on [DATE]. B. Record review of R #19's MDS assessments revealed and admission MDS dated [DATE]. C. Record review of R #19's Multidisciplinary Care Conference note dated 01/26/26 revealed the following: 1. a care conference meeting was held for R #19 on 01/26/26 (not within 7 days after the completion of the admission MDS assessment). 2. staff documented that R #19's care plan was reviewed and updated. D. On 03/03/26 at 2:47 PM, during an interview with MDS Coordinator #1 the following was confirmed: 1. The IDT meets within 48 to 72 hours of the resident's admission to the facility. 2. They do not meet again within 7 days of completion of the admission MDS to review the care plan. Revisions R #9 E. Record review of R #9's admission Record, no date, revealed the following: 1. R #9 was admitted to the facility on [DATE]. 2. R #9 had the following diagnoses: a. Thrombocytosis (a condition characterized by an abnormally high platelet count). b. Hypertensive heart disease without heart failure (a critical, often asymptomatic stage of chronic high blood pressure where the heart adapts to increased workload). c. Atherosclerotic heart disease (hardening of the arteries in the heart from plaque building up gradually inside them). F. On 02/24/26 at 2:55 PM, during an observation and interview with R #9, the following was revealed: 1. Both of R #9's lower legs were swollen. 2. R #9's left arm was swollen. 3. R #9 stated he did not know why his left arm and legs were swollen. He also did not know what staff were doing about the swelling. G. Record review of R #9's physician's orders revealed the following: 1. An order dated 02/22/26, for furosemide (diuretic medication to help treat fluid retention (edema) and swelling that is caused by congestive heart failure) 40 mg once a day for edema. 2. An order dated 10/28/25 and discontinued on 02/21/26, for furosemide 20 mg once a day for edema. 3. An order dated 02/24/26, for furosemide 40 mg (Furosemide) two times a day for edema for 5 days, resume 40 mg daily after 5 days. H. Record review of R #9's quarterly MDS, dated [DATE], revealed staff documented R #9 was taking diuretic medication. I. Record review of R #9's care plan, revised 02/03/26, revealed staff did not document that R #9 had an order for diuretic medications or interventions in place to monitor R #9 for side effects of diuretic medication. J. On 03/02/26 at 10:33 AM, during an interview, MDS Coordinator #1 confirmed the following: 1. R #9 had orders for diuretic medication. 2. Diuretic medication is a high-risk medication (drugs that carry a significantly higher risk of causing severe patient harm or death when used improperly). 3. Staff documented on R #9's quarterly MDS that he was taking diuretic medication. 4. Staff did not document on R #9's care plan that R #9 was taking a diuretic medication or any interventions to monitor R #9 for the side effects of diuretic medication. 5. Staff were expected to document all high-risk medications and interventions to monitor high-risk medications on resident care plans. R #61 K. Record review of R #61's physician's orders revealed the following: 1. An order dated 01/10/26 to admit to hospice. 2. An order dated 02/25/26 to admit to hospice. L. Record review of R #61's care plan dated 01/12/26 revealed the following: 1. R #61 receives additional support services through hospice [name of local hospice provider]. 2. Staff did not update R #61's care plan to reflect the change in hospice providers. M. On 03/03/26 at 2:33 PM, during an interview with Unit Manager #2 the following was confirmed: 1. R #61 was originally admitted to hospice on 01/10/26. 2. R #61's first hospice care provider went out of business. 3. R #61 was admitted to a different hospice care company on 02/10/26.

Based on record review and interview, the facility did not maintain ongoing communication and collaboration with the dialysis (clinical purification of blood as a substitute for the normal function of the kidney) facility regarding dialysis care and did not monitor the resident before and after dialysis treatment for 1 (R #7) of 1 (R #7) residents reviewed for dialysis care. This deficient practice could likely result in the facility being unaware of the resident's condition, possible complications that arise during dialysis treatment, and residents may not receive the appropriate monitoring and care. The findings are: A. Record review of R #7's admission record, no date, revealed R #7 had a diagnosis of end stage renal disease (ESRD; chronic irreversible kidney failure). B. Record review of R #7's physician orders revealed an order, dated 01/09/26, for R #7 to have dialysis Tuesdays, Thursdays, and Saturdays at 09:30 AM. C. Record review of R #7's Electronic Medical Record (EMR) revealed staff did not document any dialysis communication on the following dates: 1. 01/10/26 2. 01/13/26 3. 01/15/26 4. 01/17/26 5. 01/20/26 6. 01/22/26 7. 01/24/26 8. 01/27/26 9. 01/29/26 10. 01/31/26 11. 02/03/26 12. 02/05/26 13. 02/07/26 14. 02/10/26 15. 02/12/26 16. 02/14/26 17. On 02/17/26, staff completed pre-dialysis information, and the dialysis center completed dialysis information, but the form did not include any post dialysis monitoring or assessments. 18. On 02/19/26, staff completed pre and post dialysis information, and the dialysis center completed dialysis information. 19. On 02/21/26, staff completed pre dialysis information, and the dialysis center completed dialysis information; however, the form did not include any post dialysis monitoring or assessments. 20. On 02/24/26, staff did not document any dialysis communication. 21. On 02/26/26, staff completed pre and post dialysis information, and the dialysis center completed dialysis information. D. On 02/27/26 at 11:30 AM, during an interview, the DON stated a nurse should complete the dialysis communication sheets when R #7 leaves and returns from dialysis. The DON confirmed the dialysis communication sheets were not completed on the above dates.

Based on record review and interview, the facility failed to ensure residents have written, signed, and dated progress notes at each visit from the provider (physician or nurse practitioner) for 1 (R #43) of 1 (R #43) resident reviewed for physician's visits, when they failed to have R #43's mental health provider: 1. Write, sign and date their progress notes at the time of the visit. 2. Provide their progress note to the facility at the time of the visit. This deficient practice could likely result in the residents' needs not being met due to facility not being provided with the most current and accurate information. The findings are:A. On 02/24/26 at 2:35 PM, during an interview with R #43 she stated she was seen by the mental health provider at the facility, and he increased her anxiety medication approximately four days ago. B. Record review of R #43's mental health progress notes revealed: 1. The most recent mental health visit note was for encounter date (date of visit) 01/16/26, the NP did not electronically sign the note until 01/27/26. 2. There were no visit notes for February 2026. C. On 03/03/26 at 2:59 PM, during an interview with Medical Records staff, she confirmed the following: 1. The mental health provider does not document his visit notes in the facilities electronic medical record at the time of the visit. 2. The mental health provider does not provide the facility with a written, signed and dated progress note after each visit.

Based on record review and interview, the facility failed to ensure the consultant pharmacist's recommendations were reviewed and implemented by the physician and/or the physician provided documentation of a rationale (set of reasons or a logical basis for a course of action) for not following the consultant pharmacist's recommendation in a timely manner for 4 (R #11, R #18, R #43 and R #48) of 6 (R #8, R #11, R #18, R #43, R #48 and R #57) residents reviewed for unnecessary medications. This deficient practice could likely result in residents being at a higher risk of adverse side effects and residents receiving medications that are no longer necessary. The findings are:R #11 A. Record review of R #11's admission record, no date, revealed he was admitted to facility on 01/13/25 and has the following diagnosis: 1. Vascular Dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance and anxiety. 2. Major depressive disorder, recurrent, moderate (characterized by multiple depressive episodes with significant symptoms and functional impairment that cause problems in day-to-day activities but do not completely disrupt daily life). B. Record review of R #11's orders dated 08/05/25 revealed the following order: 1. Escitalopram Oxalate Oral Tablet 5 mg (milligrams) give 5 mg by mouth one time a day for depression. C. Record review of Pharmacy Consultation Report for R #11 dated 11/30/25, revealed R #11 was reviewed the following: 1. R #11 has been taking Escitalopram 5 mg once a day for Depression since 08/05/25. Please evaluate the current dose and consider a dose reduction. 2. The physician did not provide a rationale for not following the recommended dose reduction. R #18 D. Record review of R #18's admission record, no date, revealed he was admitted to facility on 02/09/24. E. Record review of Pharmacy Consultation Report for December 2025, revealed R #18's medical record was reviewed by the pharmacist and no recommendations were made. F. Record review of Pharmacy Consultation Report for January 2025, revealed R #18's medical record was reviewed by the pharmacist and no recommendations were made. R #43 G. Record review of R #43's admission Record (no date) revealed she was admitted to facility on 06/26/25 and has the following diagnosis: 1. Anxiety disorder, unspecified (diagnosis when a patient exhibits symptoms of anxiety that cause significant distress or impairment in daily functioning, but symptoms do not fully align with the criteria of other specific anxiety disorder diagnoses). 2. Dementia in other diseases classified elsewhere, mild, with anxiety (dementia is not primary but rather secondary to another condition where a patient may experience cognitive decline alongside anxiety). 3. Major depressive disorder, recurrent, moderate. H. Record review of R 43's Note to Attending Physician/Prescriber dated 12/24/25, revealed the following: 1. R #43 has been taking paroxetine (medication used to treat depression) 20 mg once a day for depression since 06/27/25. Please evaluate the current dose and consider a dose reduction. 2. Agree, condition stable: attempt dose reduction to paroxetine 10 mg once a day for depression was marked on the form. 3. Important: please add resident specific documentation to support the above action (referencing #2) or check below if information was added to physician progress notes. 4. The form had no documentation from the physician/prescriber, and the form was not checked to indicate information was added to physician progress notes. 5. The form was not signed by the attending physician/prescriber. 6. The area for the physician's signature was filled in by nursing staff as follows: Telephone order read back (name of provider) noted by (name of RN) 7. The form was also noted with order entered 01/25/26 by nurse. I. Record review of R #43's physician orders revealed the following: 1. An order dated 06/26/25 for paroxetine 20 mg, give 1 tablet one time of day related to depression. Discontinued 01/23/26. 2. An order dated 01/23/26 for paroxetine 10 mg, give 1 tablet on time of day related to depression. J. Record review of R #43's progress notes dated 12/24/25 through 03/03/26 revealed the following: 1. Staff did not document regarding the delay (greater than 1 month) in acting on the pharmacist's recommendation for the dose reduction of paroxetine. 2. No resident specific documentation to support the action of decreasing the paroxetine dose for R #43 was documented. R #48 K. Record review of R #48's admission record, no date, revealed he was admitted to facility on 01/13/25 and has the following diagnosis: 1. Dementia in other diseases classified elsewhere, unspecified severity with agitation (describes a group of symptoms affecting memory, thinking and social abilities). 2. Major depressive disorder, recurrent, moderate (a mental disorder). 3. Depression, unspecified (a mood disorder that causes a persistent feeling of sadness and loss of interest. 4. Anxiety disorder, unspecified (a feeling of worry, nervousness, or unease). L. Record review of R #48's orders dated 10/17/25 revealed the following orders: 1. Seroquel Oral Tablet 25 MG, give 1 tablet by mouth one time a day related to major depressive disorder, recurrent, moderate. 2. Seroquel Oral Tablet 0.5 MG, give 1 tablet by mouth one time a day related to major depressive disorder, recurrent, moderate. M. Record review of Pharmacy Consultation Report for R #48 dated 11/30/25, revealed the recommendation for R #48 as follows: 1. R #48 is receiving two active orders for Seroquel Oral Tablet 25 MG, give 12.5 mg once daily and 25 mg once daily for the same indication. 2. Confirm that both doses of Seroquel should be administered to R #48 or if only one is intended, to avoid duplicate therapy and ensure safe administration. 3. The physician did not provide a rationale for the two doses of Seroquel. N. On 03/3/26 at 2:47 PM, during an interview with the Director of Clinical Risk Management, she stated her expectation is for the staff to take care of the pharmacy review, and it be completed. O. On 03/05/26 2:59 PM during an interview with the ADON, he confirmed that R #18 was reviewed in November 2025 for a pain scale for Acetaminophen. There were no notes from the physician. ADON confirmed that there was no pharmacy review for December 2025 and January 2025 in the binder for R #18. ADON's expectation is that he would talk to floor nurses to review the pharmacy recommendations the nurses' present to the physician. ADON stated there is a team health binder in nurses' station that is used by nurses to have physicians' sign documents. ADON stated this helps staff to track the physicians' and nurses can remind the physician to complete paperwork, sign, and provide a rationale on pharmacy consults.

Based on observation and interview, the facility did not secure insulin and insulin needles in a treatment cart for 50 residents on the North Unit (residents were identified by the resident matrix provided by the Administrator on 02/23/26) for randomly sampled residents. This deficient practice could allow residents to obtain medications not prescribed to them, which could cause adverse side effects, and to access needles that could cause puncture wounds, skin cuts, or the transmission of serious infections. The findings are: A. On 02/24/26 at 1:53 PM, during an observation of the North Unit, it was observed that staff left a treatment cart unlocked and unattended. The cart contained insulin and insulin needles. B. On 02/24/26 at 1:56 PM, during an interview, ADON #1 confirmed the cart was unlocked and contained needles and insulin. ADON #1 confirmed that staff must lock the cart when they are not with it.

Based on observation and interview, the facility failed to store food under sanitary conditions for 99 residents who eat food from the kitchen (residents were identified by the resident matrix provided by the administrator on 02/24/26) when staff failed to label and date all items in the kitchen dry pantry and refrigerators. Failure to store food under safe and sanitary conditions could likely lead to foodborne illnesses in residents. The findings are:A. On 02/24/26 at 9:32 AM, an observation of the kitchen revealed the following: 1. The dry pantry had: a. a bag of elbow pasta that was opened, unsealed and not dated. b. a bag of cornbread mix that was opened, unsealed and not dated. 2. The walk-in refrigerator had a package of corn tortillas that was opened, unsealed and not dated. 3. The refrigerator in the kitchen had: a. Several Styrofoam cups with lids on trays with only 1 cup on the tray labeled and dated. b. Several Styrofoam soup bowls with lids on trays with only 1 bowl labeled and dated. B. On 03/03/26 at 3:13 PM, during an interview with the Dietary Manager (DM), she confirmed the following: 1. All items in the dry food pantry should be placed in a Ziplock bag, labeled and dated after opening. 2. The corn tortillas should be closed after use and dated. 3. She stated she didn't know that each drink and soup had to be labeled and dated. She thought that one item per tray was sufficient for labeling items.

Based on record review, observation, and interview, the facility failed to ensure medical records were complete and accurate for 4 (R #19, R #27, R #61 and R #96) of 4 (R #19, R #27, R #61 and R #96) residents reviewed for documentation accuracy. This deficient practice has the potential to negatively impact on the care staff provided to meet residents' needs due to missing or inaccurate records and resident information. The findings are: R #19 A. Record review of R #19's admission record (no date) revealed the following 1. R #19 was admitted to the facility on [DATE]. 2. Primary diagnosis; Cerebral infarction due to embolism of right middle cerebral artery (stroke caused by blockage of one of the major blood vessels of the brain) B. On 02/25/26 at 1:09 PM, during an observation and interview with R #19, her left arm was noted to be swollen. R #19 stated her arm has been swollen since she had a stroke last month. C. Record review of R #19's progress notes dated 01/23/26 through 02/25/26 revealed the following: 1. Nursing note dated 01/23/26: Patient admitted with a diagnosis of hemiplegia (paralysis or severe weakness affecting one side of the body) and hemiparesis (one-sided muscle weakness that can occur due to disruptions in the brain, spinal cord, or nerves connected to the affected muscles) following cerebral infarction affecting the left non-dominant side (refers to the left side of the body that is not preferred for tasks). Edema present to left upper and lower extremities. Patient exhibits minimal movement of the left side. 2. Nursing note dated 01/24/26: Presence of edema (swelling from trapped fluid building up in the tissues of the body), left arm & leg D. Record review of R #19's weekly skin checks revealed the following: 1. Skin check dated 01/24/26, edema left arm and leg. 2. Skin check dated 01/31/26, no edema present. 3. Skin check dated 02/07/26, no edema present. 4. Skin check dated 02/14/26, no edema present. 5. Skin check dated 02/21/26, no edema present. 6. Skin check dated 02/28/26, no edema present. E. On 03/03/26 at 12:37 PM, during an interview, CNA #1 confirmed R #19 has edema to her left arm and has had it since admission. Per CNA #1 staff elevates R #19's left arm with a pillow to help with edema. F. On 03/03/26 at 1:06 PM, during an interview with the wound care nurse, he confirmed that R #19 does have edema to her left arm. G. On 03/03/26 at 2:06 PM, during an interview with LPN #1 the following was revealed: 1. R #19 has had edema to her left arm since she was admitted to the facility on [DATE]. 2. The edema to R #19's left arm appears the same today 03/03/26 as it did upon her admission on [DATE]. 3. He is unsure why staff did not document the edema on her skin checks since R #19 has continued with left arm edema since admission. R #27 H. Record review of R #27's admission record, no date, R #27 was admitted to the facility on [DATE]. I. Record review of R #27's physician's order, dated 02/10/26, revealed an order for pregabalin (used to treat neuropathic pain (nerve pain) from diabetes) 100 mg, given by mouth 3 times a day. J. On 02/27/26 at 1:32 PM, during an observation, R #27's control substance log for pregabalin 100 mg, showed staff documented that there should be 7 capsules. Observation of the medication card revealed there were only 5 capsules. K. On 02/27/26 at 1:32 PM, during an interview, LPN #8 stated that she had given R #27 two doses of pregabalin that day and that she documented in R #27's medication administration record (MAR) but that she had not documented it on the control substance log. LPN #8 stated that she updates the controlled substance log when has time during the day. L. Record review of R #27's MAR, dated 02/27/26, revealed staff documented the AM and midday doses as given. M. On 01/27/26 at 1:47 PM, during an interview, the DON stated that the controlled substance log should be updated and current at the time narcotics are dispensed. R #61 N. Record review of R #61's physician's orders revealed the following: 1. An order dated 01/10/26 to admit to [name of local hospice agency] hospice. 2. An order dated 02/25/26 to admit to [name of another local hospice agency] hospice. O. On 03/03/26 at 2:33 PM, during an interview with Unit Manager #2 the following was confirmed: 1. R #61 was originally admitted to a hospice company on 01/10/26. 2. R #61's first hospice care provider went out of business. 3. R #61 was admitted to a different hospice care company on 02/10/26. 4. R #61 had two active orders for hospice. 5. Staff should have discontinued the first order when R #61 changed hospice providers. R #96 P. Record review of R #96's Medical Orders for Scope of Treatment (MOST; medical document that outlines a resident's wishes regarding their healthcare during emergencies, particularly at the end of life) form (dated 11/15/23) revealed R #96 did not want medical staff to attempt resuscitation (DNR code status; do not resuscitate) in case of an emergency. Q. Record review of R #96's Multidisciplinary Care Conference forms revealed the following: 1. Care conference dated 06/03/25 revealed staff documented R #96's code status as DNR. 2. Care conference dated 06/03/25 revealed staff documented R #96's code status as Full code (attempt resuscitation). R. Record review of R #96's electronic medical record on 02/26/26 revealed R #96 medical record did not have a code status on the main screen. S. Record review of R #96's physician's orders revealed the following: 1. Review of R #96's physician's orders on 02/26/26 revealed no orders in place for R #96's code status. 2. Review of R #96'S physician's orders on 02/27/26 revealed staff added an order on 02/27/26 for R #96's code status as DNR. T. On 03/03/26 at 2:12 PM, during an interview with Unit Manager #2 the following was confirmed: 1. R #96's MOST form states her code status is DNR. 2. Facility staff will follow the signed MOST form on file to determine a resident's code status. 3. Physician's orders should be in place to match the MOST form, as it is a legal and signed document stating the resident's wishes. 4. She is unsure why the Care Conference forms have different code statuses, but the facility staff are directed to follow the MOST form on file.

Based on record review and interview, the facility failed to implement an effective training program for the Developmental Disability Caregivers (DDC, provides daily living assistance, medical support, companionship, and advocacy for individuals with intellectual or developmental disabilities) for 3 (DDC #1, DDC #2, and DDC #3) of 3 (DDC #1, DDC #2, and DDC #3) DDC's who provided care for R #89. If the DDC staff are not trained, then they could likely not have the knowledge to safely care for residents in the facility. The findings are: A. Record review of R #89's admission Record, no date revealed the following: 1. R #89 was admitted to the facility on [DATE]. 2. R #89 had a diagnosis of unspecified intellectual disabilities (a condition that limits intelligence and disrupts abilities necessary for living independently). B. Record review of R #89's progress notes revealed the following: 1. On 02/05/26 at 11:47 PM, R #89's DDC (the record did not specify which DDC) was at his bedside. 2. On 02/06/26 at 12:53 AM, R #89's DDC was present (the record did not specify which DDC). 3. On 02/06/26 at 5:52 AM, R #89's DDC was present. 4. On 02/06/26 at 9:33 AM, staff documented that at 8:45 AM, the DON and ADON witnessed R #89 with his arms tied to the bed rails. The ADON educated DDC #1 that restraints were not allowed in the facility, and DDC #1 was relieved by DDC #2. C. On 03/03/26 at 12:17 PM, during an interview, the DON stated the following: 1. R #89 would have DDCs who stayed with him around the clock. 2. She understood that the DDCs were supposed to provide R #89 with the same services they provided in his home, such as feeding, redirection, and companionship. D. On 03/03/26 at 12:42 PM, during an interview, ADON #1 stated the following: 1. DDC #2 was with R #89 when he first arrived. 2. DDC #3 relieved DDC #2 on 02/05/26 but he was not sure what time. 3. DDC #1 relieved DDC #3 sometime during the night shift between 02/05/26 and 02/06/26. 4. DDC #2 relieved DDC #1 at approximately 9:30 AM on 02/06/26. E. On 03/03/26 at 12:50 PM, during an interview, the DON confirmed the following: 1. DDC #1, DDC #2, and DDC #3 did not receive any training from the facility regarding facility policies and expectations. 2. She assumed the DDCs' employer required the same training for the DDCs as the facility required for its staff. 3. She was not sure what training DDC #1, DDC #2, or DDC #3 had received. 4. The facility did not provide DDC #1, DDC #2, or DDC #3 any training regarding its policies and expectations before they assisted R #89 in the facility.

Based on record review and interview, the facility failed to ensure residents and/or their representatives were informed in advance of medication changes and understood the reasons, risks, and benefits of the medications for 1 (R #43) of 1 (R #43) residents reviewed for psychiatric medication side effects. If the residents or their representatives are not informed of the risks and benefits of the medication or treatment alternatives, they are not able to make informed decisions regarding resident's care. The findings are:A. On 02/24/26 at 2:35 PM, during an interview with R #43 she stated the following: 1. The mental health provider increased her anxiety medication approximately four days prior. 2. The mental health provider did not discuss the increase with her. 3. She learned about the increase when the nurse informed her. B. Record review of R #43's physician's orders revealed the following: 1. An order dated 11/04/25 for buspirone (medication primarily used to treat anxiety disorders) 15 mg, give half (0.5) tablet by mouth two times a day for anxiety. Discontinued date 02/18/26. 2. An order dated 02/18/26 for buspirone 15 mg, give 1 tablet by mouth two times a day for anxiety. C. Record review of R #43's MAR for February 2026 revealed the following: 1. R #43 received 1 tablet of buspirone 15 mg on 02/18/26 at 4:00 PM. 2. R #43 received 1 tablet of buspirone 15 mg on 02/19/26 at 8:00 AM. D. Record review of R #43's mental health provider visits notes revealed the following: 1. The most recent visit notes were dated 1/16/26 and 03/02/26. 2. No visit notes dated 02/18/26. 3. For the visit note dated 03/02/26 the provider documented the following: a. 02/19/26, R #43 was interviewed for follow up, R #43 presented calm, cooperative and with appropriate interactions. R #43 has been reported to have increased anxiety by facility staff. When asked about anxiety, R #43 denied and reported that she only gets anxious when she needs to go to the restroom and she is not assisted quickly enough making her think she may not be able to hold her urine. Mood is stable and she denies significant signs and symptoms of depression. R #43 reports she is sleeping well. b. 03/02/26, R #43 was interviewed for follow-up. R #43 presented calm, cooperative, and with appropriate interactions. R #43 reports she has been feeling well and denies any crying episodes R #43 reports signs and symptoms of depression and anxiety are well controlled and states that she has been sleeping well. Mood is stable. E. Record review of R #43's Informed Consent (legal and ethical requirement in healthcare that ensures patients understand the risks, benefits, and alternatives of a treatment before agreeing to it) for psychoactive (medications that alter mental processes, affecting mood, perception, cognition, and behavior, and are used primarily to treat mental health disorders) medications dated 02/19/26 at 10:02 AM revealed the following: 1. Psychoactive Medication: Prior to initiating an order for psychoactive medication, the community will obtain and document informed consent from the appropriate representative. Informed consent includes review of the risk/benefits including side effects and black box warnings (the most serious safety alerts issued by the U.S. Food and Drug Administration (FDA) to indicate significant risks associated with certain medications). F. On 03/03/26 at 2:31 PM, during an interview with Unit Manager #2 the following was confirmed: 1. The mental health provider informs the residents of any dosage changes or new medications. 2. The nurse completes the consent form before the medication is started. 3. R #43's consent was not completed before she started the medication.

Based on observation, record review, and interview, the facility failed to notify the provider of recommendations from off-site provider for 1 (R #67) of 7 (R #1, R #8, R #9, R #40, R #67, R #89, and R #103) residents reviewed for wound care, when staff failed to notify the provider that R #67's wound care specialist ordered a change in R #67's wound care. This deficient practice could likely result in residents not receiving necessary care or having a worsening medical condition due to lack of changes in treatment. The findings are: A. Record review of R #67's admission Record, no date, revealed the following: 1. R #67 was admitted to the facility on [DATE]. 2. R #67 had the following diagnoses: a. Peripheral vascular disease (a slow, progressive circulation disorder caused by narrowed, blocked, or spasmodic vessels). b. Non-pressure chronic ulcer of left ankle with muscle involvement (deep, non-healing skin breaches extending to the muscle layer). B. On 02/25/26 at 9:33 AM, during an observation of R #67 in his room, revealed R #67 had a bandage on his left lower leg. C. Record review of R #67's off-site wound care provider order, dated 02/20/26, revealed the following: 1. An order for a wound vacuum (wound vac, a medical treatment that uses a vacuum pump, tube, and dressing to apply controlled suction to a wound. This removes fluids, reduces edema, promotes blood flow, and stimulates new tissue growth to accelerate healing) to be applied to R #67's left foot at 125 millimeters of mercury (mm/Hg, unit of measure for vacuum) pressure. 2. An order to use black foam when replacing the dressing. D. Record review of R #67's physician's orders revealed the following: 1. An order dated 01/13/26 for wound care to arterial ulceration (painful, slow-healing, or non-healing, punched-out wounds, typically appearing on the feet, heels, or toes) on left medial (in the middle) foot cleanse wound bed with normal saline, pat dry, apply iodasorb (a sterile, antimicrobial gel or dressing used to treat chronic, exuding wound) to wound bed, followed by adaptic (non-adhering wound dressing made of knitted cellulose acetate fabric impregnated with a petrolatum emulsion), followed by abdominal pad (non-adhering wound dressing made of knitted cellulose acetate fabric impregnated with a petrolatum emulsion), wrap foot with cast padding and ace bandage every other day and as needed. 2. Staff did not document the order received from the off-site wound care provider on 02/20/26. E. On 02/27/26 at 1:33 PM, during an interview, the Wound Care Nurse stated the following: 1. R #67 saw the off-site wound care provider on 02/20/26. 2. The off-site wound care provider ordered a wound vac for R #67 because healing of his foot wound had stalled (occurs when a wound fails to progress through normal repair phases). 3. He did not see the orders from the off-site wound care provider until 02/23/26. 4. He ordered the wound vac on 02/23/26, but it did not arrive at the facility until 02/27/26. 5. He did not notify the facility provider that the off-site wound care provider had ordered a wound vac for R #67. 6. He did not notify the off-site wound care provider or the facility provider that the wound vac would not arrive until 02/27/26. 7. He should have notified the provider that the off-site provider ordered a wound vac for R #67's foot wound. 8. He should have notified the off-site wound care clinic and the facility provider that there would be a delay in the arrival of the wound vac. F. On 02/27/26 at 2:04 PM, during an interview, ADON #2 confirmed the following: 1. When residents go to an off-site provider for wound care, they usually return with orders from that provider. 2. Staff are expected to notify the facility provider immediately about any changes made by the off-site wound care provider. 3. If the provider instructs staff to follow the off-site provider's orders, facility staff are expected to enter those orders immediately. 4. The provider should be notified immediately of any delay in obtaining the supplies needed to perform the ordered wound care. 5. She confirmed that R #67's wound care order was dated 01/13/26. 6. She confirmed that R #67's order from the off-site wound care provider dated 02/20/26 was not entered into the medical record. 7. She confirmed that R #67's medical record did not include documentation that the facility provider was notified of the off-site wound care provider's order for a wound vac.

Based on record review and interview, the facility failed to ensure residents remained free from physical restraints (any device used to prevent freedom of movement or action) unless staff used them to treat a specific medical condition (indication or characteristic of a medical, physical or psychological condition) as identified through an assessment for 1 (R #89) of 2 (R #3 and R #89) residents reviewed for physical restraints. This deficient practice could likely result in physical restraints being used for punishment or staff convenience; causing injury or unnecessarily restricting residents from freedom, movement, or activity. The findings are: A. Record review of R #89's admission Record, no date, revealed the following: 1. R #89 was admitted to the facility on [DATE]. 2. R #89 had the following diagnoses: a. Unspecified intellectual disabilities (a condition that limits intelligence and disrupts abilities necessary for living independently). b. Depression (serious mood disorder characterized by persistent sadness, loss of interest in activities). c. Anxiety disorder (mental health condition characterized by persistent, excessive, and uncontrollable fear or worry that interferes with daily life). B. Record review of R #89's progress note, dated 02/06/26, revealed the following: 1. On 02/06/25 at 8:45 AM, a CNA notified the ADON and DON that R #89 was restrained to the bed. 2. The ADON and DON observed R #89's arms restrained to the bed rails. 3. The ADON removed the restraints. 4. The ADON educated R #89's Developmental Disability Caregiver (DDC, provides daily living assistance, medical support, companionship, and advocacy for individuals with intellectual or developmental disabilities) that the facility does not allow restraints. C. On 03/02/26 at 3:15 PM, during an interview, ADON #1 stated the following: 1. On 02/06/26, one of the CNAs notified him that R #89 was tied to the bed. 2. ADON #1 notified the DON and they went to R #89's room. 3. R #89's DDC was lying on R #89's legs and R #89's arms were tied to the bed rails with blankets. 4. He untied the blankets from R #89's arms and assessed R #89 for injury. 5. R #89's DDC told him that he restrained R #89 because R #89 was trying to hit and kick him. R #89 said he was going to break the window. 6. ADON #1 explained to the DDC that the facility was restraint free and he was not allowed to restrain R #89. D. On 03/02/26 at 3:35 PM, during an interview, the DON stated the following: 1. On 02/06/26 at approximately 8:45 AM, she was notified by ADON #1 that a staff member observed R #89 restrained to the bed. 2. When she and ADON #1 arrived to R #89's room, they saw R #89's arms tied to the bed rails. 3. ADON #1 removed the restraints from R #89's arms. 4. ADON #1 told R #89's DDC that he cannot restrain R #89. 5. After this, she interviewed staff to see if anyone else had seen anything. 6. LPN #16 told her that on 02/06/26 around 6:30 AM he was notified that R #89 was restrained to the bed (a separate incident earlier in the morning). E. On 03/03/26 at 9:00 AM, during an interview, LPN #16 stated the following: 1. On 02/06/26 around 6:30 AM to 7:00 AM, he went into R #89's room there was a sheet tied around R #89's feet. 2. He untied the sheet from R #89's feet. 3. He educated R #89's DDC that the facility was a restraint free facility and he cannot restrain R #89. F. On 03/03/26 at 9:59 AM, during an interview, the DON confirmed the following: 1. The facility does not allow residents to be restrained. 2. R #89 should not have been restrained. G. Record review of facility restraint policy, dated 09/30/23, revealed Physical restraints shall only be used for the safety and wellbeing of the resident(s) and only after other alternatives have been tried unsuccessfully. Restraints shall only be used to treat the resident's medical symptoms and never for discipline or staff convenience, or for the prevention of falls.

Based on record review and interview, the facility failed to report an allegation of abuse to the State Survey Agency for 1 (R #89) of 2 (R #3 and R #89) residents reviewed for physical restraints (any device used to prevent freedom of movement or action). If the facility fails to report incidents of possible abuse to the State Agency, then the State Agency is unable to ensure residents have a safe environment. The findings are: A. Record review of R #89's progress note, dated 02/06/26, revealed the following: 1. On 02/06/25 at 8:45 AM, a facility staff member notified the ADON (the documentation did not specify which ADON) and the DON that R #89 was restrained to the bed. 2. The ADON and DON observed R #89's arms restrained to the bed rails. 3. The ADON removed the restraints from R #89's arms. 4. The ADON educated R #89's developmental disability caregiver (DDC, provides daily living assistance, medical support, companionship, and advocacy for individuals with intellectual or developmental disabilities) that the facility does not allow restraints. B. On 03/02/26 at 3:35 PM, during an interview, the DON stated the following: 1. On 02/06/26 at approximately 08:45 AM, she was notified by ADON #1 that a staff member observed R #89 restrained to the bed. 2. ADON #1 and the DON went to R #89's room and saw R #89's arms tied to the bed rails with blankets. 3. ADON #1 removed the restraints from R #89's arms. 4. ADON #1 educated R #89's DDC that he cannot restrain R #89. 5. After this, she interviewed staff to determine whether anyone else had witnessed the incident. 6. LPN #16 told her that on 02/06/26 around 6:30 AM he saw R #89 restrained to the bed and had educated R #89's DDC that he could not restrain R #89. C. On 03/03/26 at 9:00 AM, during an interview, LPN #16 stated the following: 1. On 02/06/26 around 6:30 AM to 7:00 AM, he went into R #89's room he went into R #89's room and observed a sheet tied around R #89's feet. 2. He said R #89's DDC said R #89 was trying to kick the window, so he tied his feet. 3. He untied the sheet from R #89's feet. 4. He educated R #89's DDC that the facility was a restraint free facility and he cannot restrain R #89. 5. R #89's DDC verbalized understanding that he cannot restrain R #89. D. Record review of the incident report submitted to the state agency, dated 02/06/26, revealed the following: 1. On 02/06/26 at 8:45 AM, R #89's arms were restrained by the DDC. 2. R #89's DDC was educated that the facility has a no restraint policy (staff are not allowed to use restraints). 3. Staff did not document that R #89 had been restrained by R #89's DDC on 02/06/26 between 6:30 AM and 7:00 AM. E. Record review of the follow-up report submitted to the state agency, dated 02/09/26, revealed staff did not document that during the investigation the DON was informed that R #89 had also been restrained by R #89's DDC on 02/06/26 between 6:30 AM and 7:00 AM. F. On 03/03/26 at 9:38 AM, during an interview, the Administrator confirmed the following: 1. LPN #16 did not notify administration when he found R #89 restrained by his DDC between 6:30 AM and 7:00 AM. 2. Staff were expected to notify administration immediately of any concerns of abuse 3. The facility did not notify the state agency that R #89 had been restrained in the facility by his DDC on 02/06/26 between 6:30 AM and 7:00 AM. 4. The facility was expected to report all allegations of abuse to the state agency within two (2) hours of the incident.

Based on record review and interview, the facility failed to complete a Significant Change (major decline or improvement in the patient's health status) MDS assessment within 14 days after the facility determined that a resident changed hospice (a specialized type of care focused on providing comfort, dignity, and support to individuals with terminal illnesses and their families during the end-of-life stage) providers for 1 (R #61) of 2 (R #18 and R #61) residents reviewed for hospice care. This deficient practice could likely result in the residents not receiving the appropriate care and services that they need. The findings are: A. Record review of R #61's physician's orders revealed an order dated 02/25/26 to admit to hospice. B. Record review of R #61's Hospice care plan revealed that R #61's began hospice services on 02/10/26. C. On 03/03/26 at 2:33 PM, during an interview with Unit Manager #2 the following was confirmed: 1. R #61 was originally admitted to hospice on 01/10/26. 2. R #61's first hospice care provider went out of business. 3. R #61 was admitted to a different hospice care company on 02/10/26. D. Record review of R #61's MDS assessments revealed the following: 1. A Significant Change MDS assessment was completed on 01/19/26 when he was first admitted to hospice. 2. No MDS assessments were completed after R #61 changed hospice providers on 02/10/26.

Based on observation, record review, and interview, the facility failed to implement care plan interventions for 1 (R #8) of 2 (R #2 and R #8) residents reviewed falls. This deficient practice could likely result in injury to residents. The findings are: A. Record review of R #8's admission Record, no date, revealed the following: 1. R #8 was admitted to the facility on [DATE]. 2. R #8 had a diagnosis of hemiplegia (a form of paralysis affecting one side of the body, caused by brain or spinal cord injury) and hemiparesis (a weakness, rather than complete paralysis, affecting one side of the body) following cerebral infarction (commonly known as ischemic stroke, is a medical emergency caused by blocked blood flow to the brain) affecting right dominant side. B. Record review of R #8's care plan, revised 10/02/26, revealed the following: 1. R #8 was at risk for falls. 2. R #8 had the following interventions in place for falls: a. Floor mats on the floor. b. Bed in the lowest position. C. On 02/27/26 at 9:02 AM, during an observation of R #8 in his room, the following was revealed: 1. R #8 was lying in his bed sleeping. 2. R #8's bed was approximately 3 feet off the ground (not in lowest position). 3. R #8's floor mats were folded up next to the window (not on floor next to bed). D. On 02/27/26 at 9:06 AM, during an interview, CNA #16 confirmed the following: 1. R #8's floor mat was folded up next to the window. 2. R #8's bed was not in lowest position. 3. She stated she was not aware that R #8 was a fall risk. 4. If residents have floor mats, they should be on the floor next to the bed when they are in bed. E. On 02/27/26 at 2:18 PM, during an interview, ADON #2 confirmed the following: 1. R #8 was a fall risk. 2. R #8's care plan interventions for falls included: a. Floor mat on floor. b. Bed in lowest position. 3. Staff were expected to ensure care plan interventions were implemented.

Based on record review and interview, the facility failed to notify the provider of abnormal vital signs (blood pressure and blood sugar) and that medication was not given for 3 (R #1, R #2, and R #9) of 3 (R #1, R #2, and R #9) residents reviewed for assessment and monitoring when staff failed to notify the provider that: 1. R #1 and R #2's blood pressure was low. 2. R #9's blood sugar was low. 3. Medication was held (not given) for R #1, R #2 and R #3. These deficient practices could likely result in residents not receiving necessary care or worsening medical conditions due to lack of or changes in treatment. The findings are: R #1A. Record review of R #1's admission record (no date) revealed the following: 1. R #1 was admitted to the facility on [DATE]. 2. R #1 had a diagnosis of hypertensive heart disease with heart failure (condition in which high blood pressure has caused significant damage to the heart leading to the heart's inability to pump blood effectively). B. Record review of R #1's physician orders revealed the following: 1. Order dated 12/11/24, for amlodipine (medication used to hypertension by relaxing the heart vessels making it easier for heart to pump blood) 5 mg, give 1 tablet by mouth one time a day for hypertension (high blood pressure). 2. Order dated 12/13/24, for lisinopril (medication used to treat hypertension by relaxing the blood vessels which lowers blood pressure and increases blood flow to the heart) 20 mg, give 1 tablet by mouth one time a day for hypertension. C. Record review of R #1's medical record revealed the following: 1. On 06/23/25 staff documented medication held due to low parameters BP 77/55 heart rate (HR) 96. 2. On 06/26/25 staff documented resident's BP 97/51. 3. On 06/30/25 staff documented This medication is on hold due to resident's BP of 97/52 4. On 07/02/25 staff documented vitals outside of parameters for administration (specific predetermined measurements for vital signs set by physician/provider used to decide whether medication should be given or not). Staff did not document R #1's BP reading. 5. On 07/04/25 staff documented resident's BP 92/47. 6. On 07/07/25 staff documented vitals outside of parameters for administration. Staff did not document R #1's BP reading. 7. Medical record did not contain any documentation that the provider was notified of R #1's low blood pressure or that R #1's medication was held. R #2 D. Record review of R #2's admission record (no date) revealed the following: 1. R #2 was admitted to the facility on [DATE]. 2. R #2 had a diagnosis of hypertensive heart disease without heart failure (condition in which high blood pressure has caused significant damage to the heart but has not yet progressed to affect the heart's ability to pump blood effectively). E. Record review of R #2's physician orders revealed the following: 1. Order dated 11/08/23, for amlodipine 5 mg, give 2 tablets by mouth one time a day for hypertension, hold BP medication of systolic BP (top number of BP reading) is less than 100 or greater than 180 or if diastolic BP (bottom number of BP reading) is less than 50 or greater than 90. F. Record review of R #2's medical record revealed the following: 1. On 06/04/25 staff documented BP 90/60, vitals outside of parameters for administration. 2. On 06/05/25 staff documented BP 89/55, vitals outside of parameters for administration. 3. On 06/10/25 staff documented BP 102/45, vitals outside of parameters for administration. 4. On 06/13/25 staff documented BP 83/46, vitals outside of parameters for administration. 5. On 06/14/25 staff documented BP 87/60, vitals outside of parameters for administration. 6. On 06/18/25 staff documented BP 95/51, vitals outside of parameters for administration. 7. On 06/20/25 staff documented BP 97/58, staff did not document whether medication was held or given. 8. On 07/01/25 staff documented this medication is on hold due to residents bp of 99/52. 9. On 07/19/25 staff documented this medication is on hold due to residents bp of 94/61. 10. On 07/25/25 staff documented BP 99/50, vitals outside of parameters for administration. 11. On 07/27/25 staff documented BP 89/59, vitals outside of parameters for administration. 12. On 07/30/25 staff documented BP 97/51, vitals outside of parameters for administration. 13. On 07/31/25 staff documented BP 98/42, vitals outside of parameters for administration. 14. Medical record did not contain any documentation that the provider was notified of R #2's low blood pressure or that R #2's medication was held. G. Record review of American Heart Association Low blood pressure-When blood pressure is too low last reviewed 05/06/24.www.heart.org/en/health-topics/high-blood-pressure/the-facts-about-high-blood-pressure/low-blood-pressure-when-blood-pressure-is-too-low revealed the following: 1. Low blood pressure occurs when blood pressure is less than 90/60. 2. Low blood pressure can happen with diuretics (medications that help the body eliminate excess fluid by increasing urine production) and other drugs used to treat high blood pressure. R #9 H. Record review of R #9's admission record (no date) revealed the following: 1. R #9 was admitted to the facility on [DATE]. 2. R #9 had a diagnosis of type 2 diabetes mellitus with hyperglycemia (chronic disease in which the body cannot use insulin properly and results in high blood sugar [BS] levels). I. Record review of R #9's physician orders revealed the following: 1. Order dated 08/28/25, for insulin glargine (medication used to improve and maintain blood sugar levels over an extended period of time) inject 28 units one time a day for diabetes mellitus type 2 (DM-2) 2. Order dated 08/22/25, for Humulin regular insulin (insulin that works to help lower blood sugar levels within 30 minutes of injection) inject as per sliding scale (insulin dosages that are adjusted based on the patient's current blood sugar level) before meals and at bedtime as follows: a. If BS level is 0-80 and conscious give 4 ounces of juice, if unconscious give glucagon (emergency medication used to treat severe low blood sugar in diabetes patients) 1 mg intramuscularly, notify doctor. b. If BS level is 81-199, no coverage (no insulin given). c. If BS level is 200-250 give 2 units. d. If BS level is 251-300 give 4 units. e. If BS level is 301-350 give 6 units. f. If BS level is 351-400 give 8 units. g. If BS level is 401 or greater give 10 units and notify doctor. J. Record review of the facility's Diabetic Management Policy dated 03/19/24 revealed the following: 1. ACUTE COMPLICATION MANAGEMENT: HYPOGLYCEMIA - Low Blood Sugar Levels a. If the BG (blood glucose/BS) level is below 70 mg/dl or other physician directed low parameter, and the resident can swallow, or the resident is tube fed: Give fast acting source of sugar and notify Medical Doctor (MD). b. Reassess the BG level in 15 minutes and document the results of the BG on the MAR. c. If the BG level remains below 70 mg/dl or other physician directed low parameter give: Additional source of sugar (e.g., another 4 ounces of orange juice or administer glucose gel. d. Recheck blood glucose in 15 minutes and document the results. e. Notify the physician of the episode. K. Record review of R #9's medical record revealed the following: 1. On 08/23/25 at 630 AM staff documented BS 70. 2. On 08/24/25 at 630 AM staff documented BS 80. 3. On 08/24/25 at 1130 AM staff documented BS 70. 4. On 08/25/25 at 430 PM staff documented BS 65. 5. On 08/25/25 at 830 PM staff documented BS 57. 6. On 08/26/25 at 1130 AM staff documented BS 62. 7. Medical record did not contain any documentation that the provider was notified of R #9's low blood sugar levels as indicated on R #9's physician's orders and as indicated in the facility's Diabetic Management Policy. L. On 10/17/25 at 11:00 AM, during an interview, the DON confirmed the following: 1. Staff did not contact the provider to notify them of R #1's and R #2's low BP readings and holding BP medications. 2. Staff did not contact the provider to notify them of R #9's blood sugar levels as indicated in the order or the facility's Diabetic Management Policy. 3. Her expectation is that if staff have concerns regarding resident's vital signs and deciding to hold medications, they should contact the provider, document the conversation held with provider and enter a new order as needed depending on what the provider's decision is regarding the medication. 4. Staff should contact the physician as stated on the physician's orders. 5. Staff should follow facility's policy regarding contacting the provider.

Based on record review and interview, the facility failed to ensure residents did not receive psychotropic medications (group of drugs that affect behavior, mood, thoughts, or perception. They are used to treat a variety of conditions including anxiety, depression, bipolar disorder, and schizophrenia) unless the medication was medically necessary and had adequate monitoring for 2 (R #16 and R #24) of 3 (R #16, R #24, and R #25) residents reviewed for depression (a common mental health condition characterized by persistent feelings of sadness, hopelessness, and loss of interest or pleasure in activities) treatment, when staff failed to: 1. Ensure a gradual dose reduction (GDR; stepwise tapering of a dose to determine if symptoms, conditions, or risks can be managed by a lower dose or if the dose or medication can be discontinued) was carried out for R #16. 2. Adequately monitor for adverse side effects (unwanted, harmful, or abnormal result) of psychotropic medication for R #16 and R #24. These deficient practices could likely result in residents receiving medications without a medical reason and being at a higher risk of adverse side. The findings are: Gradual Dose Reduction A. Record review of R #16's admission documents, no date, revealed the following: 1. R #16 was admitted to the facility on [DATE]. 2. R #16 had the following diagnoses: a. Dementia without behavioral disturbance (a condition where a person experiences cognitive decline, such as memory loss, difficulty with attention, and problem-solving, but does not exhibit significant behavioral changes or disturbances). b. Insomnia (a sleep disorder characterized by persistent difficulty falling asleep, staying asleep, or waking up too early in the morning, despite having adequate opportunity to sleep). c. Major depressive disorder (MDD), single episode (refers to a distinct episode of depression that meets the diagnostic criteria for MDD but occurs only once in the individual's lifetime). B. Record review of R #16's physician orders, multiple dates, revealed the following: 1. An order dated 10/17/24, for escitalopram oxalate (an antidepressant medication used primarily to treat MDD and generalized anxiety disorder) 20 mg, once a day for depression. 2. An order dated 10/17/24 for oxcarbazepine (an anticonvulsant medication primarily used to treat partial-onset seizures in adults and children) 300 mg, twice a day for anticonvulsant, and was discontinued on 05/17/25. 3. An order dated 05/17/25 for oxcarbazepine 300 mg, twice a day for depression. 4. An order dated 11/22/24 for trazadone (antidepressant medication that is also used to treat anxiety and insomnia) 25 mg, once a day for sleep aide. 5. An order dated 06/29/25 for trazadone 25 mg, once a day for insomnia. C. Record review of R #16's PHQ-9 (a comprehensive, nine-question questionnaire that covers a wider range of depressive symptoms) assessment, multiple dates, revealed the following assessment scores (the PHQ-9 scoring ranges from 0 being no depression symptoms to 27 being severe depression symptoms): 1. On 10/17/24, R #16's score was 0. 2. On 12/29/24, R #16's score was 0. 3. On 01/24/25, R #16's score was 0. 4. On 04/26/25, R #16's score was 0. 5. On 07/28/25, R #16's score was 0. D. Record review of R #16's pharmacist recommendation dated 07/28/25, revealed the following: 1. R #16 had been taking escitalopram 20 mg once a day since 10/18/24. 2. The pharmacist recommended R #16 be evaluated to decrease the dose of escitalopram. 3. The provider selected resident with good response, maintain current dose. 4. The provider selected disagree with the pharmacist recommendation. 5. The provider did not document a clinical rationale for why R #16 should not have a dose reduction. E. Record review of R #16's entire medical record, no date, revealed the provider did not document a clinical rationale for why a GDR had not been conducted for R #16 for escitalopram 20 mg, oxcarbazepine 300mg, or trazadone 25 mg. F. On 10/09/25 at 2:04 PM, during an interview, LPN #16 stated R #16 did not have any symptoms of depression. G. On 10/09/25 at 3:32 PM, during an interview, the SSD confirmed R #16 always scored 0 on the PHQ-9 assessments, indicating he was not depressed. H. On 10/09/25 at 2:11 PM, during an interview, the DON confirmed the following: 1. R #16 had a diagnosis of MDD and insomnia. 2. R #16 had not shown any signs or symptoms of depression since admission. 3. R #16 was taking the same dose of escitalopram and oxcarbazepine since he arrived on 10/17/24. 4. R #16 was taking the same dose of trazadone since it was ordered on 11/22/24. 5. The provider had not conducted a GDR on escitalopram, oxcarbazepine, or trazadone. 6. The pharmacist recommended a GDR for escitalopram on 07/28/25 and the provider declined the GDR. 7. R #16's provider did not document a clinical rationale for why a GDR should not be conducted for escitalopram. 8. R #16's provider did not document a clinical for why a GDR should not be conducted for oxcarbazepine or trazadone. Monitoring R #16 I. Record review of R #16's physician's orders, multiple dates, revealed the following: 1. An order dated 10/17/24, for escitalopram oxalate, 20 mg, once a day for depression. 2. A black box warning (the most serious warning the U.S. Food and Drug Administration (FDA) can issue on drug and device labeling, alerting healthcare providers and patients to the risk of death or serious injury associated with the product) attached to the escitalopram order in the EMR system that stated closely monitor all antidepressant-treated patients for clinical worsening and for emergence of suicidal thoughts and behaviors. 3. An order dated 06/29/25 for trazadone 25 mg, once a day for insomnia. 4. A black box warning (the most serious warning the U.S. Food and Drug Administration (FDA) can issue on drug and device labeling, alerting healthcare providers and patients to the risk of death or serious injury associated with the product) attached to the trazadone order in the EMR system that stated closely monitor all antidepressant-treated patients for clinical worsening and for emergence of suicidal thoughts and behaviors. 5. An order dated 05/07/25, for behavior monitoring for compulsive behaviors. J. On 10/10/25 at 9:20 AM during an interview, LPN #17 stated the following: 1. R #16 had a black box warning for escitalopram and trazadone that indicated closely monitor all antidepressant-treated patients for clinical worsening and for emergence of suicidal thoughts and behaviors. 2. R #16 was not being monitored for suicidal thoughts or suicidal behaviors. 3. R #16 was not being monitored for depression symptoms. 4. Staff must acknowledge black box warnings when they enter an order for a medication that has a black box warning. 5. She had never been instructed what to do when the black box warning pops up, so she just acknowledges them. 6. She did not notify the provider about black box warnings when they popped up. K. On 10/10/25 at 12:05 PM, during an interview, the DON confirmed the following: 1. R #16's order for escitalopram had a black box warning that said, closely monitor all antidepressant-treated patients for clinical worsening and for emergence of suicidal thoughts and behaviors. 2. R #16's order for trazadone had a black box warning that said, closely monitor all antidepressant-treated patients for clinical worsening and for emergence of suicidal thoughts and behaviors. 3. Staff were not monitoring R #16 for suicidal thoughts or suicidal behaviors. 4. Staff were not monitoring R #16 for depression symptoms. 5. Staff were expected to notify the provider if a black box warning pops up. 6. Staff did not document in R #16's medical record whether the provider was notified about the black box warnings. 7. She was not sure if staff were expected to monitor residents for the signs or symptoms that were included in black box warnings. L. On 10/10/25 at 12:55 PM, during an interview, the Psychiatric Nurse Practitioner (PNP) confirmed the following: 1. He would expect staff to monitor all residents who were taking anti-depressants for worsening of depressive symptoms and suicidal thoughts and behaviors. 2. He was not notified about the black box warning on R #16's escitalopram or trazadone. 3. He would expect residents to be monitored for suicidal thoughts and suicidal behaviors if there was a black box indicating they should be monitored. R #24 M. Record review of R #24's admission Record, no date, revealed R #24 was admitted on [DATE] with the following diagnoses. 1. Other specified Depressive Episodes (refer to a category that applies to individuals who exhibit symptoms characteristic of a depressive disorder but do not meet the full criteria for any specific depressive disorder.) 2. Mild Neurocognitive Disorder due to known physiological condition with behavioral disturbance (also known as Mild Cognitive Impairment, is a condition in which individuals demonstrate cognitive impairment with minimal impairment of instrumental activities of daily living.) 3. Major Depressive Disorder recurrent, severe with Psychotic symptoms. 4. Unspecified Dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and Anxiety. N. Record review of R #24's physician orders revealed an order dated 07/02/25 for Duloxetine HCI (a selective serotonin and norepinephrine reuptake inhibitor used to treat major depressive disorder, generalized anxiety disorder, and certain types of chronic pain) oral capsule delayed release give 1 capsule by mouth at bedtime for major depressive disorder, recurrent, severe with psychotic symptoms. The black box warning associated with R #24's Duloxetine medication in physicians orders reads as follows: 1. Suicidal thoughts and behavior. 2. Monitor all antidepressant-treated patients for clinical worsening, and for emergence of suicidal thoughts and behaviors. O. Record review of R #24's MAR, dated 10/01/25-10/31/25 revealed the following behaviors and anti-psychotic interventions monitored for psychosis every shift for use of antipsychotic medication in R #24's MAR as follows: 1. Monitor behaviors of psychosis every shift for use of antipsychotic medication: a. Yelling, b. screaming, c. refusing care, d. refusing medication, e. false accusations. 2. Anti-psychotic interventions: 1. allow to express feelings, 2. offer emotional support, 3. redirect resident, 4. two times a day for monitoring. P. Record review of R #24's entire medical record, no date, revealed R #24 did not have any documentation for monitoring suicidal thoughts and suicidal behaviors for the medication Duloxetine HCI (used to treat major depressive disorder.) Q. On 10/10/25 at 1:45 PM during an interview with LPN #26 stated, she is documenting the interventions and monitoring R #24's antipsychotic medication in R #24's MAR when she works with R #24. LPN #26 did confirm R #24 is on Duloxetine (antidepressant medication). LPN #26 stated for R #24 there's no documentation regarding suicidal ideations in R #24's MAR. LPN #26 stated if the order in the MAR doesn't state to monitor and provide interventions for suicidal thoughts and suicidal behaviors then the nurses won't document. LPN #26 did confirm that if the medication has a black box warning the nurses are to look at that and it should be put in the MAR to monitor the resident. R. On 10/10/25 at 1:54 PM during an interview with the DON regarding R #24's antidepressant medication black box warnings; the DON confirmed R #24 had no documentation and was not being monitored for suicidal ideations on the R #24's MAR. The DON stated that suicidal behaviors for the black box warning for Duloxetine has increased the risk of suicidal thoughts and behaviors in pediatric and young adult patients, and R #24 is not in either of these categories. The DON stated that her expectation is that the nurses will assess the residents and keep communication with the physician and inform the CNAs to assist in monitoring residents and for the nurses to document appropriately for each residents' black box warning. S. On 10/14/25 at 12:29 PM, during an interview, the Medical Director confirmed the following: 1. Oxcarbazepine is an anti-convulsant medication and is not approved to be prescribed for the diagnosis of depression. 2. A GDR for antidepressant medications should be attempted if a resident is not showing signs of depression. 3. Providers are expected to document a clinical rationale for why a GDR should not be attempted. 4. All residents who are being treated with antidepressant medications should be monitored for worsening of depression symptoms and suicidal thoughts or behaviors. 5. If a black box warning indicates that a resident should be monitored for suicidal thoughts or suicidal behaviors, staff should monitor the resident for suicidal thoughts and suicidal behaviors.

Based on record review and interview, the facility failed to develop and implement accurate, person-centered comprehensive care plan for 1 (R #16) of 3 (R #16, R #24, and R #25) residents reviewed for depression when staff failed to: 1. Include what behaviors staff were expected to monitor for related to his diagnosis of depression. 2. Include non-pharmacological interventions for R #16's diagnosis of depression. These deficient practices could likely result in staff being unaware of the current and actual needs of the residents. The findings are: A. Record review of R #16's admission documents, no date, revealed the following: 1. R #16 was admitted to the facility on [DATE]. 2. R #16 had a diagnosis of major depressive disorder (MDD), single episode (refers to a distinct episode of depression that meets the diagnostic criteria for MDD but occurs only once in the individual's lifetime). B. Record review of R #16's physician's orders, multiple dates, revealed the following: 1. An order dated 10/17/24, for escitalopram oxalate (an antidepressant medication used primarily to treat MDD and generalized anxiety disorder) 20 mg, once a day for depression. 2. A black box warning (the most serious warning the U.S. Food and Drug Administration (FDA) can issue on drug and device labeling, alerting healthcare providers and patients to the risk of death or serious injury associated with the product) attached to the escitalopram order in the EMR system that stated closely monitor all antidepressant-treated patients for clinical worsening and for emergence of suicidal thoughts and behaviors. 3. An order dated 10/17/24 for oxcarbazepine (an anticonvulsant medication primarily used to treat partial-onset seizures in adults and children) 300 mg, twice a day for anticonvulsant, and was discontinued on 05/17/25. 4. An order dated 05/17/25 for oxcarbazepine 300 mg, twice a day for depression. 5. An order dated 05/07/25, for behavior monitoring for compulsive behaviors. C. Record review of R #16's progress notes, multiple dates, revealed the following: 1. On 11/04/24, R #16 was making sexually inappropriate verbal comments towards female staff. 2. On 12/24/24, staff documented that R #16 became frustrated and very upset with staff. R #16 was cussing under his breath and was not easily redirected (a proactive strategy to guide a child away from challenging or undesirable actions toward more positive and acceptable ones before the behavior escalates). 3. On 12/29/24, staff documented R #16 was agitated throughout shift. 4. On 04/08/25, staff documented that R #16 had been having inappropriate behaviors toward female staff. 5. On 04/26/25, social services progress note, staff documented that R #16 continued to have negative sexual behaviors toward female staff. 6. On 04/27/25, staff documented that R #16 had sexual behaviors. 7. On 07/11/25, staff documented that R #16 had sexual behaviors toward a female resident and female staff member. 8. On 07/20/25, staff documented that R #16 had been talking about having sexual relations with staff and residents. Staff notified the on-call provider. The on-call provider ordered a psychiatric referral. 9. On 07/21/25, staff documented that R #16 stated he wasn't feeling well due to staff saying he was having sexual behaviors. 10. On 09/14/25, staff documented that R #16 was sexually inappropriate with female residents in his room. D. Record review of R #16's care plan, revised on 05/29/25, revealed the following: 1. Staff documented that R #16 behavior should be monitored. 2. Staff did not document what behaviors R #16 should be monitored for related to depression diagnosis or anti-depressant medication. 3. Staff did not document what non-pharmacological interventions staff were expected to implement for R #16's diagnosis of depression. 4. Staff did not document what compulsive behaviors R #16 had that needed to be monitored. 5. Staff did not document what interventions staff were expected to implement when R #16 exhibited compulsive behaviors. 6. Staff did not document that R #16 had sexually inappropriate behaviors with female staff and female residents. E. On 10/10/25 at 9:20 AM during an interview, LPN #17 stated the following: 1. R #16 was taking an anti-depressant for depression. 2. R #16 had a black box warning for escitalopram and trazadone orders that indicated closely monitor all antidepressant-treated patients for clinical worsening and for emergence of suicidal thoughts and behaviors. 3. R #16 was not monitored for suicidal thoughts or suicidal behaviors. 4. R #16 was not monitored for depression symptoms. 5. R #16 did not have any non-pharmacological interventions in place for his diagnosis of depression. 6. R #16 was being monitored for inappropriate sexual behaviors toward female staff and female residents. F. On 10/10/25 at 12:05 PM, during an interview, the DON confirmed the following: 1. R #16's order for escitalopram had a black box warning that said, closely monitor all antidepressant-treated patients for clinical worsening and for emergence of suicidal thoughts and behaviors. 2. R #16's care plan did not include any specific behaviors related to depression that staff should monitor for. 3. R #16's care plan did not include any non-pharmacological interventions for his diagnosis of depression. 4. R #16's care plan did not include for staff to monitor R #16 for worsening depression or emergence of suicidal thoughts or suicidal behaviors. 5. Staff should include what interventions are in place to treat depression on the care plan. 6. Staff should include what behaviors residents were being monitored for on the care plan.

Based on record review, and interviews, the facility failed to meet professional standards of practice (established guidelines and expectations that ensure the delivery of high-quality care to residents) for 3 (R #1, R #2 and R #9) of 3 (R #1, R #2 and R #9) residents reviewed for assessment and monitoring when facility staff failed to: 1. Administer medications as ordered for R #1, R #2 and R #9. 2. Contact the provider to notify them when medication was held due to possible adverse effects (unintended effect that is undesirable, unpleasant, or harmful) of medication for R #1, R #2 and R #9. If the facility is not providing care per physician's orders, notifying the provider of changes and providing care that meets professional standards of practice, then residents are likely to experience adverse effects, worsening of their condition, and potential complications from not receiving the care ordered by the physician. The findings are: R #1 A. Record review of R #1's admission record (no date) revealed the following: 1. R #1 was admitted to the facility on [DATE]. 2. R #1 had a diagnosis of hypertensive heart disease with heart failure (condition in which high blood pressure has caused significant damage to the heart leading to the heart's inability to pump blood effectively). B. Record review of R #1's physician orders revealed the following: 1. Order dated 12/11/24, for amlodipine (medication used to hypertension by relaxing the heart vessels making it easier for heart to pump blood) 5 mg, give 1 tablet by mouth one time a day for hypertension (high blood pressure). 2. Order dated 12/13/24, for lisinopril (medication used to treat hypertension by relaxing the blood vessels which lowers blood pressure and increases blood flow to the heart) 20 mg, give 1 tablet by mouth one time a day for hypertension. 3. The physician orders did not contain an order to hold medications based on specific parameters (specific predetermined measurements for vital signs [blood pressure] set by physician/provider used to decide whether medication should be given or not). C. Record review of R #1's medication administration record (MAR; a form used to document medication administration) dated June 2025, revealed the following: -amlodipine 1. On 06/23/25 staff documented 5 = hold (do not give medication)/see progress notes. 2. On 06/26/25 staff documented 5. 3. On 06/30/25 staff documented 5. -lisinopril 4. On 06/23/25 staff documented 5. 5. On 06/26/25 staff documented 5. 6. On 06/30/25 staff documented 5. D. Record review of R #1's medication administration record dated July 2025, revealed the following: -amlodipine 1. On 07/02/25 staff documented 4 = vitals outside of parameters for administration (specific predetermined measurements for vital signs [blood pressure] set by provider indicating when medication is to be held) 2. On 07/04/25 staff documented 5. 3. On 07/07/25 staff documented 4. -lisinopril 4. On 07/02/25 staff documented 4. 5. On 07/04/25 staff documented 5. 6. On 07/07/25 staff documented 4. E. Record review of R #1's progress notes for June 2025 revealed the following: 1. Staff did not document they notified the provider regarding holding R #1's BP medication. 2. On 06/23/25 staff documented medication held due to low parameters BP 77/55 heart rate (HR) 96. 3. On 06/26/25 staff documented resident's BP 97/51. 4. On 06/30/25 staff documented This medication is on hold due to resident's BP of 97/52 F. Record review of R #1's progress notes for July 2025 revealed the following: 1. Staff did not document they notified the provider regarding holding R #1's BP medication. 2. On 07/02/25 staff did not document what R #1's BP reading was or why BP medication was held. 3. On 07/04/25 staff documented resident's BP 92/47. 4. On 07/07/25 staff did not document what R #1's BP reading was or why BP medication was held. R #2 G. Record review of R #2's admission record (no date) revealed the following: 1. R #2 was admitted to the facility on [DATE]. 2. R #2 had a diagnosis of hypertensive heart disease without heart failure (condition in which high blood pressure has caused significant damage to the heart but has not yet progressed to affect the heart's ability to pump blood effectively). H. Record review of R #2's physician orders revealed the following: 1. Order dated 11/08/23, for amlodipine 5 mg, give 2 tablets by mouth one time a day for hypertension, hold BP medication of systolic BP (top number of BP reading) is less than 100 or greater than 180 or if diastolic BP (bottom number of BP reading) is less than 50 or greater than 90. I. Record review of R #2's MAR dated June 2025, revealed the following: -amlodipine 1. R #2's blood pressure medication was held 18 out of 30 days in June 2025. 2. On 06/02/25 staff documented 4 but staff did not document R #2's BP reading or HR. 3. On 06/04/25 staff documented 4 BP 90/60, HR 62. 4. On 06/05/25 staff documented 4 BP 89/55, HR 74. 5. On 06/06/25 staff documented 4 BP 117/59, HR 52. 6. On 06/09/25 staff documented 4 BP 108/53, HR 78. 7. On 06/10/25 staff documented 4 BP 102/45, HR 59. 8. On 06/12/25 staff documented 4 BP 101/57, HR 58. 9. On 06/13/25 staff documented 4 BP 83/46, HR 72. 10. On 06/14/25 staff documented 4 BP 87/60 HR 54. 11. On 06/16/25 staff documented 9 = Other/See progress notes but staff did not document R #2's BP reading or HR. 12. On 06/18/25 staff documented 4 BP 95/51 HR 110. 13. On 06/20/25 staff documented 5 BP 97/58, HR 61. 14. On 06/22/25 staff documented 5 but staff did not document R #2's BP reading or HR. 15. On 06/23/25 staff documented 4 BP 118/62, HR 67. 16. On 06/24/25 staff documented 4 BP 100/55, HR 91. 17. On 06/27/25 staff documented 4 but staff did not document R #2's BP reading or HR. 18. On 06/28/25 staff documented 4 but staff did not document R #2's BP reading or HR. 19. On 06/29/25 staff documented 4 but staff did not document R #2's BP reading or HR. J. Record review of R #2's MAR dated July 2025, revealed the following: -amlodipine 1. R #2's blood pressure medication was held 19 out of 31 days in July 2025. 2. On 07/01/25 staff documented 5 BP 99/52, HR 47. 3. On 07/02/25 staff documented 4 but staff did not document R #2's BP reading or HR. 4. On 07/03/25 staff documented 5 but staff did not document R #2's BP reading or HR. 5. On 07/04/25 staff documented 5 BP 104/59, HR 47. 6. On 07/07/25 staff documented 4 but staff did not document R #2's BP reading or HR. 7. On 07/08/25 staff documented 4 but staff did not document R #2's BP reading or HR. 8. On 07/12/25 staff documented 4 but staff did not document R #2's BP reading or HR. 9. On 07/13/25 staff documented 4 BP 103/87, HR 76. 10. On 07/14/25 staff documented 9 but staff did not document R #2's BP reading or HR. 11. On 07/16/25 staff documented 4 but staff did not document R #2's BP reading or HR. 12. On 07/18/25 staff documented 5 but staff did not document R #2's BP reading or HR. 13. On 07/19/25 staff documented 5 BP 94/61, HR 59. 14. On 07/21/25 staff documented 4 but staff did not document R #2's BP reading or HR. 15. On 07/22/25 staff documented 4 but staff did not document R #2's BP reading or HR. 16. On 07/23/25 staff documented 4 BP 105/59, HR 54. 17. On 07/25/25 staff documented 4 BP 99/50, HR 69. 18. On 07/27/25 staff documented 4 BP 89/59, HR 61. 19. On 07/30/25 staff documented 4 BP 97/51, HR 77. 20. On 07/31/25 staff documented 4 BP 98/42, HR 54. K. Record review of R #2s progress notes for June 2025 revealed the following: 1. Staff did not document they notified the provider regarding holding R #2's amlodipine for several days. 2. On 06/02/25 staff did not document R #2's blood pressure or the reason the amlodipine was held. 3. On 06/05/25 staff documented hold medication per nurse, BP and HR low. 4. On 06/06/25 and 06/09/25 staff did not document regarding holding amlodipine even though the documented BP readings on the MAR were within the parameters to give the medication. 5. On 06/12/25 staff documented hold medication BP was low, staff did not document communication to the provider to determine the need to hold medication even though the documented BP reading was within the parameters to give. 6. On 06/13/25 staff did not document any communication to the provider regarding significantly low BP of 83/46. 7. On 06/14/25 staff documented amlodipine held due to low parameters. No documentation that the provider was informed that R #2's BP remained low at 87/60. 8. On 06/16/25 staff did not document R #2's BP reading and documented patient had an appointment. No documentation that provider was notified that R #2 missed his medication due to being at an appointment. 9. On 06/22/25 staff documented resident's BP 99/56, HR 53. 10. On 06/23/25 and 06/24/25 staff did not document regarding holding amlodipine even though the documented BP readings on the MAR were within the parameters to give the medication. 11. On 06/27/25, 06/28/25 and 06/29/25 staff did not document R #2's BP readings or the reason that amlodipine was held. L. Record review of R #2's progress notes for July 2025 revealed the following: 1. Staff did not document that they notified the provider regarding holding R #2's medication for several days. 2. On 07/02/25 staff did not document what R #2's blood pressure reading was or why amlodipine was held. 3. On 07/03/25 staff documented resident's BP 99/54. 4. On 07/04/25 staff documented amlodipine is on hold due to resident's pulse (Heart rate/HR) of 47. Documentation did not include whether the provider was consulted or notified of low HR since R #2's amlodipine order does not have HR parameters indicating when to hold the medication. 5. On 07/07/25, 07/08/25 and 07/12/25 staff did not document R #2's BP or the reason why amlodipine was held. 6. On 07/13/25 staff did not document regarding holding amlodipine even though the documented BP reading on the MAR was within the parameters to give the medication. 7. On 07/14/25 staff did not document R #2's BP reading and documented resident is out of facility on transport, reported to charge nurse. No documentation that provider was notified that R #2 missed his medication due to being at an appointment. 8. On 07/16/25 staff did not document R #2's BP reading or the reason why amlodipine was held. 9. On 07/18/25 staff documented resident's BP 95/55, HR 63. 10. On 07/21/25 and 07/22/25 staff did not document R #2's BP or the reason why amlodipine was held. 11. On 07/23/25 staff documented BP and HR low, nurse notified staff did not document why amlodipine was held even though the documented BP reading on the MAR was within the parameters to give the medication. M. Record review of American Heart Association Low blood pressure-When blood pressure is too low last reviewed 05/06/24.www.heart.org/en/health-topics/high-blood-pressure/the-facts-about-high-blood-pressure/low-blood-pressure-when-blood-pressure-is-too-low revealed the following: 1. Low blood pressure occurs when blood pressure is less than 90/60. 2. Low blood pressure can happen with diuretics (medications that help the body eliminate excess fluid by increasing urine production) and other drugs used to treat high blood pressure. R #9 N. Record review of R #9's admission record (no date) revealed the following: 1. R #9 was admitted to the facility on [DATE]. 2. R #9 had a diagnosis of type 2 diabetes mellitus with hyperglycemia (chronic disease in which the body cannot use insulin properly and results in high blood sugar [BS] levels). O. Record review of R #9's physician orders revealed the following: 1. Order dated 08/28/25, for insulin glargine (medication used to improve and maintain blood sugar levels over an extended period of time) inject 28 units one time a day for diabetes mellitus type 2 (DM-2) 2. Order dated 08/22/25, for Humulin regular insulin (insulin that works to help lower blood sugar levels within 30 minutes of injection) inject as per sliding scale (insulin dosages that are adjusted based on the patient's current blood sugar level) before meals and at bedtime as follows: a. If BS level is 0-80 and conscious give 4 ounces of juice, if unconscious give glucagon (emergency medication used to treat severe low blood sugar in diabetes patients) 1 mg intramuscularly, notify doctor. b. If BS level is 81-199, no coverage (no insulin given). c. If BS level is 200-250 give 2 units. d. If BS level is 251-300 give 4 units. e. If BS level is 301-350 give 6 units. f. If BS level is 351-400 give 8 units. g. If BS level is 401 or greater give 10 units and notify doctor. P. Record review of R #9's MAR dated August 2025, revealed the following: -insulin glargine 1. On 08/20/25 staff documented 13 medication not available. 2. On 08/21/25 staff documented 5. 3. On 08/25/25 staff documented 5. 4. On 08/26/25 staff documented 6 = hospitalized -Humulin 5. On 08/23/25 at 630 AM staff documented 4 BS 70. 6. On 08/24/25 at 630 AM staff documented 4 BS 80. 7. On 08/24/25 at 1130 AM staff documented 9, staff did not document BS level. 8. On 08/24/25 at 430 PM staff documented 4 BS 70. 9. On 08/25/25 at 430 PM staff documented 4 BS 65. 10. On 08/25/25 at 830 PM staff documented 4 BS 57. 11. On 08/26/25 at 1130 AM staff documented 4 BS 62. Q. Record review of Diabetic Management Policy dated 03/19/24 revealed the following: 1. ACUTE COMPLICATION MANAGEMENT: HYPOGLYCEMIA - Low Blood Sugar Levels a. If the BG (blood glucose/BS) level is below 70 mg/dl or other physician directed low parameter, and the resident can swallow, or the resident is tube fed: Give fast acting source of sugar and notify MD. b. Reassess the BG level in 15 minutes and document the results of the BG on the MAR. c. If the BG level remains below 70 mg/dl or other physician directed low parameter give: Additional source of sugar (e.g., another 4 ounces of orange juice or administer glucose gel. d. Recheck blood glucose in 15 minutes and document the results. e. Notify the physician of the episode. R. Record review of R #9's progress notes for August 2025 revealed the following: 1. On 08/21/25 staff did not document R #9's BS level or the reason why insulin glargine was held. 2. On 08/25/25 for insulin glargine, staff documented blood glucose low. Staff did not consult the provider regarding holding the medication since the medication does not have hold parameters. 3. On 08/23/25, 08/24/25, 08/25/25 and 08/26/25 staff did not document that they gave juice, glucagon, rechecked the BS level or notified the provider of R #9's BS levels of 80 or less. S. On 10/17/25 at 11:00 AM, during an interview, the DON confirmed the following: 1. Staff did not contact the provider to notify them of R #1's and R #2's BP medications being held. 2. R #1's amlodipine and lisinopril orders did not have parameters indicating when the medications should be held. 3. R #2's amlodipine was held outside of set parameters. 4. R #9's insulin glargine was held, and the order did not have parameters indicating when to hold the medication. 5. Staff did not follow R #9's Humulin insulin order or the facility policy regarding low blood sugars. 6. Her expectation is that if staff have concerns regarding administering medications, they contact the provider, document the conversation held with provider and enter a new order as needed depending on what the provider's decision is regarding the medication.

Based on record review, and interview, the facility failed to ensure residents received necessary behavioral health care to meet their needs for 1 (R #16) of 3 (R #16, R #24, and R #25) residents reviewed for behavioral health concerns when: 1. Staff delayed psychiatric services for R #16 after a psychiatric referral on 12/18/24 and 07/20/25. 2. Staff failed to refer R #16 for recommended therapy services on 03/14/25. 3. Staff did not have an effective process for referring residents to behavioral health services. These deficient practices could likely result in residents not receiving the behavioral or mental health care and assistance needed to attain or maintain the highest practicable physical, mental, and psychosocial well-being. The findings are: A. Record review of R #16's admission documents, no date, revealed the following: 1. R #16 was admitted to the facility on [DATE]. 2. R #16 had the following diagnoses: a. Parkinson's Disease (a progressive neurodegenerative disorder that affects movement, balance, and coordination). b. Dementia without behavioral disturbance (a condition where a person experiences cognitive decline, such as memory loss, difficulty with attention, and problem-solving, but does not exhibit significant behavioral changes or disturbances). c. Insomnia (a sleep disorder characterized by persistent difficulty falling asleep, staying asleep, or waking up too early in the morning, despite having adequate opportunity to sleep). d. Major depressive disorder (MDD), single episode (refers to a distinct episode of depression that meets the diagnostic criteria for MDD but occurs only once in the individual's lifetime). B. Record review of R #16's physician's orders, multiple dates, revealed the following: 1. An order dated 10/17/24, for escitalopram oxalate (an antidepressant medication used primarily to treat MDD and generalized anxiety disorder) 20 mg, once a day for depression. 2. An order dated 10/17/24 for oxcarbazepine (an anticonvulsant medication primarily used to treat partial-onset seizures in adults and children) 300 mg, twice a day for anticonvulsant, and was discontinued on 05/17/25. 3. An order dated 05/17/25 for oxcarbazepine 300 mg, twice a day for depression. 4. An order dated 12/18/24, to refer R #16 to [Name of psychiatric provider] for evaluation and treatment. 5. An order dated 05/07/25, for behavior monitoring for compulsive behaviors. 6. An order dated 07/20/25, for psych consult due to inappropriate sexual behaviors. C. Record review of R #16's progress notes, multiple dates, revealed the following: 1. On 11/04/24, R #16 was making sexually inappropriate verbal comments towards female staff. 2. On 12/24/24, staff documented that R #16 became frustrated and very upset with staff. R #16 was cussing under his breath and was not easily redirected (a proactive strategy to guide a child away from challenging or undesirable actions toward more positive and acceptable ones before the behavior escalates). 3. On 12/29/24, staff documented R #16 was agitated throughout shift. 4. On 04/08/25, staff documented R #16 had been having inappropriate behaviors toward female staff. 5. On 04/26/25, on the quarterly social services evaluation progress note, staff documented that R #16 continued to have negative sexual behaviors toward female staff. 6. On 04/27/25, staff documented R #16 had sexual behaviors. 7. On 07/11/25, staff documented R #16 had sexual behaviors toward a female resident and female staff member. 8. On 07/20/25, staff documented R #16 had been talking about having sexual relations with staff and residents. Staff notified the on-call provider. The on-call provider ordered a psychiatric referral. 9. On 07/21/25, staff documented R #16 stated he wasn't feeling well due to staff saying he was having sexual behaviors. 10. On 09/14/25, staff documented R #16 was sexually inappropriate with female residents in his room. 11. On 10/06/25, staff documented R #16 had self-harm and the psychiatric provider was notified. D. Record review of R #16's administration record (method for staff to document treatments or behaviors), dated July 2025, revealed staff documented R #16 had compulsive behaviors on the following dates: 1. 07/09/25. 2. 07/20/25. E. Record review of R #16's administration record, dated August 2025, revealed staff documented R #16 had compulsive behaviors on the following dates: 1. 08/05/25 2. 08/06/25 F. Record review of R #16's administration record, dated September 2025, revealed staff documented R #16 had compulsive behaviors on the following dates: 1. 09/08/25 2. 09/14/25 G. Record review of R #16's provider progress notes, multiple dates, revealed the following: 1. On 05/23/25, the provider documented that R #16 had depression and was not followed by psychiatry. 2. On 07/01/25, the provider documented that R #16 had a diagnosis of depression and was not followed by psychiatry. 3. On 08/23/25, the provider documented that R #16 had a diagnosis of depression and was not followed by psychiatry. H. Record review of R #16's Psychiatric Evaluation (a comprehensive assessment of an individual's mental health status conducted by a qualified mental health professional, such as a psychiatrist, psychologist, or social worker), multiple dates, revealed R #16 was seen on: 1. 03/14/25, the psychiatric provider recommended R #16 continue therapy services (resident was not receiving therapy services at that time, see finding I and M). 2. 10/06/25, after an episode of self-harm. I. Record review of R #16's entire medical record, no date, revealed R #16 was not seen for therapy services at the facility. J. On 10/10/25 at 9:20 AM during an interview, LPN #17 stated the following: 1. R #16 was taking an anti-depressant for a diagnosis of depression. 2. R #16 did not have any non-pharmacological interventions in place for his diagnosis of depression. 3. She was unsure if R #16 was receiving behavioral health services. 4. R #16 frequently exhibited sexual behaviors toward female staff and female residents. 5. Staff were monitoring R #16 for his sexual behaviors toward female staff and female residents. 6. R #16's order to monitor compulsive behaviors was related to sexual behaviors. 7. She was the nurse working when R #16 had an episode of self-harm on 10/06/25. 8. R #16 had never stated suicidal thoughts or showed suicidal behaviors prior to 10/06/25. K. On 10/10/25 at 10:02 AM, during an interview, the SSD stated the following: 1. R #16 had a referral for [Name of psychiatric company] on 12/18/24. 2. R #16 was not seen by the psychiatric provider until 03/14/25. 3. She stated that when a referral is placed for a psychiatric provider, the nurses were expected to verbally notify her, then she sends the referral to the psychiatric provider. 4. R #16 had another referral, dated 07/20/25, for a psychiatric consult due to increased sexual behaviors. 5. R #16 was not seen by the psychiatric provider until 10/06/25. 6. She stated she did not have a method to track when she was verbally notified about psychiatric referrals. L. On 10/10/25 at 12:05 PM, during an interview, the DON confirmed the following: 1. Staff were expected to verbally notify the SSD when a psychiatric referral was ordered. 2. The SSD was expected to send the referral to the psychiatric provider. 3. There was no tracking method to ensure the SSD was notified and the referral was sent to the psychiatric provider. 4. Her expectation was for nursing staff to notify the psychiatric provider if a resident is having increased behaviors. 5. She was unable to determine when the SSD was notified about R #16's referrals on 12/18/24 or 07/20/25. 6. R #16 was seen by the psychiatric provider on 03/14/25 and after his episode of self-harm on 10/06/25. M. On 10/10/25 at 12:20 PM, during an interview, the Medical Records Director confirmed R #16 was not being seen for counseling. N. On 10/10/15 at 12:55 PM, during an interview, the psychiatric nurse practitioner (PNP) confirmed the following: 1. He usually received referrals from the SSD via email. 2. He was unsure when he was notified about R #16's first referral on 12/18/24. 3. He saw R #16 on 03/14/25. 4. He was not notified that a new referral for R #16 was placed on 07/20/25. 5. He was not notified that R #16 had sexual behaviors. 6. If he had been notified about R #16 having sexual behaviors, he would have followed up with him. 7. He saw R #16 after an episode of self-harm on 10/06/25. 8. He confirmed he did not see R #16 between the 03/14/25 and 10/06/25 visits.

Based on record review and interview, the facility failed to ensure the physician provided documentation of a rationale (set of reasons or a logical basis for a course of action) for not following the consultant pharmacist's recommendation for 1 (R #16) of 3 (R #16, R #24, and R #25) residents reviewed for depression. This deficient practice could likely result in residents receiving medications that are no longer necessary and may cause unnecessary drug interactions (changes to medication action caused by being combined with other foods, beverages, or drugs) or adverse side effects (unwanted, undesirable effects from medication). A. Record review of R #16's admission documents, no date, revealed the following: 1. R #16 was admitted to the facility on [DATE]. 2. R #16 had the following diagnoses: a. Dementia without behavioral disturbance (a condition where a person experiences cognitive decline, such as memory loss, difficulty with attention, and problem-solving, but does not exhibit significant behavioral changes or disturbances). b. Insomnia (a sleep disorder characterized by persistent difficulty falling asleep, staying asleep, or waking up too early in the morning, despite having adequate opportunity to sleep). c. Major depressive disorder (MDD), single episode (refers to a distinct episode of depression that meets the diagnostic criteria for MDD but occurs only once in the individual's lifetime). B. Record review of R #16's physician's orders, multiple dates, revealed the following: 1. An order dated 10/17/24, for escitalopram oxalate (an antidepressant medication used primarily to treat MDD and generalized anxiety disorder) 20 mg, once a day for depression. 2. An order dated 10/17/24 for oxcarbazepine (an anticonvulsant medication primarily used to treat partial-onset seizures in adults and children) 300 mg, twice a day for anticonvulsant, and was discontinued on 05/17/25. 3. An order dated 05/17/25 for oxcarbazepine 300 mg, twice a day for depression. 4. An order dated 11/22/24 for trazadone (antidepressant medication that is also used to treat anxiety and insomnia) 25 mg, once a day for sleep aide. 5. An order dated 06/29/25 for trazadone 25 mg, once a day for insomnia. C. Record review of R #16's pharmacist recommendation, dated 07/28/25, revealed the following: 1. R #16 had been taking escitalopram 20 mg once a day since 10/18/24. 2. The pharmacist recommended R #16 be evaluated to decrease the dose of escitalopram. 3. The provider documented resident with good response, maintain current dose. 4. The provider documented disagree with the pharmacist recommendation. 5. The provider did not document a clinical rationale for why R #16 should not have a dose reduction. D. Record review of R #16's entire medical record, no date, revealed the provider did not document a clinical rationale for why a GDR should not be conducted for R #16 for escitalopram 20 mg. E. On 10/09/25 at 2:11 PM, during an interview, the DON confirmed the following: 1. R #16 was taking the same dose of escitalopram and oxcarbazepine since he arrived on 10/17/24. 2. The pharmacist recommended a GDR for escitalopram on 07/28/25 and the provider declined the GDR. 3. R #16's provider did not document a clinical rationale for why a GDR should not be conducted for escitalopram. F. On 10/14/25 at 12:29 PM, during an interview, the Medical Director confirmed the following: 1. A GDR for antidepressant medications should be attempted if a resident was not showing signs of depression. 2. Providers were expected to document a clinical rationale for why a GDR should not be attempted.

Based on record review and interview, the facility failed to provide activities of daily living (ADL) assistance for 4 (R #8, R #10, R #11, and R #24) of 5 (R #8, R #10, R #11, R #24, and R #25) residents reviewed for ADL care when staff failed to: 1. Assist R #8 and R #11 with toileting. 2. Assist R #10 with ADL care. 3. Assist R #24 with brushing his teeth and showering. These deficient practices caused R #8 and R #25 psychological distress, and feeling embarrassed. The findings are: R #8 A. On 02/18/25 at 8:41 AM, during an interview with CNA #8, he stated on 02/16/25, in the morning, there were only two (2) CNA's working on the South Unit. CNA #8 said there was 58 residents on the South Unit that day. CNA #8 said R #8 was assisted to the bathroom by the LPN #8 and Activity Director (AD) and was left on the toilet for approximately an hour. CNA #8 said he was assisting another resident when R #8 was taken to the bathroom at 11:00 am. CNA #8 said that when he finished, he noticed R #8's call light was still on. CNA #8 said that when he went to her room at approximately 12:00 PM, R #8 was still on the toilet in her bathroom waiting for assistance. B. On 02/18/25 at 9:42 AM, during an interview with R #8, she said on 02/16/25, at 11:00 AM, she was assisted to the bathroom. R #8 said she is assisted with the Sara lift (a patient-assisting device that helps patients stand up and move around) and it takes two people to help her. R #8 said when she finished in the bathroom, she turned on the call light. R #8 said it was a little before 12:00 PM, before CNA #8 was able to get her off the toilet. R #8 said she was upset and crying. R #8 said she felt like no one cared. R #8 said it takes 15 minutes to an hour for her call light to be answered. R #8 said that there is usually only one CNA on her hall. R #8 said that when she needs assistance getting out of bed or to the bathroom, she has to wait longer because the CNA assigned to her hall has to find someone to help. C. Record review of R #8's care plan dated 08/12/24, revealed R #8 needs assistance with ADL's. D. Record review of R #8's Quarterly MDS dated [DATE], revealed R #8 is dependent (helper does all of the effort. Resident does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the resident to complete the activity) for toileting. E. On 02/18/25 at 2:49 PM, during an interview, AD #8 said on 02/16/25, she assisted LPN #8 transfer R #8 to the toilet. AD said she was finishing an activity with residents and was asked to assist at 11:00 AM. AD #8 said that there were only two CNA's on the South Unit and there were a lot of call lights on. AD #8 said she tries to help when she sees call lights, but she does not work the floor. F. On 02/19/25 at 10:50 AM, during an interview, CNA #10 said there are a lot of residents on the South Unit that are two people assist. CNA #10 said that on 02/16/25 there was only 2 CNA's and they weren't able to do showers, vital signs, or any documentation. CNA #10 said residents end up wetting themselves and have bowel movements because they can't get to them in time. R #10 G. On 02/17/25 at 2:43 PM, during an interview, R #10 said she usually waits 45 minutes to get assistance. R #10 said she is a two person assist because she needs the hoyer lift (a mechanical device that helps move people with limited mobility). R #10 said there are a lot of residents on the South Unit that need the hoyer lift. R #10 said there are only 3 CNA's scheduled on the South Unit. R #10 said that sometimes there are only 2 CNA's for the entire unit. R #10 said that when she needs help, the CNA has to try and find someone to help them. R #10 said they come in and turn off the light and tell her they need to find someone to help and then don't come back for 30 to 45 minutes. H. Record review of R #10's care plan dated 11/12/24, revealed R #10 requires assistance to meet basic ADL needs. I. Record review of R #10's Quarterly MDS dated [DATE], revealed R #10 is dependent (helper does all of the effort. Resident does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the resident to complete the activity) for toileting, shower/bathe self, upper body dressing, lower body dressing, putting on/taking off footwear, and personal hygiene. R #11 J. On 02/19/25 at 10:55 AM, during an interview with CNA #11, she said there is not enough staff. CNA #10 said residents are having accidents and wetting themselves because they can't get to them in time. CNA #11 said R #11 needs assistance to get to the bathroom and he has had accidents because he can't wait. K. On 02/19/25 at 10:58 AM, during an interview, R #11 said has had to wait 30 minutes to an hour to get help because staff don't answer the call lights. R #11 said he has had quite a few accidents. R #11 said he needs help to go to the bathroom. L. Record review of R #11's care plan dated 11/19/24, revealed R #11 requires assistance to meet ADL needs. M. Record review of R #11's Quarterly MDS dated [DATE], revealed R #11 is partial/moderate assistance (helper does less that half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort) for sit to lying, lying to sitting on side of bed, sit to stand, chair/bed-to-chair transfer, and toilet transfer. Assistance with Oral Care N. Record review of R #24's Face Sheet revealed the following diagnosis of a Traumatic Brain Injury and was admitted to the facility in 2009. O. On 02/17/25 at 9:08 AM, during an interview, R #24's family member (FM) stated staff do not brush R #24's teeth daily after meals. R #24 is not interviewable. P. Record review of R #24's Quarterly MDS dated [DATE], revealed R #24 requires substantial/maximal assistance (helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort). Q. Record review of R #24's care plan dated 12/03/24, revealed R #24 requires substantial/maximal assistance. R. Record review of R #24's ADL sheet, dated December 2024, revealed the following: 1. On 12/11/24, staff did not document that R#24 received oral care after each meal. 2. On 12/22/24, staff did not document that R#24 received oral care after each meal. 3. On 12/29/24, staff did not document that R#24 received oral care after each meal. S. Record review of R #24's ADL sheet, dated January 2025, revealed the following: 1. On 01/01/25, staff did not document that R#24 received oral care after each meal. 2. On 01/03/25, staff did not document that R#24 received oral care after each meal. 3. On 01/05/25, staff did not document that R#24 received oral care after each meal. 4. On 01/06/25, staff did not document that R#24 received oral care after each meal. 5. On 01/07/25, staff did not document that R#24 received oral care after each meal. 6. On 01/09/25, staff did not document that R#24 received oral care after each meal. 7. On 01/12/25, staff did not document that R#24 received oral care after each meal. 8. On 01/17/25, staff did not document that R#24 received oral care after each meal. 9. On 01/19/25, staff did not document that R#24 received oral care after each meal. 10. On 01/26/25, staff did not document that R#24 received oral care after each meal. 11. On 01/28/25, staff did not document that R#24 received oral care after each meal. 12. On 01/31/25, staff did not document that R#24 received oral care after each meal. T. Record review of R #24's ADL sheet, dated February 2025, revealed the following: 1. On 02/02/25, staff did not document that R#24 received oral care for all shifts. 2. On 02/03/25, staff did not document that R#24 received oral care for all shifts. 3. On 02/04/25, staff did not document that R#24 received oral care for all shifts. 4. On 02/06/25, staff did not document that R#24 received oral care for all shifts. 5. On 02/07/25, staff did not document that R#24 received oral care for all shifts. 6. On 02/09/25, staff did not document that R#24 received oral care for all shifts. 7. On 02/10/25, staff did not document that R#24 received oral care for all shifts. 8. On 02/13/25, staff did not document that R#24 received oral care for all shifts. 9. On 02/14/25, staff did not document that R#24 received oral care for all shifts. 10. On 02/17/25, staff did not document that R#24 received oral care for all shifts. 11. On 02/18/25, staff did not document that R#24 received oral care for all shifts. 12. On 02/19/25, staff did not document that R#24 received oral care for all shifts. U. On 02/18/25 at 10:51 AM, during an interview with the CNA #9, he stated R #24 requires total assistance for oral hygiene. CNA #9 confirmed R #24 is scheduled for oral hygiene after meals. CNA #9 also stated R #24 can't do oral hygiene himself. CNA #9 confirmed he did not complete oral hygiene yet, as of the time of the interview. V. On 02/18/25 at 11:12 AM, during an interview with LPN #8, she confirmed R #24 receives oral hygiene daily, and R #24 can't complete oral hygiene alone. LPN #8 stated R #24's oral hygiene is done after every meal, and the CNAs are assigned to do it. R #24 W. On 02/17/25 at 9:08 AM, during an interview with FM #24, she stated, R #24 is scheduled to get showered three times a week. FM #24 stated R #24 goes days without a shower, and R #24 had a noticeable smell. R #24 stated that she feels the R #24 is not getting showered due to the facility being short staffed. FM #24 confirmed she reported to the Administrator that the staff are not following the shower schedule because she felt they were short of staff. X. Record review of R #24's Quarterly MDS for ADL-bathing dated 01/23/25, revealed R #24 required substantial/maximal assistance-helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort. Y. Record review of R #24's care plan dated 12/03/24 for ADL-bathing revealed R #24 requires substantial/maximal assistance-helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort. Z. Record review of R #24's shower schedule no date revealed R #24 shower nights are Mondays, Wednesdays, and Fridays. AA. Record review of R #24's ADL documentation survey report for December 2024, revealed staff did not document showers were done for R #24 on the following dates: 1. On 12/02/24, staff documented NA (not applicable) R #24 did not receive a shower day shift and no documentation for night shift. 2. On 12/04/24, staff documented NA, R#24 did not receive a shower for all shifts. 3. On 12/06/24, staff documented NA for night shift R #24 did not receive a shower. 4. On 12/09/24, staff documented NA, R #24 did not receive a shower for all shifts. 5. On 12/11/24, staff did not document R #24 did not receive a shower for all shifts. 6. On 12/13/24, staff documented NA for night shift R #24 did not receive a shower. 7. On 12/16/24, staff documented NA for day shift R #24 did not receive a shower and no documentation for night shift. 8. On 12/18/24, staff documented NA staff documented NA (not applicable) R #24 did not receive a shower for all shifts. 9. On 12/25/24, staff documented NA, R #24 did not receive a shower for all shifts. 10. On 12/27/24, staff documented NA, R #24 did not receive a shower for night shift. 11. On 12/30/24, staff documented NA, R #24 did not receive a shower for all shifts. BB. Record review of R #24's ADL documentation survey report dated January 2025 revealed the following: 1. On 01/08/25, staff documented NA that R #24 did not receive a shower day shift and no documentation for night shift. 2. On 01/20/25, staff documented NA that R #24 did not receive a shower day shift and no documentation for night shift. 3. On 01/24/25, staff documented NA that R #24 did not receive a shower day shift and no documentation for night shift. CC. Record review of R #24's ADL, documentation survey report dated February 2025, revealed the following: 1. On 02/05/25, staff documented NA, R #24 did not receive a shower for night shift. 2. On 02/12/25, staff documented NA, R #24 did not receive a shower for night shift. 3. On 02/14/25, staff did not document that R #24 received a shower for all shifts. 4. On 02/17/25, staff did not document that R #24 received a shower for all shifts. 5. On 02/19/25, staff did not document that R #24 received a shower for all shifts. DD. On 02/20/25 at 12:26 PM, during an interview, CNA #28 stated she follows the shower schedule but when the facility is short staffed, sometimes shower don't happen. CNA #28 further stated that if there is enough staff the resident who missed a shower will get a shower on next day if possible. EE. On 02/20/25 at 12:36 PM, during an interview, CNA #8 stated staff shower residents as scheduled for the most part. CNA #8 continued to stated that when the facility is short staffed, the CNAs are not able to complete showers. CNA #8 stated sometimes on the following day it's already too busy and CNAs don't have time to make up showers. FF. On 02/20/25 at 2:25 PM, during an interview the ADON did not confirm or deny the missed showers for R #24 for the month of February on the ADL sheet, when asked. 52223

Based on record reviews, observation, and interviews, the facility failed to ensure the facility had sufficient staff to meet the needs of 5 (R #8, R #10, R #11, R #25, and R #26) of 6 (R #8, R #10, R #11, R #24, R #25, and R #26) residents reviewed for staffing when staff failed to: 1. To transfer R #8. 2. Change R #10's brief. 3. To assist R #11 to the toilet as needed. 4. Assist R #24 with oral care and showers. 5. Change R #25's brief after 30 minutes or longer. This deficient practice caused R #25 psychological distress, feeling embarrassed and crying when discussing how she was left soiled when she has to wait to be changed. The findings are: A. Record review of R #25's Admission Record, (Face Sheet) no date revealed the following: 1. admitted [DATE]. 2. Diagnosis of Chronic Kidney Disease, Stage 4 (a long-term condition where the kidneys gradually lose their ability to filter waste products and excess fluid from the blood. Severe). B. Record review of R #25 physician orders revealed on 12/11/24, Torsemide Oral Tablet (Diuretic medicine that helps to remove excess water and sodium from the body through urine) 10 mg. C. Record review of R #25's MDS assessment dated [DATE], revealed R #25 is Dependent- (helper does all of the effort. Resident does none of the effort to complete the activity. Or the assistance of two or more helpers is required for the resident to complete the activity.) D. On 02/18/25 at 9:33 AM, during an interview and observation with R #25, revealed R #25 was visibly in distress, head down with tears running down her face when discussing staffing. R #25 stated the facility is short staffed and she feels like they save her until they are done with all the other residents. R #25 stated staff take a long to answer the call lights. R #25 further stated when there is a storage of staff CNAs can take 30 minutes or longer to answer call lights. R #25 stated for the shift from 6:00 AM and 4:00 PM (day shift) is when there is staff shortage. R #25 stated the facility needs more help to answer the call lights faster. R #25 stated that when CNAs come they turn the call lights off and say they are short staffed, and she will need to wait. R #25 stated she feels embarrassed because she's left wet to wait for assistance for a long time. E. On 02/18/25 at 11:28 AM, during an observation by another resident's room, R #25 called out in hallway to surveyor, and R #25 stated I need help, I need to be changed. R #25 stated she had been waiting 25 minutes. F. On 02/19/25 at 1:52 PM, during an interview CNA #10 confirmed there is a lot of residents who use the Hoyer lift (a mechanical device that helps move people with limited mobility). and two people are always needed for safety. CNA #10 confirmed the residents complain that call lights are not being answered on time due to needing two staff to assist the residents with the hoyer lift, leaving the unit without CNAs. G. On 02/18/25 at 10:12 am, during an interview with the ADON, she stated her expectation is that the call lights be answered within five minutes after the call light is activated. The ADON said if there is a resident that needs a two person assist that it will take a little longer to answer other call lights. The ADON said that she is not aware of any residents that have waited 15-30 minutes or longer for assistance. R #8 H. On 02/18/25 at 8:41 AM, during an interview with CNA #8, he stated that on 02/16/25, in the morning, there were only two (2) CNA's working on the South Unit. CNA #8 said that there were 58 residents on the South Unit that day. CNA #8 said R #8 was assisted to the bathroom by the LPN #8 and Activity Director (AD) around 11:00 AM and was left on the toilet for approximately an hour. CNA #8 said he assisted another resident when he saw R #8 being assisted to the bathroom. CNA #8 said when he finished assisting another resident, he noticed R #8's call light was still on. CNA #8 said he went to R #8's room at 12:00 PM (02/16/25), R #8 was still on the toilet in her bathroom waiting for assistance. I. On 02/18/25 at 9:42 AM, during an interview, R #8 stated on 02/16/25, at 11:00 AM, she was assisted to the bathroom. R #8 said she was assisted with the Sara lift (a patient-assisting device that helps patients stand up and move around) and requires two people to help her. R #8 said when she finished in the bathroom, she turned on the call light. R #8 said it was a little before 12:00 PM, before CNA #8 was able to get her off the toilet. R #8 said she was upset and cried. R #8 further stated she felt like no one cared. R #8 said it takes 15 minutes to an hour for her call light to be answered. R #8 said that there is usually only one (1) CNA on her hall. R #8 said when she needs assistance getting out of bed or to the bathroom, she has to wait longer because the CNA assigned to her hall has to find someone to help. J. On 02/18/25 at 2:49 PM, during an interview, AD #8 stated on 02/16/25, she assisted LPN #8 transfer R #8 on the toilet. AD said she finished an activity with the residents and was asked to assist at approximately 11:00 AM. AD #8 stated there were only two CNA's on the South Unit and there were a lot of call lights on. AD #8 said she tried to help when she sees call lights, but she does not work the floor. K. On 02/19/25 at 10:50 AM, during an interview, CNA #10 said there are a lot of residents on the South Unit that are two people assist. CNA #10 said on 02/16/25 there was only two (2) CNA's and they were not able to complete showers, take vital signs, or complete any documentation. CNA #10 said the residents end up wetting themselves and have bowel movements because they can not get to them in time. L. On 02/18/25 at 10:12 am, during an interview ADON stated that it is not acceptable for a resident to be left on the toilet for an hour. R #10 M. On 02/17/25 at 2:43 PM, during an interview, R #10 said she usually waits 45 minutes to get assistance. R #10 said she is a two person assist because she needs the hoyer lift. R #10 said there are a lot of residents on the South Unit that need the hoyer lift. R #10 said that there are only three (3) CNA's scheduled on the South Unit. R #10 said sometimes there are only two (2) CNA's for the entire unit. R #10 said when she needs help, the CNA has to try and find someone to help them. R #10 said they come in and turn off the light and tell her they need to find someone to help and then don't come back for 30 to 45 minutes. R #11 N. On 02/19/25 at 10:55 AM, during an interview with CNA #11, she said there is not enough staff. CNA #10 said residents are having accidents and wetting themselves because they can't get to them in time. CNA #11 said R #11 needs assistance to get to the bathroom and he has had accidents because he can't wait. O. On 02/19/25 at 10:58 AM, during an interview, R #11 said he has had to wait 30 minutes to an hour to get help because staff don't answer the call lights. R #11 said he has had quite a few accidents. R #11 said he needs help to go to the bathroom. P. Record review of the transfer list dated 02/14/25 revealed the following: 1. There are 17 residents on the South Unit that require the assistance of two staff members due to hoyer lift. 2. There are seven residents on the South Unit that require the assistance of two staff members due to Sara lift. 3. There are five residents on the North Unit that require the assistance of two staff members due to hoyer lift. 4. There are two residents on the North Unit that require the assistance of two staff members due to Sara lift. R #24 Q. On 02/17/25 at 9:08 AM, during an interview with R #24's sister stated staff do not brush R #24 teeth daily. R #24's sister stated that there is not enough staff. FM #24 she stated, R #24 is scheduled to get showered three times a week. FM #24 stated R #24 goes days without a shower, and R #24 had a noticeable smell. R #24 stated that she feels the R #24 is not getting showered due to the facility being short staffed. FM #24 confirmed she reported to the Administrator that the staff are not following the shower schedule because she felt they were short of staff. R. Record review of R #24's Quarterly Minimum Data Set (MDS) dated [DATE], revealed R #24 requires substantial/maximal assistance (helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort). For ADL-bathing, R #24 requires substantial/maximal assistance-helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort. S. Record review of R #24's care plan dated 12/03/24, revealed R #24 requires substantial/maximal assistance. ADL-bathing revealed R #24 requires substantial/maximal assistance-helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort. T. Record review of R #24's ADL sheet for December 2024, revealed the following: 1. On 12/11/24, R #24 did not receive any oral care. 2. On 12/22/24, R #24 did not receive any oral care. 3. On 12/29/24, R #24 did not receive any oral care. U. Record review of R #24's ADL sheet for January 2025, revealed the following: 1. On 01/01/25, R #24 did not receive any oral care. 2. On On 01/03/25, R #24 did not receive any oral care. 3. On 01/05/25, R #24 did not receive any oral care. 4. On 01/06/25, R #24 did not receive any oral care. 5. On 01/07/25, R #24 did not receive any oral care. 6. On 01/09/25, R #24 did not receive any oral care. 7. On 01/12/25, R #24 did not receive any oral care. 8. On 01/17/25, R #24 did not receive any oral care. 9. On 01/19/25, R #24 did not receive any oral care. 10. On 01/26/25, R #24 did not receive any oral care. 11. On 01/28/25, R #24 did not receive any oral care. 12. On 01/31/25,R #24 did not receive any oral care. V. Record review of R #24's ADL sheet for February 2025, revealed the following: 1. On 02/02/25, R #24 did not receive any oral care. 2. On 02/03/25, R #24 did not receive any oral care. 3. On 02/04/25, R #24 did not receive any oral care. 4. On 02/06/25, R #24 did not receive any oral care. 5. On 02/07/25, R #24 did not receive any oral care. 6. On 02/09/25, R #24 did not receive any oral care. 7. On 02/10/25, R #24 did not receive any oral care. 8. On 02/13/25, R #24 did not receive any oral care. 9. On 02/14/25, R #24 did not receive any oral care. 10. On 02/17/25, R #24 did not receive any oral care. 11. On 02/18/25, R #24 did not receive any oral care. 12. On 02/19/25, R #24 did not receive any oral care. W. On 02/18/25 at 10:51 AM, during an interview, CNA #9 stated R #24 requires total assistance for oral hygiene. CNA #9 confirmed R #24 is scheduled for oral hygiene after meals. CNA #9 confirmed R #24 need assistance because R #24 is unable do oral hygiene himself. CNA #9 confirmed he did not complete oral hygiene for R #24 on 02/18/25. X. Record review of R #24's shower schedule revealed R #24 shower days are Mondays, Wednesdays, and Fridays. Y. Record review of R #24's ADL documentation survey report for December 2024, revealed staff did not document showers were done for R #24 on the following dates: 1. On 12/02/24, Staff documented NA (not applicable) R #24 did not receive a shower day shift and no documentation for night shift. 2. On 12/04/24, Staff documented NA, R#24 did not receive a shower for all shifts. 3. On 12/06/24, Staff documented NA for night shift R #24 did not receive a shower. 4. On 12/09/24, Staff documented NA, R #24 did not receive a shower for all shifts. 5. On 12/11/24, Staff did not document R #24 did not receive a shower for all shifts. 6. On 12/13/24, Staff documented NA for night shift R #24 did not receive a shower. 7. On 12/16/24, Staff documented NA for day shift R #24 did not receive a shower and no documentation for night shift. 8. On 12/18/24, Staff documented NA, staff documented NA (not applicable) R #24 did not receive a shower for all shifts. 9. On 12/25/24, Staff documented NA, R #24 did not receive a shower for all shifts. 10. On 12/27/24, Staff documented NA, R #24 did not receive a shower for night shift. 11. On 12/30/24, Staff documented NA, R #24 did not receive a shower for all shifts. Z. Record review of R #24's ADL documentation survey report dated January 2025 revealed the following: 1. On 01/08/25, Staff documented NA that R #24 did not receive a shower day shift and no documentation for night shift. 2. On 01/20/25, Staff documented NA that R #24 did not receive a shower day shift and no documentation for night shift. 3. On 01/24/25, Staff documented NA that R #24 did not receive a shower day shift and no documentation for night shift. AA. Record review of R #24's ADL, documentation survey report dated February 2025, revealed the following: 1. On 02/05/25, Staff documented NA, R #24 did not receive a shower for night shift. 2. On 02/12/25, Staff documented NA, R #24 did not receive a shower for night shift. 3. On 02/14/25, Staff did not document that R #24 received a shower for all shifts. 4. On 02/17/25, Staff did not document that R #24 received a shower for all shifts. 5. On 02/19/25, Staff did not document that R #24 received a shower for all shifts. BB. On 02/20/25 at 12:26 PM, during an interview, CNA #28 stated she follows the shower schedule but when the facility is short staffed, sometimes shower don't happen. CNA #28 further stated that if there is enough staff the resident who missed a shower will get a shower on next day if possible. CC. On 02/20/25 at 12:36 PM, during an interview, CNA #8 stated showers happen as scheduled for the most part but, when the facility is short staffed, the CNAs don't do showers. Sometimes the next day it's already too busy and CNAs don't have time to make up showers. DD. On 02/14/25 at 3:01 PM, during an observation of the North Unit, there were 46 residents and two CNA's working the unit. EE. On 02/14/25 at 3:10 PM, during an observation of the South Unit, there were 56 residents and two CNA's working the unit. 52223

Based on record review and interview, the facility's administration failed to use its resources effectively to attain and maintain the residents' highest practicable physical, mental and psychosocial well-being when they did not consult their Medical Director when deciding to continue to accept new residents during an outbreak of Scabies (a contagious skin condition caused by mites (Sarcoptes scabiei) causing intense itching), not to track the staff that contracted Scabies and which of the staff interacted with the residents (to track possible sources of scabies among staff and residents), and ensure all staff that interact with the residents and their belongings were consistently educated in preventative measures. These deficient practices could lead to delayed containment of future outbreaks of communicable diseases. The findings are: A. Record review of the (Name of State Agency) Report submitted by the facility to the State on 01/18/18 revealed: 12 residents and 7 staff found with rash and were given treatment cream applied to rash, and isolation precautions (special precautions used to contain a communicable disease) on ones w/ (with) rash. B. Record review of the Facility 5 Day Follow Up Report to the State received on 01/24/18 revealed the following: 1. 01/05/18 - 3 residents treated for [REDACTED].> 2. 01/06/18 - the 5 new residents and roommates will be treated today and adjoining room residents will be treated [MEDICATION NAME] (as a preventative), 1 housekeeper and 3 additional staff sent home 3. 01/20/18 - 3 resident with rash and order to treat Pt (patient) and roommates, 1 CNA sent home with rash and cream to treat. Decision made to lock down facility. All Pts on Isolation precautions. orders to treat all pts (patients) with [MEDICATION NAME] cream a medication used to treat scabies). 4. 01/23/18 - 2 new residents with rash 5. Fax Cover Sheet for this report from Facility: Incident Date 01/18/18 12 Residents and 7 Staff 6. Document (5 Day Follow Up) revealed: 13 Residents (not 12) Medical Director C. Record review of the facility follow up report that was submitted to the (name of State Agency) on 01/24/18 revealed: January 8, 2018 After much discussion with the Regional Team, it was determined that admissions will continue on a case by case bases (sic); and skin checks will be done immediately upon admission. New residents will be placed in a deep clean room. D. On 02/01/18 at 11:00 am, during an interview with the Medical Director, when asked if he was involved in the decision-making process that happened on 01/08/18 to continue admissions during the outbreak, he stated, I was not involved in that decision. I should have been. I would have stopped admissions. E. On 02/05/18 at 2:07 pm, during an interview with the Administrator, when asked about the report of the 01/08/18 decision to continue admissions, he stated, I did not take the building (responsibility as the new administrator) until (January)10th. Employee Tracking and Education F. On 01/29/18 at 10:24 am, during an interview, the ICN (Infection Control Nurse) was asked, Do you have documentation on staff members who were treated (for scabies)? The ICN stated, No, HR (Human Resources) would have that; they (staff) were sent home to be treated by their family doctor. We did not treat families, that is up to the staff member. G. On 01/29/18 at 2:16 pm, during an interview, the DON stated, We do not have policies and procedures for employees with illness or communicable disease. If employees had rash, we sent them home and taught them about treatment. H. On 01/29/18 at 12:55 pm, during an interview with Human Resources and the DON, when asked about HR's involvement with the staff during the outbreak, he stated, My role is procedures. When their (employee's) supervisor made the decision for staff to go home, I explained how they (the employees) would be paid. The clinical (staff) would have handed out treatment and medication. The DON stated, I have a list of staff we sent home. Our medical director ordered a bulk order (for [MEDICATION NAME] cream (medication to kill scabies and their eggs)) but wrote scripts (prescriptions) for some individuals, some staff received medication from floor stock. I. On 02/01/18 at 11:23 am, during an interview, the ADON (Assistant Director of Nurses) stated, On 01/19/18, I spoke with the State Epidemiology person. She stated for staff, they should be sent to our occupational health group to confirm and treat. After I spoke with her, a housekeeper came (about a rash) and I sent her to HR (Human Resources) to get paperwork. On the next day, a CNA came regarding a rash and I sent her to HR. HR has the paperwork for getting diagnosed and treated for [REDACTED]. J. On 02/01/18 at 01:19 pm, during an interview, HR was asked asked about how the employees were treated, he stated, When employees were sent to me I referred them---I told them they could go to the public health department or their private physician. They were referred by nursing supervisors. I can do a claim if they need reimbursement for treatment--a worker's comp (compensation) kind of thing. That is it. K. On 02/02/18 at 2:07 pm, during an interview, the ICN stated, I used packets for education on using PPE (personal protective equipment-gown, gloves, etc.), a handout on infection control, a handwashing performance check off (where the staff member return demonstrates handwashing and is assessed by an evaluator), and a picture of the steps of hand washing. On 01/22/18, I inserviced PPE for all department managers and facility contracted managers. I said I would be inservicing each department. The Therapy Manager said he would inservice his own staff. I provided the packets. The performance review of handwashing was blank (when the therapy manger returned them to the ICN). When asked if she had indicated to the Therapy Manager that he did not meet what she had planned for infection control education and process surveillance (the return demonstration of handwashing), she said she did not speak to him about that. When asked if she had reported to anyone like her (supervisor) that the packets were not complete she stated, No, the employees in Therapy are contracted and are not on my watch. She confirmed Housekeeping/Laundry, Maintenance and Therapy Departments were contracted employees. L. Record Review of list (no date) provided by administration revealed: (Name of Facility) Staff Members Treated revealed 9 names. This list did not include the 2 housekeeping persons who were treated for [REDACTED]. M. On 02/01/18 at 2:00 pm, during an interview, the Housekeeping/Laundry Manager stated, In my department, I instructed the staff on scabies, how to protect themselves, what to do. I instructed them in using PPE (personal protective equipment.) I do not have documents for training. There were 2 people in my department who had to be treated for [REDACTED]. N. Record review of physician's orders [REDACTED].#28 revealed: Isolation for Scabies, Ivermectin (medication that can be used to treat scabies) 0.2mg (milligram-a metric unit of measure)/kg (kilogram-a metric unit of weight) PO (by mouth) x 1 (for one dose). O. Record review of the provider (either the physician or midlevel provider that work with the physician) encounter for R #9, dated 01/09/18, revealed: Scabies: treated w (with) ivermectin and sx (symptoms resolved) P. Record review of the physician's note for R #62, dated 01/19/18, revealed: A/P (Assessment/Plan) Scabies Q. On 01/29/18 at 2:16 pm, during an interview, the DON stated, In general, we do weekly infection control meetings. I map out infections (showing type of infection and location on a building map) for the Month. My December mapping does not include scabies. We put scabies on a separate list. That is a separate map and information and the Infection Control Nurse has that. We do not have policies and procedures for employees with illnesses. R. On 01/29/18 at 3:25 pm, during an interview, the Administrator was asked for surveillance information including any time line or line list (list of key information for every case during an outbreak investigation) compiled on the scabies outbreak. The administrator stated, After checking with my staff, we cannot provide you with that documentation.

Based on record review, interview, and observations the facility failed to provide proper infection control practices affecting all 92 residents in the facility (residents identified by census list provided by the administrator on 01/29/18), when they 1) failed to utilize surveillance (an ongoing, systematic collection, analysis, interpretation and dissemination of information regarding infections) during a scabies (a contagious skin condition caused by mites (Sarcoptes scabiei) causing intense itching) outbreak, 2) failed to involve the medical director in a decision to continue admissions during a scabies outbreak, 3) failed to adequately address tracking and treatment of [REDACTED].>4) failed to have policies and procedures for employee health and restrictions for communicable disease, 5) failed to perform annual review of the infection control program, 6 ) failed to remove contact precautions (a type of isolation used to prevent the spread of diseases transmitted by contact) for a resident after the physician ordered the precautions discontinued for 1 (R #68) of 2 (R #57 and R #58) residents reviewed for contact precautions and, 7) assure proper infection control practices by staff when a blood glucose monitor was returned to the clean supply bin before the glucometer (a machine used to measure blood sugar) was disinfected for 1 (R #90) of 1 (R #90) resident surveyed for insulin administration. 8) failed to use infection control practices by staff in the kitchen while preparing and serving meals in the kitchen. The deficient practices resulted in the spread of scabies to residents and staff caring for those residents with residents experiencing itching, discomfort, isolation, and disruption of the resident's environment. The deficient practices could lead to residents being exposed to food borne illness. The findings are: Scabies Outbreak A. Record review of the (Name of State Agency) Report submitted by the facility to the State on 01/18/18 revealed: 12 residents and 7 staff found with rash and were given treatment cream applied to rash, and isolation precautions (special precautions used to contain a communicable disease) on ones w/ (with) rash. B. Record review of the Facility 5 Day Follow Up Report to the State received on 01/24/18 revealed the following: 1. 01/05/18 - 3 residents treated for [REDACTED].> 2. 01/06/18 - the 5 new residents and roommates will be treated today and adjoining room residents will be treated [MEDICATION NAME] (as a preventative), 1 housekeeper and 3 additional staff sent home 3. 01/20/18 - 3 resident with rash and order to treat Pt (patient) and roommates, 1 CNA sent home with rash and cream to treat. Decision made to lock down facility. All Pts on Isolation precautions. orders to treat all pts (patients) with [MEDICATION NAME] cream a medication used to treat scabies). 4. 01/23/18 - 2 new residents with rash 5. Fax Cover Sheet for this report from Facility: Incident Date 01/18/18 12 Residents and 7 Staff 6. Document (5 Day Follow Up) revealed: 13 Residents (not 12) C. Record review of physician's orders [REDACTED].#28 revealed: Isolation for Scabies, Ivermectin (medication that can be used to treat scabies) 0.2mg (milligram-a metric unit of measure)/kg (kilogram-a metric unit of weight) PO (by mouth) x 1 (for one dose). D. Record review of the provider (either the physician or midlevel provider that work with the physician) encounter for R #9, dated 01/09/18, revealed: Scabies: treated w (with) ivermectin and sx (symptoms resolved) E. Record review of the physician's note for R #62, dated 01/19/18, revealed: A/P (Assessment/Plan) Scabies Surveillance during Scabies Outbreak F. Record review of medical records revealed 18 residents (R #9, R #10, R #13, R #18, R #19, R #23, R #28, R #29, R #35, R #37, R #55, R #57, R #59, R #62, R #68, R #70, R #95 and R #99) were treated for [REDACTED].#57 and R #62 who were later discovered to have also been treated for [REDACTED]. G. Record review of medical records and a census listing of treated residents dated 01/29/18 have provided approximate numbers of residents treated for [REDACTED].#6, R #7, R #8 R #12, R #14, R #15, R #20, R #21, R #24, R #25, R #26, R #27, R #30, R #31, R #32, R #33, R #34, R #36, R #39, R #40,R #41, R #43, R #44, R #45, R #46, R #48, R #50, R #51, R #52, R #53, R #54, R #58, R #60, R #64, R #66, R #67, R #75, R #76, R #77, R #81, R #83, R #84, R #86, R #87, R #89, R #92, R # 93, and R #99.) H. On 01/29/18 10:24 am, during an interview, the ICN she stated, I am working on a timeline for the rashes. (The ICN indicated a sheet of paper where there are a few entries and confirms that the paper is her time line (also known as line list containing data elements for surveillance). When she was asked, Do you have names (of residents with scabies), dates, doctors, treatments on a list? The ICN replied, No, I haven't really put everything together. I been using a census sheet to write who was treated and their MAR (medication administration record) including residents who the doctor decided to treat [MEDICATION NAME] (as a preventative). I have no list to show where the residents came from (from what other facilities). I am now in the process of figuring a timeline now that everyone has been treated. She was further asked, Do you have documentation on staff members who were treated? The ICN stated, No, HR (Human Resources) would have that I was involved in the skin checks on the employees on 01/06/18 after additional resident cases were found. The staff that had itching or rash I sent home. I did not do any map plotting out the rashes, I know it was both North and South wings. We were not tracking which staff were taking care of which resident. I haven't done that yet, I am still working on the tracking and the time line. I do not have any Infection Control Book or policies and procedures. I haven't taken over that part yet, I've only been doing this (Infection Control) for a month. I. On 01/29/18 at 2:16 pm, during an interview, the DON stated, In general, we do weekly infection control meetings. I map out infections (showing type of infection and location on a building map) for the Month. My December mapping does not include scabies. We put scabies on a separate list. That is a separate map and information and the Infection Control Nurse has that. We do not have policies and procedures for employees with illnesses. J. On 01/29/18 at 3:25 pm, during an interview, the Administrator was asked for surveillance information including any time line or line list (list of key information for every case during an outbreak investigation) compiled on the scabies outbreak. The administrator stated, After checking with my staff, we cannot provide you with that documentation. K. Review of Center for Disease Control-Scabies-Resources for Health Professionals-Multiple Cases (https://www.cdc.gov/parasites/scabies/health_professionals/multiple.html) revealed: Control and Treatment: Establish appropriate procedures for infection control and treatment: Maintain records with patient age, age, sex, room number, roommate(s) name(s), skin scraping status and result(s), and name(s) of all staff who provided hands-on care to the patient before implementation of infection control measures: symptoms can take up to 2 months to appear in exposed persons and staff. Use epidemiologic data about distribution of confirmed cases by building, room, floor, wing, occupation (for staff), dates of admission, and onset of scabies-like condition to determine: 1) levels of risk for patients and staff; 2) extent of the outbreak (e.g. confined or widespread in the facility; and 3) temporal relationship among cases. Identify and treat all persons (e.g. staff, relatives, patients, etc.) having prolonged, direct skin-to-skin contact with an infested person before he/she was treated. Offer treatment to household members (e.g. spouses, children, etc.) of staff who are receiving scabies treatment. Communication: Ensure a proactive employee health services approach to scabies including providing information about scabies to all staff and providing dermatologic consultation for employees and, when appropriate their household members. Medical Director L. Record review of the facility follow up report that was submitted to the (name of State Agency) on 01/24/18 revealed: January 8, 2018 After much discussion with the Regional Team, it was determined that admissions will continue on a case by case bases (sic); and skin checks will be done immediately upon admission. New residents will be placed in a deep clean room. M. On 02/01/18 at 11:00 am, during an interview with the Medical Director, when asked if he was involved in the decision-making process that happened on 01/08/18 to continue admissions during the outbreak, he stated, I was not involved in that decision. I should have been. I would have stopped admissions. N. On 02/05/18 at 2:07 pm, during an interview with the Administrator, when asked about the report of the 01/08/18 decision to continue admissions, he stated, I did not take the building (responsibility as the new administrator) until 10th (of January). L(NAME)K DOWN on 01/20/18 O. Record review of the Facility 5 Day Follow Up Report to the State received on 01/24/18 revealed the following: 1. 01/20/18 - 3 residents with rash and order to treat Pt (patient) and roommates, 1 CNA was sent home with rash and cream to treat. The Medical Director was contacted. The decision made to lock down facility. All residents were put on isolation precautions. All staff to wear PPE (personal protective equipment (gloves, gowns, shoe covers ect (sic)) in all rooms. Activity staff offered one to one visit for residents. 2. 01/20/18 - All residents on isolation precautions. All residents currently receiving room trays for all meals. 3. 01/23/18 - 2 new rashes found and those residents continued on isolation. The rest of the residents were taken off (isolation) due to no signs or symptoms of rash. P. On 01/29/18 at 09:44 am, during an interview with the DON, when asked to define what the lockdown on 1/20/18 meant, she said, Lockdown means we were not taking any new residents. We asked visitors if the needed to visit, to visit with caution. Employee Tracking and Education Q. On 01/29/18 at 10:24 am, during an interview, the ICN (Infection Control Nurse) was asked, Do you have documentation on staff members who were treated? The ICN stated, No, HR (Human Resources) would have that. They (staff) were sent home to be treated by their family doctor. We did not treat families. That is up to the staff member. R. On 01/29/18 at 2:16 pm, during an interview, the DON stated, We do not have policies and procedures for employees with illness or communicable disease. If employees had rash, we sent them home and taught them about treatment. S. On 01/29/18 at 12:55 pm, during an interview with the Human Resource Manager and the DON, when asked about HR's involvement with the staff during the outbreak, the HR Manager stated, My role is procedures. When their (employee's) supervisor made the decision for staff to go home, I explained how they (the employees) would be paid. The clinical (staff) would have handed out treatment and medication. The DON stated, I have a list of staff we sent home. Our medical director ordered a bulk order (for [MEDICATION NAME] cream--a medication used to treat scabies) but wrote scripts (prescriptions) for some individuals, some staff received medication from floor stock. T. On 02/01/18 at 11:23 am, during an interview, the ADON (Assistant Director of Nurses) stated, On 01/19/18, I spoke with the State Epidemiology person. She stated for staff, they should be sent to our occupational health group to confirm and treat. After I spoke with her, a housekeeper came (about a rash) and I sent her to HR (Human Resources) to get paperwork. On the next day, a CNA (Certified Nursing Assistant) came and I sent her to HR. HR has the paperwork for getting diagnosed and treated. I don't know who was keeping track of the employees. U. On 02/01/18 at 01:19 pm, during an interview, HR was asked about how the employees were treated, he stated, When employees were sent to me I referred them---I told them they could go to the public health department or their private physician. They were referred by nursing supervisors. I can do a claim if they need reimbursement for treatment--a worker's comp (compensation) kind of thing. That is it. V. On 02/02/18 at 2:07 pm, during an interview, the ICN stated, I used packets for education on using PPE (personal protective equipment-gown, gloves, etc.), a handout on infection control, a handwashing performance check off (where the staff member return demonstrates handwashing and is assessed by an evaluator), and a picture of the steps of hand washing. On 01/22/18, I inserviced PPE for all department managers and facility contracted managers. I said I would be inservicing each department. The Therapy Manager said he would inservice his own staff. I provided the packets. The performance review of handwashing was blank (when he returned them to the ICN). When asked if she had indicated to the Therapy Manager that he did not meet what she had planned for infection control education and process surveillance (the return demonstration of handwashing), she said she did not speak to him about that. When asked if she had reported to anyone like her (supervisor) that the packets were not complete she stated, No, the employees in Therapy are contracted and are not on my watch. She confirmed Housekeeping/Laundry, Maintenance and Therapy Departments were contracted employees. W. Record Review of list (no date) provided by administration revealed: (Name of Facility) Staff Members Treated revealed 9 names. This list did not include the 2 housekeeping persons who were treated for [REDACTED]. X. On 02/01/18 at 2:00 pm, during an interview, the Housekeeping/Laundry Manager stated, In my department, I instructed the staff on scabies, how to protect themselves, what to do. I instructed them in using PPE (personal protective equipment.) I do not have documents for training. There were 2 people in my department who had to be treated for [REDACTED]. Continuing discontinued contact precautions for[DIAGNOSES REDACTED] (,[MEDICAL CONDITION]. dificile-a bacterial infection). Y. On 01/28/18 at 3:44 pm, during an interview, LPN #1 stated, (Name of R #68) is on contact precautions (a type of isolation used to prevent the spread of diseases transmitted by contact) for[DIAGNOSES REDACTED] Z. On 01/28/18 at 3:51 pm, during observation, there was no sign on the door of R #68's room indicating that the resident was on precautions or to see the nurse before entering. AA. On 01/28/18 at 4:41 pm, during an interview with LPN #1, when asked about lack of sign on R #68's door indicating precautions or to see nurse before entering, she stated, I am not sure if there should be signage on the door. The equipment gowns, gloves and shoe covers if we have them should be in there. Our staff is always the same staff and knows the resident is on precautions. BB. On 01/29/18 at 10:39 am, during an interview, the DON stated, (Name of R #68) has been treated. His isolation was DC'd (discontinued) on 01/19/18. There was a handwritten order, but it did not go into the computer. I don't know why it didn't get it out to staff. CC. Record review of a physician's orders [REDACTED]. Dx:[DIAGNOSES REDACTED] Yearly Updating of the Infection Control Program DD. Record review of the facility Infection Control Program Standards of Practice revealed a revision date of 11/16 (November 2016) and there was no notation of a yearly review. EE. On 02/05/17 at 11:00 am, during an interview with the DON, when asked about yearly review of infection control policies she stated, I was not aware we needed to review infection control policies yearly. I did not know that some of the infection control policies are in the facility assessment. I am aware now. Glucometer Disinfection FF. On 02/05/18 at 11:10 am, during medication pass observation, LPN #2 performed a fingerstick glucose check with a glucometer (a machine used to measure blood sugar) on R #90. LPN #2 then placed the glucometer in a bin that holds new lancets (a device to puncture the skin to obtain blood), packets of alcohol wipes, and a bottle of test strips to use with the machine. LPN #2 then removed the glucometer from the bin and performed disinfection on the device. GG. On 02/05/18 at 11:20 am, during an interview, LPN #2 stated, I should have cleaned the glucometer before I put it back in the bin with the supplies-to keep the supplies clean. HH. On 02/05/18 at 11:00 am, during an interview, the DON stated, The nurse should have disinfected the glucometer before placing it with clean supplies. The glucometer could have contaminated the supplies. Dining II. During dining observation on 01/28/18 at 5:32 pm revealed that LPN #2 not to use hand hygiene between serving residents R #21 and R #70. JJ. During dining observation on 01/28/18 at 5:48 pm revealed LPN #2 handling a cup from the top along the rim while assisting R #55 without wearing gloves. KK. On 01/28/18 at 5:51 pm, during dining observation, CNA #1 was observed feeding R #96 and rubbing his nose and mustache and proceeded to feed R #55. LL. On 02/05/18 at 4:43 pm, during an interview, DON confirmed that staff should use hand hygiene between tasks or touching any part of their face/body and staff should not hold cups from the rim. Kitchen MM. On 01/29/18 at 8:55 am, during observation, it was revealed that Cook (C) #2 was frying eggs with a pair of gloves and then immediatly went on to the next task of serving resident food trays without changing gloves or his washing hands. NN. During observation on 02/01/18 11:53 am, while C #1 was taking temperature of the food, he was seen blowing on the thermometer after wiping it down with a alcohol swab. OO. On 02/01/18 at 12:05 pm, during an interview, the Dietary Manager (DM) confirmed that all staff should wash their hands between tasks. PP. On 02/01/18 at 12:52 pm, during an iterview, the DM stated that C #2 should not blow on the thermometer before checking the temperature of the food.

Based on record review and interview, the facility failed to 1) ensure the timely reporting of the UA (urinanalysis) to the physician (there was a two day delay), 2) ensure the facility nurses informed the nursing administration regarding abnormal laboratory results when they were unable to contact the primary care physician, and 3) contact the Medical Director when the facility was unable to contact the primary care physician in a timely manner for 1 (R #1) of 4 (R #1, R #2, R #3, and R #4) of residents reviewed for pressure wounds and/or urinary tract infections. This deficient practice resulted in the resident becoming septic (having a systemic infection) from an untreated urinary tract infection resulting in hospitalization , debility, and acute injury to the kidneys. The findings are: A. Record review of a local hospital's medical records revealed R #1 was admitted on [DATE] with acute severe [MEDICAL CONDITION] (high level of sodium in the blood), acute kidney injury likely secondary to severe volume depletion (dehydration),[MEDICAL CONDITION] (life threatening illness cause by the body's reaction to infection) secondary to urinary tract infection, acute severe [MEDICAL CONDITION] (the functioning of the brain is affected by some agent or condition) likely due to severe [MEDICAL CONDITION]. Temp 99.1 (elevated), pulse 100 per minute ([MEDICAL CONDITION]- rapid heartbeat), respiratory rate 14, SaO2 (oxygen saturation) 99% (on room air). emergency room record read, Patient was diagnosed with [REDACTED]. B. On 04/26/17 at 8:45 am, during an interview, LPN #1 stated, On April 4th, I noticed a change in (name of R #1's) behavior--she was less vocal, eating less and leaning to the left. I called and got an order for [REDACTED]. I had told the doctor that (name of R #1) was not acting like herself, not eating, and may have a UTI (urinary tract infection) and could I have a UA order. It is the responsibility of the nurse to check the fax machine, get the reports and to notify the doctor. I don't know why there was a delay in notifying the doctor. C. Record review of the facility medical record revealed an UA, dated 04/06/17, result for R #1 that revealed, turbid color (opaque, thick with suspended matter), protein (may indicated kidney damage), leukocyte esterase (product of white blood cells), blood, white blood cells (pus), red blood cells and bacteria (results are characteristic of a urinary tract infection). The fax date of the document being sent to facility was 04/06/17. There is a handwritten notation on the bottom of the chart, 4-8-17 Faxed to doctor. D. On 04/26/17 at 09:00 am, during an interview, LPN #3 stated, On 04/08/17, it was a Saturday. The culture and sensitivity came in over the fax. I called the office and it was just the exchange (answering service). The exchange said the doctor was not returning calls until Monday, but I told her I needed to speak with someone. I was connected to someone (name of an individual with an unknown title); she took the message. Sunday (04/09/17), I passed on (in report) to continue monitoring her. When asked what the procedure would be if she could not get in contact with the doctor, she stated, I can call the ADON who is on call if I have a concern, but the resident didn't look sick. E. Record review of the facility medical record of urine microbiology report (C&S) dated 04/08/07 revealed Colony count greater than 100,000 cfu (colony forming units)/ml (a metric measure), E. Coli (escheria coli-a bacteria that is the common cause of urinary tract infections). Hand written notation on the form: 4/8/17 faxed to office, notified exchange, 1700 called again and spoke with (Name of individual, unknown title). 4/10/17 called at 1234 (12:34 pm) left message, called again @ (sic) 1400 left message marked urgent. The fax date of the document being sent to facility was 04/08/17. F. On 04/26/17 at 1:20 pm, during an interview, CNA #3 stated, I was the one who took care of her the day she was transfered out. She was not responding well at all, she was limp, rag doll, wasn't voiding (passing urine) and I did report it to the nurse. She was not eating. At breakfast and lunch, the food just drooled out of her mouth. I gave that (information) in report, too. G. On 04/26/17 at 1:50 pm, during an interview, LPN #2 stated, On 04/10/17, when I made rounds, (name of R #1) was very lethargic. She had a huge change of condition. I called the doctor and left a message a couple of times. In report, they said she was not doing good and not eating or drinking and had no output (urine). The doctor called me back and told me to transport (the resident to the emergency room ). H. Record review of the facility departmental notes dated 04/10/17 at 6:33 pm revealed: Per (name of primary doctor) sent Pt (patient) to (Name local hospital for further evaluation) and Tx (treatment) . Ambulance called and arrived at 1730 (5:30 pm) to transport Pt out. I. On 04/26/17 at 1:00 pm, during an interview with the ADON #1 regarding the urine analysis report received on 04/06/17, she stated that she could not find documentation of a call to the physician on that date to notify him of the results. She stated, I would have expected to see that it had been called. I can only assume there was a delay (in notification). When the ADON was asked about the 04/08/17 documentation of the nurse regarding unsuccessful attempts to notify the doctor of results, the ADON stated, We have an on call ADON available if they (the staff) have concerns. The nurse should have called the on call (ADON). I was not called; it came to my attention on Monday, I don't recall when.[MEDICAL CONDITION] would be a possible outcome of the delay. She affirmed the facility has a physician medical director available to them at all times, including evenings and weekends. ADON #1 stated they did not have any policy or procedures for reporting laboratory results or assessments. J. Record review of the faciilty's undated Abuse and Neglect Policy revealed: Purpose: To prohibit abuse of residents from any source. Types of Abuse: Neglect to provide goods or services necessary to avoid physical harm, mental anguish, or mental illness.

Based on record review and interview, the facility failed to implement their neglect policy when they failed to follow up on abnormal laboratory results and change of condition in a timely manner for 1 (R #1) of 4 (R #1, R #2, R #3, and R #4) of residents reviewed for pressure wounds and/or urinary tract infection. This deficient practice resulted in the resident becoming septic (having a systemic infection) from an untreated urinary tract infection resulting in hospitalization , debility, and acute injury to the kidneys. The findings are: A. Record review of the faciilty's undated Abuse and Neglect Policy revealed: Purpose: To prohibit abuse of residents from any source. Types of Abuse: Neglect to provide goods or services necessary to avoid physical harm, mental anguish, or mental illness. B. Record review of a local hospital's medical records revealed R #1 was admitted on [DATE] with acute severe [MEDICAL CONDITION] (low level of sodium in the blood), acute kidney injury likely secondary to severe volume depletion (dehydration),[MEDICAL CONDITION] (life threatening illness cause by the body's reaction to infection) secondary to urinary tract infection, acute severe [MEDICAL CONDITION] (the functioning of the brain is affected by some agent or condition) likely due to severe [MEDICAL CONDITION]. Temp 99.1 (elevated), pulse 100 per minute ([MEDICAL CONDITION]- rapid heartbeat), respiratory rate 14, SaO2 (oxygen saturation) 99% (on room air). ER record read, Patient was diagnosed with [REDACTED]. C. 04/26/17 at 8:45 am, during an interview, LPN #1 stated, On April 4th, I noticed a change in (name of R #1's) behavior--she was less vocal, eating less and leaning to the left. I called and got an order for [REDACTED]. I had told the doctor that (name of R #1) was not acting like herself, not eating, and may have a UTI (urinary tract infection) and could I have a UA order. It is the responsibility of the nurse to check the fax machine, get the reports and to notify the doctor. I don't know why there was a delay in notifying the doctor. D. Record review of the facility medical record revealed a urinalysis, dated 04/06/17, result for R #1 that revealed, turbid color (opaque, thick with suspended matter), protein (may indicated kidney damage), leukocyte esterase (product of white blood cells), blood, white blood cells (pus), red blood cells and bacteria (results are characteristic of a urinary tract infection). The fax date of the document being sent to facility was 04/06/17. There is a handwritten notation on the bottom of the chart, 4-8-17 Faxed to doctor. E. On 04/26/17 at 09:00 am, during an interview, LPN #3 stated, On 04/08/17, it was a Saturday. The culture and sensitivity came in over the fax. I called the office and it was just the exchange (answering service). The exchange said the doctor was not returning calls until Monday, but I told her I needed to speak with someone. I was connected to someone (name of an individual with an unknown title); she took the message. Sunday (04/09/17), I passed on (in report) to continue monitoring her. When asked what the procedure would be if she could not get in contact with the doctor, she stated, I can call the ADON (Assistant Director of Nurses) who is on call if I have a concern, but the resident didn't look sick. F. Record review of the facility medical record of urine microbiology report dated 04/08/07 revealed Colony count greater than 100,000 cfu (colony forming units)/ml (a metric measure), E. Coli (escheria coli-a bacteria that is the common cause of urinary tract infections). Hand written notation on the form: 4/8/17 faxed to office, notified exchange, 1700 called again and spoke with (Name of individual, unknown title). 4/10/17 called at 1234 (12:34 pm) left message, called again @ (sic) 1400 left message marked urgent. The fax date of the document being sent to facility was 04/08/17. G. On 04/26/17 at 1:20 pm, during an interview, CNA #3 stated, I was the one who took care of her the day she was transferred out. She was not responding well at all, she was limp, rag doll, wasn't voiding (passing urine) and I did report it to the nurse. She was not eating. At breakfast and lunch, the food just drooled out of her mouth. I gave that (information) in report, too. H. On 04/26/17 at 1:50 pm, during an interview, LPN #2 stated, On 04/10/17, when I made rounds, (name of R #1) was very lethargic. She had a huge change of condition. I called the doctor and left a message a couple of times. In report, they said she was not doing good and not eating or drinking and had no output (urine). The doctor called me back and told me to transport (the resident to the emergency room ). I. Record review of the facility departmental notes dated 04/10/17 at 6:33 pm revealed: Per (name of primary doctor) sent Pt (patient) to (Name local hospital for further evaluation) and Tx (treatment) . Ambulance called and arrived at 1730 (5:30 pm) to transport Pt out. J. On 04/26/17 at 1:00 pm, during an interview with the ADON (Assistant Director of Nurses) #1 regarding the urine analysis report received on 04/06/17, she stated that she could not find documentation of a call to the physician on that date to notify him of the results. She stated, I would have expected to see that it had been called. I can only assume there was a delay (in notification). When then ADON was asked about the 04/08/17 documentation of the nurse regarding unsuccessful attempts to notify the doctor of results, the ADON stated, We have an on call ADON available if they (the staff) have concerns. The nurse should have called the on call. I was not called; it came to my attention on Monday, I don't recall when.[MEDICAL CONDITION] would be a possible outcome of the delay. She affirmed the facility has a physician medical director available to them at all times, including evenings and weekends. ADON #1 stated they did not have any policy or procedures for reporting laboratory results or assessments.

Based on record review and interview, the facility failed to 1) ensure the timely reporting of the UA (urinanalysis) to the physician (there was a two day delay), 2) ensure the facility nurses informed the nursing administration regarding abnormal laboratory results when they were unable to contact the primary care physician, and 3) contact the Medical Director when the facility was unable to contact the primary care physician in a timely manner for 1 (R #1) of 4 (R #1, R #2, R #3, and R #4) of residents reviewed for pressure wounds and/or urinary tract infections. This deficient practice resulted in the resident becoming septic (having a systemic infection) from an untreated urinary tract infection resulting in hospitalization , debility, and acute injury to the kidneys. The findings are: A. Record review of a local hospital's medical records revealed R #1 was admitted on [DATE] with acute severe [MEDICAL CONDITION] (high level of sodium in the blood), acute kidney injury likely secondary to severe volume depletion (dehydration),[MEDICAL CONDITION] (life threatening illness cause by the body's reaction to infection) secondary to urinary tract infection, acute severe [MEDICAL CONDITION] (the functioning of the brain is affected by some agent or condition) likely due to severe [MEDICAL CONDITION]. Temp 99.1 (elevated), pulse 100 per minute ([MEDICAL CONDITION]- rapid heartbeat), respiratory rate 14, SaO2 (oxygen saturation) 99% (on room air). ER record read, Patient was diagnosed with [REDACTED]. B. 04/26/17 at 8:45 am, during an interview, LPN #1 stated, On April 4th, I noticed a change in (name of R #1's) behavior--she was less vocal, eating less and leaning to the left. I called and got an order for [REDACTED]. I had told the doctor that (name of R #1) was not acting like herself, not eating, and may have a UTI (urinary tract infection) and could I have a UA order. It is the responsibility of the nurse to check the fax machine, get the reports and to notify the doctor. I don't know why there was a delay in notifying the doctor. C. Record review of the facility medical record revealed a urinalysis, dated 04/06/17, result for R #1 that revealed, turbid color (opaque, with suspended matter), protein (may indicated kidney damage), leukocyte esterase (product of white blood cells), blood, white blood cells (pus), red blood cells and bacteria (results are characteristic of a urinary tract infection). The fax date of the document being sent to facility was 04/06/17. There is a handwritten notation on the bottom of the chart, 4-8-17 Faxed to doctor. D. On 04/26/17 at 09:00 am, during an interview, LPN #3 stated, On 04/08/17, it was a Saturday. The culture and sensitivity came in over the fax. I called the office and it was just the exchange (answering service). The exchange said the doctor was not returning calls until Monday, but I told her I needed to speak with someone. I was connected to someone (name of individual with unknown title); she took the message. Sunday (04/09/17), I passed on (in report) to continue monitoring her. When asked what the procedure would be if she could not get in contact with the doctor, she stated, I can call the ADON (Assistant Director of Nurses) who is on call if I have a concern, but the resident didn't look sick. E. Record review of the facility medical record of urine microbiology report dated 04/08/07 revealed Colony count greater than 100,000 cfu (colony forming units)/ml (a metric measure), E. Coli (escheria coli-a bacteria that is the common cause of urinary tract infections). Hand written notation on the form: 4/8/17 faxed to office, notified exchange, 1700 called again and spoke with (Name). 4/10/17 called at 1234 (12:34 pm) left message, called again @ (sic) 1400 left message marked urgent. The fax date of the document being sent to facility was 04/08/17. F. On 04/26/17 at 1:20 pm, during an interview, CNA #3 stated, I was the one who took care of her the day she was transferred out. She was not responding well at all, she was limp, rag doll, wasn't voiding (passing urine) and I did report it to the nurse. She was not eating. At breakfast and lunch, the food just drooled out of her mouth. I gave that (information) in report, too. G. On 04/26/17 at 1:50 pm, during an interview, LPN #2 stated, On 04/10/17, when I made rounds, (name of R #1) was very lethargic. She had a huge change of condition. I called the doctor and left a message a couple of times. In report, they said she was not doing good and not eating or drinking and had no output (urine). The doctor called me back and told me to transport (the resident to the emergency room ). H. Record review of the facility departmental notes dated 04/10/17 at 6:33 pm revealed: Per (name of primary doctor) sent Pt (patient) to (Name local hospital for further evaluation) and Tx (treatment) . Ambulance called and arrived at 1730 (5:30 pm) to transport Pt out. I. On 04/26/17 at 1:00 pm, during an interview with the ADON (Assistant Director of Nurses) #1 regarding the urine analysis report received on 04/06/17, she stated that she could not find documentation of a call to the physician on that date to notify him of the results. She stated, I would have expected to see that it had been called. I can only assume there was a delay (in notification). When then ADON was asked about the 04/08/17 documentation of the nurse regarding unsuccessful attempts to notify the doctor of results, the ADON stated, We have an on call ADON available if they (the staff) have concerns. The nurse should have called the on call. I was not called; it came to my attention on Monday, I don't recall when.[MEDICAL CONDITION] would be a possible outcome of the delay. She affirmed the facility has a physician medical director available to them at all times, including evenings and weekends. ADON #1 stated they did not have any policy or procedures for reporting laboratory results or assessments.

Based on record review and interview, the facility neglected to follow up on abnormal laboratory results in a timely manner for 1 (R #1) of 4 (R #1, R #2, R #3, and R #4) of residents reviewed for pressure wounds and/or urinary tract infection. This deficient practice resulted in the resident becoming septic (having a systemic infection) from an untreated urinary tract infection resulting in hospitalization , debility, and acute injury to the kidneys. The findings are: A. Record review of a local hospital's medical records revealed R #1 was admitted on [DATE] with acute severe [MEDICAL CONDITION] (low level of sodium in the blood), acute kidney injury likely secondary to severe volume depletion (dehydration),[MEDICAL CONDITION] (life threatening illness cause by the body's reaction to infection) secondary to urinary tract infection, acute severe [MEDICAL CONDITION] (the functioning of the brain is affected by some agent or condition) likely due to severe [MEDICAL CONDITION]. Temp 99.1 (elevated), pulse 100 per minute ([MEDICAL CONDITION]- rapid heartbeat), respiratory rate 14, SaO2 (oxygen saturation) 99% (on room air). ER record read, Patient was diagnosed with [REDACTED]. B. 04/26/17 at 8:45 am, during an interview, LPN #1 stated, On April 4th, I noticed a change in (name of R #1's) behavior--she was less vocal, eating less and leaning to the left. I called and got an order for [REDACTED]. I had told the doctor that (name of R #1) was not acting like herself, not eating, and may have a UTI (urinary tract infection) and could I have a UA order. It is the responsibility of the nurse to check the fax machine, get the reports and to notify the doctor. I don't know why there was a delay in notifying the doctor. C. Record review of the facility medical record revealed a urinalysis, dated 04/06/17, result for R #1 that revealed, turbid color (opaque, thick with suspended matter), protein (may indicated kidney damage), leukocyte esterase (product of white blood cells), blood, white blood cells (pus), red blood cells and bacteria (results are characteristic of a urinary tract infection). The fax date of the document being sent to facility was 04/06/17. There is a handwritten notation on the bottom of the chart, 4-8-17 Faxed to doctor. D. On 04/26/17 at 09:00 am, during an interview, LPN #3 stated, On 04/08/17, it was a Saturday. The culture and sensitivity came in over the fax. I called the office and it was just the exchange (answering service). The exchange said the doctor was not returning calls until Monday, but I told her I needed to speak with someone. I was connected to someone (name of an individual with an unknown title); she took the message. Sunday (04/09/17), I passed on (in report) to continue monitoring her. When asked what the procedure would be if she could not get in contact with the doctor, she stated, I can call the ADON (Assistant Director of Nurses) who is on call if I have a concern, but the resident didn't look sick. E. Record review of the facility medical record of urine microbiology report dated 04/08/07 revealed Colony count greater than 100,000 cfu (colony forming units)/ml (a metric measure), E. Coli (escheria coli-a bacteria that is the common cause of urinary tract infections). Hand written notation on the form: 4/8/17 faxed to office, notified exchange, 1700 called again and spoke with (Name of individual, unknown title). 4/10/17 called at 1234 (12:34 pm) left message, called again @ (sic) 1400 left message marked urgent. The fax date of the document being sent to facility was 04/08/17. F. On 04/26/17 at 1:20 pm, during an interview, CNA #3 stated, I was the one who took care of her the day she was transferred out. She was not responding well at all, she was limp, rag doll, wasn't voiding (passing urine) and I did report it to the nurse. She was not eating. At breakfast and lunch, the food just drooled out of her mouth. I gave that (information) in report, too. G. On 04/26/17 at 1:50 pm, during an interview, LPN #2 stated, On 04/10/17, when I made rounds, (name of R #1) was very lethargic. She had a huge change of condition. I called the doctor and left a message a couple of times. In report, they said she was not doing good and not eating or drinking and had no output (urine). The doctor called me back and told me to transport (the resident to the emergency room ). H. Record review of the facility departmental notes dated 04/10/17 at 6:33 pm revealed: Per (name of primary doctor) sent Pt (patient) to (Name local hospital for further evaluation) and Tx (treatment) . Ambulance called and arrived at 1730 (5:30 pm) to transport Pt out. I. On 04/26/17 at 1:00 pm, during an interview with the ADON (Assistant Director of Nurses) #1 regarding the urine analysis report received on 04/06/17, she stated that she could not find documentation of a call to the physician on that date to notify him of the results. She stated, I would have expected to see that it had been called. I can only assume there was a delay (in notification). When then ADON was asked about the 04/08/17 documentation of the nurse regarding unsuccessful attempts to notify the doctor of results, the ADON stated, We have an on call ADON available if they (the staff) have concerns. The nurse should have called the on call. I was not called; it came to my attention on Monday, I don't recall when.[MEDICAL CONDITION] would be a possible outcome of the delay. She affirmed the facility has a physician medical director available to them at all times, including evenings and weekends. ADON #1 stated they did not have any policy or procedures for reporting laboratory results or assessments

The facility failed to store, prepare, and distribute food under safe and sanitary conditions when they failed to keep food refrigerated below 41 degrees Fahrenheit (F), serve the unsafe food to the residents, utilize equipment unsafely, maintain the kitchen and dish washing areas, and have possible cross contamination when testing for proper maintaining temperatures. These deficient practices resulted in an Immediate Jeopardy (IJ) being identified at the facility on 06/10/14 at 7:45 pm. The facility took corrective action by providing an acceptable Plan of Removal. Based on the plan, interventions included retraining of all kitchen staff on ensuring that the residents get the diets as ordered, proper testing of maintenance temperatures, repairing the kitchen and dish washing areas, and educating on safe food temperatures. Based on the Plan of Removal and observation, the IJ was lifted on 06/13/14 at 3:30 pm. This resulted in the scope and severity being reduced from a scope and severity of L to Level 2, Scope F. Based on observation, interview and record review, the facility failed to: 1) provide training and education to the kitchen staff, 2) maintain their equipment effectively, 3) ensure safe internal food temperatures, 4) discard potentially hazardous food, and 5) employ competent staff who could carry out the responsibilities of the food service department. These systemic failures created a risk for cross contamination and food borne illness which had the ability to affect all of the 103 residents who resided in this facility. Residents were identified by the Resident Census list provided by the Director of Nursing on 06/09/14. The findings are: A. Observation of the kitchen on 06/09/14 at 8:40 am revealed that the Cook (C #1) had prepared the residents' breakfast and was in the process of cooking their lunch. An interview with C #1, at that time, revealed that she was the only cook in the kitchen on this day because the Dietary Manager passed away approximately six weeks prior and the full time cook was on vacation for the week. B. Observation of the "reach-in" refrigerator on 06/09/14 at 8:45 am revealed that it was broken. The thermometer read 50 degrees Fahrenheit (F) and there were five metal trays on the shelves that contained individual servings of fruit; approximately 75 servings. An interview with C #1, at that time, revealed that the reach in refrigerator had been broken for a couple of days and she had contacted maintenance to complete a work order. C. Observation of the kitchen and the dish machine area on 06/09/14 at 9:00 am revealed that the equipment and the environment had not been well maintained. The walk-in refrigerator did not have an internal thermometer and the door was rusted at the bottom, the freezer condenser was leaking a fluid on to the floor, the steamer was broken and placed into a storage closet, the right half of the oven was inoperable, the floor drains and sink pipes were leaking and backing up, a pellet (metal plate warmer) warmer was used as a plate warmer (dangerous due to excessive heat on the residents' plates), the floor was cracked and missing pieces and grout, the walls under the dish machine had large holes which were covered by a big piece of card board, the garbage disposal was leaking a white liquid all over the dish room floor, and the entire dish room smelled of rotten meat. D. An interview with the Maintenance Director on 06/09/14 at 1:00 pm confirmed that the kitchen and the dish room had not been maintained in a safe and functional fashion. He stated that the steamer had been broken for a few months, the reach in refrigerator had been broken for a week or so, and the facility was aware of the other repairs that were needed. E. Observation of the walk-in refrigerator on 06/09/14 at 9:10 am revealed that there were approximately 50 individual cartons of milk shakes (nutritional supplement) that were placed on the "ready to use" shelf. All of the shakes were defrosted and they did not contain a date or a label. F. Review of the manufacturer's label revealed that the milk shakes should be stored frozen and discarded after 14 days of defrost. An interview with C #1 on 06/09/14 at 9:05 am revealed that she was unaware that the milk shakes had an expiration date and they needed to be dated and/or labeled to ensure that the residents would not receive potentially hazardous food. G. An interview with C #1 on 06/09/14 at 9:05 am revealed that she had worked in the facility approximately two years and she had not received continuing education relative to safe food handling. She stated that she was in charge of food production this week; however she did not feel qualified or appropriately trained to complete her responsibilities and duties in a safe manner. H. An interview with the facility's Registered Dietitian (RD) #1 on 06/11/14 at 9:16 am confirmed that the kitchen staff had not received in-service training relative to safe food handling since 2011. She stated that she had a contract with the facility but she was unaware of the contents or if it was her responsibility to help educate the staff. I. Observation of the steam table on 06/10/14 at 11:00 am revealed that C #1 was ready to take the temperature of the food that she had prepared for the residents' lunch. C #1 placed a stem dial thermometer through several pieces of smothered steak and documented that the temperature of the "ready to eat" steak and onions was 140 degrees F. When interviewed, at that time, about what the temperature of the smothered steak was before she removed it from the oven, C #1 stated that she was uncertain. C #1 stated that she did not know that the smothered steak should have reached a safe internal temperature of 155 degrees F to ensure food safety. J. Review of the Safe Food Temperature poster that was taped to the wall in the kitchen revealed that it contained guidelines for safe internal temperature of potentially hazardous foods. Per the guidelines, ground beef should reach a minimum of 155 degrees F to ensure that hazardous bacteria could not survive. K. Review of the "Trayline Temperature Log" dated 06/05/14 -06/11/14 revealed that the facility failed to document the temperature of the food before serving the residents and they failed to routinely document the holding temperatures. On 06/05/14, 06/06/14, and 06/07/14, the temperature of the food prepared for breakfast and lunch was not recorded and the holding temperature was not recorded on any of the days during that time period. L. Observation of the kitchen on 06/10/14 at 4:00 pm revealed that a dietary worker (D) #3 had removed pureed chicken from the oven and she was prepared to take the temperature. D #3 removed a stem dial thermometer from the preparation table and inserted the probe into the chicken before it was sanitized. An interview with D #3, at that time, revealed that she was a fairly new kitchen employee and she had not been trained on safe food handling. M. Observation of the kitchen on 06/10/14 at 5:00 pm revealed that the Cook, C #2, had prepared the residents' dinner meal. When asked to first calibrate the thermometer to ensure food safety, C #2 was unable to complete that task effectively. N. An interview with C #1 on 06/11/14 at 12:50 pm revealed that she had cooked the residents' lunch meal. C #1 stated that she did not season the residents' food or follow the recipes because she did not have enough time. She added that she was the only cook in the kitchen during the preparation of breakfast and lunch and she did not think that there was enough time to perform her responsibilities and duties effectively. C #1 stated that she was the only cook on this day, but more than that, she stated that, "I also have to wash my own pots and pans as well." O. Observation of the dining room on 06/11/14 at 12:30 pm, revealed a large plastic tub that housed the residents' beverages. There was an assortment of juices and a gallon of milk in the plastic tub. There beverages were not held on ice and the temperature of the milk was recorded at 70 degrees F. P. Review of the temperature log dated 06/11/14 revealed that staff had failed to record the temperature of the milk or the tropical fruit before the lunch meal began. The temperature of the tropical fruit and milk were taken and recorded on 06/11/14 at 12:30 pm and both were holding in the danger zone. The milk, as stated above, was holding at 70 degrees F and the fruit was holding at 60 degrees F. Q. An interview with RD #1 on 06/11/14 at 12:35 pm confirmed that staff had failed to take and record the temperature of the milk and the fruit before the lunch service began. She stated that it was the facility's policy to take the temperature of both hot and cold food before serving the residents and it was also their policy to take and record the food temperatures during the meal service to ensure that the food was holding at or above 135 degrees. When interviewed, at that time, about why the staff had failed to follow the facility's policy relative to the taking and recording the temperature of the food, RD #1 was uncertain. R. Observation of the kitchen on 06/12/14 from 11:00 am until 12:00 pm revealed that the third compartment sink and the cook's preparation sink did not have garbage disposals. Both sinks had floor drains that were backed up and over flowing. When the floor drain in the third compartment sink area backed up, white and brown particles (which resembled potato skins) backed up and over flowed into the food preparation area. S. Observation of the dishroom on 06/12/14 at 1:00 pm revealed that D #3 was responsible for the operation of the dish machine. D #3 was observed scraping food from dirty dishes, spraying soiled cookware, and loading dishes into racks for cleaning. D #3 pushed the dirty dishware through the dish machine with bare hands. Once the dishes had been cleaned and sanitized, D #3 removed the dishes with the same hand that she used to scrape and load the dirty dishes. D #3 did not wear gloves nor did she wash or sanitize her hands after handling the dirty dishes and before removing the clean dishes from the racks. This created a potential for cross contamination. T. An interview with D #3 on 06/12/14 at 1:00 pm revealed that she had only been working in the kitchen/dishroom for a few months. She stated that when she was hired at this facility she worked in the housekeeping department and then she was transferred to the kitchen. When interviewed about the potential for cross contamination while operating the dish machine, D #3 stated that she had not been trained to work in the dish room nor the kitchen. U. Review of D #3's personal file revealed that she was hired in December 2013 for a housekeeping position and in February 2014 she was transferred to the dietary department. Further review of her personal file revealed that she had no previous training and this was her first place of employment. V. An interview with the Human Resources (HR) Manager on 06/13/14 at 2:00 pm confirmed that D #3 had no previous food service experience before she was hired by this facility. The HR Manager stated that D #3 was young and this was her first job. Review of her personal file with the HR Manager, at this time, revealed that the facility had not provided D #3 with any training or education relative to safe food handling.

The facility failed to provide a mechanical soft diet to a resident with swallowing difficulties. Resident #92 had [DIAGNOSES REDACTED]. The Speech Therapist had assessed that the resident needed a mechanical soft diet and "Safety awareness was ongoing during treatment due to patient's cognitive deficits." On [DATE] during the evening meal, Resident #92 was given a hamburger and a lunch meat sandwich that was cut in to four pieces. Two CNAs and a cook provided the hamburger and sandwich and one nurse watched from outside while the resident was feeding himself so fast that he did not take breaths between taking bites. These deficient practices resulted in an Immediate Jeopardy (IJ) being identified at the facility on [DATE] at 2:30 pm. The facility took corrective action by providing an acceptable Plan of Removal. Based on the plan, interventions included retraining of all facility staff on ensuring that the residents get the diets as ordered, and proper monitoring of the residents while they eat. Based on the Plan of Removal and observation, the IJ was lifted on [DATE] at 3:30 pm. This resulted in the scope and severity being reduced from a scope and severity of K to Level 3, Scope G. Based on interview and record review, the facility failed to ensure that each resident's environment was free of accidents hazards and they received the necessary supervision to prevent accidents. The facility failed to: 1) Monitor residents in the dining room who had chewing/swallowing difficulties (R#s 37, 52, 80, & 92), 2) Follow the physician's diet order (R #92), 3) Act immediately when a resident was at risk for choking (R #92), and 4) Develop a care plan to reduce their risk for choking accidents (R #92). This deficient practice adversely affected one (R #92) resident and had the potential to affect three (R #52, R #80, and R #37) additional residents who were at risk for accidents. Resident #92 experienced a choking episode in the facility and subsequently expired. The findings are: Resident #92 A. Review of the "Resident Incident Report" dated [DATE] at 6:30 pm revealed that R #92 was in the dining room when staff noticed that he was "hunched over his wheelchair." The resident "appeared blue in face, lips purple and residents (sic) airway occluded; food chunks removed from residents (sic) mouth." Further review of facility records revealed that in response, R #92 was transferred to the hospital, where he expired on [DATE]. B. Review of the clinical record for R #92 revealed that he was admitted to this facility on [DATE] with [DIAGNOSES REDACTED]. 1. R #92's current physician's orders [REDACTED]. 2. According to R #92's most current Minimum Data Set ((MDS) dated [DATE], the resident had swallowing problems, received a mechanically altered diet, and required supervision during meals, with the physical assistance of one staff. C. Review of the incident report dated [DATE] revealed that R #92 did not want his mechanical soft diet, consequently staff provided him with a hamburger and a cold cut sandwich (of regular consistency). D. Review of the investigation that the facility completed on [DATE] revealed many written statements from staff which indicated that R #92 had refused his meal often, was non-compliant with his diet order and he had demanded that they provide him with an alternate meal. The following information was obtained from the written statements that staff provided relative to R #92's choking incident that ultimately resulted in his death. 1. A Certified Nursing Assistant (CNA #10) wrote that she was picking up meal tickets in the dining room the night of [DATE] when R #92 stated that he did not want the regular meal he wanted a hamburger and a cold cut sandwich. CNA #10 asked him again to make sure that was what he wanted. CNA #10 wrote the residents meal order. 2. The cook, C #1, wrote that on [DATE] between the hours of 5:30 pm and 6:00 pm she was working the evening shift in the kitchen serving line. She received a ticket for a cold cut sandwich and a hamburger for this resident. C #1 made the order according to the ticket but did not "check it against the diet order." C #1 added that the CNAs then picked up the tray and took it into the dining room. 3. CNA #9 wrote that she went to the dining room around 5:00 pm and she started passing out drinks until dietary was ready to give out the meal trays. She gave R #92 his meal tray which consisted of a sandwich (which she cut into 4 pieces) and a hamburger. CNA #9 wrote, "I left him (pt) (patient) with his food and went to pass out more trays..." 4. A Licensed Practical Nurse (LPN #4) wrote that on [DATE] at 6:15 pm she was walking past the dining room window and noted that R #92 was eating his meal. She noted that he was bent over his food and gulping a sandwich very fast using his fingers to shove it in his mouth with no time to chew. After 10 minutes someone beat on the dining room window and called me "STAT" (immediately) to the dining room. When she reached the resident she noted "blue palor (SIC) and choking sounds." E. An interview with LPN #4 on [DATE] at 10:02 am revealed that she was walking past the dining room when she observed R #92 "shoving" food into his mouth. When interviewed about if she was aware that R #92 had swallowing difficulties and was at risk for choking, LPN #4 stated she was aware. When interviewed about why she did not act immediately when she first observed R #92 shoving food into his mouth, she stated, "I was on a break and going out to smoke." When interviewed about if she immediately alerted the CNAs in the dining room that R #92 was shoving food into his mouth and not taking time to chew, LPN #4 stated, "No, I did not." F. An interview with the Director of Operations and the Administrator (Adm #2) on [DATE] at 3:45 pm revealed that it was the facility's policy to always act immediately when they observed residents shoving food into their mouths especially if they are at risk for choking. G. Review of thirteen additional statements that staff documented relative to R #92's behaviors in the dining room revealed that he was non-compliant with his diet order, he would demand regular texture foods, he would leave the dining room if staff did not adhere to his demands, he requested a hamburger and a cold cut sandwich often and he could become physically and verbally abusive to staff. H. An interview with the Director of Nursing (DON) and the Administrator (Adm #2) on [DATE] at 10:00 am confirmed that R #92 was non-compliant with his mechanically altered diet. I. Review of the clinical record and the care plans developed for R #92 revealed staff failed to develop a care plan relative to R #92's potential for accidents (choking) due to his non-compliance with his diet and his resulting behaviors. J. An interview with the DON on [DATE] at 9:30 am confirmed that the facility had failed to care plan R #92's non-compliance with diet and behaviors so as to prevent choking accidents. When the staff failed to develop the non-compliance care plan, staff were uninformed of how to intervene when R #92 exhibited behaviors in the dining room which placed R #92 at risk for accidents. K. Review of the Speech Therapist's, (ST #2) "Summary of Dysphagia Treatment..." for R #92 dated [DATE] through [DATE] revealed the following information: 1. "Skilled therapeutic treatment included: Patient education on the swallowing process, signs/symptoms of aspiration, as well as, establishment of compensatory strategies and precautionary measures. Safety and compensatory strategies included diet analysis and diet management for established diet, alternating solids/liquids, alternating temperatures/textures for increased sensation, placement of food on stronger and unaffected side to decrease oral residue on weaker side, buccal sweeps. slower rate of presentations, multiple swallows, trunk positioning at 90 degree angle, and use of chin tuck to facilitate oral and pharyngeal control of the bolus by widening the valleculae (a depression behind the roof of the tongue) to prevent spillage to the pyriform sinuses (a recess on either side of the voice box) or trachea..." 2. "During treatment, education on the need for a modified diet reiterated to prevent risk of aspiration..." 3. "Safety awareness was ongoing during treatment due to patient's cognitive deficits." L. Review of R #92's current care plan revealed it did not include the compensatory techniques described by the ST to prevent aspiration/choking accidents. M. Review of the "Plan of Treatment" dated [DATE] through [DATE] revealed the following information under the heading for Clinical Narrative: "... He (R #92) does not consistently recognize his deficits and that his memory is not intact nor does he recognize that is (sic) deficits are problematic. Cognitive function impedes overall safety awareness, thought organization (sic), sequential planning, judgment/reasoning, and functional problem solving." N. An interview with the Speech Therapist (ST #2) on [DATE] at 9:50 am confirmed that she was the therapist that had worked with R #92 relative to his cognition deficit and his swallowing difficulties. ST #2 confirmed that R #92 was not able to make his own decisions of daily care because his "cognitive function impedes his overall safety awareness." O. An interview with the Director of Operations and the Administrator (Adm #2) on [DATE] at 3:45 pm confirmed that there was a potential for accidents when staff : 1) changed R #92's meal ticket from mechanical soft to a regular hamburger and a cold cut sandwich without getting approval, 2) prepared the meal ticket before checking the diet against the physician's orders [REDACTED]. 3) gave the meal to R #92 then walked away without monitoring him, 4) did not act immediately when he was first observed at risk for choking, and 5) did not develop an individualized accident care plan designed to prevent choking accidents and which reflected the resident's behaviors, diet refusals, and need for specific feeding techniques identified by the ST. Resident #52 P. Observation of R #52 during lunch on [DATE] at 12:00 pm revealed that R #52 had part of her meat cut by the staff and the resident was feeding herself. R #52 was observed picking up the remainder of the uncut meat, place the large uncut piece of meat in her mouth, and then tear off a piece of the meat with her teeth. The surveyor left the room and soon after, on return to the dining room, R #52 was observed to have a choking episode. R #52 was taken from the dining room to an adjacent room and was attended to by the facility staff. Q. Review of facility documentation for R #52 revealed a "Resident Incident Report" dated on [DATE] at 12:32 pm. The record documented the following events "Res (resident) in back dining room, fed by ST (speech therapist). Res started choking when fed piece of meat. Res diet recently changed to regular texture. ST notified nurse and (Nurse Practitioner (NP)) of choking episode which rushed to resident, noticed resident breathing. Res spitting up phlegm. Res instructed to cough with 0 (no) results. (NP) dislodged piece of meat from residents throat. Res given liquids to clear throat. Res noted not able to keep anything down. Order from (NP) to send res to (hospital) non-emergent. Res sent to (hospital) at 12:50 pm." R. Interview with the Speech Therapist (ST) on [DATE] at 3:30 pm revealed that the incident report was incorrect. The ST stated she was not feeding R #52 at the time of the choking incident; she happened to be in the dining room when R #52 began choking and she attended to the resident. She did not feel R #52 was having a choking episode. The ST continued to explain that her definition of a choking episode is when a resident is unable to talk or breathe. S. Interview with the Nurse Practitioner (NP) on [DATE] at 8:47 am regarding R #52's choking episode during lunch on [DATE] also revealed the facility incident report was incorrect. The NP stated she did not dislodge anything from R #52's throat during this episode. She continued to state when she put a tongue depressor into R #52s mouth to assess her when she was choking, R #52 had a gag reflex and the resident continued to vomit stomach contents. T. An interview was conducted with LPN #1 on [DATE] at 9:00 am regarding R #52's choking episode on [DATE] during lunch. LPN #1 stated she was not present when R #52 began to choke, the ST told her R #52 was choking on a piece of rice and was having a problem with something lodged in her throat. She thought the ST was feeding R #52, the NP told her she dislodged a piece of meat from R #52's mouth. She thought the resident was choking. She had documented the events on R #52's incident report by what she was told, which she confirmed was incorrect. Resident #80 U. Review of the clinical record for R #80 revealed that she was admitted to the facility on [DATE] with the [DIAGNOSES REDACTED]. V. Review of the quarterly Minimum Data Set (MDS) assessment for R #80 revealed that the facility coded her as having a swallowing disorder in Section "K." W. Review of the "Departmental Notes" dated [DATE], [DATE], [DATE], [DATE], and [DATE] revealed that R #80 experienced choking episodes. Staff documented that R #80 tended to eat fast, not chew her food properly, was on a mechanical soft diet with thickened liquids and required close supervision when dining. X. Review of the Speech Therapy (ST #2) "Progress Note" dated [DATE] through [DATE] revealed that R #80 had episodes of choking while dining on a mechanical soft diet with thickened liquids. Per the notes, R #80 refused a pureed diet and her thickened liquids. Y. Review of two Incident Reports dated [DATE] and [DATE] revealed that R #80 experienced a choking episode and staff had to perform the Heimlich maneuver. Z. Review of the hand written note from the Physical Therapist (PT) dated [DATE] revealed that, "At approximately 11:45 am on tues (Tuesday) feb (February) 4th a resident (R #80) by the name of (provided the name) demonstrated the universal choking sign. I approached resident while she was still choking leaned her forward tapped her back with base of palm. The resident went silent could not see in her mouth finger swept and didn't feel any obstruction. I then proceeded to do Heimlich maneuver. After 5 or 6 thrusts resident started to wheeze and stared forcefully gasping for air." AA. Review of the "Incident Report" dated [DATE] at 12:30 pm confirmed that R #80 was in the dining room when she started to choke on her food. The PT noticed that the resident was choking and performed abdominal thrusts. No further investigation was documented. BB. An interview with PT on [DATE] at approximately 10:45 am confirmed that he had performed the Heimlich maneuver and abdominal thrusts when R #80 choked in the dining room on [DATE]. When interviewed what he did after that, he stated, "Nothing." When asked about if he discussed this incident with ST or nursing; he stated "No, I did not, I just documented what happened on an incident report." When interviewed about why he did not follow up with nursing or ST to ensure that R #80 would not experience another accident and choking incident, PT stated he was unsure. CC. Review of the nutritional care plan dated [DATE] revealed that R #80 was at risk for choking and staff documented that one of her goals was to "... not suffocate related to choking food" dated [DATE]. Review of the hand written revisions revealed that R #80 was an increased risk for aspiration related to being non-compliant with her mechanical diet and nectar thickened liquids. The goal written on [DATE] was "Resident will not aspirate x (times) 90 days." One of the interventions was dated [DATE] and it read that the Speech Therapist was to complete a screening for R #80. DD. An interview with the DON and ST #2 on [DATE] at approximately 1:30 pm revealed that the facility had failed to complete the screening for R #80 and she continued to be at risk for accidents related to swallowing difficulties and choking. When interviewed why the screening had not been completed, ST2 and the DON stated that they were uncertain. R #80 remained at risk for accidents and choking episodes. Resident #37 EE. Review of the medical record for R #37 revealed that she was admitted to this facility on [DATE] with the [DIAGNOSES REDACTED]. FF. An interview with R #37 on [DATE] at 7:30 am revealed that she stayed in bed most of the day and she stated that she had experienced a choking episode recently while eating in her room. GG. Review of the "Incident Log" dated [DATE] through [DATE] revealed that R #37 experienced a choking incident on [DATE]. Review of the nutritional care plan dated [DATE] confirmed that R #37 had a choking episode and she was referred to the Speech Therapist. HH. Review of the "Modified Barium Swallow Study Report" (MBSS) dated [DATE] revealed that R #37 had "Significant esophageal impairment to include tertiary peristalsis (the food would not go down her throat), diminished esophageal motiligy (sic), a large gas volume, and symptoms of reflux." The recommendations included: 1. Regular diet 2. Aggressive pharmaceutical management of reflux 3. Alternate a bit of food followed by a sip of liquid 4. Slow rate of presentation 5. Reflux precautions 6. GI consult may be warranted. II. Review of the ST #1's "Plan of treatment" dated [DATE] (approximately 50 days after the choking incident) revealed the "Closing Summary" read, "The patient was evaluated and educated on normal swallow function; esophageal dysphagia (poor swallowing), and appropriate diet for GERD (gastroesophageal reflux disease)." JJ. Review of the care plans dated [DATE] and revised on [DATE], [DATE], [DATE], [DATE], [DATE], and on [DATE] revealed that the recommendations from the MBSS and ST #1 had not been added to the care plan which left R #37 at continued risk for accidents and choking. KK. An interview with the DON on [DATE] at approximately 2:00 pm confirmed that the recommendations from the MBSS and ST #1 were not implemented which left R #37 at continued risk for accidents and choking.

The facility failed to provide a mechanical soft diet to a resident with swallowing difficulties. Resident #92 had [DIAGNOSES REDACTED]. The Speech Therapist had assessed that the resident needed a mechanical soft diet and "Safety awareness was ongoing during treatment due to patient's cognitive deficits." On [DATE] during the evening meal, Resident #92 was given a hamburger and a whole lunch meat sandwich that was cut in to four pieces. Two CNAs and a cook provided the hamburger and sandwich and one nurse watched from outside while the resident was feeding himself so fast that he did not take breaths between taking bites. These deficient practices resulted in an Immediate Jeopardy (IJ) being identified at the facility on [DATE] at 2:30 pm. The facility took corrective action by providing an acceptable Plan of Removal. Based on the plan, interventions included retraining of all facility staff on ensuring that the residents get the diets as ordered, and proper monitoring of the residents while they eat. Based on the Plan of Removal and observation, the IJ was lifted on [DATE] at 3:30 pm. This resulted in the scope and severity being reduced from a scope and severity of J to Level 3, Scope G. Based on record review and interview, the facility failed to ensure that one (R #92) of three residents (#s 37, 80, and 92) sampled due to risk of choking was free from neglect. The facility failed to: 1. Monitor residents in the dining room who had swallowing difficulties, and 2. Act immediately when one (R #92) resident was observed at risk for choking. This failed practice possibly led to R #92 experiencing a choking episode in the facility and subsequently expired. The findings are: A. Review of the "Resident Incident Report" dated [DATE] at 6:30 pm revealed that R #92 was in the dining room when staff noticed that he was "hunched over his wheelchair." The resident "appeared blue in face, lips purple and residents (sic) airway occluded (blocked); food chunks removed from residents (sic) mouth." B. Review of the "Intake Information" form dated [DATE] revealed that there were 14 questions (#1- #14) that required answers. The following information was obtained from #5, #6, #7 and #8: 1. #5. What happened? "Resident (R #92) was in dining room. Resident had a mechanical soft diet. Resident requested regular sandwich and hamburger. Resident choked on dinner. Care is given to resident. Abdominal thrusts, suctioning, 911 called. Resident expired at hospital. Resident is transferred to hospital and expired at hospital. Safety of all residents is ensured, verify all diet orders, re-educate staff to textures, refer residents to speech as indicated investigation is instituted." 2. #6. When did the problem occur? "[DATE] 6:30 pm" 3. #7. Is the resident/patient still in the facility? "No, expired" 4. #8. How did it happen? "Neglect" C. Review of the clinical record for R #92 revealed that he was admitted to this facility on [DATE] with [DIAGNOSES REDACTED]. D. Review of the nutritional care plan revised on [DATE] revealed that R #92 had a mechanical soft diet and per the activities of daily living care plan, also dated [DATE], R #92 had dementia and a stroke with [MEDICAL CONDITION] ([DIAGNOSES REDACTED]). E. Review of the Speech Therapist's (ST #2) "Summary of Dysphagia Treatment..." for R #92 dated [DATE] through [DATE] revealed the following information: 1. "Skilled therapeutic treatment included: Patient education on the swallowing process, signs/symptoms of aspiration, as well as, establishment of compensatory strategies and precautionary measures. Safety and compensatory strategies included diet analysis and diet management for established diet, alternating solids/liquids, alternating temperatures/textures for increased sensation, placement of food on stronger and unaffected side to decrease oral residue on weaker side, [MEDICATION NAME] sweeps, slower rate of presentations, multiple swallows, trunk positioning at 90 degree angle, and use of chin tuck to facilitate oral and pharyngeal control of the bolus by widening the valleculae (a depression behind the roof of the tongue) to prevent spillage to the pyriform sinuses (a recess on either side of the voice box) or trachea..." 2. "During treatment, education on the need for a modified diet reiterated to prevent risk of aspiration..." 3. "Safety awareness was ongoing during treatment due to patient's cognitive deficits." F. Review of the "Plan of Treatment" dated [DATE] through [DATE] revealed a Clinical Narrative that read, "... He (R #92) does not consistently recognize his deficits and that his memory is not intact nor does he recognize that is (SIC) deficits are problematic. Cognitive function impedes overall safety awareness, thought organziation (SIC), sequential planning, judgment/reasoning, and functional problem solving." G. An interview with the Speech Therapist (ST #2) on [DATE] at 9:50 am confirmed that she was the therapist that had worked with R #92 relative to his cognition deficit and his swallowing difficulties. ST #2 confirmed that R #92 was not able to make his own decisions of daily care because his "cognitive function impedes his overall safety awareness." H. Review of the investigation completed by the facility and the statements from staff revealed the following information: 1. A Certified Nursing Assistant (CNA #10) wrote that she was picking up meal tickets in the dining room the night of [DATE] when R #92 stated that he did not want the regular meal, he wanted a hamburger and a cold cut sandwich. CNA #10 asked him again to make sure that was what he wanted. CNA #10 wrote the residents diet order. 2. The cook, C #1, wrote that on [DATE] between the hours of 5:30 pm and 6:00 pm, she was working the evening shift in the kitchen serving line. She received a ticket for a cold cut sandwich and a hamburger. C #1 made the order according to the ticket but did not "check it against the diet order." C #1 added that the CNAs then picked up the tray and took it into the dining room. 3. CNA #9 wrote that she went to the dining room around 5:00 pm and she started passing out drinks until dietary was ready to give out the meal trays. She gave R #92 his meal tray which consisted of a sandwich (which she cut into 4 pieces) and a hamburger. CNA #9 wrote, "I left him (pt) (patient) with his food and went to pass out more trays..." 4. A Licensed Practical Nurse (LPN #4) wrote that on [DATE] at 6:15 pm she was walking past the dining room window and noted that R #92 was eating his meal. She noted that he was bent over his food and gulping a sandwich very fast using his fingers to shove it in his mouth with no time to chew. After 10 minutes someone beat on the dining room window and called me "STAT" (immediately) to the dining room. When she reached the resident she noted "blue palor (SIC) and choking sounds." I. An interview with LPN #4 on [DATE] at 10:02 am revealed that she was walking past the dining room when she observed R #92 "shoving" food into his mouth. When interviewed about if she was aware that R #92 had swallowing difficulties and was at risk for choking, LPN #4 stated she was aware. When interviewed about why she did not act immediately when she first observed R #92 shoving food into his mouth she stated, "I was on a break and going out to smoke." When interviewed about if she immediately alerted the CNAs in the dining room that R #92 was shoving food into his mouth and not taking time to chew, LPN #4 stated, "No, I did not." J. An interview with the Director of Operations and the Administrator (Adm #2) on [DATE] at 3:45 pm revealed that it was the facility's policy to always act immediately when they observed residents shoving food into their mouths especially if they are at risk for choking. They stated that the staff involved were neglectful when they: 1) Changed R #92's meal ticket from mechanical soft to a regular hamburger and a cold cut sandwich without getting approval, 2) prepared the meal ticket before checking the diet against the physician's orders [REDACTED].#92 then walked away without monitoring him, and 4) did not act immediately when he was first observed choking.

The facility failed to provide a mechanical soft diet to a resident with swallowing difficulties. Resident #92 had [DIAGNOSES REDACTED]. The Speech Therapist had assessed that the resident needed a mechanical soft diet and "Safety awareness was ongoing during treatment due to patient's cognitive deficits." On [DATE] during the evening meal, Resident #92 was given a hamburger and a whole lunch meat sandwich that was cut in to four pieces. Two CNAs and a cook provided the hamburger and sandwich and one nurse watched from outside while the resident was feeding himself so fast that he did not take breaths between taking bites. These deficient practices resulted in an Immediate Jeopardy (IJ) being identified at the facility on [DATE] at 2:30 pm. The facility took corrective action by providing an acceptable Plan of Removal. Based on the plan, interventions included retraining of all facility staff on ensuring that the residents get the diets as ordered, and proper monitoring of the residents while they eat. Based on the Plan of Removal and observation, the IJ was lifted on [DATE] at 3:30 pm. This resulted in the scope and severity being reduced from a scope and severity of J to Level 3, Scope G. Based on record review and interview, the facility failed to implement policies and procedures that prohibit neglect when the facility failed to: 1. Monitor residents in the dining room who had swallowing difficulties, and 2. Act immediately when one (R #92) resident was observed at risk for choking. This failed practice possibly led to R #92 experiencing a choking episode in the facility and subsequently expired. The findings are: A. Review of the facility's undated "Abuse and Neglect Policy" defined neglect as, "Failure to provide goods or services necessary to avoid physical harm, mental anguish, or mental illness." B. Review of the "Resident Incident Report" dated [DATE] at 6:30 pm revealed that R #92 was in the dining room when staff noticed that he was "hunched over his wheelchair." The resident "appeared blue in face, lips purple and residents (sic) airway occluded (blocked) ; food chunks removed from residents (sic) mouth." C. Review of the "Intake Information" form dated [DATE] revealed that there were 14 questions (#1 - #14) that required answers. The following information was obtained from #5, #6, #7 and #8: 1. #5. What happened? "Resident (R #92) was in dining room. Resident had a mechanical soft diet. Resident requested regular sandwich and hamburger. Resident choked on dinner. Care is given to resident. Abdominal thrusts, suctioning, 911 called. Resident expired at hospital. Resident is transferred to hospital and expired at hospital. Safety of all residents is ensured, verify all diet orders, re-educate staff to textures, refer residents to speech as indicated investigation is instituted." 2. #6. When did the problem occur? "[DATE] 6:30 pm" 3. #7. Is the resident/patient still in the facility? "No, expired" 4. #8. How did it happen? "Neglect" D. Review of the clinical record for R #92 revealed that he was admitted to this facility on [DATE] with [DIAGNOSES REDACTED]. E. Review of the nutritional care plan revised on [DATE] revealed that R #92 had a mechanical soft diet and per the activities of daily living care plan, also dated [DATE], R #92 had dementia and a stroke with [MEDICAL CONDITION] ([DIAGNOSES REDACTED]). F. Review of the Speech Therapist (ST) #2's "Summary of Dysphagia Treatment..." for R #92 dated [DATE] through [DATE] revealed the following information: 1. "Skilled therapeutic treatment included: Patient education on the swallowing process, signs/symptoms of aspiration, as well as, establishment of compensatory strategies and precautionary measures. Safety and compensatory strategies included diet analysis and diet management for established diet, alternating solids/liquids, alternating temperatures/textures for increased sensation, placement of food on stronger and unaffected side to decrease oral residue on weaker side, [MEDICATION NAME] sweeps, slower rate of presentations, multiple swallows, trunk positioning at 90 degree angle, and use of chin tuck to facilitate oral and pharyngeal control of the bolus by widening the valleculae (a depression behind the roof of the tongue) to prevent spillage to the pyriform sinuses (a recess on either side of the voice box) or trachea..." 2. "During treatment, education on the need for a modified diet reiterated to prevent risk of aspiration..." 3. "Safety awareness was ongoing during treatment due to patient's cognitive deficits." G. Review of the "Plan of Treatment" dated [DATE] through [DATE] revealed a Clinical Narrative that read, "... He (R #92) does not consistently recognize his deficits and that his memory is not intact nor does he recognize that is (SIC) deficits are problematic. Cognitive function impedes overall safety awareness, thought organziation (SIC), sequential planning, judgment/reasoning, and functional problem solving." H. An interview with the ST #2 on [DATE] at 9:50 am confirmed that she was the therapist that had worked with R #92 relative to his cognition deficit and his swallowing difficulties. ST #2 confirmed that R #92 was not able to make his own decisions of daily care because his "cognitive function impedes his overall safety awareness." I. Review of the investigation completed by the facility and the statements from staff revealed the following information: 1. A Certified Nursing Assistant (CNA #10) wrote that she was picking up meal tickets in the dining room the night of [DATE] when R #92 stated that he did not want the regular meal, he wanted a hamburger and a cold cut sandwich. CNA #10 asked him again to make sure that was what he wanted. CNA #10 wrote the residents diet order. 2. The cook, C #1, wrote that on [DATE] between the hours of 5:30 pm and 6:00 pm, she was working the evening shift in the kitchen serving line. She received a ticket for a cold cut sandwich and a hamburger. C #1 made the order according to the ticket but did not "check it against the diet order." C #1 added that the CNAs then picked up the tray and took it into the dining room. 3. CNA #9 wrote that she went to the dining room around 5:00 pm and she started passing out drinks until dietary was ready to give out the meal trays. She gave R #92 his meal tray which consisted of a sandwich (which she cut into 4 pieces) and a hamburger. CNA #9 wrote, "I left him (pt) (patient) with his food and went to pass out more trays..." 4. A Licensed Practical Nurse (LPN #4) wrote that on [DATE] at 6:15 pm she was walking past the dining room window and noted that R #92 was eating his meal. She noted that he was bent over his food and gulping a sandwich very fast using his fingers to shove it in his mouth with no time to chew. After 10 minutes someone beat on the dining room window and called me "STAT" (immediately) to the dining room. When she reached the resident she noted "blue palor (SIC) and choking sounds." J. An interview with LPN #4 on [DATE] at 10:02 am revealed that she was walking past the dining room when she observed R #92 "shoving" food into his mouth. When interviewed about if she was aware that R #92 had swallowing difficulties and was at risk for choking, LPN #4 stated she was aware. When interviewed about why she did not act immediately when she first observed R #92 shoving food into his mouth she stated, "I was on a break and going out to smoke." When interviewed about if she immediately alerted the CNAs in the dining room that R #92 was shoving food into his mouth and not taking time to chew, LPN #4 stated, "No, I did not." K. An interview with the Director of Operations and the Administrator (Adm #2) on [DATE] at 3:45 pm revealed that it was the facility's policy to always act immediately when they observed residents shoving food into their mouths especially if they are at risk for choking. They stated that the staff involved were neglectful when they: 1) Changed R #92's meal ticket from mechanical soft to a regular hamburger and a cold cut sandwich without getting approval, 2) prepared the meal ticket before checking the diet against the physician's orders [REDACTED].#92 then walked away without monitoring him, and 4) did not act immediately when he was first observed choking.

The facility failed to provide a mechanical soft diet to a resident with swallowing difficulties. Resident #92 had [DIAGNOSES REDACTED]. The Speech Therapist had assessed that the resident needed a mechanical soft diet and "Safety awareness was ongoing during treatment due to patient's cognitive deficits." On 05/30/14 during the evening meal, Resident #92 was given a hamburger and a lunch meat sandwich that was cut in to four pieces. Two CNAs and a cook provided the hamburger and sandwich and one nurse watched from outside while the resident was feeding himself so fast that he did not take breaths between taking bites. These deficient practices resulted in an Immediate Jeopardy (IJ) being identified at the facility on 06/11/14 at 2:30 pm. The facility took corrective action by providing an acceptable Plan of Removal. Based on the plan, interventions included retraining of all facility staff on ensuring that the residents get the diets as ordered, and proper monitoring of the residents while they eat. Based on the Plan of Removal and observation, the IJ was lifted on 06/13/14 at 3:30 pm. This resulted in the scope and severity being reduced from a scope and severity of J to Level 3, Scope G. Based on observation, record review, and interview, the facility failed to ensure that each resident who was assessed to have chewing and/or swallowing difficulties received the appropriate food texture and/or food form. This deficient practice adversely affected one (R#92) resident but it had the potential to affect 69 of the 103 residents who currently resided in this facility that were assessed to need modified food forms. Residents were identified by the Resident Census list provided by the Director of Nursing on 06/09/14. The findings are: A. Review of a complaint that was investigated by the facility on 05/31/14 revealed that R #92 had received food from the kitchen that was not prepared appropriately per his physician ordered diet. R #92 was ordered a mechanically altered diet and he received a hamburger and a sandwich that were regular in texture. R #92 began to choke in the dining room and subsequently passed away. B. Review of the clinical record for R #92 revealed that he had a physician ordered mechanically soft diet due to a swallowing disorder. R #92 suffered a [MEDICAL CONDITIONS] which left him with swallowing difficulties. C. Review of the incident report dated 05/31/14 revealed that R #92 died on [DATE] after he experienced a choking incident at 6:45 pm in the facility's dining room. D. Review of the statement provided by the cook (C) #1 revealed that she was working the kitchen tray line on 05/30/14 between 5:30 pm and 6:00 pm when she received a ticket for a cold cut sandwich and a hamburger for R #92. C #1 prepared the ticket but failed to check R #92's diet order to ensure that he was able to receive a regular sandwich and hamburger. C #1 provided R #92 with an inappropriate diet texture per his physician's orders [REDACTED]. E. Review of the "Resident Count By All Diet Restrictions Report" dated 06/13/14 revealed that there were 69 residents currently residing in this facility with therapeutic diet orders. Thirty-six residents had a mechanical soft diet, 13 were ordered a pureed diet, one resident had a finger foods diet, four residents had a ground diet, and 15 residents were ordered thickened liquids. All of these resident had the potential to be affected if the staff did not ensure that they received the correct therapeutic diet. F. Observation of the kitchen on 06/10/14 at 10:30 am revealed that a dietary worker (D) #3 was prepared to puree some food for those residents who required texture change for chewing or swallowing concerns. D #3 removed the lid from the blender, added some hot food, then poured in some food thickener. D #3 did not measure any of the ingredients or follow a recipe. G. An interview with the Registered Dietitian (RD) #1 on 06/10/14 at 10:35 am confirmed that the kitchen staff did not have any recipes for thickening foods. She stated that there was a recipe printed on the side of the box that the thickening agent came in; however it only provided a recipe for thickening liquids, not how to thicken solid food. Consequently, there was a potential for the thickened foods to be prepared incorrectly with different textures than ordered, which could lead to the residents experiencing difficulties chewing and swallowing their food.

Based on record review and interview, the facility failed to develop an individualized accident care plan designed to prevent choking accidents and which reflected the resident's behaviors, diet refusals, and need for specific feeding techniques identified by the Speech Therapist for one (R #92) of one residents that expired because of a risk for choking. Resident #92 experienced a choking episode in the facility and subsequently expired. The findings are: A. Review of the "Resident Incident Report" dated [DATE] at 6:30 pm revealed that R #92 was in the dining room when staff noticed that he was "hunched over his wheelchair." The resident "appeared blue in face, lips purple and residents (sic) airway occluded; food chunks removed from residents (sic) mouth." Further review of facility records revealed that in response, R #92 was transferred to the hospital, where he expired on [DATE]. B. Review of the clinical record for R #92 revealed that he was admitted to this facility on [DATE] with [DIAGNOSES REDACTED]. 1. R #92's current physician's orders [REDACTED]. 2. According to R #92's most current Minimum Data Set ((MDS) dated [DATE], the resident had swallowing problems, received a mechanically altered diet, and required supervision during meals, with the physical assistance of one staff. C. Review of the incident report dated [DATE] revealed that R #92 did not want his mechanical soft diet, consequently staff provided him with a hamburger and a cold cut sandwich (of regular consistency). D. Review of the investigation that the facility completed on [DATE] revealed many written statements from staff which indicated that R #92 had refused his meal often, was non-compliant with his diet order and he had demanded that they provide him with an alternate meal. The following information was obtained from the written statements that staff provided relative to R #92's choking incident that ultimately resulted in his death. 1. A Certified Nursing Assistant (CNA #10) wrote that she was picking up meal tickets in the dining room the night of [DATE] when R #92 stated that he did not want the regular meal he wanted a hamburger and a cold cut sandwich. CNA #10 asked him again to make sure that was what he wanted. CNA #10 wrote the residents meal order. 2. The cook, C #1, wrote that on [DATE] between the hours of 5:30 pm and 6:00 pm she was working the evening shift in the kitchen serving line. She received a ticket for a cold cut sandwich and a hamburger for this resident. C #1 made the order according to the ticket but did not "check it against the diet order." C #1 added that the CNAs then picked up the tray and took it into the dining room. 3. CNA #9 wrote that she went to the dining room around 5:00 pm and she started passing out drinks until dietary was ready to give out the meal trays. She gave R #92 his meal tray which consisted of a sandwich (which she cut into 4 pieces) and a hamburger. CNA #9 wrote, "I left him (pt) (patient) with his food and went to pass out more trays..." 4. A Licensed Practical Nurse (LPN #4) wrote that on [DATE] at 6:15 pm she was walking past the dining room window and noted that R #92 was eating his meal. She noted that he was bent over his food and gulping a sandwich very fast using his fingers to shove it in his mouth with no time to chew. After 10 minutes someone beat on the dining room window and called me "STAT" (immediately) to the dining room. When she reached the resident she noted "blue palor (SIC) and choking sounds." E. An interview with LPN #4 on [DATE] at 10:02 am revealed that she was walking past the dining room when she observed R #92 "shoving" food into his mouth. When interviewed about if she was aware that R #92 had swallowing difficulties and was at risk for choking, LPN #4 stated she was aware. When interviewed about why she did not act immediately when she first observed R #92 shoving food into his mouth, she stated, "I was on a break and going out to smoke." When interviewed about if she immediately alerted the CNAs in the dining room that R #92 was shoving food into his mouth and not taking time to chew, LPN #4 stated, "No, I did not." F. Review of thirteen additional statements that staff documented relative to R #92's behaviors in the dining room revealed that he was non-compliant with his diet order, he would demand regular texture foods, he would leave the dining room if staff did not adhere to his demands, he requested a hamburger and a cold cut sandwich often and he could become physically and verbally abusive to staff. H. An interview with the Director of Nursing (DON) and the Administrator (Adm #2) on [DATE] at 10:00 am confirmed that R #92 was non-compliant with his mechanically altered diet. I. Review of the clinical record and the care plans developed for R #92 revealed staff failed to develop a care plan relative to R #92's potential for accidents (choking) due to his non-compliance with his diet and his resulting behaviors. J. Review of the Speech Therapist's, (ST #2) "Summary of Dysphagia Treatment..." for R #92 dated [DATE] through [DATE] revealed the following information: 1. "Skilled therapeutic treatment included: Patient education on the swallowing process, signs/symptoms of aspiration, as well as, establishment of compensatory strategies and precautionary measures. Safety and compensatory strategies included diet analysis and diet management for established diet, alternating solids/liquids, alternating temperatures/textures for increased sensation, placement of food on stronger and unaffected side to decrease oral residue on weaker side, [MEDICATION NAME] sweeps. slower rate of presentations, multiple swallows, trunk positioning at 90 degree angle, and use of chin tuck to facilitate oral and pharyngeal control of the bolus by widening the valleculae (a depression behind the roof of the tongue) to prevent spillage to the pyriform sinuses (a recess on either side of the voice box) or trachea..." 2. "During treatment, education on the need for a modified diet reiterated to prevent risk of aspiration..." 3. "Safety awareness was ongoing during treatment due to patient's cognitive deficits." K. Review of R #92's current care plan revealed it did not include the compensatory techniques described by the ST to prevent aspiration/choking accidents. L. Review of the "Plan of Treatment" dated [DATE] through [DATE] revealed the following information under the heading for Clinical Narrative: "... He (R #92) does not consistently recognize his deficits and that his memory is not intact nor does he recognize that is (sic) deficits are problematic. Cognitive function impedes overall safety awareness, thought organization (sic), sequential planning, judgment/reasoning, and functional problem solving." M. An interview with the Speech Therapist (ST #2) on [DATE] at 9:50 am confirmed that she was the therapist that had worked with R #92 relative to his cognition deficit and his swallowing difficulties. ST #2 confirmed that R #92 was not able to make his own decisions of daily care because his "cognitive function impedes his overall safety awareness." N. An interview with the DON on [DATE] at 9:30 am confirmed that the facility had failed to care plan R #92's non-compliance with diet and behaviors so as to prevent choking accidents. When the staff failed to develop the non-compliance care plan, staff were uninformed of how to intervene when R #92 exhibited behaviors in the dining room which placed R #92 at risk for accidents.

Based on interview and record review, the facility failed to provide each resident with the care and services required to ensure that they did not experience intolerable pain on a daily basis for one (R #125) of one sampled residents for pain. This deficient practice possibly led to R #125 having moderate to severe constant pain daily. The findings are: A. During an interview with R #125 on 06/09/14 at 11:00 am revealed that she was in constant pain. She stated that she had a radical [PROCEDURE] a few years prior and now she [MEDICAL CONDITION] in her lymph nodes. R #125 stated that her arms and back hurt constantly and the facility had not provided her with pain interventions that were effective. B. Review of the clinical record for R #125 revealed that she was admitted to this facility on 03/21/14 with [DIAGNOSES REDACTED]. C. During an interview with a Licensed Practical Nurse (LPN #5) on 06/12/14 at 9:30 am confirmed that she was assigned to R #125 for her nursing needs. LPN #5 stated that R #125 constantly complained of pain and requested medication routinely. D. During an interview with a Certified Nursing Assistant (CNA #1) on 06/12/14 at 9:40 am confirmed that she was assigned to R #125 for her activities of daily living needs. CNA #1 stated that R #125 complained everyday of pain in her arm and back. E. During an interview with the Advanced Registered Nurse Practitioner (ARNP) on 06/12/14 at 9:45 am confirmed that R #125 [MEDICAL CONDITION] and complained of constant pain. The ARNP stated that she ordered 50 milligrams (mg) of [MEDICATION NAME] every six hours for pain, but R #125 requested something stronger, like [MEDICATION NAME], because the [MEDICATION NAME] was ineffective. The ARNP stated that she would not order a more potent pain medication for R #125 because she did not want her to become addicted. The ARNP added that R #125 had pain in her arm and back due to swelling of her lymph nodes. F. Review of the Medication Administration Record [REDACTED]. Per the MAR, R #125 was given Tylenol on 06/03/14, 06/04/14, 06/08/14, and on 06/10/14 for pain, however, there was no written documentation relative to the effectiveness of the pain medication. G. Review of the "Pain Assessment" sheet dated June 2014 revealed that staff were to: "Check resident for level of pain utilizing numeric rating scale 0-10 = or verbal description three times daily." M= Mild MO=Moderate S= Severe VS = Very Severe H. Review of the "Pain Assessment" documentation dated June 2014 revealed that for twelve days in the month from 06/01/14 through 06/12/14, R #125 had experienced pain routinely. Staff documented that R #125 had experienced mild to severe pain. I. During an interview with LPN #5 on 06/12/14 at 9:30 am, revealed that R #125 experienced mild to moderate pain on a daily basis and it was the facility's policy to provide the pain medication and then document the effectiveness on the reverse side of the MAR indicated [REDACTED]. J. Review of the reverse side of the June 2014 MAR indicated [REDACTED]. K. An interview with the Director of Nurses (DON) and the Medical Director (MD and R#125's attending physician) on 06/12/14 at 10:00 am confirmed that R #125 had complained of constant pain; however, they would not prescribe a stronger medication because they did not want her to become drug dependent. When interviewed about what non-pharmacological interventions were provided to help alleviate R #125's pain, the DON and the MD were unsure. When interviewed about why the facility did not document the effectiveness of R# 125's pain medications to ensure that her pain had been relieved, the DON and the MD were unsure. L. Review of the "Pain - Clinical Protocol" dated April 2007 revealed the following information: 1. "The physician and staff will identify individuals who have pain or who are at risk for having pain." 2. "The staff and physician will identify the nature and severity of pain including characteristics." 3. "The staff and physician will also evaluate how pain is affecting mood, activities of daily living, sleep and selected quality of life measures, including deconditioning, gait disturbances, social isolation and falls." 4. "The staff will evaluate and report how much and how often the individual requested for pain medications." 5. "Staff will provide the elements of a comforting environment and appropriate physical and complementary interventions; like heat or ice, repositioning, massage, and the opportunity to talk about chronic pain." 6. "Staff will reassess the individual's pain and consequences of pain at regular intervals." 7. "Periodically the physician will evaluate and summarize the status of an individual with chronic or fluctuating pain including active conditions that exacerbate pain, consequences or complications of pain, and effectiveness of current interventions for pain." 8. "If the resident's pain is complex or not responding to standard interventions, the Attending Physician may consider a psychiatric evaluation or referral to a pain clinic or specialist." M. Review of the pain care plan dated 03/26/14 for R #125 revealed that she had made statements of pain to the facility. The approaches included: 1. "Pain assessment per protocol" 2. "Identify location and rate of pain prior to and after any interventions Attempt to document effectiveness of non-pharmacological interventions as appropriate." 3. "Adjust daily routine as necessary to aid in pain relief." 4. "Report unrelieved or unacceptable levels of pain to MD as needed." N. Review of the admission Minimum Data Set ((MDS) dated [DATE] revealed that R #125 had a Brief Interview for Mental Status (BIMS) of 15 which indicated that she had no cognitive impairment. In Section "J" of the MDS assessment the resident was coded as having pain frequently and on a scale from 0-10 her pain was coded a "3." O. An interview with the DON and the MD on 06/12/14 at 10:00 am revealed that the facility had failed to follow their Pain - Clinical Protocol and R #125's care plan when they did not: 1) re-evaluate R# 125's pain and make the appropriate referrals, 2) revise the pain schedule, 3) offer non-pharmacological interventions,4) identify the nature of the pain and 5) identify the location and rate of pain prior to and after any interventions. P. The facility failed to document when R #125 received pain medications and they failed to document the effectiveness of her pain medications, consequently they were unable to make the appropriate interventions to ensure that she could manage her frequent pain.

Based on record review and interview, the facility failed to document when one resident received pain medications and they failed to document the effectiveness of her pain medications; consequently the facility failed to determine the appropriate interventions to ensure that the resident could manage her frequent pain for one (R #125) of one sampled residents for pain. This deficient practice possibly led to R #125 having moderate to severe constant pain daily. The findings are: A. During an interview with R #125 on 06/09/14 at 11:00 am revealed that she was in constant pain. She stated that she had a radical [PROCEDURE] a few years prior and now she [MEDICAL CONDITION] in her lymph nodes. R #125 stated that her arms and back hurt constantly and the facility had not provided her with pain interventions that were effective. B. Review of the clinical record for R #125 revealed that she was admitted to this facility on 03/21/14 with [DIAGNOSES REDACTED]. C. During an interview with a Licensed Practical Nurse (LPN #5) on 06/12/14 at 9:30 am confirmed that she was assigned to R #125 for her nursing needs. LPN #5 stated that R #125 constantly complained of pain and requested medication routinely. D. During an interview with a Certified Nursing Assistant (CNA #1) on 06/12/14 at 9:40 am confirmed that she was assigned to R #125 for her activities of daily living needs. CNA #1 stated that R #125 complained everyday of pain in her arm and back. E. During an interview with the Advanced Registered Nurse Practitioner (ARNP) on 06/12/14 at 9:45 am confirmed that R #125 [MEDICAL CONDITION] and complained of constant pain. The ARNP stated that she ordered 50 milligrams (mg) of [MEDICATION NAME] every six hours for pain, but R #125 requested something stronger, like [MEDICATION NAME], because the [MEDICATION NAME] was ineffective. The ARNP stated that she would not order a more potent pain medication for R #125 because she did not want her to become addicted. The ARNP added that R #125 had pain in her arm and back due to swelling of her lymph nodes. F. Review of the Medication Administration Record [REDACTED]. Per the MAR, R #125 was given Tylenol on 06/03/14, 06/04/14, 06/08/14, and on 06/10/14 for pain, however, there was no written documentation relative to the effectiveness of the pain medication. G. Review of the "Pain Assessment" sheet dated June 2014 revealed that staff were to: "Check resident for level of pain utilizing numeric rating scale 0-10 = or verbal description three times daily." M= Mild MO=Moderate S= Severe VS = Very Severe H. Review of the "Pain Assessment" documentation dated June 2014 revealed that for twelve days in the month from 06/01/14 through 06/12/14, R #125 had experienced pain routinely. Staff documented that R #125 had experienced mild to severe pain. I. During an interview with LPN #5 on 06/12/14 at 9:30 am, revealed that R #125 experienced mild to moderate pain on a daily basis and it was the facility's policy to provide the pain medication and then document the effectiveness on the reverse side of the MAR indicated [REDACTED]. J. Review of the reverse side of the June 2014 MAR indicated [REDACTED]. K. An interview with the Director of Nurses (DON) and the Medical Director (MD and R#125's attending physician) on 06/12/14 at 10:00 am confirmed that R #125 had complained of constant pain; however, they would not prescribe a stronger medication because they did not want her to become drug dependent. When interviewed about what non-pharmacological interventions were provided to help alleviate R #125's pain, the DON and the MD were unsure. When interviewed about why the facility did not document the effectiveness of R #125's pain medications to ensure that her pain had been relieved, the DON and the MD were unsure. L. Review of the "Pain - Clinical Protocol" dated April 2007 revealed the following information: 1. "The physician and staff will identify individuals who have pain or who are at risk for having pain." 2. "The staff and physician will identify the nature and severity of pain including characteristics." 3. "The staff and physician will also evaluate how pain is affecting mood, activities of daily living, sleep and selected quality of life measures, including deconditioning, gait disturbances, social isolation and falls." 4. "The staff will evaluate and report how much and how often the individual requested for pain medications." 5. "Staff will provide the elements of a comforting environment and appropriate physical and complementary interventions; like heat or ice, repositioning, massage, and the opportunity to talk about chronic pain." 6. "Staff will reassess the individual's pain and consequences of pain at regular intervals." 7. "Periodically the physician will evaluate and summarize the status of an individual with chronic or fluctuating pain including active conditions that exacerbate pain, consequences or complications of pain, and effectiveness of current interventions for pain." 8. "If the resident's pain is complex or not responding to standard interventions, the Attending Physician may consider a psychiatric evaluation or referral to a pain clinic or specialist." M. Review of the pain care plan dated 03/26/14 for R #125 revealed that she had made statements of pain to the facility. The approaches included: 1. "Pain assessment per protocol" 2. "Identify location and rate of pain prior to and after any interventions Attempt to document effectiveness of non-pharmacological interventions as appropriate." 3. "Adjust daily routine as necessary to aid in pain relief." 4. "Report unrelieved or unacceptable levels of pain to MD as needed." N. Review of the admission Minimum Data Set ((MDS) dated [DATE] revealed that R #125 had a Brief Interview for Mental Status (BIMS) of 15 which indicated that she had no cognitive impairment. In Section "J" of the MDS assessment the resident was coded as having pain frequently and on a scale from 0-10 her pain was coded a "3." O. An interview with the DON and the MD on 06/12/14 at 10:00 am revealed that the facility had failed to follow their Pain - Clinical Protocol and R #125's care plan when they did not: 1) re-evaluate R #125's pain and make the appropriate referrals, 2) revise the pain schedule, 3) offer non-pharmacological interventions,4) identify the nature of the pain and 5) identify the location and rate of pain prior to and after any interventions.