Every finding on record at Casa Maria Healthcare

Based on observation, record review, and interview, the facility failed to maintain an effective pest control program. This deficient practice has the potential to affect all 99 residents as identified by the census provided by the admission Coordinator (AC) on 08/14/26. If the facility fails to maintain an effective pest control program, then residents are at risk of increased health concerns and may cause them to feel distress or embarrassment. The findings are:A. Record review of the facility's Pest Control policy, dated 08/2020, revealed the following:1. The facility maintained an ongoing pest control program to ensure the building and grounds were kept free of insects, rodents, and other pests.2. Facility staff were to report any sign of rodents or insects in the facility.3. The Supervisor was to take immediate action to remove the pests from the facility.4. If necessary, the Supervisor will notify the administrator and call the extermination company for assistance. B. Record review of the facility's Maintenance Work Orders policy, dated August 2020, revealed facility staff were to fill out work order forms and submit them to the Maintenance Director. Staff were to deliver emergency maintenance requests directly to the Maintenance Director. C. Record review of the facility's The Equipment Lifecycle System (TELS, a building management platform that helps maintenance staff with facility maintenance, life safety code inspection and testing, and asset management) report revealed the following:1. Dated 05/27/26, ants and a mouse were reported in resident room [ROOM NUMBER]. The report did not indicate who reported ants and mouse.2. Dated 06/04/26, a mouse was reported in resident room [ROOM NUMBER]. The report did not indicate who reported the mouse. 3. Dated 06/18/26, ants were reported in resident room [ROOM NUMBER]. The report did not indicate who reported the ants. 4. Dated 07/16/26, a rodent was reported in resident room [ROOM NUMBER]. The report did not indicate who reported the rodent. D. Record review of the facility's extermination reports from a local company revealed the following:1. On 05/22/26, interior rodent service was performed where all rodent stations were cleared, and traps were reset as needed.2. On 06/24/26, exterior rodent service was performed where all bait stations were checked and replaced as needed.3. On 06/25/26, one room in the 100 Hall and two rooms in the 200 Hall were serviced due to pest activity. The report did not indicate which rooms in the 100 and 200 Halls were serviced. 4. On 07/30/26, interior rodent service was performed where all traps were checked and reset due to pest activity. E. On 08/14/26 at 9:35 am, during an interview and observation of R #1 in his room, revealed a black piece of tape about four inches long on the bottom of the wall, near the baseboard. R #1 stated the tape covered the area where mice entered the room and pointed toward it. R#1 stated he was unaware of how the hole formed or how long it had been there. R #1 stated having mice come from the hole made him feel embarrassed and dirty. R #1 stated someone from the facility, he could not remember who, covered the hole with the black tape when he reported it. F. On 08/14/26 at 11:53 am, during an interview and observation with the On-Site Administrator (OSADM; Administrator from sister facility sitting in for ADM) in R #1's room, the OSADM removed the tape on the wall and revealed a hole about three inches long behind the baseboard. The OSADM stated this did not meet her expectations because staff should have reported the hole to the maintenance department, and the maintenance department should have repaired the wall. G. On 08/14/26 at 1:10 pm, during an interview, the Regional Maintenance Director (RMD; regional corporate staff sitting in for the Maintenance Director) stated the pest extermination company treated the facility once monthly and should have been called each time staff reported evidence of pests or rodents. The RMD stated the Maintenance Director should have been notified immediately of signs of pests or rodents. The RMD stated the Maintenance Director should have contacted the pest extermination company to treat the affected area. The RMD stated the Maintenance Director failed to contact the pest extermination company each time signs of pests or rodents were reported. The RMD stated he was not aware of the hole in R #1's room and he expected the hole to be repaired, not taped over. The RMD stated staff in every building, including this one, were trained to report any environmental issues to the maintenance department.

Based on observation, interview, and record review, the facility failed to provide a safe and homelike environment for all residents on the 200 Hall by allowing a black liquid with a strong, foul odor to overflow from the shower drains in the resident bathroom and rooms. If the facility fails to maintain a safe and homelike environment, then the residents are likely to feel uncomfortable, and existing health issues could worsen.The findings are:A. Record review of the facility's Resident Rooms and Environment policy, dated August 2020, revealed the facility staff were to create a personalized, homelike atmosphere by paying close attention to cleanliness and pleasant, neutral scents. B. Record review of the facility's Maintenance Work Orders policy, dated August 2020, revealed the facility staff were to fill out work order forms and submit them to the Maintenance Director. Staff were to deliver emergency maintenance requests directly to the Maintenance Director. C. On 08/14/26 at 9:30 am, an observation of resident rooms 201, 203, 205, 207, 209, 211, 213, and 215 revealed a large amount of foul-smelling black liquid overflowing from the shower drains onto the restroom and bedroom floors. D. On 08/14/26 at 9:30 am, during an interview, Certified Nurse Aide (CNA) #1 stated she consistently worked on the 200 Hall. She stated the pipes had been flooding for months and plumbers had been in the building frequently. She stated facility staff were expected to complete work orders when issues occurred in the facility, and the maintenance department addressed the issues from there. E. On 08/14/26 at 9:35 am, during an interview, R #1 stated his room always smelled like a sewer. F. On 08/14/26 at 9:41 am, during an interview, R #4 and her Power of Attorney (POA; legal authorization for a designated person to make decisions about another person's property, finances, or medical care) stated the facility had plumbing issues since R #4 was admitted two weeks earlier. R #4's POA stated the facility constantly has a strong sewer smell. G. On 08/14/26 at 10:03 am, during an interview, R #6 stated he knew there were plumbing issues in the building because the shower was clogged a few days earlier. R #6 stated he could not remember the date this occurred and he still received a shower, so it did not affect him. R #6 stated he does not like the smell. H. On 08/14/26 at 11:13 am, during an interview, CNA #2 stated the smell in the building had never been as bad as it was on the date of interview. She stated she was worried for the residents whose health may be affected long term by breathing the foul odor. I. On 08/14/26 at 1:10 pm, during an interview, the Regional Maintenance Director (RMD) stated the building had experienced plumbing issues for the previous two weeks, and the problem had worsened. He stated he expected facility staff to notify the Maintenance Director by completing work orders. He stated, depending on the nature of the issue, the Maintenance Director was responsible for taking necessary action, such as calling a plumber or contacting his supervisor for assistance. J. On 08/14/26 at 1:20 pm, during an interview, the Director of Nursing (DON) stated it was not safe for residents to smell and breathe the foul odor coming from the black liquid overflowing from the shower drains. He stated the building had plumbing issues on 08/13/26 but not to this level. He stated the nursing staff had been trained on how to report issues and should have notified him of foul-smelling black liquid as soon as it became an issue. He stated he expects the residents in the building to live in a safe and homelike environment.

Based on observation, record review, and interviews, the facility failed to complete a physician ordered referral to an orthopedic specialist for post fall follow up care for 1 (R #1) of 3 (R #1, R #2, and R #3) residents reviewed. This deficient practice could result in a delay in evaluation and treatment for possible injuries. The findings are: A. Record review of the facility's Resident Care and Services policy, dated 01/2026, revealed the following:1. Residents are provided with the necessary care and services to maintain the highest practicable physical, mental, and social well-being in an environment that enhances quality of life in the scope of a long-term care facility. Care and services are provided in a manner that consistently enhances self-esteem and self-worth.2. Residents will be informed about medical treatments and have the right to refuse care. B. Record review of R #1's Face Sheet revealed she was admitted to the facility on [DATE] with the following diagnoses:1. History of falling,2. Osteoporosis (bones become extremely porous and are subject to fracture and slow healing),3. Difficulty in walking. C. Record review of R #1's annual Minimum Data Set (MDS; a federally mandated assessment instrument completed by facility staff), dated 05/13/26, revealed the following:1. A Brief Interview for Mental Status (BIMS; a screening for cognitive impairment) score of 14, cognitively intact.2. R #1 required supervision or touching assistance (helper provides verbal cues and/or touching/steadying and/or contact guard assistance as the resident completed the activity). D. Record review of R #1's Progress Notes revealed the following:1. Dated 05/12/26:- R #1 sustained a fall in the restroom while taking a shower. She slipped between the shower wall and the toilet and fell back onto the toilet seat. She did not inform nursing of the fall, because she was not injured and did not feel the need to report it.- R #1 reported left shoulder pain later the same evening to the nurse on duty. R #1 informed the nurse she slipped in the shower and fell back onto the toilet seat. R #1 did not hurt herself and did not think she needed to tell anyone.- The nurse on duty assessed R #1's pain at 2 out of 10 (one to ten pain scale; 0 means no pain and 10 represents the worst pain imaginable).- The nurse on duty notified the provider and the nurse manager that R #1 had an unwitnessed fall. The provider instructed staff to monitor according to facility protocol, notify the provider of any changes in patient's condition, and to ensure all safety measures were in place.- The nurse on duty administered 650 milligrams (mg) of acetaminophen (oral pain medication) for R #1's generalized discomfort.2. Dated 05/13/26, R #1 obtained a mobile x-ray (portable imaging system designed to bring X-ray capabilities directly to the patient's location) ordered for shoulder pain.3. Dated 05/14/26, R #1 was seen by a provider for a follow-up on her shoulder pain from a fall on 05/12/26. New orders were not issued.4. Dated 05/14/26, R #1's x-ray results revealed a left closed nondisplaced fracture of the surgical neck of left humerus (a break/crack in the upper left arm). Orders for R #1 to wear her arm in a sling for four weeks, non-weight bearing, and a referral to an orthopedic provider. E. Record review of R #1's Radiology Report, dated 05/14/26, revealed the x-ray was unable to determine if the fracture was recent or an old fracture. F. Record review of R #1's Physician Orders, dated 05/14/26, revealed an order for R #1 to be referred to an orthopedic specialist for her left shoulder. G. Record review of the facility's Referral Log, not dated, revealed there was not any documentation indicating staff scheduled or completed R #1's orthopedic referral. H. On 06/25/26 at 10:00 am, during an observation and interview, R #1 stated her left shoulder hurt a little. She stated she did not see an orthopedic specialist. R #1 stated her pain was a 2 out of 10 on the pain scale. R #1 grimaced when she touched her shoulder to indicate where her pain was. R #1 stated she wanted to talk to the orthopedic specialist to see if surgery was an option, but she did not hear anything from the facility about an appointment being scheduled. I. On 06/25/26 at 1:15 pm, during an interview, Medical Records (MR) stated she was responsible for making all resident appointments in the facility. The MR stated a provider made a referral to the nursing staff. She stated the nursing staff were supposed to bring the referral to her, so she could track the referral and make the appointment. The MR stated the nursing staff did not inform her about R #1's referral to an orthopedic specialist, so she did not make the appointment. J. On 06/25/26 at 1:26 pm, during an interview, the Director of Nursing (DON) stated he was not aware of R #1's referral to an orthopedic specialist, because he was new to the building. The DON stated there was not any evidence staff completed the orthopedic referral. The DON stated this did not meet his expectations, because all referral appointments should be started as soon as the nursing staff receive the referral. He stated it was expected for the nursing staff to pass it on to Medical Records, so Medical Records could schedule the appointment within one or two business days.

Based on interview and record review, the facility failed to prevent misappropriation of resident money when a payment app account was used by a staff member for 1 (R #1) of 4 (R #1, R #2, R #3 and R #4) residents reviewed for exploitation (the fact of making use of a situation to gain unfair advantage for oneself). This deficient practice is likely to cause residents to feel unsafe, and experience anger and frustration. The findings are:A. Record review of R #1's admission Record revealed she was admitted to the facility on [DATE] with the following diagnoses:1. Hypertrophic cardiomyopathy (heart disease),2. Non-ST Elevated (NSTEMI) Myocardial Infarction (a typer of heart attack),3. Type 2 diabetes mellitus (DM2, a condition that results from insufficient production of insulin, causing high blood sugar),4. Gastroesophageal reflux disease (GERD; A digestive disease in which stomach acid or bile irritates the food pipe lining),5. Cognitive communication deficit (impairments to cognitive functions).B. Record review of R #1's Minimum Data Set (MDS; a federally mandated assessment instrument completed by facility staff) dated 12/19/25, revealed a Brief Interview for Mental Status (BIMS; a screening for cognitive impairment) score of 11, moderately impaired.C. Record review of the facility's Initial Incident Report dated 01/19/26 revealed R #1 reported to the facility that Certified Nurse Aide (CNA) 1 took R #1's phone without R #1's knowledge and transferred $100.00 to CNA #1's account without R #1's permission. D. Record review of the facility's Investigative Narrative Report (report of the facility's investigation and findings) dated 01/19/26 revealed the following:1. $100.00 was withdrawn from R #1's payment app account on 12/16/25.2. CNA #1 used R #1's phone to transfer $100.00 to CNA #1's personal payment app account.3. The allegation of exploitation against CNA #1 is substantiated.E. On 02/05/26 at 3:00 pm during an interview with R #1, she stated that her phone had been used by CNA #1 to transfer $100.00 from her personal payment app account to CNA #1's account. R #1 stated that she did not know CNA #1 used her phone because she never gave CNA #1 permission to use it. R #1 stated she realized the money was missing when she received her bank statement in January 2026. R #1 stated that she was happy to get the money back and chose not to file charges.F. On 02/05/26 at 3:40 pm during an interview with Administrator (ADM), he stated that R #1's son contacted the facility claiming that CNA #1 transferred $100.00 of R #1's money to CNA #1's personal account. The ADM stated the investigation that he conducted did confirm the allegation of exploitation which led him to file a police report and terminate CNA #1's employment.

Based on observation and interview, the facility failed to post nurse staffing data daily at the beginning of the shift that included the following: 1. Facility name. 2. The current date. 3. The total number and the actual hours worked by the following categories of licensed and unlicensed nursing staff directly responsible for resident care per shift: -Registered nurses. -Licensed practical nurses. -Certified nurse aides. -Resident census. This deficient practice has the potential to affect all 96 residents as identified by the census provided by the Admissions Coordinator (Admit) on 12/14/25 and could likely result in residents and visitors not having the staffing information readily available. The findings are:and visitors not having the staffing information readily available. The findings are:A. On 12/14/25 at 12:15 pm a random observation of the facility revealed the facility's staff data posting was dated 12/11/25.B. On 12/14/25 at 12:32 pm, during an interview with the Admit, she confirmed the staff data posting was for 12/11/25 and had not been updated daily.

Based on observation and interview, the facility failed to ensure safe medication storage practices by not ensuring the medical supply storage rooms were kept free of expired medications.This deficient practice has the potential to affect all 96 residents as identified by the census provided by the Administrator on 12/14/25. If the facility does not ensure safe storage practices, then residents are at risk for adverse effects due to improper storage. The findings are: A. On 12/18/25 at 10:05 am during an observation of the medical storage, the refrigerator in the storage room revealed the following: 1. One Novolog Mix 70/30 Flex Pen (a pre-filled, disposable insulin pen that combines 70% intermediate-acting insulin aspart protamine and 30% rapid-acting insulin aspart). Expiration date: 03/31/242. Three Novolog Mix 70/30 Flex Pens. Expiration date: 06/30/25.B. On 12/19/25 at 10:07 am during an interview with Licensed Practical Nurse (LPN) #3, she confirmed the pens were expired and should be properly disposed.

Based on observation, record review, and interview, the facility failed to conduct regular inspections of all bed frames, mattresses, and bed rails as part of a regular maintenance program to identify areas of possible entrapment 13 (R #2, R #4, R #5, R #6, R #10, R #12, R #13, R #19, R #54, R #55, R #63, R #84, and R #88) of 13 (R #2, R #4, R #5, R #6, R #10, R #12, R #13, R #19, R #54, R #55, R #63, R #84, and R #88). This deficient practice could likely result in serious injury or death if residents become trapped between the mattress, side rail, footboard and headboard. The findings are: Cross reference findings for 700A. On 12/16/25 at 2:07 pm during an interview with the Director of Nursing (DON) and Administrator (ADMIN), they stated bed evaluations, assessments and regular maintenance should be completed for all residents' beds and they have not been done. They stated this does not meet their expectations for safety.

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) unless the medication was medically necessary for 2 (R #2 and R #4) of 3 (R #2, R #4 and R #54) residents reviewed for unnecessary medications, when staff failed to: 1. Ensure psychotropic medications were necessary to treat a specific condition as diagnosed and documented in the clinical record for R #2 and R #4, 2. Ensure as needed psychotropic medications are limited to only 14 days or indicate the duration of the as needed (PRN) order for R #2. These deficient practices could likely lead to adverse drug effects and poor patient outcomes. The findings are:R #2A. Record review of R #2's admission record revealed she was admitted into the facility on [DATE] with the following diagnoses:1. Insomnia (a common sleep disorder making it hard to fall asleep, stay asleep),2. Major depressive disorder (a mental health disorder characterized by persistently depressed mood or loss of interest in activities, causing significant impairment in daily life),3. Psychotic Disorder (a severe mental illness causing a loss of touch with reality). B. Record review of R #2's physician orders revealed an order for Lorazepam (anti-anxiety medication) Oral Tablet 0.5 milligrams (MG). Give 1 tablet by mouth every 4 hours as needed for anxiety, restlessness. Start Date: 11/11/25. C. Record review of R #2's monthly Medication Administration Record (MAR) for December 2025 revealed R #2 was administered Lorazepam on the following days:1. 12/06/25 at 3:00 am2. 12/06/25 at 9:10 am3. 12/10/25 at 9:52 pm4. 12/13/25 at 7:33 amR #4D. Record review of R #4's admission record revealed she was admitted into the facility on [DATE] with the following diagnoses: 1. Schizophrenia (a disorder that affects an individual's ability to think, feel, and behave clearly),2. Dementia (a group of conditions characterized by impairment of at least two brain functions, such as memory loss and judgment),3. Parkinsonism (a general term for movement disorders sharing symptoms with Parkinson's disease),4. Major Depressive Disorder (a mental health disorder characterized by persistently depressed mood or loss of interest in activities, causing significant impairment in daily life),5. Anxiety Disorder (mental health conditions causing intense, excessive, and persistent fear or worry that significantly interferes with daily life). E. Record review of R #4's physician orders revealed the following:1. Olanzapine Oral Tablet 10 milligrams (MG). Give 1 tablet by mouth two times a day for mood. Start date 03/27/24.2. Trazadone hydrochloride (HCl: antidepressant medication) Oral Tablet. Give 75 mg by mouth at bedtime for Insomnia. Start date 04/21/25. F. Record review of R #4's monthly Medication Administration Record (MAR) for December 2025 revealed: 1. R #4 was administered Olanzapine two times daily from 12/01/25-12/15/25.2. R #4 was administered Trazadone daily from 12/01/25-12/15/25. G. On 12/18/25 at 12:10 pm, during an interview with the Director of Nursing (DON), she confirmed the following:1. R #2 has an active order for Lorazepam for anxiety. This order is not limited to 14 days nor does it indicate the duration of the PRN order. 2. R #2 does not have a diagnosis of anxiety. 3. R #4 has an active order for Olanzapine however mood is not an appropriate indication of use. 4. R #4 has an active order for Trazadone for insomnia. 5. R #4 does not have a diagnosis of insomnia. The DON stated this does not meet her expectation. Medications should have an appropriate indication of use related to the residents' diagnosis. PRN psychotropics should indicate the duration or be limited to 14 days.

Based on observation, record review, and interview, the facility failed to create an accurate and complete baseline care plan (minimum healthcare information necessary to properly care for a resident immediately upon their admission to the facility) within 48 hours of admission for 4 (R #7, R #15, R #79, R #106) of 6 (R #7, R #8, R #15, R #35, R #79, and R #106) residents reviewed for care plans. This deficient practice could likely result in residents not receiving the appropriate care and may place residents at risk of an adverse event (undesirable experience, preventable or non-preventable, that caused harm to a resident because of medical care or lack of medical care) or worsening of current condition after admission. The findings are:R #15A. Record review of R #15's admission Record revealed she was admitted to the facility on [DATE] with the following diagnoses:1. Unspecified nondisplaced fracture (break) of surgical neck of left humerus (bone of the upper arm, forming a joint at the shoulder and elbow),2. Unspecified fracture of the lower end of right radius, (one of two larger bones in forearm),3. Depression (a mood disorder that causes a persistent feeling of sadness and loss of interest),4. Anxiety (feelings of fear or apprehension).B. Record review of R #15's Baseline Care Plan dated 05/10/25 revealed that staff failed to complete and sign the document until 05/17/25, missing the 48-hour deadline.C. On 12/18/25 at 12:00 pm during an interview with the DON, she confirmed R #15's Baseline Care Plan does not meet her expectations because it was completed thirteen days after admission. R #79D. Record review of R #79's admission Record revealed she was admitted to the facility on [DATE] with the following diagnoses:1. Unspecified fracture (break) of sacrum (a large flat bone in the lower part of the spine, forming the rear section of the pelvis),2. Essential (primary) hypertension (HTN; high blood pressure),3. Osteoarthritis (chronic degeneration of the joint cartilage),4. Retention of urine (condition where the bladder does not empty completely, leading to difficulty in urinating and potential health complications).E. Record review of R #79's Baseline Care Plan 11/26/25 revealed it was marked completed on 11/26/25 and was signed by the last author (activity director) on 12/09/25, missing the 48-hour deadline.F. On 12/18/25 at 12:00 pm during an interview with the DON, she confirmed R #79's Baseline Care Plan does not meet her expectations because it was completed eighteen days after admission.R #106G. Record review of R #106's admission Record revealed he was admitted to the facility on [DATE] with the following diagnoses:1. Displaced intertrochanteric fracture of right femur (hip fracture that occurs between the two bony protrusions at the top of the thigh bone),2. Chronic respiratory failure with hypoxia (low levels of oxygen in the body tissues),3. Collapsed vertebra(small bones forming the back bone), lumbar (lower part of the spine) region,4. Wedge compression fracture of T11-T12 vertebra (a break in a backbone that collapse on one side resulting in a wedge shape),5. Gastrostomy (a surgical opening into the stomach through the outer wall of the abdomen) status,6. Personal history of antineoplastic (inhibit or prevent the growth and spread of tumors or malignant cells) chemotherapy (chemical substance used to treat cancer) and irradiation (expose to radiation),7. Long term (current) use of anticoagulants (blood thinner).H. On 12/14/25 at 2:20 pm, during an interview and observation with R #106 in his room, R #106 had a feeding pump (medical device used to deliver liquid nutrition) connected through a tube in his abdomen. R #106 stated he has had a feeding tube since he had cancer eight years ago. I. Record review of Minimum Data Set (MDS; a federally mandated assessment instrument completed by facility staff) dated 12/15/25:1. Section J: Current Tobacco Use answer is yes,2. Section N: Medications, Anticoagulant use is currently taking.J. Record review of R #106's Baseline Care Plan dated 12/12/25 revealed the following:1. The Nursing Services section (Bb of section one) does not indicate that R #106 is a current smoker. 2. The Nursing Services section (Cc of section one) does not indicate that R #106 currently takes an anticoagulant. 3. The nutritional services section (section four) does not contain any information.K. On 12/18/25 at 12:00 pm during an interview with the DON, she stated R #106's Baseline Care Plan does not meet her expectations because it should indicate that he is a current smoker, he currently takes an anticoagulant and uses a feeding tube, but it does not.

Based on observation, record review, and interview, the facility failed to ensure staff revised the care plan for 4 (R #2, R #5, R #54, and R #55) of 4 (R #2, R #5, R #54, and R #55) residents reviewed when staff failed to:Revise care plans for R #2 and R #55 for the use of bed rails,Revise care plan for R #5's dependence on staff for bed mobility,Revise care plan to include interventions for bed rail usage for R #54. These deficient practices are likely to result in residents' care and needs not being addressed if care plans are not updated. The findings are: R#2A. Record review of R #2's admission record revealed R #2 was admitted to the facility on [DATE] with the following diagnoses: 1. Morbid obesity (severe degree of being overweight and a significant health concern),2. Muscle weakness (when your muscles cannot work as hard as they should),3. Lack of coordination (difficulty in making controlled purposeful movements),4. Need for assistance with personal care. B. Record review of R #2 care plan revised on 11/11/25 revealed no interventions for the use of bed rails. C. Record review of R #2's Electronic Health Record (EHR), reveals there are no current orders for the use of bedrails. D. On 12/14/25 at 3:49 pm during a random observation of R #2's room revealed quarter size bed rails on the upper left and right sides of the bed. E. On 12/14/25 at 3:50 pm during an interview with R#2, she confirmed she uses the bed rails for positioning and mobility. R#5 F. Record review of R #5's admission record revealed R #5 was admitted into the facility on [DATE] with the following diagnoses:1.Esophagitis, unspecified without bleeding (inflammation of the food pipe where specific cause isn't identified),2. Anxiety Disorder (mental health conditions that cause fear, dread and other symptoms that are out of proportion to the situation),3. Anemia in Chronic kidney disease (complication where kidneys produce less hormones in producing red blood cells leading to fatigue, paleness),4. Muscle weakness, 5. End of stage renal disease (kidneys are severely damaged and can't filter waste effectively),6. Unspecified Systolic (congestive) heart failure (heart can't pump out enough blood throughout the body),7. Fatty liver not elsewhere classified (fat buildup in the liver).G. On 12/15/25 at 9:55 am during an observation of R #5 revealed R #5 was unable to turn and reposition without assistance, quarter size bed rails were noted on both sides of the bed.H. Record review of R #5's Minimum Data Set (MDS) federally mandated clinical assessment tool used in nursing homes to gather demographic and clinical information about residents) dated 12/02/25 revealed R #5 is dependent on staff for bed mobility rolling from left to right. I. Record review of R #5's care plan dated 06/3/24 revealed R #5 can turn and reposition himself in bed without assistance.J. On 12/18/25 at 4:47 pm during an interview with the Director of Nursing (DON), she confirmed R #5's care plan should have been revised to reflect that resident is dependent on staff for repositioning and should have been added to care plan. R #54K. Record review of R #54 admission record revealed she was admitted into the facility on [DATE] with the following diagnoses: 1. Major Depressive Disorder (a mental health disorder characterized by persistently depressed mood or loss of interest in activities, causing significant impairment in daily life),2. Insomnia (a common sleep disorder making it hard to fall asleep, stay asleep),3. Anxiety Disorder (mental health conditions causing intense, excessive, and persistent fear or worry that significantly interferes with daily life),4. Hyperlipidemia (a condition in which there are high levels of fat particles in the blood; high cholesterol),5. Heart failure (impaired heart function). L. Record review of R #54 physician orders revealed an order for quarter size bed rails used for mobility and transfers. Start date 01/09/23. M. Record review of R #54 care plan revised on 11/11/25 revealed no interventions for the use of bed rails. N. On 12/14/25 at 3:55pm during a random observation of R #54's room revealed quarter size bed rails on the upper left and right sides of the bed. O. On 12/15/25 at 10:34 am during an interview with R #54's representative, she confirmed she uses the bed rails for positioning and mobility. P. On 12/17/25 at 1:37pm during an interview with the DON, she confirmed R #54's care plan was not revised to include the use of bed rails and should have been. R #55Q. Record review of R #55's admission record revealed R #55 was admitted into the facility on [DATE] with the following diagnoses:1.History of falling,2. Lack of Coordination, 3. Hyperlipidemia, unspecified (high levels of fat in the blood),4. Depression (a mood disorder that causes a persistent feeling of sadness and loss of interest),5. Need for assistance with personal care,6. Chronic Systolic R (congestive) heart failure (heart can't pump out enough blood throughout the body).R. On 12/14/25 at 4:13 pm during a random observation of R #55's room revealed bed rails were in use for R #55.S. Record review of R #55's care plan dated 12/17/25 revealed use of 1/4 bed rails used for bed mobility and transfers.T. On 12/18/25 at 4:48 pm, during an interview with the DON, she confirmed R #55's care plan was not revised prior to 12/17/25 indicating the use of bed rails for bed mobility.

Based on observation, record review, and interview, the facility failed to ensure residents were assessed for risk of entrapment (state of being stuck or caught on bed rail) in bed rails for 13 (R #2, R #4, R #5, R #6, R #10, R #12, R #13, R #19, R #54, R #55, R #63, R #84, and R #88) of 13 (R #2, R #4, R #5, R #6, R #10, R #12, R #13, R #19, R #54, R #55, R #63, R #84, and R #88) residents reviewed for accidents. This deficient practice has the potential to cause serious injury by becoming trapped between the mattress and bed rail. The findings are: R#2A. Record review of R #2's admission record revealed R #2 was admitted to the facility on [DATE] with the following diagnoses: 1. Morbid obesity (severely overweight),2. Muscle weakness (reduction in the power exerted by muscles),3. Lack of coordination,4. Need for assistance with personal care. B. On 12/14/25 at 3:49 pm during a random observation of R #2's room revealed quarter size bed rails on the upper left and right sides of the bed. C. Record review of R #2's care plan revised on 11/11/25 revealed no interventions for the use of bed rails. D. Record review of R #2's electronic health records revealed the following: 1. There were no physician orders for use of bed rails, 2. There were no assessments completed for R #2 to determine risk of entrapment,3. There were no consents for the use of bed rails prior to installation,4. Documentation of the bed's dimensions was appropriate for the resident's size and weight. E. On 12/14/25 at 3:50 pm during an interview with R #2, she confirmed she uses the bed rails for positioning and mobility. R #4F. Record review of R #4's admission record revealed she was admitted into the facility on [DATE] with the following diagnoses: 1. Schizophrenia (a disorder that affects an individual's ability to think, feel, and behave clearly),2. Dementia (a group of conditions characterized by impairment of at least two brain functions, such as memory loss and judgment),3. Parkinsonism (a general term for movement disorders sharing symptoms with Parkinson's disease),4. Major Depressive Disorder (a mental health disorder characterized by persistently depressed mood or loss of interest in activities, causing significant impairment in daily life),5. Anxiety Disorder (mental health conditions causing intense, excessive, and persistent fear or worry that significantly interferes with daily life). G. Record review of R #4 care plan revised on 06/22/24 revealed R #4 uses quarter size bed rails for mobility and transfers. H. Record review of R #4's electronic health records revealed the following: 1. There were no physician orders for use of bed rails,2. There were no assessments completed for R #4 to determine risk of entrapment,3. There were no consents for the use of bed rails prior to installation,4. Documentation of the bed's dimensions was appropriate for the resident's size and weight. I. On 12/14/25 at 3:52 pm during a random observation of R #4's room revealed quarter size bed rails on the upper left and right sides of the bed. J. On 12/14/25 at 3:53 pm during an interview with R #4, she confirmed she uses the bed rails for positioning and mobility. R#5K. Record review of R #5's admission record revealed R #5 was admitted into the facility on [DATE] with the following diagnoses:1.Esophagitis, unspecified without bleeding (inflammation of the food pipe where specific cause isn't identified),2. Anxiety Disorder, 3. Anemia in Chronic kidney disease (complication where kidneys produce less hormones in producing red blood cells leading to fatigue, paleness),4. Muscle weakness, 5. End of stage renal disease (kidneys are severely damaged and can't filter waste effectively),6. Unspecified Systolic (congestive) heart failure (Heart can't pump out enough blood throughout the body),7. Fatty (change of) liver not elsewhere classified (fat buildup in the liver).L. On 12/15/25 at 9:46 am, during an observation of resident lying in bed, 1/4 side rails were in use and were on both sides of the bed. M. Record review of R #5's care plan dated 07/29/24 revealed 1/4 assist bars on bed for mobility and transfer. N. Record review of R #5's medical record revealed the record did not contain the following:1. Assessment of the resident for risk of assessment,2. Review of risk and benefits of the bed rails with the resident or resident representative, 3. Consent from the resident or resident representative,4. Documentation of the bed's dimensions was appropriate for the resident's size and weight. R #6O. Record review of R #6's admission record revealed she was admitted into the facility on [DATE] with the following diagnoses: 1. Muscle Wasting Atrophy (the thinning and loss of muscle tissue), 2. Major Depressive Disorder (a mental health disorder characterized by persistently depressed mood or loss of interest in activities, causing significant impairment in daily life)3. Chronic Obstructive Pulmonary Disease (COPD; lung disease) P. Record review of R #6's care plan revised on 10/06/25 revealed R #6 uses quarter size bed rails for mobility and transfers. Q. Record review of R #6's electronic health records revealed the following:1. There were no physician orders for use of bed rails,2. There were no assessments completed for R #6 to determine risk of entrapment,3. There were no consents for the use of bed rails prior to installation,4. Documentation of the bed's dimensions was appropriate for the resident's size and weight. R. On 12/15/25 at 12:19 pm during a random observation of R #6's room revealed quarter size bed rails on the upper left and right sides of the bed. R # 10S. Record review of R #10's admission record revealed R #10 was admitted to the facility on [DATE].T. On 12/14/25 at 12:20 AM, during an observation, R #10's bed had two quarter side rails were in use on both sides of the bed. U. Record review of R #10's physician orders, dated 10/13/25 through 12/14/25, revealed the resident did not have a physician order for bed rails. V. Record review of R #10's baseline care plan dated 10/14/25 revealed staff did not document the residents' use of bedrails. W. Record review of R #10's admission MDS, dated [DATE], revealed R #10 did not use bed rails. X. Record review of R #10's medical record revealed the record did not contain the following:1. Assessment of the resident for risk of assessment,2. Review of risk and benefits of the bed rails with the resident or resident representative, 3. Consent from the resident or resident representative,4. Documentation of the bed's dimensions was appropriate for the resident's size and weight. R #12Y. Record review of R #12's admission record revealed she was admitted into the facility on [DATE] with the following diagnoses: 1. Asthma (a chronic lung condition causing airway inflammation, narrowing, and mucus),2. Muscle weakness (reduction in the power exerted by muscles),3. Difficulty walking. Z. Record review of R #12's care plan revised on 08/28/25 revealed R #12 did not have interventions for the use of bed rails. AA. Record review of R #12's electronic health records revealed the following: 1. There were no physician orders for use of bed rails.2. There were no assessments completed for R #12 to determine risk of entrapment.3. There were no consents for the use of bed rails prior to installation. 4. Documentation of the bed's dimensions was appropriate for the resident's size and weight. BB. On 12/14/25 at 2:48 pm during a random observation of R #12's room revealed quarter size bed rails on the upper left and right sides of the bed.R #13 CC. Record review of R #13's admission record revealed she was admitted into the facility on [DATE] with the following diagnoses: 1. Anxiety (feelings of fear or apprehension),2. Depression (a mood disorder that causes a persistent feeling of sadness and loss of interest),3. Epilepsy (a seizure disorder),4. Muscle Weakness (reduction in the power exerted by muscles). DD. Record review of R #13's care plan revised on 07/08/25 revealed R #13 did not have interventions for the use of bed rails. EE. Record review of R #13's electronic health records revealed the following:1. There were no physician orders for use of bed rails,2. There were no assessments completed for R #13 to determine risk of entrapment,3. There were no consents for the use of bed rails prior to installation, 4. Documentation of the bed's dimensions was appropriate for the resident's size and weight. FF. On 12/14/25 at 2:48 pm during a random observation of R #13's room revealed quarter size bed rails on the upper left and right sides of the bed. R#19GG. Record review of R #19's admission record revealed R #19 was admitted into the facility on [DATE] with the following diagnoses: 1. Muscle weakness (generalized),2. Need for assistance with personal care, 3. Spinal Stenosis, cervical region (narrowing of spinal canal in the neck, putting pressure on spinal cord),4. Chronic obstructive pulmonary disease, unspecified (lung disease causing inflammation and damage to airways and air sacs),5. Impetigo, unspecified (high contagious bacterial skin infection causing red sores often around the nose and mouth),6. Other lack of coordination, 7. Hypokalemia (blood potassium levels are low).HH. Record review of R #19's physician order dated 07/09/24 revealed an order for 1/4 assist bars on bed for bed mobility/transfers.II. Record review of R#19's care plan dated 04/12/23 revealed one quarter size side rails used for bed mobility. JJ. Record review of R #19's medical record revealed the record did not contain the following:1. Assessment of the resident for risk of assessment,2. Review of risk and benefits of the bed rails with the resident or resident representative, 3. Consent from the resident or resident representative,4. Documentation of the bed's dimensions was appropriate for the resident's size and weight. R #54KK. Record review of R #54's admission record revealed she was admitted into the facility on [DATE] with the following diagnoses: 1. Major Depressive Disorder (a mental health disorder characterized by persistently depressed mood or loss of interest in activities, causing significant impairment in daily life),2. Insomnia (a common sleep disorder making it hard to fall asleep, stay asleep),3. Anxiety Disorder (mental health conditions causing intense, excessive, and persistent fear or worry that significantly interferes with daily life),4. Hyperlipidemia (a condition in which there are high levels of fat particles in the blood; high cholesterol),5. Heart failure (impaired heart function). LL. Record review of R #54's care plan revised on 11/11/25 revealed no interventions for the use of bed rails. MM. Record review of R #54's physician orders revealed an order for quarter-sized bed rails used for mobility and transfers. Start date 01/09/23. NN. Record review of R #54's electronic health records revealed the following: 1. There were no assessments completed for R #13 to determine risk of entrapment,2. There were no consents for the use of bed rails prior to installation, 3. Documentation of the bed's dimensions was appropriate for the resident's size and weight. OO. On 12/14/25 at 3:55pm during a random observation of R #54's room revealed quarter size bed rails on the upper left and right sides of the bed. PP. On 12/15/25 at 10:34 am during an interview with R #54's representative she confirmed she uses the bed rails for positioning and mobility. R#55QQ. Record review of R #55's admission record revealed R #55 was admitted into the facility on [DATE] with the following diagnoses:1.History of falling, 2. Lack of Coordination, 3. Hyperlipidemia, unspecified (high levels of fat in the blood),4. Depression, unspecified,5. Need for assistance with personal care, 6. Chronic Systolic (congestive) heart failure (heart can't pump out enough blood throughout the body).RR. On 12/14/25 at 4:20 pm, during an observation of R #55's room revealed bed rails on both sides of the bed were in use. SS. Record review of R#55's care plan dated 12/17/25 revealed 1/4 bed rails used for bed mobility but not prior to this date.TT. On 12/14/25 at 12:30 pm, during an interview, R#55 stated he does utilize his bed rails to get in and out of bed. UU. Record review of R #55's medical record revealed the record did not contain the following:1. Assessment of the resident for risk of assessment,2. Review of risk and benefits of the bed rails with the resident or resident representative, 3. Consent from the resident or resident representative,4. Documentation of the bed's dimensions was appropriate for the resident's size and weight. R #63VV. Record review of R #63's admission record revealed R #63 was admitted to the facility on [DATE].WW. On 12/14/25 at 2:28 PM, during an observation, R #63's bed had two quarter side rails on both sides of the bed in place. XX. Record review of R #63's physician orders, dated 02/07/25 through 12/14/25, revealed the resident did not have a physician order for bed rails. YY. Record review of R #63's care plan, dated 09/17/25, revealed staff did not document the residents' use of bedrails. ZZ. Record review of R 63's quarterly MDS, dated [DATE], revealed R #63 did not use bed rails. AAA. Record review of R #63's medical record revealed the record did not contain the following:1. Assessment of the resident for risk of assessment,2. Review of risk and benefits of the bed rails with the resident or resident representative, 3. Consent from the resident or resident representative,4. Documentation of the bed's dimensions were appropriate for the resident's size and weight. R #84BBB. Record review of R #84's admission record revealed R #84 was readmitted to the facility on [DATE].CCC. On 12/14/25 at 12:44 PM, during an observation, R #84's bed had two bilateral (relating to two sides) quarter side rails (horizontal metal or plastic bars that extend about a quarter of the length of a bed) in place. DDD. On 12/14/25 at 12:45 PM, during an observation, R #84 used bed rails to adjust her positioning while sitting up in bed.EEE. Record review of R #84's physician orders dated 10/30/25 through 12/14/25, revealed the resident did not have a physician order for bed rails. FFF. Record review of R #84's care plan, dated 10/30/25, revealed bed rails for bed mobility and positioning were not documented.GGG. Record review of R #84 comprehensive Minimum Data Set, dated [DATE], revealed R #84 did not use bed rails.HHH. Record review of R #84's medical record revealed the record did not contain the following:1. Assessment of the resident for risk of assessment,2. Review of risk and benefits of the bed rails with the resident or resident representative, 3. Consent from the resident or resident representative,4. Documentation of the bed's dimensions was appropriate for the resident's size and weight. R #88 III. Record review of R #88's admission record revealed she was admitted into the facility on [DATE] with the following diagnoses: 1. Muscle Weakness (reduction in the power exerted by muscles),2. Lack Of Coordination,3. Muscle Wasting Atrophy (the thinning and loss of muscle tissue).JJJ. Record review of R #88's care plan revised on 07/14/25 revealed interventions for the use of quarter size bed rails to aide in mobility and repositioning. KKK. Record review of R #88's physician orders revealed an order for quarter size bed rails used for mobility and transfers. Start date 01/08/23. LLL. Record review of R #88's electronic health records revealed the following: 1. There were no assessments completed for R #88 to determine risk of entrapment,2. There were no consents for the use of bed rails prior to installation, 3. Documentation of the bed's dimensions was appropriate for the resident's size and weight. MMM. On 12/15/25 at 11:52 am during a random observation of R #88's room revealed quarter size bed rails on the upper left and right sides of the bed. NNN. On 12/15/25 at 11:53 am during an interview with R #88, he confirmed he uses the bed rails for positioning and mobility. OOO. On 12/17/25 at 1:33pm during an interview with the Administrator (ADM), he confirmed there were several residents who were having their bed rails removed due to proper documentation and requirements not being in place. The administrator stated he was working with the DON to identify residents who were not at risk for removal of the bedrails. PPP. On 12/17/25 at 1:37pm during an interview with the DON, she confirmed residents did not have the appropriate requirements for bed rails and were currently being reassessed. She stated that each resident that has bed rails needs to have an assessment/referral completed by therapy, physician orders with indication of use for bed rails, education with consent for residents/representative, and updated care plan. She confirmed this was not done and does not meet her expectations.

Based on record review and interview, the facility failed to ensure each resident's drug regimen (plan to manage a person's medication) was free from unnecessary drugs by ensuring indication of use is based on the residents' current diagnosis for 3 (R #2, R #4, and R #54) of 3(R #2, R #4, and R #54) residents reviewed for unnecessary medications. This deficient practice could likely lead to adverse drug effects and poor patient outcomes. The findings are: R #2A. Record review of R #2's admission record revealed she was admitted into the facility on [DATE] with the following diagnoses: 1. Insomnia (a common sleep disorder making it hard to fall asleep, stay asleep),2. Major Depressive Disorder (a mental health disorder characterized by persistently depressed mood or loss of interest in activities, causing significant impairment in daily life),3. Psychotic Disorder (a severe mental illness causing a loss of touch with reality). B. Record review of R #2's physician orders revealed the following:1. Cetirizine hydrochloride (HCl) Oral Tablet 10 milligrams (MG). Give 10 MG by mouth in themorning for seasonal allergies. Start Date 09/12/25.2. Acetaminophen 8 Hour Oral Tablet Extended Release 650 milligrams (MG). Give 1 tablet by mouth two times a day for pain do not administer more than 2000 MG per 24 hours. Start Date 10/30/25. 3. Tramadol hydrochloride (HCl) Oral Tablet 50 milligrams (MG) Give 1 tablet by mouth every 4 hours as needed for pain. Start Date 11/11/25.C. Record review of R #2's Medication Administration Record (MAR) dated December 2025 revealed: 1. R #2 was administered Cetirizine daily from 12/01/25-12/15/25,2. R #2 was administered Acetaminophen two times daily from 12/01/25-12/15/25, 3. R #2 was administered Tramadol as needed on the following dates:1. 12/02/25 at 10:20 am,2. 12/06/25 at 3:00 am,3. 12/10/25 at 3:05 pm,4. 12/10/25 at 9:52 pm,5. 12/13/25 at 7:34 am. D. On 12/18/25 at 12:10 pm during an interview with the Director of Nursing (DON), she confirmed R #2 does not have diagnoses of seasonal allergies nor pain. R #2's medication regimen does not meet her expectations because the indication of use for the medications, Cetirizine, Acetaminophen and Tramadol does not reflect R #2's current diagnoses or indicate treating a symptom of R #2's current diagnoses as she would expect. R #4E. Record review of R #4's admission record revealed she was admitted into the facility on [DATE] with the following diagnoses: 1. Schizophrenia (a disorder that affects an individual's ability to think, feel, and behave clearly),2. Dementia (a group of conditions characterized by impairment of at least two brain functions, such as memory loss and judgment),3. Parkinsonism (a general term for movement disorders sharing symptoms with Parkinson's disease),4. Major Depressive Disorder (a mental health disorder characterized by persistently depressed mood or loss of interest in activities, causing significant impairment in daily life),5. Anxiety Disorder (mental health conditions causing intense, excessive, and persistent fear or worry that significantly interferes with daily life).F. Record review of R #4's physician orders revealed an order for Methotrexate Sodium Oral (a medication used as chemotherapy or immune system suppressant) Tablet 15 MG. Give 15 mg by mouth one time a day every Saturday for Rheumatoid Arthritis (RA; a disease where the immune system mistakenly attacks the joint lining). Start date 10/02/25. G. Record review of R #4's Medication Administration Record (MAR) dated December 2025 revealed R #4 was administered Methotrexate on the following dates:1. 12/07/25 at 8:00 am,2. 12/13/25 at 8:00am. H. On 12/18/25 at 12:10 pm during an interview with the Director of Nursing (DON), she confirmed R #4 does not have a diagnosis of RA. She stated R #4's medication regimen does not meet her expectations because the indication of use for Methotrexate does not reflect R #4's current diagnoses or indicate treating a symptom of R #4's current diagnoses as she would expect. R #54I. Record review of R #54's admission record revealed she was admitted into the facility on [DATE] with the following diagnoses: 1. Major Depressive Disorder (a mental health disorder characterized by persistently depressed mood or loss of interest in activities, causing significant impairment in daily life),2. Insomnia (a common sleep disorder making it hard to fall asleep, stay asleep),3. Anxiety Disorder (mental health conditions causing intense, excessive, and persistent fear or worry that significantly interferes with daily life),4. Hyperlipidemia (a condition in which there are high levels of fat particles in the blood; high cholesterol),5. Heart failure (impaired heart function). J. Record review of R #54's physician orders revealed an order for Zyrtec (antihistamine; allergy medication) Oral Tablet 10 milligrams (MG). Give 1 tablet via G-Tube (gastrostomy tube; a feeding tube surgically placed into the stomach to provide nutrition, hydration, and medication) one time a day for allergies. Start Date 10/08/24. K. Record review of R #54's Medication Administration Record (MAR) dated December 2025 revealed R #54 was administered Zyrtec daily from 12/01/25-12/15/25. L. On 12/18/25 at 12:10 pm during an interview with the Director of Nursing (DON), she confirmed R #54 does not have a diagnosis of allergies. She stated R #54's medication regimen does not meet her expectations because the indication of use for Zyrtec does not reflect R #54's current diagnoses or indicate treating a symptom of R #54's current diagnoses as she would expect.

Based on observation and interview, the facility failed to complete the following:1. Maintain the ice and water machine in a manner to prevent contamination and foodborne pathogens (a bacterium, virus, or other microorganism that can cause disease), 2. Properly store food items by tracking when to discard, labeling and covering perishable foods, and dating all foods stored in refrigerator, freezer, or pantry.3. Maintain the kitchen environment in a clean and sanitary manner. 4. Temperature tracking sheet on the outside of the refrigerator was dated November 2025. 5. Ensuring food served to residents was sanitary.These failures have the potential to result in cross contamination, the growth of foodborne pathogens, and foodborne illnesses. The findings are:Ice and water machineA. On 12/14/25 at 2:00 pm a random observation of the dining area revealed the ice and water machine had dried residue and what appeared to be dried food particles and splatters covering the outside of the machine and the table the machine sits on.Food storageB. On 12/14/25 at 2:05 pm a random observation of the Resident's fridge located in the satellite kitchen (kitchen area where staff hold and serve meals) revealed the following:1. One case of yogurt with an expiration date of 10/24/25.2. One blueberry yogurt cup with an expiration date of 10/24/25.3. A plastic container with what appeared to be discolored and mushy fruit (strawberries and melon) with no label or date.4. A gallon of milk with an expiration date of 11/26/25.5. A plate of food that appeared to be turkey, mashed potatoes, and stuffing labeled with R #48's name and dated 11/27/25.6. Two aluminum pans that contained a cheese pasta labeled with mac and cheese dated 11/28/25.7. What appeared to be a turkey leg wrapped in plastic wrap and dated 11/28/25.C. On 12/14/25 at 2:35 pm, a random observation of the refrigerator in the satellite kitchen revealed the following:1. Two pitchers that contained an orange liquid with no label or date.2. Two pitchers that contained a red liquid with no label or date.3. One bowl of what appeared to be lettuce, tomato, and onion with no label or date.4. One plastic tub that contained approximately 40 individual plastic containers of what appeared to be mayonnaise with no labels or dates.5. One plastic tub that contained approximately 40 individual plastic containers of what appeared to be Jello with no labels or dates.6. The trashcan located near the hand-washing sink was overflowing with trash to the point where the lid to the trashcan could not close completely.D. On 12/14/25 at 2:40 pm during an interview with the Dietary Aide (DA) #1, she confirmed the items kept resident's refrigerator and the other refrigerator should be labeled and dated and confirmed they were not. DA #1 stated that leftovers (food that is saved) should be thrown out after three days and confirmed the leftovers are old. Clean and sanitary environmentE. On 12/16/25 at 12:00 pm a random observation of the satellite kitchen revealed the wall behind the handwashing sink was covered with what appeared to be dirty, dried food particles, and dried liquid splash marks.F. On 12/14/25 at 2:45 pm a random observation of the main kitchen revealed the following:1. The drain located in the corner of the kitchen was full of what appeared to be food particles and liquid. 2. The food particles and liquid from the corner drain overflowed onto the floor surrounding the drain.3. The floor throughout the kitchen area was dirty with food particles, trash, and spilled liquids.4. The cart where the clean pots and pans are stored was covered in what appeared to be food particles and dried liquid splashes.5. The trash can locate near the food preparation table was overflowing with trash where the lid to the trashcan could not close properly.G. On 12/16/25 at 12:21 pm during an interview with the Regional Nutritionist (RDN), she refused to state whether the kitchen areas met her expectations.Sanitary Food PracticeH. On 12/15/25 at 1:42 PM during a random observation of resident activity, R #101 was seen opening food tray delivery cart sitting in 100 Hall, just after food trays had been delivered. R #101 was seen removing a small bowl of vegetables from the food cart belonging to another resident. R #95 walked up at that time and R #101 asked R #95 to heat up the bowl of vegetables. R #95 took bowl to nurses station and asked staff to warm up the bowl of vegetables. CNA #1 came back with the bowl of vegetables and took it too R #101's room and set it on the bedside table. R #101 was not in the room at that time.I. On 12/15/25 at 1:53 PM, during an interview and observation, CNA #1 was observed carrying bowl of vegetables to R #101's room. During an interview with CNA #1, she stated that R #95 gave her the food and asked her to heat it up for R #101. She admitted that serving R #101 food provided by another resident violated proper sanitary practices.

Based on observation, record review, and interview, the facility failed to maintain proper infection prevention measures for 3(R #6, R #54, and R #98) of 3(R #6, R #54, and R #98) residents reviewed by not: Ensuring Enhanced Barrier Protection (EBP) signage is visibly posted outside resident's room when precautions are in place. Ensuring Personal Protective Equipment is available (PPE) is available,Ensuring EBP signage was posted properly.Infection Control Signs and PPER #6C. Record review of R #6's admission record revealed R #6 was admitted into the facility on [DATE]. D. Record review of R #6's significant change comprehensive assessment dated [DATE] revealed the following:Two, stage three pressure ulcers (involves full-thickness skin loss, where the wound extends through the skin into the fatty tissue), One, stage four pressure ulcer (the most severe type of bedsore, involving full-thickness tissue loss where skin, fat, and underlying muscle, tendon, or bone become exposed and damaged, creating deep, crater-like wounds often with tunneling or undermining and a high risk of serious infection), One, unstageable pressure ulcer (where the wound's depth is hidden by dead tissue) due to non-removable dressing or deviceOne, unstageable pressure ulcer/injury presenting as deep tissue injury (pressure injury often starting at the muscle-bone interface, appearing as purple/maroon intact skin or a blood blister, and can quickly progress to severe wounds despite initial skin appearance). E. On 12/14/25 at 12:17pm during a random observation of the 400-hall revealed the following:1. R #6 did not have EBP (enhanced barrier precaution) sign posted at the entry of his room. 2. R #6 have PPE (personal protective equipment) readily available at the entry of his room.R #54 F. Record review of R #54's admission records revealed R #54 was admitted into the facility on [DATE].G. Record review of R #54's physician orders revealed an order for enteral feeding through gastrostomy tube (G-tube; a tube inserted through the abdomen into the stomach to provide nutrition, fluids, and medication to the body). Start date 12/08/23. H. On 12/14/25 at 12:17pm during a random observation of the 400-hall revealed 1. R #54 did not have EBP (enhanced barrier precaution) sign posted at the entry of her room.2. R #54 have PPE (personal protective equipment) readily available at the entry of her room. R #98I. Record review of R #98's admission records revealed R #98 was admitted into the facility on [DATE].J. Record review of R #98's physician orders revealed an order for Enhanced Barrier precautions due to foley catheter (a flexible tube inserted through the urethra into the bladder to drain urine continuously). Start date 6/24/24 K. On 12/14/25 at 12:17pm during a random observation of the 400-hall revealed R #98 did not have EBP (enhanced barrier precaution) sign posted at the entry of his room.L. On 12/14/25 at 3:59 pm during an interview with Certified Nurse Aide (CNA) #2, she confirmed there was not an EBP sign posted at the entry of R #98's room. M. On 12/18/25 at 12:10 pm during an interview with the Director of Nursing (DON), she confirmed the pressure ulcers, enteral feeding tubes and foley catheters require EBP signs posted outside of the residents' rooms with PPE available for staff. She stated that her expectation is residents with open wounds or indwelling devices should have precautions in place and followed.

Based on record review and interview, the facility failed to ensure residents were provided activities according to their preference for 1 (R #4) of 1 (R #4) resident reviewed for activities of daily living. This deficient practice is likely to result in the residents' personal choices not being honored and loss of dignity. The findings are: A. Record review of R #4 admission record revealed R #4 was admitted on [DATE].B. Record review of R #4's care plan, revised on 06/22/24 revealed R #4 prefers activities that identify with prior lifestyle. She prefers current events, educational programs, movies, sports, and television.C. On 12/14/25 at 3:52 pm during an interview with R #4, she stated she was upset because the facility had taken the power strip that connected her television to the outlet earlier this morning. She stated she could not watch television anymore because the television cord does not reach the outlet. She stated the facility informed her that it was a safety hazard.D. Record review of the facility's Electrical Safety for Residents policy revision January 2011, revealed when power strips are used the following precaution must be taken:1. Install internal ground faults and over-current protection devices,2. Secure power strips so that they do not cause trip hazards,3. Use power strips that are adequate for the number and types of devices used. E. On 12/17/25 at 1:33pm during an interview with the Administrator (ADM), he confirmed the power strip was removed from R #4's room. The administrator stated the facility was consulting an electrician to make changes to the outlets however alternatives were not put in place to allow residents to continue to watch tv in their room.

Based on record review and interview, the facility failed to ensure the resident's current advance directive (a document which provides an individual's wishes for emergency and lifesaving care) and the resident's Electronic Health Record (EHR) revealed the same resident wishes for 3 (R #9, R #79, and R #84) of 6 (R #9, R #10, R #63, R #67, R #79, and R #84) residents reviewed for advance directives. This deficient practice is likely to cause confusion and delay potentially lifesaving procedures. The findings are:R #9A. Record review of the face sheet in R #9's EHR revealed R #9 was admitted into the facility on [DATE], and his current Advance Directive was listed as Attempt Resuscitation/CPR (CPR; a lifesaving emergency measure that combines chest compression with artificial ventilation are desired). B. Record review of R #9's MOST (MOST; a legal document which outlines the care the resident wants when they become incapacitated and unable to speak for themselves) form revealed the form was signed and dated [DATE] and revealed R #9's advance directive was Do Not Resuscitate (DNR; lifesaving measures are not desired).C. Record review of R #9's Physician's order dated [DATE] revealed and order to Attempt Resuscitation/CPR.D. Record review of R #9's Care Plan revision dated [DATE], documented R #9 as a Full Code (lifesaving procedures desired). E. On [DATE] at 3:24 pm, during an interview with Director of Nursing (DON), she confirmed that all of R #9's paperwork in the medical chart including face sheet, physician orders, and care plan revealed Full Code/Attempt CPR and the MOST form revealed DNR. She stated this does not meet her expectations and all Advance Directive documentation should match throughout the chart. R #79F. Record review of R #79's admission Record revealed she was admitted to the facility on [DATE].G. Record review of R #79's MOST form dated [DATE] revealed R #79 chose not to attempt resuscitation/DNR.H. Record review of R #79's current physician orders dated [DATE] revealed an order to attempt resuscitation/CPR.I. Record review of R #79's care plan dated [DATE] revealed it does not indicate any advance directive.J. On [DATE] at 3:00 pm during an interview with the DON, she confirmed R #79's physician order and care plan should match the signed MOST form and it does not. R #84K. Record review of R #84's face sheet revealed R #84's code status is Do Not Resuscitate.L. Record review of R #84's MOST form signed and dated [DATE] revealed R #84's wishes to Do Not Resuscitate.M. Record review of R #84's Physician's orders dated [DATE] revealed an Advance Directive order as Full code/CPR.N. Record review R #84's of Care Plan dated [DATE] did not include an Advance Directive. O. On [DATE] at 3:24 pm, during an interview with Director of Nursing (DON), she confirmed all of R #84's Advance Directed information was not documented correctly in care plan and the physician orders should match the MOST form. She stated this does not meet her expectations and all Advance Directive documentation should match throughout the chart.

Based on observation, record review, and interview, the facility failed to create an accurate baseline care plan (minimum healthcare information necessary to properly care for a resident immediately upon their admission to the facility) within 48 hours of admission for 4 (R #7, R #15, R #79, R #106) of 6 (R #7, R #8, R #15, R #35, R #79, and R #106) residents reviewed for care plans. This deficient practice could likely result in residents not receiving the appropriate care and may place residents at risk of an adverse event (undesirable experience, preventable or non-preventable, that caused harm to a resident because of medical care or lack of medical care) or worsening of current condition after admission. The findings are:R #7A. Record review of R #7's admission Record revealed she was admitted to the facility on [DATE] with the following diagnoses:1. Metabolic encephalopathy2. End Stage Renal DialysisB. Record review of R #7's Baseline Care Plan revealed the following:1. The Social Services section (section two) does not contain any information.2. The Rehabilitative Services section (section three) does not contain any information.3. The Nutritional Services section (section four) states R #7 should be on a regular diet and was signed by the Director of Nutritional Services on 08/30/25.4. The Activities section (section five) does not contain any information.C. On 12/18/25 at 12:00 pm during an interview with the Director of Nursing (DON) she stated that R #7's baseline care plan does not meet her expectations because it is not accurate and not completed.R #15D. Record review of R #15's admission Record revealed she was admitted to the facility on [DATE] with the following diagnoses:1. Unspecified nondisplaced fracture of surgical neck of left humerus2. Unspecified fracture of the lower end of right radius3. Depression4. Anxiety disorderE. Record review of R #15's Baseline Care Plan revealed that it was not completed and signed until 05/22/25.F. On 12/18/25 at 12:00 pm during an interview with the DON, she confirmed that R #15's Baseline Care Plan does not meet her expectations because it was completed thirteen days after admission. R #79G. Record review of R #79's admission Record revealed she was admitted to the facility on [DATE] with the following diagnoses:1. Unspecified fracture of sacrum2. Essential (primary) hypertension3. Osteoarthritis4. Retention of urineH. Record review of R #79's Baseline Care Plan revealed it was marked completed on 11/26/25 and was signed by the last author (activity director) on 12/09/25.I. On 12/18/25 at 12:00 pm during an interview with the DON, she confirmed that R #79's Baseline Care Plan does not meet her expectations because it was completed eighteen days after admission.R #106J. Record review of R #106's admission Record revealed he was admitted to the facility on [DATE] with the following diagnoses:1. Displaced intertrochanteric fracture of right femur2. Chronic respiratory failure with hypoxia3. Collapsed vertebra, lumbar region4. Wedge compression fracture of T11-T12 vertebra5. Gastrostomy status6. Personal history of antineoplastic chemotherapy and irradiation7. Long term (current) use of anticoagulantsK. On 12/14/25 at 2:20 pm, during an interview and observation with R #106 in his room, R #106 was observed to have a feeding pump connected through a tube in his abdomen. R #106 stated he has had a feeding tube since he had cancer eight years ago. L. Record review of R #106's Baseline Care Plan revealed the following:1. The Nursing Services section (Bb of section one) does not indicate that R #106 is a current smoker.2. The Nursing Services section (Cc of section one) does not indicate that R #106 currently takes an anticoagulant.3. The nutritional Services section (section four) does not contain any information.M. On 12/18/25 at 12:00 pm during an interview with the DON, she stated that R #106's Baseline Care Plan does not meet her expectations because it should indicate that he is a current smoker, he currently takes an anticoagulant and uses a feeding tube, but it does not.

Based on observation, interview and record review, the facility failed to ensure the medication error rate did not exceed 5 percent (%) when staff performed four medication errors out of 32 opportunities for 1 (R #106) of 6 (R #15, R #35, R #41, R #79, R #101, and R #106) residents reviewed during medication administration. This resulted in a medication error rate of 12.5%. This deficient practice could likely result in the residents receiving incorrect medication, not receiving the desired therapeutic effect, and exposing the residents to a higher risk of side effects. The findings are:A. On 12/17/25 at 8:06 am during an observation of medication administration through R #106's feeding tube, Licensed Vocational Nurse (LVN) #1 prepared [crushing or pouring from a capsule] four different medications for administration and combined all four medications into one medication cup. B. Record review of the facility's policy dated 04/12/23 stated crushed medications are not mixed into the same medicine cup, unless approved by the prescribing physician. C. Record review of physician orders:1. Eliquis 5 mg 1 Tablet via G-Tube,2. Ferrous Sulfate Oral 325mg tablet, give 1 tablet via G-Tube,3. Pantoprazole Sodium oral tablet delayed release, give 1 tablet viat G-Tube,4. Tylenol 325mg, give 2 tablets via G-tube every 6 hours as needed for pain. D. On 12/18/25 at 3:24 PM, during an interview with the Director of Nursing (DON), she stated medications should be prepared in separate medicine cups before administering them through a feeding tube. She confirmed crushed medications should not be combined into one medication cup and this did not meet her expectations.

Based on observation and interview, the facility failed to ensure call lights in the residents' rooms were within reach of the residents while in the room for 1 (R #5) of 5 (R #2, R #5, R #54, R #88 and R #98) residents reviewed for call lights. This deficient practice could likely result in residents being unable to notify staff when they need assistance. The findings are:A. On 12/15/25 at 9:57am during a random observation of R #5's room, his call light was observed to be on the side of his bed between the mattress and bed rail. B. On 12/15/25 at 9:58 am, during an interview with R #5, he confirmed he could not reach his call light. C. On 12/15/25 am at 10:02 am during an interview with Certified Nurse Aide (CNA) #3, she confirmed R #5's call light was not in his reach and should always be within his reach.

Based on record review and interview, the facility failed to provide activities of daily living (ADL; activities related to personal care such as bathing, showering, dressing, walking, toileting, and eating) assistance for baths or showers for 3 (R #1, R #2, and R #3) of 3 (R #1, R #2, and R #3) residents reviewed for ADL care. This deficient practice is likely to affect the dignity and health of the residents. The findings are:R #1A. Record review of R #1's admission Record revealed R #1 was admitted to the facility on [DATE] with the following diagnoses:1. History of falling,2. Seizures (convulsions),3. Lack of coordination,4. Cognitive communication deficit (communication problems caused from cognitive impairment),5. Traumatic subdural hemorrhage (a collection of blood between the outer layer and middle layers of the brain's covering due to a traumatic brain injury),6. Generalized muscle weakness (the body's inability to contract muscles properly), 7. Reduced mobility,8. Muscle wasting,9. Difficulty in walking.B. Record review of R #1's admission Minimum Data Set (MDS; a federally mandated assessment instrument completed by facility staff) dated 07/18/25, revealed a Brief Interview for Mental Status (BIMS; a screening for cognitive impairment) score of 15, cognitively intact.C. Record review of R #1's care plan dated 04/24/25 revealed that R #1 requires supervision or touching assistance from staff to shower or bathe.D. On 09/11/25 at 12:46 am during an interview with R #1, he stated he has not been receiving his shower or bath on his regular scheduled times. R #1 stated he remembers getting a shower today, but he had not been getting his showers three times a week as ordered.E. Record review of the facility's POC ADL charting (Point of care activities of daily living care provided during shift), no date, revealed R #1 is scheduled for a shower on Mondays, Wednesdays, and Fridays.F. Record review of R #1's survey documentation report for the month of August 2025 revealed the following:1. R #1 received showers on 08/07/25, 08/15/25, and 08/23/25.2. No documentation to show R #1 was offered or assisted with a bath or shower for six days from 08/01/25 to 08/07/25.3. No documentation to show R #1 was offered or assisted with a bath or shower for seven days from 08/08/25 to 08/17/25.4. No documentation to show R #1 was offered or assisted with a bath or shower for seven days from 08/18/25 to 08/23/25.G. Record Review of R #1's survey documentation report for the month of September 2025 revealed the following:1. R #1 received showers on 09/06/25 and on 09/08/25.2. No documentation to show R #1 was offered or refused a bath or shower for six days from 09/01/25 to 09/06/25.R #2H. Record review of R #2's admission Record revealed R #2 was admitted to the facility on [DATE] with the following diagnoses:1. Metabolic Encephalopathy (brain dysfunction),2. Fracture of superior rim of left pubis, subsequent encounter for fracture with routine healing (fracture of the pelvis),3. Unspecified fracture of the T7-T8 Vertebra, subsequent encounter for fracture with routine healing (fracture of the spine),4. Difficulty in walking,5. Generalized muscle weakness.I. Record review of R #2's quarterly Minimum Data Set, dated [DATE], revealed the following:1. BIMS score of 15, cognitively intact.2. R #2 requires partial/moderate assistance to shower or bathe.J. Record review of the facility's shower schedule, no date, revealed R #2 is scheduled for a shower on Mondays, Wednesdays, and Fridays.K. Record review of R #2's survey documentation report for the month of August 2025 revealed the following:1. Resident #2 was showered with total dependence as a one-person physical assist on 08/18/25, 08/20/25, and 08/29/25.2. The survey documentation report did not contain any documentation to show R #2 was offered or assisted with a bath or shower for five days from admission, days from 08/13/25 to 08/18/25.3. The survey documentation report did not contain any documentation to show R #2 was offered or assisted with a bath or shower for seven days from 08/22/25 to 08/29/24.R #3L. Record review of R #3's admission Record revealed R #3 was admitted to the facility on [DATE] with the following diagnoses:1. Unspecified dementia (a group of conditions characterized by impairment of at least two brain functions, such as memory loss and judgment),2. Muscle weakness,3. Lack of coordination,4. Difficulty in walking.M. Record review of R #3's quarterly Minimum Data Set, dated [DATE] revealed the following:1. BIM score of 00, severe impairment.2. R #3 is totally dependent with maximum assistance to shower or bathe.N. Record review of the facility's shower schedule, no date, revealed R #3 is scheduled for a shower on Mondays, Wednesdays, and Fridays.O. Record review of R #3's survey documentation report for the month of August 2025 revealed the following:1. R #3 was showered on 08/06/25, and 08/25/25 with total dependence and one-person assist.2. The survey documentation report did not contain any documentation to show R #3 was offered or assisted with a bath or shower for five days from admission, days from 08/01/25 to 08/06/25.3. The survey documentation report did not contain any documentation to show R #3 was offered or assisted with a bath or shower for eighteen days, from 08/07/25 to 08/25/25.4. The survey documentation report did not contain any documentation to show R #3 was offered or assisted with a bath or shower for six days from 08/26/25 to 08/31/25.5. The survey documentation report revealed R #3 refused a bath or shower on 08/26/25.P. On 09/02/25 at 11:02 am during an interview with the Regional Nurse Consultant (RNC #1), she stated her expectation is for the shower schedule to be followed and confirmed it was not for R #1, R #2, and R #3.

Based on record review and interviews, the facility failed to prevent an accident for 1 (R #1) of 3 (R #1, R #2, and R #3) residents reviewed for falls when: 1. R #1 sustained (14) falls in a 6.5 month period. 2. The facility did not implement adequate interventions to prevent falls 3. Neurochecks for unwitnessed falls and falls in which the resident hit her head were incomplete per policy. 4. One- to-one staffing was assigned to R #1, however staff were assigned other duties and R #1 had 3 falls during the time she was ordered to have one-to-one staffing in which she sustained injury to her head. These deficient practices likely resulted in R #1 sustaining multiple acute subarachnoid hemorrhage (bleeding between the space between the brain and tissue covering the brain) and passing away (6) days after her last fall at the facility. The findings are: A. Record review of R #1's face sheet revealed R #1 was admitted to the facility on [DATE] with multiple diagnoses including: - Unspecified dementia without behavioral disturbance, - Psychotic disturbance, - Mood disturbance, - Anxiety, - Unspecified fracture of right ilium (the large broad bone forming the upper part of each half of the pelvis), subsequent encounter for fracture with routine healing. - Urinary tract infection, site not specified. - Essential hypertension (high blood pressure.) - Other reduced mobility. - Need for assistance with personal care. - Specified sequelae of cerebral infarction (symptoms that occur after a stroke.) - Unspecified dementia, unspecified severity. - Age-related osteoporosis with current pathological fracture, right pelvis. - Repeated falls. B. Record review of R #1's quarterly Minimum Data Set (MDS; a federally mandated assessment instrument completed by facility staff), dated [DATE], revealed the following: 1. A Brief Interview for Mental Status (BIMS; a screening for cognitive impairment) score of 04, severe impairment, 2. Wandered daily, 3. Utilized a wheelchair for mobility, 4. Required substantial to maximal assistance when walking up to 50 feet, 5. Functional limitation in range of motion on one side of lower extremities (legs), 6. Had shortness of breath when lying flat, 7. Had two or more falls without injury since admission, reentry, or prior assessment, 8. Took an anticoagulant and indication was noted, 9. Did not receive any physical, occupational, or restorative therapy. 10. Signed by the Registered Nurse (RN)/MDS and the Social Worker. 11. Assessment marked completed on [DATE]. C. Record review of R #1's Physician Orders revealed an order for Eliquis (blood thinner to prevent/treat blood clots) 2.5 milligram tablet to be given twice daily and started on [DATE]. D. Record review of R #1's Care Plan, dated [DATE], revealed R #1 was a high risk for falls and included the following interventions: 1. Dated [DATE], review information on past falls and attempt to determine cause of falls. Record possible root causes. Alter remove any potential causes if possible. 2. Dated [DATE], Physical Therapy (PT) to evaluate and treat as ordered or as needed (PRN). 3. Dated [DATE], intervention related to fall risk included R #1 had frequent urinary track infections (UTI) which resulted in behavior changes. Consider UTI with each fall and get a urology consult as soon as possible. 4. The care plan did not address the resident's use of Eliquis or the risk associated with use. E. Record review of the facility's Neurological Assessments policy, dated ,d+[DATE], revealed nursing staff to perform neurological assessments as follows: 1. Upon Attending Physician order. 2. Following an unwitnessed fall. 3. Following a fall or other accident/injury involving head trauma. 4. When indicated by resident's condition. 5. To be completed every 30 minutes four times (a check to be completed every 30 minutes for two hours), then every hour four times (a check to be completed every hour for four hours), then every four hours four times (a check to be completed every four hours for 16 hours), and then every shift for a combined total of 72 hours. F. Record review of R #1's Fall with Injury report, R #1's Electronic Health Record (EHR), R #1's progress notes and R #1's neurocheck evaluation revealed the following: 1. Progress noted dated [DATE], R #1 was on the floor behind door. Resident noted to have blood on face, gown, and floor, large bump and abrasion noted to forehead, bump and bruising noted to right forearm. Resident unable to give description of fall. For fall dated [DATE], the facility did not complete 15 out of sixteen required neurochecks (a brief neurological assessment performed by staff repeatedly to monitor a resident's neurological status). 2. Progress note dated [DATE], an unknown Certified Nursing Assistant (CNA) notified the nurse that R #1 was on the floor. For fall dated [DATE], the facility did not complete four out of sixteen required neurochecks. Care Plan revised [DATE], intervention related to fall risk included anticipate and meet the resident needs and be sure R #1's call light is within reach and encourage R #1 to use it for assistance as needed. R #1 needs prompt response to all requests for assistance. 3. Progress Note dated [DATE], the nurse heard a loud bang and saw the CNA at back door on 100 hall. Resident lay supine on the floor. Dated [DATE], a hospital emergency room After Visit Summary - the reason for the visit was a fall. Diagnoses listed were unspecified fall and closed head injury. The EHR did not contain a Fall with Injury report for [DATE]. For fall dated [DATE], the facility did not complete 12 out of sixteen required neurochecks. 4. Progress note dated [DATE], R #1 was crawling on floor. For fall dated [DATE], the facility did not complete 12 out of sixteen required neurochecks. Care Plan revised [DATE], intervention related to fall risk included offer to assist R #1 to the toilet to avoid impulsiveness. 5. Progress note dated [DATE], R #1 reported she slipped out of her wheelchair. The EHR had no other record of this fall, injury to resident or new interventions. Care Plan revised [DATE] (9 days after the slip), intervention related to fall risk included apply Dycem (a non-slip material) to wheelchair. For fall dated [DATE], the facility did not complete eight out of sixteen required neurochecks. 6. Progress note dated [DATE], the author of the note went into the resident's room and saw the resident on floor next to the bed. For fall dated [DATE], the facility completed a total of sixteen neurochecks, but none of the checks were completed on [DATE] (within the 72 hours that neurochecks are supposed to be completed). There were no updates to the care plan following this fall. 7. Progress note dated [DATE], R #1 was on the floor between the wheelchair and the bed. For fall dated [DATE], the facility did not complete four out of sixteen required neurochecks. Care Plan revised [DATE], intervention related to fall risk included increased rounding (a practice where nursing staff periodically check on residents) on resident. 8. Progress note dated [DATE], another resident, name unknown, reported there was a woman on the floor in his room. Staff found R #1 on the floor when they entered his room. For fall dated [DATE], the facility failed to complete any neurochecks after the first day. Care Plan revised [DATE], intervention related to fall risk included treat resident clinically with medications as ordered. 9. Progress note dated [DATE], R #1 was on the floor in bedroom. For fall dated [DATE], the facility did not complete one out of of sixteen required neurochecks. No updates to the care plan. 10. Progress note dated [DATE], R #1 stood up and her legs gave out. R #1 was taken to the hospital for chest pain. For fall dated [DATE], the facility did not complete 13 out of sixteen required neurochecks. EHR did not identify if there were any injuries as it related to the fall. 11. Progress note dated [DATE], R #1 was found laying on the floor by (unknown initials). R #1's wheelchair was inside the facility door, and the resident was on the floor. Fall with Injury report dated [DATE], revealed staff found resident lying on the ground. Resident pushed open side door and attempted to walk out of facility. Resident fell to floor and acquired a wound to left eyebrow and bruising to left cheekbone. For fall dated [DATE], the facility did not complete six out of sixteen required neurochecks. G. Record review of R #1's progress notes dated [DATE], identified Elopement Risk - updated care plan. Resident was one-to-one (staffing ratio of one employee to one resident) for 14 days to monitor for triggers and daily routine. H. Record review of R #1's Care Plan related to high risk for falls dated [DATE] revealed Resident to be 1 on 1 when awake and Resident will be supervised when in observation areas when 1 on 1 is not available. I. Record review of the R #1's EHR dated [DATE] and [DATE], handwritten notes which described what R #1 did throughout the day while one-to-one staffing was provided. The EHR did not contain additional documentation for other dates of one-on-one staffing, such as notes which described what R #1 did throughout the day while the one-to-one staffing would have been provided. J. Record review of R #1's EHR, R #1's progress notes and R #1's neurocheck evaluation revealed the following: 1. Fall with Injury report dated [DATE], revealed staff saw resident lying on her back holding on to her head. Staff assessed resident. Resident had a quarter size hematoma to back of head. No other injuries noted. Progress notes dated [DATE], R #1 lay on the ground, on her back, and held her head. For fall dated [DATE], the facility did not complete seven out of sixteen required neurochecks. 2. Progress note dated [DATE] at 12:52 am, Change of Condition: R #1 hit her head which caused a subarachnoid hemorrhage (bleeding in the space between the brain and the tissue covering the brain) during an unwitnessed fall. Fall with Injury report dated [DATE], revealed an aide found the resident on floor in bedroom. The resident walked from restroom back to bed and fell to floor. Resident sustained large hematoma to left side of head which caused pain to patient. Resident had skin tear to left elbow and bruise to the left hip and right inner knee. Emergency Services was called, and resident was transported to the hospital. Progress noted dated [DATE] at 7:37 am revealed spoke with daughter after return from ER, per daughter all scans and labs were normal. For fall dated [DATE] at 12:52 am, the facility did not complete 15 out of sixteen required neurochecks. K. Record review of R #1's hospital emergency room (ER) Physician's Documentation, dated [DATE], revealed .This patient has been recently seen in this Emergency Department today. The patient has been recently seen in this Emergency Department, this week, last week, a couple of weeks ago, last month, for similar complaints. Patient returns to the ED [Emergency Department] via EMS [Emergency Medical Services]. She resides at a local ECF [Extended Care Facility]. She has had increasing frequency of falls. She was here earlier in the evening for a fall. Imaging studies were without traumatic abnormality. She was returned to the ECF. Once there, she fell again. Staff state that she was found on the floor. Now she has AMS [Altered Mental Status], staring off to the right. She is not speaking to me, she is agitated. HPI [History of Present Illness] obtained from daughter. L. Record review of R #1's hospital discharge documentation, dated [DATE], revealed the following. 1. Computed tomography (CT scan; a noninvasive diagnostic imaging procedure that uses a computer to take data from several X-ray images of structures inside a human and converts them into pictures on a monitor) head without contrast showed multiple acute subarachnoid hemorrhage in the pontine, parietal, and frontal parietal areas (areas of the brain). 2. Multiple acute subarachnoid hemorrhage secondary to anticoagulation with Eliquis, status post multiple mechanical falls. M. Record review of R #1's Nursing Note, dated [DATE], revealed R #1 returned to the facility from hospital, status post (status after an intervention) subarachnoid hemorrhage from fall. N. Record review of R #1's Clinical Physician Order, dated [DATE], revealed an order for hospice with a diagnosis of subarachnoid hemorrhage. O. Record review of R #1's Minimum Data Set, dated dated dated [DATE] identified that R #1 was deceased . P. On [DATE] at 9:25 am and [DATE] at 9:11 am, during an interview with R #1's daughter, she stated her mother passed away on [DATE] due to injuries she sustained from a fall at the facility, which never should have happened. She stated her mother fell a total of 11 times from [DATE] to [DATE]. She stated her concern was, each time her mother fell , the facility did not do anything to mitigate the falling or to prevent it from happening. She stated four or five of her mother's falls resulted in trips to the emergency room . R #1's daughter stated she had to ask for a care plan meeting, because the facility did not schedule one to put interventions in place. She explained that during the last meeting on [DATE], it was agreed that her mother would have one-to-one staffing. She stated the one-to-one only lasted two days. R #1's daughter stated if the facility would have done their part, then her mother probably would not have had the fall that cost her life. R #1's daughter also stated her mother was not able to use a call light appropriately due to the decline in her mental abilities. She stated her mother did not know what it was for or when to push the button. Q. On [DATE] at 10:04 am, during an interview with the Director of Nursing (DON), she stated R #1's team met and placed R #1 on a one-on-one staffing intervention on [DATE]. The DON stated she would not expect for a resident to continue to have falls if one-to-one staffing was provided. The DON stated the staff that provided one-on-one staffing should have documented what occurred while the one-on-one staffing was provided, but she was not able to provide additional documentation that one-on-one staffing was scheduled beyond [DATE] and [DATE]. R. On [DATE] at 8:42 am, during an interview with CNA #1, she stated she was the one-on-one staff assigned to R #1 during her second fall on [DATE]. CNA #1 stated she was assigned other duties, such as answering call lights and passing out drinks to other residents, while assigned as R #1's one-on-one staff. S. On [DATE] at 8:51 am, during an interview with CNA #2, she stated that she was assigned to work two shifts as R #1's one-on-one staff, but she could not remember the dates. CNA #2 stated on the first day she was assigned as R #1's one-on-one staff, R #1 fell and went to the hospital before she arrived at work. CNA #2 stated she remembered walking into work on the second day she was assigned to be R #1's one-on-one staff and saw the bruises to R #1's face and arms. CNA #2 stated she was assigned to answer call lights for other residents while assigned as R #1's one-on-one staff. Based on record review and interviews, Immediate Jeopardy was identified in person to the Administrator on [DATE] at 10:35 am. The facility took corrective action by providing an acceptable Plan of Removal (POR) on [DATE] at 11:06 am. The facility's implementation of the POR was verified onsite on [DATE] at 12:00 pm with completion of the following: 1. A re-evaluation of all residents fall risks and care plans. 2. An audit of previous falls in the past 30 days to ensure new interventions were put in place and neurological checks were completed. 3. Reeducation of staff regarding one-on-one staffing expectations and completing neurological checks. After removal of the Immediate Jeopardy, the deficiency remained at a G scope and severity for a pattern of harm.

Based on record review and interview, the facility staff failed to report incidents of alleged abuse for 2 (R #1 and R #2) of 2 (R #1 and R #2) residents sampled. If the staff failed to report allegations of abuse to the facility administration then corrective measures may not be acted on, and the facility would be unable to assure residents are free from abuse and neglect. The findings are: R #1 A. Record review of R #1's face sheet revealed she was admitted to the facility on [DATE]. R #1 was dependent on care on activities of daily living. Her diagnoses included but were not limited to: - Reduced mobility (severe chronic illness that requires immobilization in bed), - Need for assistance with personal care, - Spinal stenosis (narrowing of the spine) lumbar region, - Morbid severe obesity (overweight), and - Sepsis (life threatening condition that arises when the body's response to infection causes injury to its own tissues and organs). B. Record review of the Minimum Data Set (MDS; a federally mandated assessment instrument completed by facility staff), dated 11/30/23, identified R #1's Brief Interview for Mental Status (BIMS; tool to screen and identify the cognitive condition of long-term care residents 0 being the lowest and 15 being the highest) score was 15, cognitively intact. C. On 02/10/24 at 2:15 pm during an interview, R #1 stated she woke up startled in the early morning hours on 01/23/24 and found Certified Nursing Assistant (CNA) #1 standing by her bedside table. R #1 asked CNA #1 what he was doing in her room in the dark, and he left her room without responding. The next morning (01/24/24), R #1 told Registered Nurse (RN) #1 that CNA #1 was in her room the night prior and it scared her. R #1 asked that CNA #1 not be allowed back into her room. CNA #1 continued to work with the resident, which R #1 stated traumatized her emotionally. D. Record review of the facility's staffing scheduled revealed CNA #1 was assigned to work with R #1 on the following shifts: - On 01/23/24, 6 pm-11:59 pm, - On 01/24/24, 12 am-6:00 am, - On 02/01/24, 6:00 pm-11:59 pm, - On 02/02/24, 12 am-6 am. E. Record review of the facility's staff schedule, dated 01/23/25 and 02/01/24, verified CNA #1 was assigned to work with R #1 F. On 02/10/24 at 4:12 pm during an interview, RN #1 stated R #1 reported to him (on 01/24/24) that she woke up on the night of 01/23/24 and was startled by CNA #1 standing in the dark near her bed. He said R #1 told him that she was upset and did not wish for CNA #1 to be allowed back in her room. RN #1 stated he did not have the ability to change the schedule, and he did not report the incident to anyone. G. On 02/10/24 at 4:30 pm during an interview, CNA #2 stated R #1 previously told her that CNA #1 made her (R #1) uncomfortable and was standing in her room in the dark. CNA #2 stated she was aware of another resident (R #2) who expressed that she was afraid of CNA #1. The CNA stated that R #2 told her that she was scared of CNA #1. CNA #2 was unable to give the exact date R #2 said this, but she thought it occurred between 02/04/24 through 02/10/24. CNA #2 stated she did not tell anyone that R #2 reported being afraid of CNA #1. R #2 H. Record review of R #2's face sheet revealed she was admitted on [DATE]. Her diagnoses included but were not limited to the following: Cerebral ischemia (a condition in which there is insufficient blood flow to the brain to meet metabolic demand), need for assistance with personal care, other reduced mobility, and weakness. I. Record review of the MDS, dated [DATE], identified R #2's BIMS score was 9, moderately impaired. J. Record review of the facility's staff schedule, dated 02/04/24 through 02/07/24, revealed CNA #1 worked on the hall where R #2's room was located and provided care for R #2. CNA #1 was the only male that had worked with R #2 during that time. Based on interview and record review, Immediate Jeopardy was identified on 03/15/24 at 4:20 pm to the administrator, in person. The facility took corrective action by proving an acceptable Plan of Removal (POR) on 03/14/24 at 4:31 pm. Implementation of the POR was verified onsite on 03/13/24 by interviewing staff regarding the education that had been given, and offsite on 03/14/24 with the completion of the resident audits regarding if any of the residents felt safe or felt abused. Plan of removal: The Nurse was educated on abuse reporting on 02/26/24. The CNA was educated on abuse reporting on 03/13/24. The facility conducted a safety audit of all residents in the building was completed on 03/14/24. The facility has begun to conduct random staff questionaries on abuse and reporting. Date started 03/13/24. Total number of staff interviewed = 27. Have you heard of a resident being abused in our facility? What did you do about it? Do you know who to report it to? There are no grievances identified that abuse or neglect was indicated or required further reporting.

Based on record review and interview, the facility failed to complete a thorough investigation regarding allegations of sexual abuse for 1 (R #1) of 1 (R #1) residents that CNA #1 worked with. This failure could likely lead to other residents' being sexully abused. The findings are: R #1 A. Record review of R #1's face sheet revealed she was admitted to the facility on [DATE]. R #1 was dependent on care for activies of daily living. Her diagnoses included but were not limited to: - Reduced mobility (severe chronic illness that requires immobilization in bed), - Need for assistance with personal care, - Spinal stenosis (narrowing of the spine) lumbar region, - Morbid severe obesity (overweight), and - Sepsis (life threatening condition that arises when the body's response to infection causes injury to its own tissues and organs). B. Record review of the Minimum Data Set (MDS; a federally mandated assessment instrument completed by facility staff), dated 11/30/23, identified R #1's Brief Interview for Mental Status (BIMS; tool to screen and identify the cognitive condition of long-term care residents 0 being the lowest and 15 being the highest) score was 15, cognitively intact. C. On 02/10/24 at 12:15 pm during an interview, R #1 revealed she woke up startled in the early morning hours on 01/23/24 and found Certified Nursing Assistant (CNA) #1 standing by her bedside table. R #1 asked CNA #1 what he was doing in her room in the dark, and he left her room without responding. The next morning (01/24/24), R #1 told Registered Nurse (RN) #1 that CNA #1 was in her room the night prior and it scared her. R #1 asked that CNA #1 not be allowed back into her room. CNA #1 continued to work with the resident, which R #1 stated traumatized her emotionally. R #1 further reported that on 02/02/24, CNA #1 entered R #1's room and began to apply Desitin cream (diaper rash cream) to her pubic area. R #1 stated that CNA #1 began to apply the Desitin cream inside her vagina and touched her clitoris [the sensitive area located on the top of the vulva (the global term that describes all the structures that make the female external genitals] in a sensual manner. R #1 stated the incident happened so quickly, and it was over before she could tell CNA #1 to stop. CNA #1 put R #1's brief back on and left the room without saying anything. R #1 stated she was so terrified that CNA #1 would come back to her room that she did not use her call light for the rest of the night, even though she woke up with her bedding saturated with urine. R #1 stated she reported this to CNA #2. D. Record review of the facility's staffing scheduled revealed CNA #1 was assigned to work with R #1 on the following shifts: - On 01/23/24, 6 pm-11:59 pm, - On 01/24/24, 12 am-6:00 am, - On 02/01/24, 6:00 pm-11:59 pm, - On 02/02/24, 12 am-6 am. E. Record review of R #1's Trauma Informed Assessment, dated 02/02/24 and completed by Social Services, and answered by R #1 revealed: 1. Is abuse, violence, or sexual assault been an event in your life that has caused or causes a problem for you in any way? a. A black man broke into her apartment in 1976 and tried to rape her. (R #1 had an event in her life in 1976 in which a black male broke into her apartment. 2. R #1 answered yes to the question Has there been a sudden event that made you feel very scared, helpless, or horrified? a. After CNA #1 she was sleeping, and that she woke up suddenly. 3. R #1 answered yes to the question Have you had nightmares or thoughts about it happening when you did not want to? a. R #1 expressed concern about CNA #1 in her room and asked RN #1 to please make sure that she had a female CNA. CNA #1 returned, and R #1 felt CNA #1 was anxious but aware of what he was doing when administering Desitin around her private area. He placed the Desitin inside the vaginal area, internally. R #1 did not feel he had any business in that area, because this was not where the medication was stood in her room in the dark and stared at her while upposed to go. 4. R #1 answered yes to the question Have you tried hard to not think about an event or went out of your way to avoid situations that reminded you of it? a. R #1 requested of staff several times for a female attendant. b. If yes, please describe: R #1 was watchful and guarded. Resident went 12 hours without allowing the male CNA to change her. The incident (sexual abuse) happened around 9:00 pm. R #1 allowed the morning nurse to change her at shift change, because the morning nurse was a female. 5. The assessment directed the assessor to evaluate for occurrence of trauma. The assessor documented no occurrence of trauma as resident would not allow herself to be touched by CNA #1 or any other male CNA. The resident only wanted a female in her room at this time. F. On 02/10/24 at 4:12 pm during an interview, RN #1 stated R #1 reported to him [on 01/24/24] that she woke up on the night of 01/23/24 and was startled by CNA #1 standing in the dark near her bed. He said R #1 told him that she was upset and did not wish for CNA #1 to be allowed back in her room. RN #1 stated he did not have the ability to change the schedule, and he did not report the incident to anyone. G. On 02/10/24 at 4:30 pm during an interview, CNA #2 stated R #1 was initially hesitant to discuss the incident between R #1 and CNA #1, but eventually the resident opened up about what happened (on 02/02/24). CNA #2 stated when she went into R #1's room the morning of 02/02/24, she found R #1 in a puddle of urine and the resident urinated through her brief. CNA #2 stated she asked R #1 why no one had changed her throughout the night, and R #1 told her CNA #1 touched her sexually during first rounds. CNA #2 stated R #1 said she did not want to call CNA #1 back into the room so she urinated on herself until the morning shift came in. CNA #2 stated R #1 previously told her that CNA #1 made her (R #1) uncomfortable and was standing in her room in the dark. CNA #2 stated she reported the incident to the facility's administrator on 02/02/24. H. On 02/10/24 at 5:23 pm during an interview with the Director of Nursing (DON), she stated Desitin cream should have only been placed on the outside of R #1's groin area and not placed internally. I. On 02/12/24, at 10:41 am during an interview with the Administrator, she stated the facility offered to send R #1 to the emergency roiagnom on [DATE], but the resident declined. She stated that during the facility's investigation of the incident, they did the random safe survey with five residents on the same hall as R #1. The Administrator said the hall did not have a large female population. The Administrator said the police were called on 02/02/24, and she spoke with the police officer. The Administrator said R #1 told the police officer there was no wrongdoing. The Administrator stated, Mostly, our decision [to unsubstantiate the allegation] was based on [Name of R #1] saying there was no wrongdoing [to the police officer], and we attributed [the allegation] to her past trauma. The Administrator stated CNA #1 was suspended pending results of the investigation, and CNA #1 returned to work a few days later. J. Record review of the police report, dated 02/02/24, revealed law enforcement was called to the facility for possible elder abuse. The police report stated an officer was dispatched to the facility on [DATE], and the officer made contact with R #1. R #1 told the officer that about two weeks ago around 2:00 am and 3:00 am, she woke up to CNA #1 standing next to her bed just staring at her. R #1 told the officer she did not call CNA #1, and the CNA left the room when R #1 asked what he wanted. R #1 told the officer that she told RN #1 about the incident and asked for a different person to care for her. R #1 told the officer that on 02/01/24 CNA #1 took care of her again, and while CNA #1 applied medication to her vaginal area, he began to rub her clitoris. R #1 told the officer it made her feel uncomfortable to the point she did not call CNA #1 back to her room for care the rest of the night. R #1 told the officer she just laid there in a pool of urine until a female staff arrived. R #1 stated she did not want to press charges, but she was upset with how the facility handled the situation. Based on interview and record review, Immediate Jeopardy was identified on 03/15/24 at 4:20 pm to the administrator, in person. The facility took corrective action by proving an acceptable Plan of removal (POR) on 03/14/24 at 4:31 pm. Implementation of the POR was verified offsite on 03/14/24 with completion of resident audits regarding if any of the residents felt safe or felt abused. Plan of removal: The center has implemented a new process to identify residents who may also be affected by an allegation of abuse. The process change includes widening the interview pool to include residents with a BIMS <11 that was not previously in place to ensure the identification of others. To continue compliance each state reportable that includes an allegation of abuse or neglect will be reviewed by a corporate partner to ensure interviews were conducted on all residents residing in the center prior to the 5 day being submitted. If an employee has an allegation of abuse or neglect against them, the IDT will meet, including Social Services, Human Resources, Director of Nursing, and and Administrator, (or their designee) and make a decision to keep or terminate the employee based on the investigation. This process will start on 03/13/24 when the RNC ([NAME] nurse consultant) educated the Administrator and Director of Nursing on performing interviews with all residents that could be at risk of an alleged incident.

Based on record review and interviews, the facility failed to prevent staff to resident sexual abuse and to protect other residents from ongoing sexual behaviors for 2 (R #1 & R #2) of 2 (R #1 and R #2) residents reviewed for abuse. This deficient practice likely resulted in psychosocial distress (unpleasant emotions associated with a highly stressful situation) for the residents who were subject to this behavior. The findings are: R #1 A. Record review of R #1's face sheet revealed she was admitted to the facility on [DATE]. R #1 was dependent on care on activities of daily living. Her diagnoses included but were not limited to: - Reduced mobility (severe chronic illness that requires immobilization in bed), - Need for assistance with personal care, - Spinal stenosis (narrowing of the spine) lumbar region, - Morbid severe obesity (overweight), and - Sepsis (life threatening condition that arises when the body's response to infection causes injury to its own tissues and organs). B. Record review of the Minimum Data Set (MDS; a federally mandated assessment instrument completed by facility staff) dated 11/30/23 identified R #1's Brief Interview for Mental Status (BIMS; tool to screen and identify the cognitive condition of long-term care residents 0 being the lowest and 15 being the highest) score was 15, cognitively intact. C. On 02/10/24 at 12:15 pm during an interview, R #1 stated she woke up startled in the early morning hours on 01/23/24 and found Certified Nursing Assistant (CNA) #1 standing by her bedside table. R #1 asked CNA #1 what he was doing in her room in the dark, and he left her room without responding. The next morning (01/24/24), R #1 told Registered Nurse (RN) #1 that CNA #1 was in her room the night prior and it scared her. R #1 asked that CNA #1 not be allowed back into her room. CNA #1 continued to work with the resident, which R #1 stated traumatized her emotionally. R #1 further reported that on 02/02/24, CNA #1 entered R #1's room and began to apply Desitin cream (diaper rash cream) to her pubic area. R #1 stated that CNA #1 began to apply the Desitin cream inside her vagina and touched her clitoris [the sensitive area located on the top of the vulva (the global term that describes all the structures that make the female external genitals] in a sensual manner. R #1 stated the incident happened so quickly, and it was over before she could tell CNA #1 to stop. CNA #1 put R #1's brief back on and left the room without saying anything. R #1 stated she was so terrified that CNA #1 would come back to her room that she did not use her call light for the rest of the night, even though she woke up with her bedding saturated with urine. R #1 stated she reported this to CNA #2. During the interview R #1 started to cry when she explained CNA #1 had touched her sexually when he rubbed Desitin on her, and she stated she feared him. D. Record review of the facility's staffing scheduled revealed CNA #1 was assigned to work with R #1 on the following shifts: - On 01/23/24, 6 pm-11:59 pm, - On 01/24/24, 12 am-6:00 am, - On 02/01/24, 6:00 pm-11:59 pm, - On 02/02/24, 12 am-6 am. E. Record review of the facility's staff schedule, dated 01/23/24 and 02/02/24, verified CNA #1 was assigned to work with R #1. F. Record review of R #1's Trauma Informed Assessment, dated 02/02/24 and completed by Social Services, revealed: 1. Is abuse, violence, or sexual assualt been an event in your life that has casued or cuases a problem for you in anyway? a. A black man broke into her apartment in 1976 and tried to rape her. (R #1 had an event in her life in 1976 in which a black male broke into her apartment.) 2. R #1 answered yes to the question Has there been a sudden event that made you feel very scared, helpless, or horrified? a. After CNA #1 stood in her room in the dark and stared at her while she was sleeping, and that she woke up suddenly. 3. R #1 answered yes to the question Have you had nightmares or thoughts about it happening when you did not want to? a. R #1 expressed concern about CNA #1 in her room and asked RN #1 to please make sure that she had a female CNA. CNA #1 returned, and R #1 felt CNA #1 was anxious but aware of what he was doing when administering Desitin around her private area. He placed the Desitin inside the vaginal area, internally. R #1 did not feel he had any business in that area, because this was not where the medication was supposed to go. 4. R #1 answered yes to the question Have you tried hard to not think about an event or went out of your way to avoid situations that reminded you of it? a. R #1 requested of staff several times for a female attendant. b. If yes, please describe: R #1 was watchful and guarded. Resident went 12 hours without allowing the male CNA to change her. The incident (sexual abuse) happened around 9:00 pm. R #1 allowed the morning nurse to change her at shift change, because the morning nurse was a female. 5. The assessment directed the assessor to evaluate for occurrence of trauma. The assessor documented no occurrence of trauma as resident would not allow herself to be touched by CNA #1 or any other male CNA. The resident only wanted a female in her room at this time. G. On 02/10/24 at 4:12 pm during an interview, RN #1 stated R #1 reported to him (on 01/24/24) that she woke up on the night of 01/23/24 and was startled by CNA #1 standing in the dark near her bed. He said R #1 told him that she was upset and did not wish for CNA #1 to be allowed back in her room. RN #1 stated he did not have the ability to change the schedule, and he did not report the incident to anyone. H. On 02/10/24 at 4:30 pm during an interview, CNA #2 stated R #1 was initially hesitant to discuss the incident between R #1 and CNA #1, but eventually the resident opened up about what happened (on 02/02/24). CNA #2 stated when she went into R #1's room the morning of 02/02/24, she found R #1 in a puddle of urine, and the resident urinated through her brief. CNA #2 stated she asked R #1 why no one had changed her throughout the night, and R #1 told her CNA #1 touched her sexually during first rounds. CNA #2 stated R #1 said she did not want to call CNA #1 back into the room so she urinated on herself until the morning shift came in. CNA #2 stated R #1 previously told her that CNA #1 made her (R #1) uncomfortable and was standing in her room in the dark. CNA #2 stated she reported the incident to the facility's administrator on 02/02/24. CNA #1 stated there was another resident (R #2) who expressed that she was afraid of CNA #1. CNA #2 could not ellbvorate on what she was afraid of, just that she was afraid. CNA #2 stated R #2 told her that she was scared of CNA #1, but CNA #2 was unable to give an exact date R #2 said this. CNA #2 stated she thought R #2 told her between 02/04/24 through 02/10/24. CNA #2 stated she did not tell anyone that R #2 reported being afraid of CNA #1. I. On 02/10/24, at 5:23 pm, during an interview with the Director of Nursing (DON), she confirmed the Desitin cream should have only been placed on the outside of R #1's groin area and not placed internally. J. On 02/12/24, at 10:41 am during an interview with the Administrator, she stated the facility offered to send R #1 to the emergency roiagnom on [DATE], but the resident declined. She stated that during the facility's investigation of the incident, they did the random safe survey with five residents on the same hall as R #1. The Administrator said the hall did not have a large female population. The Administrator said the police were called on 02/02/24, and she spoke with the police officer. The Administrator said R #1 told the police officer there was no wrongdoing. The Administrator stated, Mostly, our decision [to unsubstantiate the allegation] was based on [Name of R #1] saying there was no wrongdoing [to the police officer], and we attributed [the allegation] to her past trauma. The Administrator stated CNA #1 was suspended pending results of the investigation, and CNA #1 returned to work a few days later. K. Record review of the police report, dated 02/02/24, revealed law enforcement was called to the facility for possible elder abuse. The police report stated an officer was dispatched to the facility on [DATE], and the officer made contact with R #1. R #1 told the officer that about two weeks ago around 2:00 am and 3:00 am, she woke up to CNA #1 standing next to her bed just staring at her. R #1 told the officer she did not call CNA #1, and the CNA left the room when R #1 asked what he wanted. R #1 told the officer that she told RN #1 about the incident and asked for a different person to care for her. R #1 told the officer that on 02/01/24 CNA #1 took care of her again, and while CNA #1 applied medication to her vaginal area, he began to rub her clitoris. R #1 told the officer it made her feel uncomfortable to the point she did not call CNA #1 back to her room for care the rest of the night. R #1 told the officer she just laid there in a pool of urine until a female staff arrived. R #1 stated she did not want to press charges, but she was upset with how the facility handled the situation. R #2 L. Record review of R #2's face sheet revealed she was admitted on [DATE]. Her diagnosis included but were not limited to: Cerebral ischemia (a condition in which there is insufficient blood flow to the brain to meet metabolic demand), need for assistance with personal care, other reduced mobility, and weakness. M. Record review of the MDS, dated [DATE], identified R #2's BIMS score was 9, moderately impaired. N. On 02/10/24, at 4:45 pm during an interview, R #2 provided a physical description of CNA #1 and said the CNA attempted to touch her twice. R #2 was unable to give dates. R #2 pointed to her genitals. R #2 stated, I told him it [her body] was mine and to leave it alone. I am afraid of him. I am afraid of him around me, because he touched me. I didn't know who to tell. I am afraid of him. It happened the other night. O. Record review of the facility's staff schedule, dated 02/04/24 through 02/07/24, revealed CNA #1 worked on the hall where R #2's room was located and provided care for R #2. Further review revealed CNA #1 was the only male that worked with R #2 during that time. P. Record review of R #2's Trauma Informed Assessment, dated 02/10/24, completed by social services revealed: 1. R #2 reported a male staff member came in and tried to feel her up. The resident stated the staff member did not wear a badge, and she never saw him before. The assessor documented, He tried to play with her privates. 2. The assessor left questions 2 through 6 blank on the form. 3. R #2 stated she did not want that staff member to come to her room. The assessor documented, She is very horrified and on guard after what happened in her room. He should have been changing her but instead was touching down there. Q. On 02/12/24 at 10:41 am during an interview with the Administrator regarding R #2, she said they offered to have a physician examine R #2 on 02/10/24, but the resident declined. The administrator said they were currently doing an investigation and CNA #1 was suspended pending results of the investigation, CNA #1 had not returned to work at this time, and the facility filed a state report.

Based on record review and interview, the facility failed to ensure residents received treatment and care in accordance with professional standards of practice when staff did not routinely check the blood sugar levels of residents with diabetes for 4 (R #'s 1, 2, 3, and 4) of 4 (R #'s 1, 2, 3, and 4) residents reviewed for diabetes mellitus [DM; an impaired ability of the body to produce or respond to insulin (a naturally occurring hormone made by your pancreas that helps your body use sugar for energy) to maintain proper sugar levels (glucose) in the blood.] This deficient practice resulted in R #1's blood sugar not being routinely checked or checked when R #1 experienced a change in condition (changes from a persons normal baseline status), which likely resulted in R #1 being hospitalized with high blood sugar levels and in a diabetic coma (life threatening complication resulting from very high blood sugar). This deficient practice is also likely to result in residents not receiving the appropriate diabetic medical care and leading to an exacerbation (to make worse) of current medical conditions and/or death. The findings are: Findings for R #1: A. Record review of R #1's face sheet and most recent Care Plan revealed an original admitted [DATE] with the following diagnosis: - Type 2 diabetes mellitus (DM2) without complications (a disease that occurs when a person's body does not use insulin effectively), - Diabetes mellitus due to underlying condition with diabetic nephropathy (a progressive disease that affects your kidneys). B. Record review of R #1's Physician Order, dated 03/09/23, revealed metformin HCL tablet (an oral drug used to control and balance blood sugar levels), 500 milligrams (MG). Give 1 tablet by mouth two times a day for diabetic management. C. Record review of R #1's Electronic Medical Record (EMR) indicated the record did not contain physician orders for diabetes management. D. Record review of R #1's progress note, dated 10/01/23, indicated R #1 did not eat and required assistance from staff. The note stated staff did not check R #1's blood glucose level (BGL) at this time. E. Record review of R #1's progress note, dated 10/04/2,3 indicated R #1 barely ate. The note stated staff did not check R #1's BGL at this time. F. Record review of R #1's progress note, dated 10/12/23 at 11:28 am, revealed R #1 was lethargic and barely opened her eyes. The note stated R #1's BGL read high on the glucometer, but staff did not document a number. The high BGL resulted in R #1 being sent to the emergency room (ER). This was the first time staff documented R #1's BGL in the resident's progress notes since her admission on 11/21/19. G. Record review of R #1's hospital admission documentation, dated 10/12/23, revealed the hospital staff documented R #1's BGL measured 1030 mg/di (milligrams per deciliter; a unit of measure that showed the concentration of a substance in a specific amount of fluid. Normal BGL is 80 to 100) and the resident's urinary analysis ( a test of your urine used to detect and manage a wide range of disorders) was positive for a bacterial infection. Hospital records identified R #1 was in a diabetic coma. The resident's A1C (a blood test that measured average blood glucose over the past two to three months) at the hospital measured 12 (very high). H. On 12/20/23 at 1:24 pm during an interview with R #1's son, he stated he had several complaints about his mother's care while at the facility. He said R #1 fell , lost a lot of weight, and the resident's diabetes was off track. He said the facility staff called and told R #1's family they needed to come to the facility and feed their mother. The facility staff told them the resident did not want to eat and was losing weight. He said staff also told them to bring her shakes and come sit with her. I. On 12/21/23 at 1:00 pm during an interview with R #1's daughter, she stated the family filed a complaint with the New Mexico Department of Health, because their mother was sent to the emergency room and ended up in the intensive care in a diabetic coma. She stated the facility knew R #1 was a diabetic. The daughter said the facility called the family on the day the resident went to the hospital, and the staff told them their mother was very lethargic. J. On 12/21/23 at 8:47 pm during an interview with Licensed Practical Nurse (LPN) #1, she stated residents who take metformin for diabetes have their blood sugar checked once a day. The LPN said R #1 was on metformin, but she did not know if staff checked the resident's blood sugar. K. On 12/21/23 at 9:08 pm during an interview with Director of Clinical Services (DCS), she stated R #1 took metformin. The DCS said the doctor saw the resident on 10/06/23 and did not assess the resident's blood sugar or DM. The DCS said some physicians order staff to check a resident's blood sugar, and other physicians do not. The DCS said she would expect nursing staff to use their judgment on when to check a resident's blood sugar level. L. On 12/22/23 at 9:31 am during an interview with Medical Doctor (MD) #1, he stated he would expect the facility staff to notify him when R #1 did not eat and became lethargic, prior to the day she went to the ER. He said the professional standard was for anyone with diabetes and took insulin or Metformin should have their BGL checked. MD #1 confirmed staff should have check R #1's BGL frequently, especially in the days prior to R #1 going to the ER when she was not eating. The MD said the facility's diabetic management was not conducted according to his expectations. N. On 12/22/23 at 9:52 am during an interview with MD #2, she stated the professional standard was if a resident took metformin then staff should check that resident's blood sugar once a day. The MD said her expectation was for staff to inform the doctor if a resident's blood sugar was very low or over 400. She said it was expected the doctors would look at a resident's blood sugar at each visit to identify any trends in the resident's BGL. MD #2 said it was expected the facility nurses would notify her or the on-call doctor immediately if a resident had a change of condition, and that the nurses would let them know the resident was on diabetic medication. MD #2 stated staff should check a resident's blood sugar levels anytime the resident had a change in condition. O. On 12/22/23 at 10:53 am during an interview with Registered Nurse (RN) #1, she stated she checked R #1's blood sugar when the resident did not eat. RN #1 stated she did not document the results of that test in the resident's record. The RN said staff have to make a judgement call whether or not to check a resident's blood sugar when the resident took metformin. RN #1 stated R #1 was lethargic and did not eat prior to going to theER on [DATE]. The RN said she informed the doctor the resident was not doing well. Findings for R #2: P. Record review of R #2's face sheet/admission record revealed an original admitted [DATE] with a diagnosis of type 2 diabetes mellitus without complications. Q. Record review of R #2's care plan, dated 10/14/23, revealed, - Focus: The resident had diabetes mellitus. - Interventions: Fasting serum blood sugar (FSBS; a medical test that measured the amount of glucose in a person's blood after an overnight fast) as ordered by doctor. R. Record review of R #2's physician orders, dated 11/21/23, revealed R #2 received 12 units of insulin one time a day, every day, for diabetes. S. Record review of R #2's physician orders, dated 09/29/23 through 12/21/23, revealed the record did not contain an order to check R #2's blood sugar level. T. Record review of R #2's Vitals- Blood Sugar Summary, dated 11/01/23 through 11/30/23, revealed staff documented they checked R #2's blood sugar level 15 times out of 30 opportunities. U. Record review of R #2's Vitals- Blood Sugar Summary, dated 12/01/23 through 12/21/23, revealed staff documented they checked R #2's blood sugar level once on 12/16/23. V. On 12/21/23 at 7:00 pm during interview, the Regional Nurse Consultant (RNC) stated R #2 received finger sticks without a doctor's order, and the resident received a long acting insulin. The RNC said blood sugar checks were built into the insulin order. 41988 Findings for R #3: W. Record review of R #3's face sheet revealed R #3 was admitted into the facility on [DATE] with a diagnosis of type 2 diabetes mellitus with hyperglycemia (high blood sugar). X. Record review of R #3's physician orders revealed the following: - An order, dated 12/09/23, for capillary blood glucose- blood sugar level (CBG): For blood glucose (BG) less than 70, give 15 grams carbohydrates, wait 15 minutes, and recheck BG. If still less then 70 then give another 15 grams carbohydrates, wait 15 minutes, and recheck BG again. If still less than 70, notify the Medical Doctor (MD). Once BG at 70, give snack containing protein. - An order, dated 12/09/23, for Basaglar KwikPen Subcutaneous Solution Pen-injector, 100 UNIT/milliliter (ml), insulin glargine. Inject 10 units subcutaneously (under the skin) in the morning for diabetes mellitus. - The record did not contain orders for nursing staff to check R #3's blood sugar to know if R #3's blood sugar was less than 70. Y. Record review of R #3's Blood Sugar Summary, dated 12/09/23 through 12/21/23, revealed staff documented they checked R #3's blood sugar once on 12/09/23. Z. On 12/21/23 at 8:49 pm during an interview with LPN #1, she stated staff checked R #3's blood sugar level at bedtime to see if there was a change. LPN #1 confirmed staff should check R #3's blood sugar levels regularly, because he received insulin. AA. On 12/22/23 at 9:35 am during an interview with MD #1, he stated if a resident's diabetes was under control then staff could conduct blood sugar checks daily or weekly. The MD said it was not acceptable for staff not to perform daily blood sugar checks for residents who receive insulin, including R #3. Findings for R #4: BB. Record review of R #4's face sheet revealed R #4 was admitted into the facility on [DATE] with a diagnosis of type 2 diabetes mellitus with hyperglycemia. CC. Record review of R #4's physician order, dated 11/27/23, revealed metformin HCI oral tablet, 500 MG (not extended release). Give one tablet by mouth two times a day for DM2. The record did not contain a physician order for blood sugar checks. DD. Record review of R #4's care plan, dated 12/06/23, revealed the following: - Focus: Diabetic potential to develop hyperglycemia (high blood sugar) and hypoglycemia (low blood sugar). - Interventions: Check fasting serum blood sugar as ordered. EE. Record review of R #4's Vitals-Blood Sugar Summary, dated 11/27/23 through 12/21/23, revealed staff did not document they checked R #4's blood sugar. FF. On 12/22/23 at 9:40 am during an interview with MD #1, he stated staff should check R #4's blood sugar levels daily or at least weekly. He said staff need to know if the resident's blood sugar levels were controlled or uncontrolled. MD #1 confirmed there should be an order to check R #4's blood sugar levels, and staff should check R #4's blood sugar regularly and according to her care plan. These deficient practices resulted in Immediate Jeopardy identified on 12/22/23. The facility Administrator was first notified of the Immediate Jeopardy on 12/22/23 at 1:44 pm. Plan Of Removal Accepted on 12/22/23 at 4:17 pm and indicated the following: 1. Residents with a diagnosis of diabetes were reviewed for blood glucose check orders, and intervention with the medical director on 12/22/23. Reviewed with (MD #2) on 12/22/23. Orders that needed to be updated with the new medical director's standards were completed on 12/22/23. 2. The new standard regarding diabetic monitoring included: those residents with a hypoglycemic by mouth medication would receive blood sugar checks three times a week, those with insulin orders would be checked with his/her insulin dose, and those who are unstable will have a HgAlc ordered and depending on the result would receive a new lab either in 3 months or in 6 months. Licensed nurses were educated on the standards set by the new medical director on or before 12/27/23. 3. Residents with a diagnosis of diabetes had a blood sugar taken on 12/22/23 to determine if blood sugar is outside of the acceptable range. Two residents identified were reviewed with the provider on 12/22/23. 4. The medical director put in a standard for residents with a change in condition that any resident with a high blood sugar to be taken along with oxygen saturation. This new directive was presented to the licensed nursing staff on 12/22/23. The education will be continued through the shift changes to ensure licensed nurses entering a shift are aware of the new changes in directive for blood sugar monitoring and change of condition. Implementation of the Plan of Removal was validated on 12/22/23 onsite through observation and interview.

Based on record review and interview, the facility failed to (1) timely recognize a change in condition of a resident after a fall and (2) failed to notify physician of change in condition for 1 (R #7) of 1 (R #7) resident reviewed for falls and change in condition. These failures resulted in the delay of treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . The findings are: A. Record review of the face sheet for R #7 indicated he was admitted to the facility on [DATE]. Primary admission diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . B. Record review of the Minimum Data Set (MDS), (a core set of screening, clinical, and functional status elements, which forms the foundation of a comprehensive assessment for all residents of nursing homes certified to participate in Medicare or Medicaid) completed [DATE] for R #7 indicated the resident's hearing, speech and vision were adequate. The MDS indicated R #7 needed minimal assistance with activities of daily living (eating, walking, bed mobility, and transfer ability.) The MDS also indicated R #7 had no impairment in range of motion and did not use a mobility device. C. Record review of a complaint received by the State Survey Agency on [DATE] alleged R #7 had fallen on [DATE] and received a bump to the head. The complaint indicated a few days later the resident was diagnosed with a brain bleed. D. Record review of facility progress notes for R #7 indicated the following: 1. On [DATE] at 2:12 pm it is noted that R #7 was found in his room on the floor in front of his bed. The nurse documented, R #7 has a bump to the back of his head the size of a penny. Ice applied, administrator, physician, and power of attorney (POA) notified. The nurse also documented neuro checks will be completed for 72 hours. 2. On [DATE] at 1:03 pm documentation indicated R #7 was weak, lethargic and not eating well, 3. On [DATE] at 1:19 pm documentation indicated R #7 was now in a wheelchair because his legs are weak. The note also indicated the resident was not swallowing his food. There is no documentation to indicate R #7's physician was notified of this change in condition. 4. There were no further progress notes in R #7's record from [DATE] until [DATE] for a resident whose condition was deteriorating and was on 72 hour monitoring for a head injury. 5. Record review of the facility neuro check form indicated no documentation from 6:00 am to 6:00 pm on either [DATE] or [DATE]. 6. On [DATE] at 10:03 am R #7 is unable to swallow liquids, is non responsive to verbal commands, and grimacing in pain. Physician was notified and R #7 sent to local Emergency Department (ED). E. Record review of the ED physician documentation dated [DATE] at 10:36 am indicated patient (R #7) presents to the ED via Emergency Medical Services (EMS) from [name of facility] for a mental and physical decline over the last week. Per EMS [Emergency Medical Services], patient has had a decreased oral intake, generalized fatigue, last week was able to ambulate [walk], now bed ridden. Patient is verbal, but words are quiet and incomprehensible. The ED physician also documented motor strength was ,d+[DATE] in the right hand, left hand, right arm and left arm. Strength was ,d+[DATE] in the right foot, left foot, right leg, and left leg. F. Record review of the radiologist report dated [DATE] for the computed tomography (CT) scan (allows doctors to see inside the body. It uses a combination of X-rays and a computer to create pictures of organs, bones, and other tissues) of R #7's head indicated, there is a subarachnoid (the area between the brain and the tissue covering the brain) blood in the posterior (back) region, superiorly (upper) on the right, and there are bilateral (affecting both sides) areas of subarachnoid blood and sulci (groove) of the parietal (relating to or forming the wall of a body part, organ, or cavity) region and right temporal lobe (each of the paired lobes of the brain lying beneath the temples). The radiologist reported this as a critical finding. G. Record review of the ED physician final disposition summary dated [DATE] at 3:57 pm indicated R #7 has a traumatic subarachnoid hemorrhage. The ED physician documented that the POA had decided on palliative (medical care that focuses on relieving pain or discomfort rather than administering a cure) care and the resident was being sent back to the nursing facility. H. Record review of nursing progress notes for R #7 dated [DATE] at 6:13 pm indicated R#7 was deceased . I. On [DATE] at 10:45 am during an interview with Registered Nurse (RN) #5, he stated he remembered R #7 and was the nurse responsible for the care of R #7 the days after the resident fell . RN #5 stated he did not complete the neurocheck form on [DATE] and [DATE] because he could not find the form. He stated he completed another form for those days. When asked where in the Electronic Health Record (EHR) the form was completed, RN #5 stated he could not find it. RN #5 also confirmed that he did not notify the physician when R#7 became weaker, would not swallow, and required the use of a wheelchair. J. On [DATE] at 11:10 am during an interview the Director of Nursing (DON) stated she was not made aware of the fall and injury to R #7 until [DATE]. She stated her first day working in the facility was [DATE]. The DON confirmed the neurocheck form for R#7 was not completed on [DATE] and [DATE]. K. On [DATE] at 8:45 am during an interview with Medical Doctor (MD) #1, he stated if the facility had notified him of R #7's change of condition, that the resident was not eating and had difficulty walking, MD #1 would have sent R #7 to the local emergency department, especially after a fall in which the head was injured. MD #1 stated he was not notified of R#7's change in condition. This resulted in an Immediate Jeopardy (IJ) being called on [DATE] at 10:40 am. The facility administrator, Director of Nursing, Executive Director, and the Clinical Services Director were notified at this time. A plan of removal was received and accepted on [DATE] at 3:00 pm. Implementation of the Plan or removal was validated onsite. The Plan of Removal included: 1. An audit of falls within the last 30 days to review for documentation, neuro checks implemented, change of condition after fall, and physician notification. 2. Neurological checks competencies initiated by Director of Nursing. 3. Director of Nursing re-educated by the Clinical Services Director on identifying change of condition, fall documentation, and notification to the physician. 4. Licensed nurses re-educated on identifying change of condition, fall documentation, and notification to the physician. 5. Daily audit five days a week to be completed during Clinical Morning Meeting to review incident/accidents, review fall documentation, neuro check completion, and notification to the physician. 6. An as the occasion requires (Ad Hoc) Quality Assurance/Performance Improvement (QAPI) meeting held.

Based on record review, observation and interview the facility failed to administer a anticoagulant medication per physicians orders for 1 (R #57) of 1 (R #57) reviewed for skin conditions. This failure resulted in R #57, who has a [DIAGNOSES REDACTED]. The findings are: A. Record review of the facility face sheet for R #57 dated 09/09/18 indicated this date was R #57 latest admission. Admission [DIAGNOSES REDACTED].(permanent shortening of muscles, tendons, and/or ligaments),[MEDICAL CONDITION]([MEDICAL CONDITION] reflux disease, a digestive disorder), chronic embolism and [MEDICAL CONDITION], dependence on supplemental oxygen, hypertension (HTN) (high blood pressure), protein deficiency [MEDICAL CONDITION] ([MEDICAL CONDITION] is a common type of [MEDICAL CONDITION] - a condition in which blood lacks adequate healthy red blood cells), asthma (a [MEDICAL CONDITION] that inflames and narrows the airways), pain, persistent vegetative state (A disorder of consciousness, or impaired consciousness, is a state where consciousness has been affected by damage to the brain). B. Record review of the care plans dated 09/28/18 for R #57 with Problem, measurable Goal and Approaches include, risk for bleeding related to (r/t) anticoagulant therapy, mechanical lift (are used to move those who are unable to stand on their own or whose weight makes it unsafe to move or lift them manually), risk for pain r/t contractures, bilateral splints to elbows, activities of choice, nutritional and dehydration risk, persistent vegetative state, oral care, risk for frequent infections r/t incontinence, history (Hx) of grand mal [MEDICAL CONDITION] (Caused due to abnormal electrical activity in the brain), [MEDICAL CONDITION], incontinent of bowel and bladder, risk for dehydration, risk for falls, risk for skin breakdown, total assist with Activities of Daily Living (ADL's). C. Record review of Care Plan for R #57 with Problem,measurable Goal and Approaches date 11/06/17 and edited on 09/28/18 revealed, Problem: is at risk for bleeding related to anticoagulation therapy d/t (due to) Hx of embolism and [MEDICAL CONDITION]. Goal: will not exhibit signs of bleeding. Approaches: Administer medications as ordered: Eliquis, Assess for presence of conditions that affect blood clotting (e.g., use of anticoagulants, decreased platelets, [DIAGNOSES REDACTED] (deficiency of clotting factors), etc.), Control active bleeding by applying pressure at site, For nosebleeds, position resident upright (unless hypotensive (low blood pressure)). Pinch nostrils together to apply pressure. Rule out hypertensive (high blood pressure) crisis, Measure vital signs. Monitor/report signs of shock ([MEDICAL CONDITION], weak thready pulse, chills, palpitations, perspiration). D. On 01/28/19 at 8:30 am during an observation R #57's left leg was noted to be swollen from the groin to the foot and approximately 1 1/2 times larger when compared to the right leg. E. On 01/29/19 at 3:30 pm during an observation R #57's left leg appears to remain swollen from the groin to the foot approximately 1 time larger when compared to the right leg. F. Record review of Medication Flowsheet for R #57 dated 01/20/18 thru 09/30/2018 revealed R # 57 was receiving Eliquis 2.5 mg twice a day via [DEVICE] for Chronic embolism and thrombus. On 09/07/18 Eliquis was not give due to resident being in the hospital. G. Record review of Medication Reconciliation Patient Discharge Summary dated 09/09/18 for R #57 revealed, .Continue taking these medications .Apixaban Base (Eliquis) 2.5 mg 1 tab two times daily .this prescription has been renewed. H. Record review of Medication Flowsheet for R #57 dated from 09/09/18 thru 01/24/19 revealed, Eliquis is not present on the Medication Flowsheet's as ordered. I. Record review of Nurses Notes for R #57 dated 01/23/19 at 11:30 pm revealed, Resident L (left) thigh noted to be bigger than R (right) 2+ (the fingers will sink into the tissue and leave an impression of the fingers when they are removed. Slight indentation, rapid return to normal +2) [MEDICAL CONDITION] (parts of your body swell and get puffy) to ankle and foot (Normal is without swelling ([MEDICAL CONDITION]) and skin does not remain depressed when pushed on). (name of Certified Nurse Practitioner (CNP)) notified and order for BLE (bilateral lower extremities (lower legs)) venous Doppler (ultrasound of the extremities) received . J. Record review of Nurses Notes for R #57 dated 01/24/19 at 6:30 pm revealed, (name of CNP) ordered for resident to be sent to ED (Emergency Department) for further treatment of [REDACTED]. K. Record review of Leg Venous Doppler report dated 01/24/19 at 2:10 pm revealed, .Conclusion: Left lower extremity deep vein thrombus. No evidence of right lower extremity deep vein thrombus. L. Record review of Nurses Notes for R #57 dated 01/24/19 at 11:00 pm revealed, Resident returned at 10:30 pm with orders for Eliquis (an anticoagulant) 10 mg (milligrams) BID (twice a day) X (times) 7 days, then Eliquis 5 mg BID. Follow up with (name of doctor) in 2-3 days. Discharge instructions for [MEDICAL CONDITION] and the prescription for Eliquis (as ordered above) were also included. M. On 01/30/19 at 7:40 am during an interview Licensed Practical Nurse (LPN) #1 stated, When I saw (name of resident #57) thigh I was almost positive he had a [MEDICAL CONDITION], it was swollen that large. He has had at least one in the past and was placed on a blood thinner (Eliquis) then. That was discontinued sometime, don't remember exactly when, after that and he had no problem until last week. With his persistent vegetative state and total lack of mobility this was always a possibility. N. On 01/31/19 at 8:05 am during an interview the Director of Nursing (DON) stated, I have no documentation as to why the Eliquis was stopped in (MONTH) (2018). I don't know why it was stopped. O. On 02/01/19 at 8:55 am during an phone interview with the Medical Director stated I did not discontinue the medication. Apparently the medication reconciliation was not done and thus the Eliquis was not transferred to the admission orders [REDACTED].

Based on interview, observation and record review the facility failed to ensure that a comprehensive care plan for a gastrostomy tube (medical procedure in which a tube (G tube) is passed into a patient's stomach through the abdominal wall, for a means of feeding) and [MEDICAL CONDITION] (a surgical procedure in which an opening (stoma) is formed by drawing the healthy end of the large intestine or colon through an incision in the anterior abdominal wall for stool to pass through) was developed for 1 ( R #3) of 4 ( R #1, #2, #3 and #4) residents reviewed for care plans. If the resident's care plan does not accurately reflect the resident's health status, treatment and interventions, residents may not get the care and treatment that they need. The findings are: A. On 09/04/18 at 4:10 pm, during an interview, R #3's Family Member #1 (FM) stated that (Name of Resident #3) was so sick and was sent to the hospital from a physician's office (Physician #1) visit on 06/13/18. FM #1 further stated that (Name of Resident #3) was admitted to the hospital intensive care unit on 06/13/18 and had his/her colon removed due to a toxic mega colon (swelling and inflammation spread into the deeper layers of your colon, the colon stops working and widens and may rupture) and required a [MEDICAL CONDITION]. FM #1 stated that his/her colon was the size of a softball, and (Name of Resident #3) needed a feeding tube. B. On 09/04/18 at 4:10 pm, during an observation, R #3 had a gastrostomy tube to the upper left abdomen, a [MEDICAL CONDITION] to right mid abdomen, and a dry dressing was noted to the left [MEDICAL CONDITION]. C. Record review of the face sheet dated 05/24/18 for R #3 revealed, an admission of date of 05/24/18. R #3 had a re-admitted [DATE] and a third admission date of [DATE]. [DIAGNOSES REDACTED]. Difficile (Infection of the large intestine (colon) caused by the bacteria [MEDICAL CONDITION]) - Resolved, leukocytosis (white cells above the normal range in the blood), and chronic [MEDICAL CONDITION] (irregular and often fast heartbeat), with long-term anticoagulant (medication to thin the blood) use, diarrhea (liquid stools), toxic mega colon, status [REDACTED].), and [MEDICAL CONDITION] (high potassium). D. Record review of the only care plan dated 05/29/18 for R #3 revealed, there was no care plan for a re-admission on 06/28/18 for the care of R #3's [MEDICAL CONDITION] and gastrostomy tube. E. On 09/06/18 at 4:25 pm, during an interview, the Director of Nursing stated that there was nothing on the care plan for (Name of Resident #3's) [MEDICAL CONDITION] care, or feeding tube care.

Based on interview, observation and record review the facility failed to ensure the comprehensive care plan was revised for severe weight loss for 1 ( R #3) of 4 ( R #1, #2, #3 and #4) residents reviewed for care plans. If the resident's care plan does not accurately reflect the resident's health status, treatment and intervention, residents may not get the care and treatment that they need. The findings are: A. On 09/04/18 at 4:10 pm, during an interview, R #3's Family Member #1 (FM) stated that (Name of Resident #3) was so sick and was sent to the hospital from a physician's office (Physician #1) visit on 06/13/18 and was admitted to the intensive care unit. R #3 had to have his/her colon removed due to a toxic mega colon (swelling and inflammation spread into the deeper layers of your colon, the colon stops working and widens and may rupture) and required a [MEDICAL CONDITION] (surgical procedure in which an opening (stoma) is formed by drawing the healthy end of the large intestine or colon through an incision in the anterior abdominal wall). FM #1 stated that his/her colon was the size of a softball, and (Name of Resident #3) needed a feeding tube (gastrostomy ([DEVICE]) - tube inserted in the stomach for nutrition). FM #1 stated that she told the Administrator, unknown date, and the Administrator was going to make sure it didn't happen again. R #3 was in the hospital from 06/13/18 through 06/28/18. B. On 09/04/18 at 4:10 pm, during an observation, R #3 had a gastrostomy tube to the upper left abdomen, a [MEDICAL CONDITION] to right mid abdomen, and a dry dressing was noted to the left [MEDICAL CONDITION]. C. Record review of the face sheet dated 05/24/18 for R #3 revealed, an admission of date of 05/24/18. R #3 had a re-admitted [DATE] and a third admission date of [DATE]. [DIAGNOSES REDACTED]. Difficile (Infection of the large intestine (colon) caused by the bacteria [MEDICAL CONDITION]) - Resolved, leukocytosis (white cells above the normal range in the blood), and chronic [MEDICAL CONDITION] (irregular and often faster heartbeat), with long-term anticoagulant (medication to thin the blood) use, diarrhea (liquid stools), toxic mega colon, status [REDACTED].), and [MEDICAL CONDITION] (high potassium). D. Record review of the care plan dated 05/24/18 for R #3 revealed, 06/12/18 - Category: Falls, at risk for falling related to below knee amputation and [MEDICAL CONDITION]. There is no interventions on the care plan for the [MEDICAL CONDITION] listed. E. Record review of a Data Collection/Evaluation Nutritional document dated 06/07/18 for R #3 revealed, Current weight 187 pounds, ideal body weight range 154-189, body mass index (BMI) 25.8. Caloric needs: 2550 per day, Protein needs: 127 grams per day and fluid needs: 2550 milliliters per day. F. Record review of vitals report for weight from admission date of [DATE] through 06/13/18 revealed: 1. 05/25/18 - 201.4 2. 05/26/18 - 197.2 3. 05/27/18 - 197.8 4. 05/30/18 - 188.8 This is a 13 pound loss, no interventions noted. 5. 06/06/18 - 178.6 This is a 23 pound loss. Recommended 1 ounce liquid protein every day. 6. 06/13/18 - 179.4 R #3 was discharged to the hospital. G. Record review of the vitals report for meal intake from 05/24/18 through 06/13/18 for R #3 revealed, 1. No amount of meal intake was documented for 05/27/18, 05/28/17, 05/29/18, 06/04/18, 06/07/18, 06/08/18, and 06/10/18. 2. Meal intake of 26-50% was documented for 06/09/18 and 06/13/18 with one refusal to eat on 06/09/18. H. Record review of the only care plan dated 05/29/18 for R #3 revealed, 05/29/18 - Category: Nutritional Status. No interventions were listed for the weight loss from 05/27/18 through 06/13/18, on the care plan. I. On 09/06/18 at 4:25 pm, during an interview, the Director of Nursing (DON) stated that there was nothing on the care plan for (Name of Resident) for his/her weight loss. The DON further stated that the [MEDICAL CONDITION] infection was listed under falls as a reason for weakness but did have any interventions listed for the weight loss.

Based on record review and interview the facility failed to provide treatment for 1 (R #3) of 1 (R #1) Resident with a history of [MEDICAL CONDITION] (C Diff) (infection of the large intestine (colon) caused by the bacteria of[DIAGNOSES REDACTED]), and repeated diarrhea. This deficient practice likely resulted in harm for R #3, by developing a toxic mega colon (swelling and inflammation spread into the deeper layers of the colon, the colon stops working and widens and may rupture), and the need for a [MEDICAL CONDITION] (a (stoma) constructed by bringing the end or loop of intestine out onto the surface of the skin, waste passes out of the [MEDICAL CONDITION] opening). The findings are: A. On 09/04/18 at 4:10 pm, during an interview, R #3's Family Member #1 (FM) stated that (Name of Resident #3) was so sick and was sent to the hospital from a physician's office (Physician #1) visit on 06/13/18. FM #1 further stated that (Name of Resident #3) was admitted to the hospital and had his/she colon removed due to a toxic mega colon and required a [MEDICAL CONDITION]. FM #1 stated that (Name of resident #3's) colon was the size of a softball. FM #1 stated that she told the Administrator, unknown date, and the Administrator was going to make sure it didn't happen again. R #3 was in the hospital from 06/13/18 through 06/28/18. B. Record review of Daily Skilled Nurses's Note for R #3 dated 06/13/18 for the day shift revealed, . 3:45 pm - Was notified by emergency room (ER) that (Name of Resident #3) was sent from the physicians office to ER. C. Record review of a office visit note for R #3 dated 06/13/18 from Physician #1 revealed, Reason for visit follow-up, extremity weakness, [MEDICAL CONDITIONS] (potentially life-threatening infection caused by a type of bacteria. It can cause [MEDICAL CONDITION], a serious inflammation of the colon), Vitals: Blood Pressure (B/P) 86/29 (normal 120/80) Pulse 101 (High- normal is 80) . D. Record review of bowel movement (BM) documentation by the Certified Nurse Aides (CNA's) for R #3 revealed, R #3 had loose stools (BM/diarrhea) on: 1. 06/01/18 10:13 pm - Loose 2. 06/03/18 at 10:30 am - Liquid 3. 06/05/18 at 2:27 am - Liquid 4. 06/05/18 at 8:35 am - Liquid 5. 06/09/18 at 11:13 am - Liquid 6. 06/10/18 at 1:21 am - Liquid 7. 06/10/18 at 3:21 am - Liquid 8. 06/10/18 at 4:29 am - Liquid 9. 06/10/18 at 5:09 am - Liquid 10. 06/11/18 at 2:39 am - Liquid 11. 06/11/18 at 6:03 am - Liquid 12. 06/12/18 at 1:13 am - Liquid 13. 06/12/18 at 6:02 am - Liquid E. Record review of Nurse's notes dated: 1. 06/ 06/18 no time documented revealed, diarrhea was checked on the day and night shift. 2. 06/ 07/18 no time documented revealed, diarrhea was checked on the day and night shift. 3. 06/ 08/18 no time documented revealed, diarrhea was checked on the day and night shift. 4. 06/10/18 no time documented revealed, diarrhea was checked on the day shift. 5. 06/11/18 no time documented revealed, diarrhea was checked on the day and night shift. There is no documented evidence that the physician was notified that R #3 was having loose, liquid bowel movements or diarrhea. F. Record review of a discharge summary from hospital #1 dated 06/28/18 for R #3 revealed, Came to the hospital due to diarrhea for weeks and had a toxic mega colon. He was told as an outpatient that he had a [DIAGNOSES REDACTED] infection. (Name of Resident #3) required a colectomy (Colectomy is bowel resection of the large bowel, the surgical removal of any extent of the colon) with [MEDICAL CONDITION] and gastrostomy ([DEVICE] - is a tube inserted through the abdomen that delivers nutrition directly to the stomach). G. Record review of a discharge summary from hospital #1 dated 06/28/18 for R #3 revealed, Date of admission: 06/13/18, Date of discharge: 06/28/18, Admission Diagnosis: [REDACTED]. Symptoms include abnormal heart rate, increased body temperature, decreased platelet count and inflammation throughout the body. People with [MEDICAL CONDITION] require close monitoring and treatment in a hospital intensive care unit and proper medications), diarrhea (loose bowel movements), [DIAGNOSES REDACTED] (low potassium), [MEDICAL CONDITION] (insufficient numbers of red blood cells). H. Record review of a discharge summary from hospital #1 dated 06/28/18 for R #3 revealed, Discharge Diagnosis: [REDACTED]. I. On 09/06/18 at 4:37 pm, during an interview, the Director of Nursing (DON) stated that she/he was not sure if the diarrhea had been reported sooner to R #3's Physician (#1) if the toxic mega colon could have been prevented. Physician #1 was called on 09/11/18 at 1:41 pm, a message was left for a return call. Physician #1 did not return the call.

Based on record review, and interview, the facility failed to maintain a resident's usual body weight for 1 (R #3) of 2 (R #1 and #3) sampled residents for weight loss. R #3 lost 22 pounds between 05/25/2018 and 06/13/18. This would be a severe weight loss percentage of 10.94%. (Center for Medicare and Medicaid (CMS)) considers a weight loss of greater then 5% in one month to be severe weight loss.) R #3 required the placement of a gastrostomy tube (also called a [DEVICE] - is a tube inserted through the abdomen that delivers nutrition directly to the stomach) on 06/14/18. The findings are: A. On 09/04/18 at 4:10 pm, during an interview, R #3's Family Member #1 (FM) stated that (Name of Resident #3) was so sick and was sent to the hospital on [DATE] from a physician's office (Physician #1). FM #1 further stated that (Name of Resident #3) was admitted to the hospital and had his/she colon removed due to a toxic mega colon (swelling and inflammation spread into the deeper layers of your colon, the colon stops working and widens and may rupture) and required a [MEDICAL CONDITION] (bowel resection of the large bowel, the surgical removal of any extent of the colon). FM #1 stated that (Name of Resident #3) required a feeding tube. B. Record review of a Data Collection/Evaluation Nutritional document dated 06/07/18 for R #3 revealed, Section 1 completed by the Dietary Manager (DM) Current weight 187 pounds, ideal body weight range 154-189,body mass index (BMI) 25.8. Section IV - Evaluation of Nutritional needs (to be completed by a registered Dietitian/Registered Diet tech) Caloric needs: 2550 per day, Protein needs: 127 grams per day and fluid needs: 2550 milliliters per day. Nutrition Intervention: Weight loss related to fluid loss. This section was completed by the facility's Dietitian. C. On 09/12/18 at 4:05 pm, during an interview, the Director of Nursing (DON), stated that she/he was not sure what the Dietitian was referring to in the note stating weight loss related to fluid loss. The DON could not find any documentation about [MEDICAL CONDITION] (ankles and/or feet are swollen due to accumulation of fluid), or fluid overload in the medical record. D. Record review of the vitals report for weight from admission date of [DATE] through 06/13/18 revealed: 1. 05/25/18 - 201.4 2. 05/26/18 - 197.2 3. 05/27/18 - 197.8 4. 05/30/18 - 188.8 This is a 13 pound loss, no interventions noted. 5. 06/06/18 - 178.6 This is a 23 pound loss. 6. 06/13/18 - 179.4 R #3 was discharged to the hospital. E. Record review of a care plan dated 05/29/18 for R #3 revealed, Nutritional Status: Resident at risk for potential weight fluctuations. Resident will remain or progress to a healthy weight through the next review. Approach: 1. Provide diet as ordered with resident food preferences as feasible. 2. Encourage fluid intake, provide water pitcher at bedside unless contraindicated. 3. Monitor and encourage intake of meals - offer alternative if less than 50% of meal is consumed, 4. Offer snacks as ordered. Provide assistance with meals, snacks as necessary. F. Record review of the vitals report for meal intake from 05/24/18 through 06/13/18 for R #3 revealed, 1. No amount of meal intake was documented for 05/27/18, 05/28/17, 05/29/18, 06/04/18, 06/07/18, 06/08/18, and 06/10/18. 2. Meal intake of 26-50% was documented for 06/09/18 and 06/13/18 with one refusal to eat on 06/09/18. G. The care plan was not updated on return to the facility on [DATE] for the use of a gastrostomy (artificial external opening into the stomach for nutritional support) tube. H. On 09/06/18 at 3:20 pm, during an interview, the DM stated that the only thing the he/she is responsible for is the likes and dislikes list, the Dietician does everything else. The DM stated I cannot not make them (residents) eat, I provide their diets and they choose what they want. We have super cereal but if they don't want it they don't have to eat it. I. On 09/12/18 at 4:05 pm, during an interview, the DON stated that (Name of Resident #3) was not on a planned weight loss and initially lost weight.

Based on record review and interview, the facility failed to keep residents free from physical and verbal neglect/abuse for 2 (R #48 and R #146) of 4 (R #16, R #48, R #61 and R #146) residents reviewed for abuse/neglect. This deficient practice likely resulted in R #48 being admitted to the hospital with [REDACTED].#146 being yelled at for peeing on the floor when taken to the bathroom, and given a cold shower. This deficient practice likely result in residents suffering from being physically abused/neglected and verbally abused. If the facility fails to maintain an environment of safety and well-being residents could feel afraid to voice their concerns. The finding are: Findings for R #48 - Neglect: A. Record review of the facility face sheet for R #48 dated 11/16/17 revealed, an readmission date of [DATE]. Admission [DIAGNOSES REDACTED]. B. Record review of a Situation, Background, Appearance and Review (SBAR) communication form dated 11/14/17 at 4:30 pm revealed, Excessive Sleeping, Sent to (local hospital) emergency room . C. Record review of a physician order [REDACTED]. D. Record review of a history and physical from (name of hospital) dated 11/14/17 revealed, Today in the morning, he had breakfast at the nursing home and then went to sleep later on and then they were not being able to wake him up. So they called emergency medical services (EMS) and EMS brought him to emergency room (ER), and the patient en route got [MEDICATION NAME] (Used to treat narcotic drug overdose. It is used to temporarily reverse the effects of opioid (medication primarily used for pain relief) medicines) with another dose probably 1 milligram (mg) and then once in the ER got 1 mg and then woke up, and then he went back to sleep, and then got another 2 mg and then later on, started to wake up. (Name of resident's) urine drug screen (UDS) was positive for opiates but that was not one of (R #48's) medications as per list given by the nursing home. The patient will be admitted to the telemetry unit (patients are electronically monitored 24 hours a day and staff are able to view a patients' heart rate and heart rhythm from the nurses' station) for observation. E. Record review for R #48 of a progress note from Certified Nurse Practitioner (CNP) #2 dated 11/22/17 revealed, Was recently hospitalized . Was given wrong narcotic medication (identified in the laboratory results as an opioid) by nursing home staff. F. On 12/13/17 at 3:00 pm, during interview RN #1 stated that the family member #1 (FM #1) told her a urine test came back positive for narcotics in the urine. When asked if she did a report she stated, No, we just did an SBAR and sent R #48 to the hospital. I told the Assistant Director of Nursing (ADON) about what FM #1 said and she did not give me any further direction. We did not do an investigation. He was over there 2 or 3 days before he left he had just started taking antibiotics for a respiratory infection. His blood sugar (BS) was 394 (normal range is 70-105). I gave insulin from (name of resident's) sliding scale order (a written scale to cover different BS results). G. On 12/13/17 at 3:15 pm, during an interview, with the Administrator, Director of Nursing (DON), and the ADON, the Administrator stated that they looked into the medications for a couple of residents on that side and did not find any issues with anything. When asked for documentation, the Administrator stated it was verbal. When asked how they found out, The Administrator stated that the FM #1 let them know and the hospital paper work. The DON stated that there was only one paper from the hospital in the chart. When asked if the incident was reported to the state licensing and certification agency, the administrator stated We struggled back and forth with that because nothing arisen. We did not report it. H. Record review of Medication Administration Record [REDACTED]. I. Record review of the care plan for R #48 dated 11/25/17 was not updated to monitor medications. J. On 12/18/17 at 11:45 am, during an interview, FM #1 stated that the only thing we know is that (Name of resident) was ok in the morning. They (the facility) called the power of attorney (POA) and was told to come down to the facility and asked if they wanted to send (Name of resident) to the hospital. The POA decided to send him. (Name of resident) was up there for a couple of days, it appears to be a narcotic overdose and the urine test proved to be an overdose. Findings for R #146 - Verbal Abuse: K. Record review of the facility face sheet for R #146 dated 11/301/7 revealed, an admission date of [DATE]. Admission [DIAGNOSES REDACTED]. L. On 12/06/17 at 2:52 pm, during an interview, when asked if staff answered the call light in a reasonable timeframe, R #146 stated No they make me wait until they can get to me. A couple of times I waited an hour. One night I had to wait and hour, and I peed all the way across the floor, the girl yelled at me and was angry with me for saying it had been an hour. M. On 12/14/17 at 1:49 pm, during a interview, the Unit Manager #2 stated that she had jotted down a note for (Name of Resident) on 12/04/17 about a CNA #5 saying Hold on a minute, I'm busy I'll be back. The Unit Manager stated that she did not write up an incident, but did talk to the CNA (identified by the Unit manager as CNA #5) involved and did not document the conversation. Unit Manager #2 stated that she followed up with the resident on 12/14/17 at 2:00 pm, and (Name of Resident) stated that the nurse aide was gruff and rude. I passed this information on the Director of Nursing and the Assistant Director of Nursing (ADON) and they left it at that. We did not think it was reportable because nothing was said out of line. Resident #146 - Physical Abuse N. Record review of the Nursing Data Collection tool for R #146 dated 11/30/17 revealed, R #146 is alert and oriented (A/O) (oriented to person, place and time) times 3 (x's 3) and able to voice concerns. O. On 12/12/17 at 7:50 am, during an interview, R #146 stated that she was being tortured because she was taken to the shower and it was cold in the room. R #146 stated I told them I did not want to take a shower. It was too cold. P. On 12/12/17 at 7:50 am, observation of the shower room used for R #146 revealed, the heat lamp only had one regular light bulb in the heat lamp. During this observation the room temperature was 72 degrees and the water temperature was 102 degrees. Q. On 12/12/17 at 7:53 am, during an interview, CNA #1 stated there is only one heat lamp for the whole shower room and the room is cold. CNA #1 stated Yes, I gave the shower. After this interview a sign was put on the shower door out of order. R. On 12/13/17 at 2:00 pm, during an interview, the Administrator stated that if a resident doesn't want to take a shower, they should not be made to take a shower. S. On 12/14/17 at 2:24 pm, during an interview, CNA #1 stated that R #146 said It was too cold. I turned the water on to the hot side and then turned it down a bit. I never have to mix cold water with the hot water. The heat lamps were not working that day. The heat lamp only had a light bulb in it.

Based on record review and interview the facility failed to implement their Abuse Policies and Procedures for 2 (R #48 and R #146) of 4 (R #16, R #48, R #61, R #146) residents sampled for abuse/neglect. This deficient practice likely result in R #48 being admitted to the hospital with [REDACTED].#146 being yelled at for peeing on the floor when taken to the bathroom, and given a cold shower. If facilities fail to follow their abuse policy, the facility could have continued abuse/neglect issues go un-noticed and not corrected, putting residents at risk for potential harm. The finding are: A. Record review of the facility Policy and Procedure titled Abuse, Neglect, Exploitation and Mistreatment dated Email Revision: 09/12/17 revealed, Policy: 1. The facility's Leadership prohibits neglect, mental, physical and/or verbal abuse, use of a physical and/or chemical restraint not required to threat a medical condition . 2. The facility shall report immediately, but not later than 2 hours after the allegation is make, if the events that cause the allegation involve abuse or result in serious bodily injury, or not later than 24 hours if the events that caused the allegation do not result in serious bodily injury to the administrator of the facility and to other officials including to the State Survey Agency and adult protective services when state law provides for jurisdiction in long-term care facilities) in accordance with State law through established procedures. 3. The facility's Leadership will conduct a prompt investigation of any allegation received of suspected abuse, neglect or exploitation or mistreatment and will implement immediate action to safeguard resident. B. Record review of the facility Policy and Procedure titled Abuse, Neglect, Exploitation and Mistreatment dated Email Revision: 09/12/17 revealed, Component VI: Investigation - 1. The facility maintains that all allegations of abuse, neglect, misappropriation of property, etc. are thoroughly investigate and appropriate actions are taken. Findings for R #48: C. Record review of the facility facesheet for R #48 dated 11/16/17 revealed, an admission date of [DATE]. Admission [DIAGNOSES REDACTED]. D. Record review of a Situation, Background, Appearance and Review (SBAR) communication form dated 11/14/17 at 4:30 pm revealed, Excessive Sleeping, Sent to (local hospital) emergency room . E. Record review of a physician order dated 11/14/17 no time, revealed Sent to (local hospital) for evaluation and treatment if needed. F. Record review of a history and physical from (name of hospital) dated 11/14/17 revealed, Today in the morning, (Name of resident) had breakfast at the nursing home and then went to sleep later on and then they were not being able to wake (Name of resident) up. So they called emergency medical services (EMS) and EMS brought resident to emergency room (ER), and the patient en route got [MEDICATION NAME] (Used to treat opioid overdose. It is used to temporarily reverse the effects of opioid (medication primarily used for pain relief) medicines) with another dose probably 1 milligram (mg) and then once in the ER got 1 mg and then woke up, and then went back to sleep, and then got another 2 mg and then later on, started to wake up. (Name of resident's) urine drug screen (UDS) was positive for opiates but that was not one of (R #48's) medications as per list given by the nursing home. The patient will be admitted to the telemetry unit (patients are electronically monitored 24 hours a day and staff are able to view a patients' heart rate and heart rhythm from the nurses' station) for observation. G. Record review for R #48 of a progress note from Certified Nurse Practitioner (CNP) #2 dated 11/22/17 revealed, Was recently hospitalized . Was given wrong narcotic medication (identified in the laboratory results as an opioid) by nursing home staff. H. Record review of the facility's Medication Administration Record [REDACTED]. I. On 12/13/17 at 3:0 0 pm, during interview, RN #1 stated that the family member #1 (FM #1) told her a urine test came back positive for narcotics in the urine. When asked if a report was completed RN #1 stated, No, we just did an SBAR and sent R #48 to the hospital. I told the Assistant Director of Nursing (ADON) about what FM #1 said and the ADON did not give me any further direction. We did not do an investigation. (Name of resident) was over there 2 or 3 days, before being hospitalized had just started taking antibiotics for a respiratory infection. R #48's blood sugar (BS) was 394 (normal range is 70-105) I gave insulin from (name of resident's) sliding scale order (a written scale to cover different BS results) (ordered dated 09/23/16). J. On 12/13/17 at 3:15 pm, during interview, with the Administrator, Director of Nursing (DON) and the ADON, the administrator stated that they looked into the medications for a couple of residents on that side and did not find any issues with anything. When asked for documentation, the Administrator stated it was verbal. When asked how they find out, stated that the FM #1 let them know and the hospital paper work. The DON stated that there was only one paper from the hospital in the chart. When asked if the incident was reported to the state survey licensing and certification department, the administrator stated We struggled back and forth with that because nothing changed. We did not report it. K. Record review of the care plan dated 11/25/17 was not updated to monitor medications. L. On 12/18/17 at 11:45 am until 12:20 pm during interview, FM #1 stated that the only thing we know is that he was ok in the morning. They (the facility) called the power of attorney (POA) and was told to come down to the facility and asked if they wanted to send (name of resident) to the hospital. The POA decided to send to ER. Was up there for a couple of days, it appears to be a narcotic overdose and the urine test proved to be an overdose. Resident #146-Verbal Abuse: M. Record review of the facility facesheet dated 11/30/17 revealed, an admission date of [DATE]. Admission [DIAGNOSES REDACTED]. N. On 12/06/17 at 2:52 pm, during an interview, when asked if staff answered the call light in a reasonable timeframe, R #146 stated No they make me wait until they can get to me. A couple of times I waited an hour. On night I had to wait and hour, and I peed all the way across the floor, the girl yelled at me and was angry with me for saying it had been an hour. O. On 12/14/17 at 1:49 pm during a interview, the Unit Manager #2 stated that she had jotted down a note for (Name of Resident) on 12/04/17 about a Certified Nurse Aide (CNA) #5 saying Hold on a minute, I'm busy I'll be back. Unit Manager stated that she did not write up an incident, but did talk to the CNA (identified by the Unit manager as CNA #5) involved and did not document the conversation. Unit Manager #2 stated that she followed up with the resident on 12/14/17 at 2:00 pm, and (Name of Resident) stated that the nurse aide was ruff and rude. I passed this information on the Director of Nursing and the Assistant Director of Nursing (ADON) and they left it at that. We did not think it was reportable because nothing was said out of line. Resident #146 - Physical Abuse: P. Record review of the Nursing Data Collection tool for R #146 dated 11/30/17 revealed, R #146 is alert and oriented (A/O) (oriented to person, place and time) times 3 (x's 3) and able to voice concerns. Q. On 12/12/17 at 7:50 am, during an interview, R #146 stated that she was being tortured because she was taken to the shower and it was cold in the room. R #146 stated I told them I did not want to take a shower. It was too cold. R. On 12/12/17 at 7:50 am, observation of the shower room used for R #146 revealed, the heat lamp only had one regular light bulb in the heat lamp. During this observation the room temperature was 72 degrees and the water temperature was 102 degrees. S. On 12/12/17 at 7:53 am, during an interview, CNA #1 stated there is only one heat lamp for the whole shower room and the room is cold. CNA #1 stated Yes, I gave the shower. After this interview a sign was put on the shower door out of order. T. On 12/13/17 at 2:00 pm, during an interview, the Administrator stated that if a resident doesn't want to take a shower, they should not be made to take a shower. U. On 12/14/17 at 2:24 pm, during an interview, CNA #1 stated that R #146 said It was too cold. I turned the water on to the hot side and then turned it down a bit. I never have to mix cold water with the hot water. The heat lamps were not working that day. The heat lamp only had a light bulb in it.

Based on record review and interview the facility failed to report to the State Survey Agency allegations of abuse/neglect within 2 hours for serious injury or 24 hours for all other incidents, for 2 (R #48 and R #146) of 4 (R #16, R #48, R #61, R #146) residents sampled for abuse/neglect. This deficient practice likely result in R #48 being admitted to the hospital with [REDACTED].#146 being yelled at for peeing on the floor when taken to the bathroom, and given a cold shower. If the facility fails to report allegations of abuse/neglect to the State Survey Agency, corrective measures may not be acted on, and the facility is unable to assure residents are free from abuse/neglect. The finding are: Resident #48: A. Record review of the facility facesheet for R #48 dated 11/16/17 revealed, an readmission date of [DATE]. Admission [DIAGNOSES REDACTED]. B. Record review of a Situation, Background, Appearance and Review (SBAR) communication form dated 11/14/17 at 4:30 pm revealed, Excessive Sleeping, Sent to (local hospital) emergency room . C. Record review of a physician order [REDACTED]. D. Record review of a history and physical from (name of hospital) dated 11/14/17 revealed, Today in the morning, he had breakfast at the nursing home and then went to sleep later on and then they were not being able to wake him up. So they called emergency medical services (EMS) and EMS brought him to emergency room (ER), and the patient en route got [MEDICATION NAME] (Used to treat opioid overdose. It is used to temporarily reverse the effects of opioid (medication primarily used for pain relief) medicines) with another dose probably 1 milligram (mg) and then once in the ER got 1 mg and then woke up, and then went back to sleep, and then got another 2 mg and then later on, started to wake up. (Name of resident's) urine drug screen (UDS) was positive for opiates but that was not one of (R #48's) medications as per list given by the nursing home. The patient will be admitted to the telemetry unit (patients are electronically monitored 24 hours a day and staff are able to view a patients' heart rate and heart rhythm from the nurses' station) for observation. E. Record review for R #48 of a progress note from Certified Nurse Practitioner (CNP) #2 dated 11/22/17 revealed, Was recently hospitalized . Was given wrong narcotic medication (identified in the laboratory results as an opioid) by nursing home staff. F. Record review of Medication Administration Record [REDACTED]. G. On 12/13/17 at 3:00 pm, during interview RN #1 stated that the family member #1 (FM #1) told her a urine test came back positive for narcotics in the urine. When asked if she did a report she stated, No, we just did an SBAR and sent R #48 to the hospital. I told the Assistant Director of Nursing (ADON) about what FM #1 said and she did not give me any further direction. We did not do an investigation. He was over there 2 or 3 days before he left he had just started taking antibiotics for a respiratory infection. His blood sugar (BS) was 394 (normal range is 70-105). I gave insulin from (name of resident's) sliding scale order (a written scale to cover different BS results) (order dated 09/23/16). H. On 12/13/17 at 3:15 pm, during an interview with the Administrator, Director of Nursing (DON), and the ADON, the Administrator stated that they looked into the medications for a couple of residents on that side and did not find any issues with anything. When asked for documentation, the Administrator stated it was verbal. When asked how they found out, The Administrator stated that the FM #1 let them know and the hospital paper work. The DON stated that there was only one paper from the hospital in the chart. When asked if the incident was reported to the state licensing and certification agency, the administrator stated We struggled back and forth with that because nothing changed. We did not report it. Resident #146 - Verbal Abuse I. Record review of the facility facesheet for R #146 dated 11/301/7 revealed, an admission date of [DATE]. Admission [DIAGNOSES REDACTED]. J. On 12/06/17 at 2:52 pm, during an interview, when asked if staff answered the call light in a reasonable timeframe, R #146 stated No they make me wait until they can get to me. A couple of times I waited an hour. One night I had to wait and hour, and I peed all the way across the floor, the girl yelled at me and was angry with me for saying it had been an hour. K. On 12/14/17 at 1:49 pm, during a interview, the Unit Manager #2 stated that she had jotted down a note for (Name of Resident) on 12/04/17 about a CNA #5 saying Hold on a minute, I'm busy I'll be back. The Unit Manager stated that she did not write up an incident, but did talk to the CNA (identified by the Unit manager as CNA #5) involved and did not document the conversation. Unit Manager #2 stated that she followed up with the resident on 12/14/17 at 2:00 pm, and (Name of Resident) stated that the nurse aide was gruff and rude. I passed this information on the Director of Nursing and the Assistant Director of Nursing (ADN) and they left it at that. We did not think it was reportable because nothing was said out of line. Resident #146 - Physical Abuse L. Record review of the Nursing Data Collection tool for R #146 dated 11/30/17 revealed, R #146 is alert and oriented (A/O) (oriented to person, place and time) times 3 (x's 3) and able to voice concerns. M. On 12/12/17 at 7:50 am, during an interview, R #146 stated that she was being tortured because she was taken to the shower and it was cold in the room. R #146 stated I told them I did not want to take a shower. It was too cold. N. On 12/12/17 at 7:50 am, observation of the shower room used for R #146 revealed, the heat lamp only had one regular light bulb in the heat lamp. During this observation the room temperature was 72 degrees and the water temperature was 102 degrees. O. On 12/12/17 at 7:53 am, during an interview, CNA #1 stated there is only one heat lamp for the whole shower room and the room is cold. CNA #1 stated Yes, I gave the shower. After this interview a sign was put on the shower door out of order. P. On 12/13/17 at 2:00 pm, during an interview, the Administrator stated that if a resident doesn't want to take a shower, they should not be made to take a shower. Q. On 12/14/17 at 2:24 pm, during an interview, CNA #1 stated that R #146 said It was too cold. I turned the water on to the hot side and then turned it down a bit. I never have to mix cold water with the hot water. The heat lamps were not working that day. The heat lamp only had a light bulb in it.

Based on record review and interview, the facility failed to thoroughly investigated allegations of abuse/neglect for 2 (R #48 and R #146) of 4 (R #16, R #48, R #61 and R #146) residents reviewed for abuse/neglect. This deficient practice likely resulted in R #48 being admitted to the hospital with [REDACTED].#146 being yelled at for peeing on the floor when taken to the bathroom, and given a cold shower. If the facility fails to investigate allegations of abuse/neglect, the facility is unable to assure residents are free from abuse/neglect. The findings are: Resident #48: A. Record review of the facility facesheet for R #48 dated 11/16/17 revealed, an readmission date of [DATE]. Admission [DIAGNOSES REDACTED]. B. Record review of a Situation, Background, Appearance and Review (SBAR) communication form dated 11/14/17 at 4:30 pm revealed, Excessive Sleeping, Sent to (local hospital) emergency room . C. Record review of a physician order [REDACTED]. D. Record review of a history and physical from (name of hospital) dated 11/14/17 revealed, Today in the morning, he had breakfast at the nursing home and then went to sleep later on and then they were not being able to wake him up. So they called emergency medical services (EMS) and EMS brought him to emergency room (ER), and the patient en route got [MEDICATION NAME] (Used to treat opioid overdose. It is used to temporarily reverse the effects of opioid (medication primarily used for pain relief) medication) with another dose probably 1 milligram (mg) and then once in the ER got 1 mg and then woke up, and then he went back to sleep, and then got another 2 mg and then later on, started to wake up. (Name of resident's) urine drug screen (UDS) was positive for opiates but that was not one of (R #48's) medications as per list given by the nursing home. The patient will be admitted to the telemetry unit (patients are electronically monitored 24 hours a day and staff are able to view a patients' heart rate and heart rhythm from the nurses' station) for observation. E. Record review for R #48 of a progress note from Certified Nurse Practioner (CNP) #2 dated 11/22/17 revealed, Was recently hospitalized . Was given wrong narcotic (identified in the laboratory results as an opioid) medication by nursing home staff. F. Record review of Medication Administration Record [REDACTED]. G. On 12/13/17 at 3:00 pm, during interview RN #1 stated that the family member #1 (FM #1) told her a urine test came back positive for narcotics in the urine. When asked if she did a report she stated, No, we just did an SBAR and sent R #48 to the hospital. I told the Assistant Director of Nursing (ADON) about what FM #1 said and she did not give me any further direction. We did not do an investigation. He was over there 2 or 3 days before he left he had just started taking antibiotics for a respiratory infection. His blood sugar (BS) was 394 (normal range is 70-105) I gave insulin from (name of resident's) sliding scale order (a written scale to cover different BS results) (order date 09/23/16). H. On 12/13/17 at 3:15 pm, during an interview with the Administrator, Director of Nursing (DON), and the ADON , the Administrator stated that they looked into the medications for a couple of residents on that side and did not find any issues with anything. When asked for documentation, the Administrator stated it was verbal. When asked how they found out, The Administrator stated that the FM #1 let them know and the hospital paper work. The DON stated that there was only one paper from the hospital in the chart. When asked if the incident was reported to the state licensing and certification agency, the administrator stated We struggled back and forth with that because nothing has arisen. We did not report it. Resident #146 - Verbal Abuse I. Record review of the facility facesheet for R #146 dated 11/301/7 revealed, an admission date of [DATE]. Admission [DIAGNOSES REDACTED]. J. On 12/06/17 at 2:52 pm, during an interview,when asked if staff answered the call light in a reasonable timeframe, R #146 stated No they make me wait until they can get to me. A couple of times I waited an hour. One night I had to wait and hour, and I peed all the way across the floor,the girl yelled at me and was angry with me for saying it had been an hour. K. On 12/14/17 at 1:49 pm, during a interview, the Unit Manager #2 stated that she had jotted down a note for (Name of Resident) on 12/04/17 about a CNA #5 saying Hold on a minute, I'm busy I'll be back. The Unit Manager stated that she did not write up an incident, but did talk to the CNA (identified by the Unit manager as CNA #5) involved and did not document the conversation. Unit Manager #2 stated that she followed up with the resident on 12/14/17 at 2:00 pm, and (Name of Resident) stated that the nurse aide was ruff and rude. I passed this information on the Director of Nursing and the Assistant Director of Nursing (ADN) and they left it at that. We did not think it was reportable because nothing was said out of line. Resident #146 - Physical Abuse L. Record review of the Nursing Data Collection tool for R #146 dated 11/30/17 revealed, R #146 is alert and oriented (A/O) (oriented to person, place and time) times 3 (x's 3) and able to voice concerns. M. On 12/12/17 at 7:50 am, during an interview, R #146 stated that she was being tortured because she was taken to the shower and it was cold in the room. R #146 stated I told them I did not want to take a shower. It was too cold. N. On 12/12/17 at 7:50 am, observation of the shower room used for R #146 revealed, the heat lamp only had one regular light bulb in the heat lamp. During this observation the room temperature was 72 degrees and the water temperature was 102 degrees. O. On 12/12/17 at 7:53 am, during an interview, CNA #1 stated there is only one heat lamp for the whole shower room and the room is cold. CNA #1 stated Yes, I gave the shower. After this interview a sign was put on the shower door out of order. P. On 12/13/17 at 2:00 pm, during an interview, the Administrator stated that if a resident doesn't want to take a shower, they should not be made to take a shower. Q. On 12/14/17 at 2:24 pm, during an interview, CNA #1 stated that R #146 said It was too cold. I turned the water on to the hot side and then turned it down a bit. I never have to mix cold water with the hot water. The heat lamps were not working that day. The heat lamp only had a light bulb in it.

Based on observation, record review and interview, the facility failed to ensure a portable oxygen tank had oxygen in it for 1 (R #289) of 1 (R 289) residents reviewed for respiratory care. This deficient practice has the potential to affect residents with [MEDICAL CONDITIONS], shortness of breath and dependence on supplemental oxygen by not supplying enough oxygen in order to prevent [MEDICAL CONDITION] (decreased oxygen to the body). The findings are: A. Record review of facility Resident Face Sheet for R #289 dated 11/13/12 revealed [DIAGNOSES REDACTED]. B. Record review of facility Care Plan for R #289 dated 02/19/14 revealed, Resident has a [DIAGNOSES REDACTED].Administer oxygen via nasal cannula as ordered. Monitor O2 SAT (oxygen saturation) .provide humidified room air C. Record review of facility SBAR (situation, background, assessment, recommendation) for R #289 dated 09/15/17 revealed, .Respiratory distress .[MEDICAL CONDITION] .asthma (with wheezing), labored or rapid breathing, and shortness of breath . 1. Record review of facility Physician telephone orders for R #289 dated 09/15/17 revealed, Send to (Name of local hospital) for eval (evaluation) and tx (treatment) respiratory distress. 2. Record review of (Name of local hospital) admitted d 9/15/17 revealed, difficulty breathing, fever .has [MEDICAL CONDITION], both lungs, predominantly upper part of lungs on both sides. (Name of doctor) acute chronic [MEDICAL CONDITION] secondary to [MEDICAL CONDITION]. On 2 liters at home, [MEDICAL CONDITION] (disease of the lungs). Plan: oxygen supplementation and titrate (increase) greater than 90%. D. On 12/07/17 at 8:16 am during an observation and interview, R #289 appeared lethargic (sluggish). He was wearing a nasal cannula (device used to deliver oxygen) connected to a portable oxygen tank and Registered Nurse (RN) #5 was asked to check the level of oxygen in the tank. RN #5 stated the oxygen tank was empty and asked Certified Nursing Assistant (CNA) #10 to fill it (oxygen tank) up. CNA #10 stated, It (oxygen tank) wasn't filled (with oxygen) when he got up. RN #5 used an oximeter (device used to check oxygen level) to check R #289's oxygen level and the device read 78 percentage of oxygen saturation. RN #5 checked the oxygen level again in approximately 5 minutes and the device read 74 percent of oxygen saturation. According to the Mayo Clinic, Normal pulse oximeter readings usually range from 95 to 100 percent. Values under 90 percent are considered low. E. On 12/12/17 at 3:27 pm during an observation and interview, Unit Manager (UM) #1 was asked why there wasn't a doctor's order for oxygen for R #289 and she stated, I haven't been over here (hall 300 and 400 unit manager) except for the last week. I ain' t had a chance to look through the old charts. It was confusing, there was no order but he has always been on oxygen. We have one (order) now. UM #1 was asked if R #289 had humidified air in the room and UN #1 stated, There should be a humidifier in the room. Observation of R #289's room revealed no humidifier. F. Record review of facility Telephone Orders (physician orders) dated 12/07/17 revealed, O2 (oxygen) at 2 LPM (liters per minute)/NC (nasal cannula) to maintain O2 sat (saturation) >(greater than) 90 percent PRN (as needed). G. On 12/12/17 at 4:15 pm during an observation and interview, Unit Manager (UM) #1 was asked to check R #289's oxygen concentrator. UM #1 stated, He (R #289) is on 4 liters (oxygen per minute). UM #1 was asked why he was on 4 liters when the doctor's orders were 2 liters and she stated, The CNAs probably put it (oxygen) on him when they put him to bed. They may have bumped it or something; I don't know. H. Record review of facility Respiratory Policies and Procedures dated 01/01/17 revealed, Review physician's orders [REDACTED]. indicating that the order has been obtained and reviewed, determine objectives of therapy ordered. check medical record for lab results, diagnosis, [MEDICAL CONDITION] condition and therapeutic goals .Start O2 flow rate at the prescribed liter flow or appropriate flow for administration device .

Based on record review and interview the facility failed to implement their infection control policy and procedures for 20 (R# 3, 11, 15, 31, 46, 49, 51, 53, 75,95, 109, 118, 130, 131, 138, 139, 140, 147, 165 and 177) of 20 (R# 3, 11, 15, 31, 46, 49, 51, 53, 75,95, 109, 118, 130, 131, 138, 139, 140, 147, 165 and 177) residents reviewed for a gastroenteritis (Inflammation that involves the stomach and small intestine. Signs and symptoms include some combination of diarrhea, vomiting, and abdominal pain, fever, lack of energy, and dehydration may also occur) infectious outbreak by 1) failing to follow the facility policy Infection Prevention and Control Policies and Procedures revised 09/2011, and 2) failing to conduct training for all staff, to prevent the gastroenteritis outbreak from spreading. This deficient practice likely caused an increase in the amount of residents that became ill. The findings are: A. On 02/07/17 at 11:30 am, during an interview with the Infection Control Registered Nurse (IC/RN), the IC/RN stated that in 12/2016 the facility had 20 residents exhibit nausea/vomiting and diarrhea. B. Record review of the facility Outbreak Log dated 12/20/16 revealed 20 residents listed as having nausea, diarrhea, or vomiting that began on 12/12/16 and the last resident onset date was 12/21/16. The residents affected are as follows: 1. R #3 - vomiting and diarrhea, onset 12/14/16. room [ROOM NUMBER] A 2. R #11 - nausea, vomiting and diarrhea, onset 12/14/16. room [ROOM NUMBER] A 3. R #15 - vomiting, onset 12/13/16. room [ROOM NUMBER] B 4. R #31 - nausea and vomiting, onset 12/13/16. room [ROOM NUMBER] A 5. R #46 - diarrhea, onset 12/13/16. room [ROOM NUMBER] A 6. R #49 - diarrhea, onset 12/13/16. room [ROOM NUMBER] B 7. R #51 - diarrhea, onset 12/19/16. room [ROOM NUMBER] B 8. R #53 - nausea and diarrhea, onset 12/14/16. room [ROOM NUMBER] B 9. R #75 - vomiting and diarrhea, onset 12/12/16. room [ROOM NUMBER] A 10. R #95 - vomiting and diarrhea, onset 12/15/16. room [ROOM NUMBER] A 11. R #109 - diarrhea, onset 12/13/16. room [ROOM NUMBER] A 12. R #118 - nausea, vomiting and diarrhea, onset 12/21/16. room [ROOM NUMBER] B 13. R #130 - diarrhea, onset 12/12/16. room [ROOM NUMBER] A 14. R #131 - diarrhea, onset 12/13/16. room [ROOM NUMBER] B 15. R #138 - diarrhea, onset 12/13/16. room [ROOM NUMBER] B 16. R #139 - vomiting and diarrhea, onset 12/13/16. room [ROOM NUMBER] B 17. R #140 - vomiting and diarrhea, onset 12/14/16. room [ROOM NUMBER] 18. R #147 - nausea, vomiting and diarrhea, onset 12/12/16. room [ROOM NUMBER] A 19. R #165 - diarrhea, onset 12/14/16. room [ROOM NUMBER] 20. R #177 - nausea and vomiting, onset 12/19/16. room [ROOM NUMBER] C. Record review of the facility's policy for Outbreak Investigation dated 09/2011 CP - III B - 2, revealed, 1. Endemic (ordinary level of a disease in a given population) disease vs. Epidemic (an excess over the expected level) disease, often two or three cases over the normal expected level are considered sufficient evidence to begin conducting an investigation. 2. Step 1: Confirmation of Outbreak- Determine if control measures are needed based on the supposition at this point that an outbreak is occurring. If needed implement control measure until facility can further define the epidemic. Collect needed specimens for culture. 3. Step 9: Notes are kept throughout the investigation, a written report is prepared and distributed to appropriate persons including the facility management, company clinical and operational staff, and if required to the health department. The report includes important findings, cause of the outbreak, means of transmission, source of outbreak, significant control and prevention measures, names and titles of consultants and health department personnel instrumental in the investigation and to whom information was reported. D. On 02/07/17 at 4:33 pm, during an interview with the IC/RN, the IC/RN stated that she did a walk around with everybody. I told the staff we needed to do deep cleaning, put out extra sanitary hand wipes every where, spoke with dietary about hand washing. When asked if any specimens of emesis (vomit) or stool (bowel movement) were collected, the IC/RN stated No. The IC/RN also stated she did not have documentation of staff education or any investigation report per the facility policy regarding the outbreak. F. On 02/08/17 at 10:22 am, during an interview with the contracted Healthcare Services Housekeeping and Laundry Supervisor (HSHLS), the HSHLS stated that, I told my staff to use proper hand washing, and change gloves. I don't remember if I did a signature page or just a verbal education. On 02/08/17 at 11:00 am, the HSHLS stated that there were no sign in sheets or documentation of inservice training. I was not told we had an outbreak. G. On 02/08/17 at 10:47 am, during an interview with the New Mexico State Epidemiology Physician (SEP), the SEP stated that he did not have a reported outbreak for the facility for 12/20/16. The SEP stated that with 20 residents being effected, it would be something the facility should report, so that we could assist. We would have instructed them do a line list, to send specimens for verification of the specific etiologic (causative) agent, to confirm the outbreak.

Based on record review, observation and interview, the facility failed to develop a comprehensive care plan to address risks for pressure ulcers (PU) for 1 (R # 119) of 7 (R # 4, 14, 23, 97, 119, 120 and 165) residents reviewed for care plans. This deficient practice likely resulted in R #119 developing three pressure ulcers that were not present on admission. The findings are: A. Record review of facility facesheet dated, 10/13/16 revealed Resident #119 current admission to the facility was 10/13/16. Admission [DIAGNOSES REDACTED]. It leads to narrowing and hardening of the arteries. This causes decreased blood flow, which can injure nerves and other tissues), pain. B. Record review of Nursing Data Collection Tool, for R #119, (Admission Nursing Assessment) dated, 10/13/16 revealed, under Section 8: titled Skin condition .2. Other skin conditions .Reddened heels .Skin color/condition - Warm - dry . The final section of the Admission Nursing Assessment is the Braden Scale for Predicting Pressure Sore Risk (the scale is to help health professionals, especially nurses, assess a patient's risk of developing a pressure ulcer). This section was not completed. C. On 02/09/17 at 12:40 pm, during an interview with the Wound Care Nurse/Licensed Practical Nurse #3 (WCN/LPN #3), WCN/LPN #3 stated, When (name of resident) got back from the hospital (10/13/16) there was all kind's of gauze wrapped over his heels. Upon removal the heels were red. D. Record review of Weekly Skin Integrity Review for R #119, dated, 11/21/16, revealed, Skin Condition: .Open Area: New: Left heel Stage 2 (partial thickness skin loss involving the epidermis (outer layer of the skin), dermis (second layer of the skin) or both). E. Record review of Wound Treatment & Progress Record, for R #119, dated, 11/21/16, revealed, Pressure ulcer (PU) left heel (stage 2) 2.5 centimeter (cm) X 3.7 cm X 0.2 cm 100% granulation (filling in of a wound during the healing process). F. Record review of Wound Treatment & Progress Record, for R #119, dated, 12/13/16, revealed, .PU (does not identify location) (stage 2) 5.9 cm X 3.5 cm X 0.1 cm . G. Record review of Wound Treatment & Progress Record, for R #119, dated, 01/23/17, revealed, .PU (does not identify location) (stage 2) 3.5 cm X 5 cm X 0.4 cm . H. Record review of Wound Treatment & Progress Record for R #119, dated, 01/04/17, revealed, a new PU, Left lateral (at, toward or from the side) ankle . 1.5 cm X 1 cm - unstageable (Full thickness tissue loss in which actual depth of the ulcer is completely obscured in the wound bed) . I. Record review of Wound Treatment & Progress Record for R #119, dated, 01/18/17, revealed, Left ischial (forms the lower and back part of the hip bone) . There is no further description of the wound. J. On 02/01/17 at 2:30 pm, an observation was made of wound care for R #119, with (Name of Wound Care Specialist (WCS)) and WCN/LPN #3 present for evaluation and wound care. 1.) Left buttock wound measured 5 cm X 3 cm X 1.0 cm, 2.) Left ankle measured 1.0 cm X 1.0 cm , 3.) Left heel measured 3 cm X 5 cm X 0.4 cm. At this time the WCS debrided (the removal of dead, damaged or infected tissue) wounds on the left buttock and left heel and gave verbal orders to WCN/LPN #3 to continue current treatment. K. On 02/10/17 at 12:00 pm, during an interview with the Minimum Data Set Coordinator (MDSC), the MDSC, when asked about R #119's care plans stated, The MDSC that was doing his care plans has retired and no longer works here. I cannot speak to what care plans may or may not have been done. L. Record review of Care Plans for R #119 with Problem, measurable Goals and Approaches, dated 11/21/16 revealed, there is no evidence of a care plan for pressure ulcers or pressure ulcer prevention prior to discovery of the PU on 11/21/16. M. On 02/08/17 at 3:30 pm, during an interview with the Director of Nursing (DON) the DON, when asked if a care plan for (name of resident) pressure ulcer risk was done prior to the development of a pressure ulcer, the DON stated, Before the pressure ulcer was discovered on 11/21/16 there was no care plan for pressure ulcer preventive measures.

Based on record review, observation, and interview, the facility failed to ensure that physician orders [REDACTED].#120 and R #164) of two (R #120 and #164) residents reviewed for extended use of a urinary catheter. R #120 and R #164 had physician orders [REDACTED]. This failure likely resulted in R #120 and #164 continuing to sustain tissue injury to the penis and increased the risk of infection. The findings are: Findings for Resident #120 A. Record review of facility face sheet dated, 05/23/16 revealed Resident #120 was admitted to the facility on [DATE] with a urinary catheter in place. B. Record review of Nurses Notes for R #120 dated, 09/13/16 at 3:30 pm, revealed, Summoned to residents room by wound nurse. (name of resident) catheter out of urethra ( tubular passage through which urine is discharged from the bladder to the exterior of the body) with catheter balloon (used to hold the urinary catheter in place) not intact, Replaced foley and catheter. Highly eroded penis .Will continue to monitor. C. Record review of Physicians Order for R #120 dated, 09/15/16 revealed, May have urology consult for enlarged prostate/placement of urinary catheter. There is no documentation in R #120's record to indicate an appointment was made with a Urologist ( medical doctor who specializes in urology). D. Record review of a Weekly Skin Integrity Review for R #120 dated 11/02/16 revealed, .Penis - catheter induced urethral erosion . E. Record review of Nurses Notes for R #120 dated 11/03/16, 2:40 pm, revealed, (name of R #120) c/o (complained of) leaking catheter. Highly eroded penis. F. On 02/06/17 at 10:20 am, an observation was made, with Licensed Practical Nurse (LPN) #4 of Resident #120's urinary catheter. This observation revealed an eroded area of the penis starting below the head of the penis and extending down the underside of the shaft approximately 5-6 centimeters (cm). G. On 02/06/17 at 2:35 pm, during an interview with the Wound Care Nurse (WCN) the WCN stated, When I found the wound in November I called the Wound Specialist and reported it to the Charge Nurse at the time. I do not know what the follow up was for the eroded penis. H. On 02/06/17 at 3:00 pm, during an interview with the Director of Nursing (DON) the DON stated, I have checked the book that consult appointments are made in and can find no indication that an urology appointment or consult for (name of R #120 )was made either in September or November 2016. I. On 02/06/17 at 3:15 pm, during a phone interview with Nurse Practitioner (NP) #1, regarding the erosion of R #120's penis, the NP stated,The treatment for [REDACTED]. Findings for R #164 J. Record review of the facility face sheet for R #164 revealed, the resident was admitted to the facility on [DATE] with a urinary catheter in place. K . Record review of nursing notes (NN) for R #164 dated 01/08/17 revealed, 1500 (3:00 pm) Res (resident #164) noted with urinary catheter pulling on penis, head of penis cut by catheter down the shaft of the penis, leg strap applied and educated pt (patient) on catheter being loose and not to pull on it, communication sent for MD (medical doctor) am. L . On 02/08/17 at 9:00 am, observation was conducted with Licensed Practical Nurse (LPN) #4 of R #164's penis tear. The tear was noted to be one inch in length. LPN #4 stated that R #164's urinary catheter is long term and sometimes residents get catheter erosion (gradual destruction of tissue). M. Record review of a physician's progress note dated 01/12/17 for R #164 revealed, Plan: Refer to Urology for assessment, consult (name of wound care specialist) for wound assessment and treatment, prescribe Bactrim DS (antibiotic) for potential infection N. On 02/09/17 at 7:40 am, during an interview with the Director of Nursing (DON), the DON stated that R #164 had not been referred or seen by a Urologist, because it is not emergent (urgent). The DON further stated, The nurse manager and myself should have followed up on 01/12/17 to make sure (name of R #164) was seen by a urologist.

Based on record review, observation, and interview, the facility failed to prevent a pressure ulcer from occurring and increasing for 3 (R # 23, 97 and 119) of 7 (R #4, 14, 23, 97, 119, 120, and 165) residents sampled for pressure ulcers. The facility failed to 1.) implement care plan interventions to prevent a pressure ulcer to the left heel for R #23, 2.) turn and reposition R #97 per the care plan resulting in a pressure ulcer that had tunneling (a narrow opening or passageway underneath the skin that can extend in any direction through soft tissue and results in dead space with potential for abscess formation) for R #97, 3.) failed to provide interventions to prevent pressure ulcers to the left heel, left lateral (at, toward or from the side) ankle and left ischium (forms the lower and back part of the hip bone) for R #119. These failed practices likely resulted in R #23, 97 and 119 developing avoidable pressure ulcers. The findings are: R #23 A. Record review of facility facesheet dated 01/04/17 revealed Resident # 23 was admitted to the facility on [DATE]. Admission [DIAGNOSES REDACTED]. B. Record review of Care plans for R #23 with Problem, measurable Goals and Approaches revealed: Pressure Ulcer - risk for skin breakdown - 01/16/17, Incontinence of bowel and bladder, Cognitive impairment - 01/16/17. C. Record review of Pressure Ulcer Risk Evaluation/Prevention Intervention Protocol for R #23 dated 01/04/17 revealed, Residents risk score to be 23. 12 or above is noted as high risk. There is no indication of interventions for pressure ulcer prevention. D. Record review of Situation - Background - Assessment - Request (SBAR) for R #23 date 01/30/17 revealed, .Pressure ulcer to left heel - unstageable (Full thickness tissue loss in which actual depth of the ulcer is completely obscured in the wound bed) . E. Care Plan for R #23 dated 01/30/17 revealed, Pressure ulcer (PU) - unstageable - left heel 2.8 (centimeter (cm)) x 2.0 (cm). F. Record review of Wound Treatment & Progress record for R #23 dated 02/06/17 revealed, PU - unstageable - 2.5 cm x 2 cm. G. Record review of the Weekly Skin Integrity Review for R #23 revealed no evidence of a skin check from 01/10/17 to 01/30/17. H. On 02/02/17 at 2:45 pm, an observation was made, with the Wound Care Nurse/Licensed Practical Nurse #3 (WCN/LPN #3), of wound care for R #23. Left heel pressure ulcer measured 2.5 cm x 1.3 cm. I. On 02/07/17 at 10:05 am, during an interview Registered Nurse # 1 (RN #1) stated that the hall nurses are responsible for doing the skin checks on residents that do not have wounds. If wounds are present, it is the WCN the does the skin checks. J. On 02/07/17 at 10:10 am, during an interview with the Director of Nursing (DON), the DON stated that the charge nurse on a given hall is responsible for doing skin checks weekly. The Unit Manager (UM) is responsible to check that the skin checks are being done. R #97 K. Record review of the Admission Facesheet dated 05/31/16 revealed R #97 was admitted to the facility with a medical [DIAGNOSES REDACTED]. L. Record review of the Comprehensive Care Plan dated 01/03/17 for R #97 revealed that a new pressure sore was identified on during a skin check 1/3/17, on the right buttock that was unstageable and measured 3.0 cm by 2.9 cm. Problem- Resident has a Pressure Ulcer, unstageable on the right buttock. Approach- Perform treatment per order document progress and report worsening of wound to physician. Assist with M. Record review of the Wound Treatment and Progress Record dated 01/09/17 revealed the pressure ulcer on the right buttock was 5 cm. long, 4 cm. wide, and .2 cm. deep. N. Record review of the Wound Treatment and Progress Record dated 01/18/17 revealed that the pressure wound on the right buttock measured 6 cm. long, 5 cm. wide, and 5 cm. deep, and was at that time a Stage IV pressure ulcer (pressure ulcer that is very deep, reaching into muscle and bone and causing extensive damage). O. On 02/09/17 at 11:10 am, during an interview, WCN/LPN #3 stated that the resident did not come into the facility with the pressure wound on the right buttock. WCN/LPN #3 stated, The one on R #97's right buttock was identified on 01/03/17. The pressure ulcer on the right buttock got worse and is now a stage IV and tunneling. R #119 P. Record review of facility facesheet dated, 10/13/16 revealed Resident #119 current admission to the facility was 10/13/16. Admission [DIAGNOSES REDACTED]. It leads to narrowing and hardening of the arteries. This causes decreased blood flow, which can injure nerves and other tissues), pain. Q. Record review of Nursing Data Collection Tool, for R #119, (Admission Nursing Assessment) dated, 10/13/16 revealed, under Section 8: titled Skin condition .2. Other skin conditions .Reddened heels .Skin color/condition - Warm - dry . The final section of the Admission Nursing Assessment is the Braden Scale for Predicting Pressure Sore Risk (the scale is to help health professionals, especially nurses, assess a patient's risk of developing a pressure ulcer). This section was not completed. R. On 02/09/17 at 12:40 pm, during an interview, the WCN/LPN #3 stated, When (name of resident) got back from the hospital (10/13/16) there was all kind's of gauze wrapped over his heels. Upon removal the heels were red. S. Record review of Weekly Skin Integrity Review for R #119, dated, 11/21/16, revealed, Skin Condition: .Open Area: New: Left heel Stage 2 (partial thickness skin loss involving the epidermis (outer layer of the skin), dermis (second layer of the skin) or both). T. Record review of Wound Treatment & Progress Record for R #119, revealed: 1. Dated 11/21/16, revealed, Pressure Ulcer (PU) left heel (stage 2) 2.5 centimeter (cm) X 3.7 cm X 0.2 cm 100% granulation (filling in of a wound during the healing process). 2. Dated, 12/13/16, revealed, .PU (does not identify location) (stage 2) 5.9 cm X 3.5 cm X 0.1 cm . 3. Dated, 01/04/17, revealed, a new PU, Left lateral ankle . 1.5 cm X 1 cm - unstageable . 4. Dated, 01/18/17, revealed, Left ischial . There is no further description of the wound. 5. Dated, 01/23/17, revealed, .PU (does not identify location) (stage 2) 3.5 cm X 5 cm X 0.4 cm . U. On 02/01/17 at 2:30 pm, an observation was made of wound care for R #119, with (Name of Wound Care Specialist (WCS)) and WCN/LPN #3 present for evaluation and wound care. 1.) Left heel measured 3 cm X 5 cm X 0.4 cm, 2.) Left ankle measured 1.0 cm X 1.0 cm , 3.) Left buttock wound measured 5 cm X 3 cm X 1.0 cm. At this time the WCS debrided (the removal of dead, damaged or infected tissue) wounds on the left buttock and left heel and gave verbal orders to WCN/LPN #3 to continue current treatment. V. Record review of Care Plans for R #119, with Problem, measurable Goals and Approaches, dated 11/21/16 revealed, there is no evidence of a care plan for pressure ulcers or pressure ulcer prevention prior to discovery of the PU on 11/21/16. W. On 02/10/17 at 12:00 pm, during an interview with the Minimum Data Set Coordinator (MDSC), the MDSC, when asked about R #119's care plans, stated, The MDSC that was doing his care plans has retired and no longer works here. I cannot speak to what care plans may or may not have been done. X. On 02/08/17 at 3:30 pm, during an interview with the DON, when asked if a care plan for R #119 pressure ulcer risk was done prior to the development of a pressure ulcer, the DON stated, Before the pressure ulcer was discovered on 11/21/16 there was no care plan for pressure ulcer preventive measures.

Based on record review, observation and interview the facility failed to evaluate urinary catheter care to prevent penile injury for 2 (R #120 and #164) of 2 (R #120 and #164) residents reviewed for urinary catheter use. This deficient practice likely contributed to uretheral erosion for R #120 and a cut to the head of the penis for R #164. The findings are: R #120 A. Record review of facility facesheet dated 05/23/16, revealed R #120 was admitted to the facility on [DATE]. Admission [DIAGNOSES REDACTED]. B. Record review of Nurses Notes, for R #120, dated, 09/13/16 at 3:30 pm, revealed, Summoned to residents room by wound nurse. (name of resident) catheter out of urethra (a tube that connects the urinary bladder to the urinary meatus (a passage or opening leading to the interior of the body) for the removal of fluids from the body) . Highly eroded (gradually destroyed bodily tissue) penis . C. Record review of Physicians Order, for R #120, dated, 09/15/16, revealed, May have urology consult for enlarged prostate/placement of foley catheter. There is no evidence that an appointment was made with urology (is the branch of medicine that focuses on surgical and medical diseases of the male and female urinary tract system and the male reproductive organs). D. Record review of Weekly Skin Integrity Review, for R #120, dated 11/02/16, revealed, .Penis - catheter induced uretheral erosion . E. Record review of Nurses Notes, for R #120, dated 11/03/16 at 2:40 pm, revealed, c/o (complained of) leaking cath. Highly eroded penis . F. On 02/06/17 at 2:35 pm, during an interview with the Wound Care Nurse/Licensed Practical Nurse #3 (WCN/LPN#3), the WCN/LPN #3 stated, When I found the wound in November I called the Wound Care Specialist (WCS) and was advised that if it began bleeding to then send (name of resident) to the hospital and there is not a lot we can do for a wound like that I reported the penile wound to Registered Nurse #4 (RN #4) who was (name of resident) nurse at that time. I don't know why a referral to a Urologist was not made. G. On 02/06/17 at 10:20 am, an observation was made, with Licensed Practical Nurse #4 (LPN #4), of R #120's eroded penis. Observation revealed a channel like eroded area of the penis starting below the head of the penis and extending along the underside of the shaft approximately 5-6 centimeters (cm) in length and 0.5-1 cm wide. H. Record review of the care plan for R #120, for an indwelling catheter dated, 06/06/16 and last reviewed on 12/08/16 revealed, no evidence of an approach to attempt to remove the urinary catheter and no evidence the penile erosion was assessed as a problem with measurable goals or approaches. I. On 02/06/17 at 3:15 pm, during a phone interview with (Name of Certified Nurse Practitioner (CNP)) the CNP stated,I was not aware that the urology consult had not been done. Without which is consult with the Urologist I am not certain if we would be able to put the foley back in, if it was removed, and if the resident is a candidate for a supra-pubic catheter (a urine drainage catheter inserted into the bladder so that urine can be drained out, usually when the normal way out for the urine is blocked. Instead of being passed up through the urethra as is usual, the supra pubic catheter is inserted through the abdominal wall just above the pubic bone and into the bladder). J. On 02/06/17 at 3:00 pm, during an interview with the Director of Nursing (DON), the DON stated, I became aware of the wound when the WCN told me about it . When asked about the Urology consult, for R #120, the DON stated, I have checked the book where the consult appointments are made and can find no indication the urology consult was made. When asked if an attempt had been made to discontinue the urinary catheter, the DON stated, We have not attempted to discontinue (name of resident) foley. Findings for R #164 K. Record review of the facility face sheet for R #164 revealed, the resident was admitted to the facility on [DATE] with a urinary catheter in place. L. Record review of nursing notes (NN) for R #164 dated 01/08/17 revealed, 1500 (3:00 pm) Res (resident #164) noted with urinary catheter pulling on penis, head of penis cut by catheter down the shaft of the penis, leg strap applied and educated pt (patient) on catheter being loose and not to pull on it, communication sent for MD (medical doctor) am. M. On 02/08/17 at 9:00 am, observation was conducted with Licensed Practical Nurse (LPN) #4 of R #164's penis tear. The tear was noted to be one inch in length. LPN #4 stated that R #164's urinary catheter is long term and sometimes residents get catheter erosion (gradual destruction of tissue). N. Record review of a physician's progress note dated 01/12/17 for R #164 revealed, Plan: Refer to Urology for assessment, consult (name of wound care specialist) for wound assessment and treatment, prescribe Bactrim DS (antibiotic) for potential infection O. On 02/09/17 at 7:40 am, during an interview with the Director of Nursing (DON), the DON stated that R #164 had not been referred or seen by a Urologist, because it is not emergent (prompt action). The DON stated, The nurse manager and myself should have followed up on 01/12/17 to make sure (name of R #164) was seen by a urologist.

Based on record review and interview the facility failed to revise the Care Plan when significant changes occurred in the health status for one resident (R # 5) of 6 (R # 1, 2, 3, 4, 5, and 6) residents sampled for revision of Care Plans related to fall risks and accidents. This failure likely caused Resident #5 to fall and fracture his nose. The findings are: Findings related to Resident #5: A. Record review of the Resident Admission Record for R #5 dated 02/04/15 revealed the resident had a [DIAGNOSES REDACTED]. B. Record review of the Nurse's Notes dated 02/09/15 thru 05/26/15 revealed that the resident has fallen 10 times since current admitted d of 02/04/15. 1) 02/09/15 at 9:30 pm, the resident was found on the ground outside next to his wheelchair. The resident stated that he went outside to smoke and hit a bump and made him fall, sustained a small scrape on right knee. 2) 02/13/15 at 8:00 am, the resident was found sitting on the floor in the bathroom between the wheelchair and the toilet. The resident stated he was trying to get his pants off and when he went to sit the wheelchair moved causing him to sit on the floor. The scab on knee from previous fall came off and left elbow hit the wheelchair causing a small skin tear. 3) 02/14/15 at 5:30 pm, the resident went out to court yard and was found lying on right side. An assessment was completed and the resident had an abrasion to the right knee. 4) 02/15/15 at (after breakfast, time unknown) the resident returned to his room after breakfast and was reaching down to pick something up from the floor when his foot slipped off the foot rest of his wheelchair causing him to fall. There were no injuries noted. 5) 02/18/15 in the morning (time unknown) the resident was found on the floor in his room. The resident stated that he fell out of his wheelchair and hit his head. The resident stated that he thought he broke his nose. The resident was sent to the emergency room and returned to the facility with a [DIAGNOSES REDACTED]. 6) 02/26/15 at 4:30 pm, the resident fell out of wheelchair onto the floor in a sitting position. He scraped his right arm and had several skin tears. 7) 03/08/15 ( time unknown) the resident was reaching to the ground and fell from wheelchair. The resident complained of back pain and sent to the emergency room and returned after evaluation, no injuries were found. 8) 04/02/15 at 8:30 pm, the resident was found lying in front of wheelchair on the floor of the transport van. The resident had been attempting to position himself on platform ramp to get out of van and didn't get a good hold when the wheelchair rolled backwards causing resident to fall from the chair. The resident was assessed and did not sustain injuries. 9) 04/11/15 (time unknown) the resident was found sitting on the floor between the bed and the wheelchair. He stated he was trying to put himself to bed. There were no injuries noted. 10) 05/26/15 at 4:30 pm, the resident was found lying on floor in his room by the bed and wheelchair. The resident sustained [REDACTED]. C. Record review of the Care Plan dated 02/09/15 revealed that the resident was at risk for falls. Interventions included; therapy to evaluate and treat, anticipate needs and provide prompt assistance, assure lighting is adequate and areas are free of clutter. There were four falls documented on the care plan without new interventions for 02/13/15, 02/14/15, 02/15/15, and 02/18/15. D. Record review of the Care Plans dated 02/28/15 revealed the resident had cognitive loss, dementia, and has memory problems related to history of [MEDICAL CONDITION]. The resident is at risk for injury. F. Record review of the Care Plan dated 03/16/15: Problem: has a history of frequent falls due to physical limitations related to amputation left lower extremity and weakness. Approaches: encourage and remind him frequently to ask for assistance from staff for transfers, keep call light within reach and answer promptly, remind him to keep his bed in lowest position with brakes locked. The falls on 04/02/15, 04/11/15 and 05/26/15 were not documented on the Care Plan and no new interventions were added. G. On 06/18/15 at 12:30 pm, during an interview the Nurse Assessment Coordinator (NAC) was asked if the resident's care plan had been updated for each fall, with new interventions added. The NAC stated, No, the resident is very resistant to care and we try to remind him not to try to transfer himself and let us know when he needs help. The NAC stated that it was true that the resident did not have each fall listed with a new intervention on the care plans. The NAC stated that they knew that should be done and would from now on.

Based on records review and interview the facility failed to implement adequate safety precautions, after multiple falls, which likely resulted in the resident falling and suffering a broken nose, skin tears/abrasions and back pain for one (#5) of one residents (#5) reviewed for accidents. The lack of safety precautions has the potential to result in the resident falling again and suffering a more serious injury. The findings are: Finidngs related to falls: A. Record review of the Resident Admission Record dated 02/04/15 revealed the resident had [DIAGNOSES REDACTED]. B. Record review Nurse's Notes dated 02/09/15 thru 05/26/15 revealed that the resident had fallen 10 times since current admitted d 02/04/15. 1) On 02/09/15 at 9:30 pm, the resident was found on the ground outside next to his wheelchair. The resident stated that he went outside to smoke and hit a bump and made him fall, sustained a small scrape on right knee. 2) On 02/13/15 at 8:00 am, the resident was found sitting on the floor in the bathroom between the wheelchair and the toilet. The resident stated he was trying to get his pants off and when he went to sit the wheelchair moved causing him to sit on the floor. The scab on knee from previous fall came off and left elbow hit the wheelchair causing a small skin tear. 3) On 02/14/15 at 5:30 pm, the resident went out to court yard and was found lying on right side. An assessment was completed and the resident had an abrasion to the right knee. 4) On 02/15/15 at (after breakfast, time unknown), the resident returned to his room after breakfast and was reaching down to pick something up from the floor when his foot slipped off the pedal of his wheelchair causing him to fall. There were no injuries noted. 5) On 02/18/15 in the morning (time unknown), the resident was found on the floor in his room. The resident stated that he fell out of his wheelchair and hit his head. The resident stated that he thought he broke his nose. The resident was sent to the emergency room and returned to the facility with a [DIAGNOSES REDACTED]. 6) On 02/26/15 at 4:30 pm, the resident fell out of wheelchair onto the floor in a sitting position. He scraped his right arm and had several skin tears. 7) On 03/08/15 (time unknown), the resident was reaching to the ground and fell from wheelchair. The resident complained of back pain and sent to the emergency room and returned after evaluation, no injuries were found. 8) On 04/02/15 at 8:30 pm, the resident was found lying in front of wheelchair on the floor of the transport van. The resident had been attempting to position himself on platform ramp to get out of van and didn't get a good hold when the wheelchair rolled backwards causing resident to fall from the chair. 9) On 04/11/15 (time unknown), the resident was found sitting on the floor between the bed and the wheelchair. He stated he was trying to put himself to bed. There were no injuries noted. 10) On 05/26/15 at 4:30 pm, the resident was found lying on floor in his room by the bed and wheelchair. The resident sustained [REDACTED]. C. Record review of Resident #5's Care Plan dated 02/09/15 revealed that the resident was at risk for falls. Interventions included, therapy to evaluate and treat, anticipate needs and provide prompt assistance, assure lighting is adequate and areas are free of clutter. There were four falls documented on the care plan without new interventions, for 02/13/15, 02/14/15, 02/15/15, and 02/18/15. D. Record review of the Care Plan dated 02/28/15 revealed the resident had cognitive loss, dementia, and has memory problems related to history of [DIAGNOSES REDACTED]. The resident is at risk for injury. E. Record Review of Resident #5's care plan dated 03/16/15 revealed: Problem has a history of frequent falls due to physical limitations related to amputation left lower extremity and weakness. Approaches Encourage and remind him frequently to ask for assistance from staff for transfers, keep call light within reach and answer promptly, remind him to keep his bed in lowest position with brakes locked. The falls on 04/02/15, 04/11/15 and 05/26/15 were not documented on the Care Plan and no new interventions were added. F. On 06/18/15 at 12:30 pm, during an interview the Nurse Assessment Coordinator (NAC) was asked if new safety precautions were initiated after each fall. The NAC stated No, the resident is very resistant to care and we try to remind him not to try to transfer himself and let us know when he needs help.

Based on record review and interview, the facility failed to follow the care plan for one (#86) of three (#43, 67, 86) Residents reviewed for weight loss. The care plan approach included notifying the physician of a weight change of five percent within thirty days. This failed practice had the potential for the physician to be unaware of significant weight loss and to put interventions in place to prevent further weight loss. The findings are: A. Record review for Resident #86 revealed: 1. The care plan, dated 08/14/13, revealed the Problem: Nutritional Status: "Resident at nutrition and dehydration risk related to: receives tube feeding secondary to dysphagia. Approach: ...Report weight change (+/-5% within 30 days) to physician, registered dietician and family ..." 2. The Vital Sign and Weight Loss Record revealed on 08/14/13 Resident #86's weighed 156 pounds. On 09/14/13 weight was 146 pounds, a significant weight loss of 7.5% in 30 days. 3. The Vital Sign and Weight Loss Record revealed on 09/16/13 Resident #86 weighed 147 pounds and on 10/16/13 weighed 140 pounds, a significant weight loss of five percent. 4. Record review revealed no evidence the physician had been notified of the significant weight loss in two months.. B. Interviews for Resident #86 revealed: 1. On 11/07/13 at 11:35 am, the Director of Nurses (DON) was interviewed. When asked if the physician had been notified of the significant weight loss, the DON stated, "I am not able to find any notification by the nurses to the physician of the weight loss since the [MEDICATION NAME] (liquid food administered through a tube inserted into the abdomen) amount was increased from 60 to 63 ml. (milliliter) per hour in early August. 2. On 11/07/13 at 4:30 pm, The East Side Unit Manager (UM) was interviewed. When asked if the facility followed the care plan, for Resident #86, to notify the physician of the weight loss, the UM stated, "No, we did not follow the care plan and notify the physician." Based on record review and interview, the facility failed to follow a Physician's recommendation for a medication change for 1 (#43) of 5 (#22, 43, 64, 67, and 82,) residents reviewed for medications. This deficient practice has the potential to result in medication interactions and possible over sedation. The findings are: A. Record review for Resident #43 revealed the following: 1. The Resident had a physician's orders [REDACTED]. 2. The pharmacy recommendation dated 10/28/13 revealed: A gradual dose reduction of [MEDICATION NAME] 25 mg by mouth once daily was recommended. 3. The physician responded by accepting the recommendation of a gradual dose reduction. The pharmacy consultant form was signed by the physician on 10/31/13. 4. On 11/07/13 a record review of the Medication Admission Record (MAR) revealed that [MEDICATION NAME] 25 mg was being given twice daily. There was no evidence on the MAR indicated [REDACTED]. The MAR indicated [REDACTED]. B. On 11/07/13 at 9:45 am, an interview was conducted with the Director of Nursing, (DON). The DON reviewed the orders in the chart and stated that giving the [MEDICATION NAME] for six days, after the physician signed and dated on the pharmacy consultant recommendation form was an error, and the medication order should have been changed on 10/31/13. C. On 11/07/13 at 11:00 am, an interview was conducted with Licensed Practical Nurse, (LPN#2). LPN #2 was asked what procedure the facility had regarding pharmacy consultant reports. LPN#2 stated "If they (The Pharmacy Consultant Reports) are given to me I make sure I note (transcribe onto the MAR) the new orders and the physician order [REDACTED].

Based on record review and interview, the facility failed to prevent a fall with injuries, while in the facility transport van, for one (#41) of three (#41, 67, and 86) residents reviewed for transportation. This had the potential to affect any resident being transported in the facility van. The findings are: A. Record review for Resident #41 revealed the following: 1. Nurse's Notes dated 09/17 /13 at 10:30 am, "...fell in transport to appointment with (Name of Physician) this morning at 0915 (9:15 am). Facility van returned to facility 3 cm (centimeter) laceration to R (right) occipital scalp. Cleansed with wound cleaner ... Unable to steri-strip (adhesive strips to hold laceration sides together); sent to ER (emergency room ) for further treatment..." 2. Nurse's Notes dated 09/21/13 at 2:30 pm, "Stated pain med (medication) helped just a little but it is worse that usual. States sometimes trouble breathing,... To ER with facility transport." 3. Radiology report from hospital dated 09/21/13 revealed, "Impression: 1. Acute fracture of the right 10 th rib ..." B. Interviews for Resident #41 revealed the following: 1. On 11/08/13 at 9:30 am, Licensed Practical Nurse (LPN) #2 was interviewed about the accident. LPN #2 stated, "I was following the van in my car. About two blocks from the facility, the van driver pulled off the road and I wondered what was going on. When I pulled up behind the van, I saw through the back window, the wheels of a wheelchair turning and knew there was a problem. When I got into the van, (Name of Resident #41) was laying on the floor of the van and the driver was trying to get him up off the floor. The wheelchair had tipped backward, the back wheels were strapped. I don't think the seat belt was on because he was not in the chair. While we were getting him back into the chair, the driver kept saying she did not secure him right. (Name of Resident #41) kept saying he was not secured at all. We saw that he had a skin tear on his arm and a laceration on his head. The van driver called the facility and informed them we were returning and what happened. The nurses met us at the van and took him in for assessment. The decision was made to send him to the emergency room for stitches. A different van driver and I took him." 2. On 11/08/13 at 9:40 am, the Administrator (ADM) was interviewed about the accident. The ADM stated, "I was not in the building but I was called as soon as the facility got the call about the accident. Our investigation did show that the van driver did not follow the safety instructions for securing the resident into the van and he did fall because of that failure.

Based on record review and interview, the facility failed to implement interventions for adequate nutrition to address a severe weight loss for one (#86) of one (#86) residents, reviewed for weight loss while on a tube feeding. This failed practice had the potential for any resident on a tube feeding to have significant weight loss. The findings are: A. Review of the medical record for Resident #86 revealed the following: 1. The hospital Discharge Summary dated 07/22/13 revealed Resident #86 returned to the facility on [DATE] following admission to the hospital for shortness of breath (SOB), and [MEDICAL CONDITION] (low oxygen level). During the hospital stay, a Percutaneous Endoscopic Gastrostomy (PEG) tube (tube inserted into the stomach for administration of food) was inserted in hospital related to aspiration pneumonia (pneumonia caused by inhaling food into the lungs). 2. The Data Collection/Evaluation-Nutritional form dated 07/19/13 revealed the ideal body weight for Resident #86 was 171 to 200 pounds. The resident's current weight was 153.2. 3. The Vital Signs and Weight Record revealed Resident #86 was weighed daily. On 07/19/13 the readmission weight was 153.2 and on 10/19/13 the weight was 141.2. A severe weight loss of greater than 7.5% in three months. 4. The care plan dated 08/14/13 revealed, "Resident at nutrition and dehydration risk related to: receives tube feeding secondary to dysphagia (difficulty swallowing). Approach: ... Report weight change (+/- 5% within 30 days) to physician ..." 5. There was no evidence of the facility notifying the physician of this severe weight loss. B. On 11/07/13 at 11:35 am, the Director of Nurses (DON) was interviewed. When asked if there were any interventions put in place, or if the physician had been notified of the severe weight loss for Resident #86, from 07/19/13 to 10/19/13, the DON stated, "I am not able to find any notification, by the nurses to the physician, of the weight loss since August 2013."

Based on record review, interview, and observation, the facility failed to comprehensively assess a pressure ulcer for 1 (#9) of 3 (9, 10, 11) sampled residents with pressure ulcers. The pressure ulcer was noticed on 10/27/12 at the facility, but not fully assessed. The resident was discharged on [DATE] to the local hospital. The local hospital assessed a Stage III pressure ulcer on 10/28/12 on resident admission. This failed practice likely caused the development of a Stage III pressure ulcer. The findings are: A. A complaint was received on 11/05/12 concerning the presence of a pressure ulcer for Resident #9. B. Record review for Resident #9 revealed the following: 1. A 10/13/12 admission Nursing Assessment revealed, "reddened area coccyx (tailbone) blanchable (turns white with pressure)" which indicated no pressure ulcer on admission. 2. A 10/27/12 Daily Skilled Nurse's Note revealed that "pressure ulcer" was checked for the day shift and the night shift. Further review of the narrative notes revealed no description, assessment, measurements,staging or treatment to the pressure ulcer. 3. Review of the October 2012 Wound Tracking Sheets revealed no entry for a pressure ulcer assessment. 4. Review of the October 2012 Medication Administration Record, [REDACTED]. 5. Review of the 10/28/12 Daily Skilled Nurses Note revealed that pressure ulcer was not checked for the day shift or night shift. An entry in the skin portion revealed, "Rt (right) hip dehisced (breaking open of the surgical incision along the suture line) draining serous sanguineous fluid (consisting of serum and blood, semi thick reddish drainage)." The narrative portion of the note revealed, "Resident in bed most of today. On last round CNA (Certified Nursing Assistant) reported Rt hip draining. Upon assessment surgical site purulent (pus) serosanguineous drainage...Send to ER (emergency room ) non emergent transport at 6:22 pm." The night shift entered, "OOF (out of facility) admitted to (name of local hospital) at 2305 (9:05 pm)." 6. There were no assessment entries related to the pressure ulcer that was found on 10/27/12 for 10/27/12 and 10/28/12. 7. Review of Resident #9's records at the local hospital's emergency room Physician's Physical dated 10/28/12 at 8:32 pm revealed, "...Quarter sized decubitus (pressure ulcer)." An anatomical chart indicated the pressure ulcer was positioned at the sacral area just above the buttocks. Under "SKIN" was written, "Wound is clean. Decubitus ulcer present, stage three. Size 2.5 cms (centimeters)." Written under "Consultation and Critical Thinking" was, "The following [DIAGNOSES REDACTED]. 8. The local hospital's Nursing Shift assessment dated [DATE] at 1:11 am revealed, "Skin Alteration Present, Wound Type pressure ulcer, stage 3, tunneling none, location sacral, infection signs none, wound appearance yellow." 9. A hospital Consultation Report dated 11/05/12 at 5:58 pm revealed, "Physical exam and on the sacrum there is a 5-7 cm diameter grade 2 to 3 sacral decubitus ulcer. It appears fairly clean with no gross gangrene (dead) or purulence (pus) noted. Impression: This patient would benefit from good evaluation with respect to removing any underlying tissue as usually the case with most decubitus ulcers, they are larger than they appear and preserve as much viable skin tissue as possible and then place a wound V.A.C. (negative pressure wound therapy device) at the same time. The surgery is tentatively scheduled for Wednesday, [DATE]." C. Interviews for Resident #9 were as follows: 1. On 11/07/12 at 10:25 am, an interview with the Director of Nurses (DON) and Registered Nurse (RN) #1 was conducted. They were asked if Resident #9 had a pressure ulcer while in the facility. RN #1 stated, "She had no pressure ulcer when she was here." The DON stated, "There was no pressure ulcer when the resident was here." 2. On 11/07/12 at 1:50 pm, an interview was conducted at the local hospital with Resident #9's Hospital Registered Nurse (HRN) #1. HRN #1 confirmed that Resident #9 had a pressure ulcer. HRN #1 stated, "(Name of Resident #9) had debridement of the pressure ulcer today. A wound VAC was just put on." D. On 11/07/12 at 1:55 pm, observation of Resident #9 at the local hospital revealed that the resident was lying in the hospital bed, was sedated from the anesthesia, and a wound VAC was in position over the resident's sacral area. The wound VAC was draining sanguineous (bloody) fluid. E. On 11/07/12 at 3:00 pm, Physician #1 verified that the resident had a pressure ulcer on the sacrum which was debrided on 11/07/12. F. On 11/08/12 at 9:50 am, CNA #1 stated that she had worked with the resident all week and when the wound dehisced she had washed the buttocks and back and did not see anything and no pressure ulcers on the residents bottom or back. G. On 11/08/12 at 11:00 am, during interview, Licensed Practical Nurse (LPN) #2, who had entered the pressure ulcer check mark on the 10/27/12 Skilled Nurses Note, was asked about entering the pressure ulcer check mark in the record. LPN #2 stated that around 3 or 4 am (on 10/28/12) she had heard the resident and had gone to check her. She stated that the resident was laying on her side with covers down. She stated that she saw a small red mark on Resident #9's back above the coccyx area (sacrum) that was approximately 1-2 cm in diameter. LPN #2 stated that it was pink and she thought that it was a pressure ulcer just starting so she had checked the pressure ulcer box in the record. She was asked if she thoroughly and comprehensively assessed the wound. LPN #2 stated that she had the night light on and did not turn on the over bed light to assess the wound. She stated that she did not disturb the resident anymore because the resident would get agitated and had pulled the blankets up. She was asked if she had told the next shift. She stated that she did not recall if she had told the next shift. H. On 11/08/12 at 11:20 am, an interview was conducted with the wound nurse, LPN #1. LPN #1 was asked if she had received reports of a pressure ulcer for Resident #9. LPN #1 stated, "No." I. On 11/08/12 at 11:45 am, the DON was told about LPN #2's findings of a pressure ulcer on Resident #9. She was asked if there was a comprehensive assessment of the pressure ulcer if it was not measured or staged. She stated that she was not aware of the pressure ulcer.

Based on record review, interview, and observation, the facility failed to assess and provide treatment for [REDACTED]. The pressure ulcer was noticed on 10/27/12 at the facility. The resident was discharged on [DATE] to the local hospital. The local hospital assessed a stage 3 pressure ulcer on 10/28/12 on resident admission. This failed practice likely caused the development of a Stage III pressure ulcer. The findings are: A. A complaint was received on 11/05/12 concerning the presence of a pressure ulcer for Resident #9. B. Record review for Resident #9 revealed the following: 1. A 10/13/12 admission Nursing Assessment revealed, "reddened area coccyx (tailbone) blanchable (turns white with pressure)" which indicated no pressure ulcer on admission. 2. A 10/27/12 Daily Skilled Nurse's Note revealed that "pressure ulcer" was checked for the day shift and the night shift. Further review of the narrative notes revealed no description, assessment, measurements,staging, or treatment to the pressure ulcer. 3. Review of the October 2012 Wound Tracking Sheets revealed no entry for the pressure ulcer assessment or treatment. 4. Review of the October 2012 Medication Administration Record, [REDACTED]. 5. Review of the 10/28/12 Daily Skilled Nurses Note revealed that pressure ulcer was not checked for the day shift or night shift. An entry in the skin portion revealed, "Rt (right) hip dehisced (breaking open of the surgical incision along the suture line) draining serous sanguineous fluid (consisting of serum and blood, semi thick reddish drainage)." The narrative portion of the note revealed, "Resident in bed most of today. On last round CNA (Certified Nursing Assistant) reported Rt hip draining. Upon assessment surgical site purulent (pus) serosanguineous drainage...Send to ER (emergency room ) non emergent transport at 6:22 pm." The night shift entered, "OOF (out of facility) admitted to (name of local hospital) at 2305 (9:05 pm)." 6. There were no entries related to the pressure ulcer that was found on 10/27/12 on the 10/28/12 skilled nurses notes, no comprehensive assessment of the pressure ulcer, and no treatment orders for the pressure ulcer. 7. Review of Resident #9's records at the local hospital's emergency room Physician's Physical dated 10/28/12 at 8:32 pm revealed, "...Quarter sized decubitus (pressure ulcer)." An anatomical chart indicated the pressure ulcer was positioned at the sacral area just above the buttocks. Under "SKIN" was written, "Wound is clean. Decubitus ulcer present, stage three. Size 2.5 cms (centimeters)." Written under "Consultation and Critical Thinking" was written, "The following [DIAGNOSES REDACTED]. 8. The local hospital's Nursing Shift assessment dated [DATE] at 1:11 am revealed, "Skin Alteration Present, Wound Type pressure ulcer, stage 3, tunneling none, location sacral, infection signs none, wound appearance yellow." 9. A hospital Consultation Report dated 11/05/12 at 5:58 pm revealed, "Physical exam and on the sacrum there is a 5-7 cm diameter grade 2 to 3 sacral decubitus ulcer. It appears fairly clean with no gross gangrene (dead) or purulence (pus) noted. Impression: This patient would benefit from good evaluation with respect to removing any underlying tissue as usually the case with most decubitus ulcers, they are larger than they appear and preserve as much viable skin tissue as possible and then place a wound V.A.C. (negative pressure wound therapy device) at the same time. The surgery is tentatively scheduled for Wednesday, [DATE]." C. Interviews for Resident #9 were as follows: 1. On 11/07/12 at 10:25 am, an interview with the Director of Nurses (DON) and Registered Nurse (RN) #1 was conducted. They were asked if Resident #9 had a pressure ulcer while in the facility. RN #1 stated, "She had no pressure ulcer when she was here." The DON stated, "There was no pressure ulcer when the resident was here." 2. On 11/07/12 at 1:50 pm, an interview was conducted at the local hospital with Resident #9's Hospital Registered Nurse (HRN) #1. HRN #1 confirmed that Resident #9 had a pressure ulcer. HRN #1 stated, "(Name of Resident #9) had debridement of the pressure ulcer today, a wound VAC was just put on." D. On 11/07/12 at 1:55 pm, observation of Resident #9 at the local hospital revealed that the resident was lying in the hospital bed, was sedated from the anesthesia and a wound VAC was in position over the resident's sacral area. The wound VAC was draining sanguineous (bloody) fluid. E. On 11/07/12 at 3:00 pm, Physician #1 verified that the resident had a pressure ulcer on the sacrum which was debrided on 11/07/12. F. On 11/08/12 at 9:50 am, Certified Nursing Assistant (CNA) #1 stated that she had worked with the resident all week prior to discharge from the nursing facility and when the wound dehisced she had washed the buttocks and back and did not see anything and no pressure ulcers on the residents bottom or back. G. On 11/08/12 at 11:00 by phone call, LPN #2 who had entered the pressure ulcer check mark on the 10/27/12 Skilled Nurses Note was asked about entering the pressure ulcer check mark in the record. LPN #2 stated that the resident was laying on her side around 3 or 4 am (10/28/12) and the night light was on. She stated that she saw a small red mark on Resident #9's back above the coccyx area (sacrum) and that it was approximately 1-2 cm. She stated that it was pink and she thought that it was a pressure ulcer just starting so she had checked the pressure ulcer box in the record. She was asked if she thoroughly and comprehensively assessed the wound. LPN #2 stated that she did not turn on the over bed light and she did not mess with the resident anymore because the resident would get agitated and had pulled the blankets up. She was asked if she had told the next shift. She stated that she did not recall if she had told the next shift. H. On 11/08/12 at 11:20 am, an interview was conducted with the wound nurse, Licensed Practical Nurse (LPN) #1. LPN #1 was asked if she had received reports of a pressure ulcer for Resident #9. LPN #1 stated, "No." I. Record review of the 24 hour shift report dated 10/27/12 revealed no notes for the pressure ulcer on the report for Resident #9. J. On 11/08/12 at 11:45 am, the DON was told about LPN #2's findings of a pressure ulcer on Resident #9. The DON confirmed that the pressure ulcer was not on the 24 hour nursing report sheet. She was asked if there was a comprehensive assessment of the pressure ulcer if it was not measured or staged. She stated that she was not aware of the pressure ulcer.

Based on record review and interview, the facility failed to provide insulin to Resident #10, an insulin dependent diabetic, from Friday, [DATE] to Monday, [DATE]. The facility also failed to provide to Resident #10 high blood pressure medication, anti-rejection medication for a kidney transplant, a blood anti-clotting medication from Friday [DATE], to Monday, [DATE], after Resident #10 had been in the hospital for mini [MEDICAL CONDITION] . The facility also failed to check the blood sugar levels of Resident #10. The resident was then found to have blood sugar levels so high that the machine could not register a level. This resulted in an immediate jeopardy at a scope of level K. An immediate jeopardy was called on [DATE] at 3:10 pm. At that time, the Administrator, Director of Nursing (DON), and Regional Corporate Director were informed. The letter of confirmation of substandard quality of care was presented to the Administrator. A Plan of Removal was accepted by the survey team at [DATE] at 5:20 pm. Acceptance of the Plan of Removal lowered the scope and severity to a level H, and included the following interventions: Immediate Plan: 1. New admissions from today [DATE] are being reviewed to ensure weekend medications are received. 2. Ensure all diabetics have their insulin today and for the weekend. This audit is being conducted now 4:15 pm [DATE] and will be completed by 5:15 pm [DATE]. 3. The pharmacy number will by posted at each nurse's station and at the FAX machine. Which will include day time and after-hours numbers (sic - incomplete sentence). 4. A nurse manager will be in over the weekend [DATE]-[DATE] to ensure medications are here and will review diabetic residents for insulin administration. 5. The nurse manager will review the in-service (stated below) again with licensed nurses. Education Plan: 1. Licensed nurses will be in-serviced tonight [DATE] and at 6:00 am on [DATE] on procedures to ensure all medications arrive for the residents from the pharmacy timely. Further, nurses will be re-educated on blood sugar checks per physician orders. 2. Each licensed staff will be educated on the proper number and procedure to call in medications to the pharmacy such as proper procedure for after-hours medication orders. 3. If the nurse is having trouble getting medication ... he/she is to call the on-call nurse and/or administrator for immediate action. 4. Nurses will monitor Medication Administration Records (MARs) to ensure there are no missed doses. Based on record review and interview, the facility failed to follow Physician order [REDACTED].#10) of 3 (#10,15,17) residents surveyed for the availability of medications during a complaint survey. Resident #10 was admitted on a Friday night [DATE] and went without insulin, blood- thinning medications, blood pressure medications, anti-rejection medications (kidney transplant) until Monday [DATE] at 11:00 am. The facility also failed to test the resident's blood sugar levels from [DATE] until [DATE]. This caused harm to Resident #10 by increasing the blood sugar levels that were higher than the blood sugar machine could register. There was also the likelihood of kidney transplant rejection and the risk of additional mini [MEDICAL CONDITION] or [MEDICAL CONDITION] (TIA's). The findings are: A Record review of physician "Initial Orders", dated [DATE], for Resident #10 revealed primary diagnoses, "TIA ([MEDICAL CONDITION])/ DM (diabetes mellitus) 2/Renal Transplant/HTN (high blood pressure)." Medications ordered revealed the following medications: [REDACTED] "[MEDICATION NAME] 20 units subq (under the skin) q (every) day for DM [MEDICATION NAME] Insulin 5 units subq TID (3 times a day) AC (before meals) for diabetes [MEDICATION NAME] 10 mg. (milligrams) q day for depression ASA (Aspirin) 81 mg. q day for TIA [MEDICATION NAME] 2 mg. q day Q HS (at bedtime) for [MEDICAL CONDITION] (enlarged prostate) [MEDICATION NAME] 5 mg. q day for renal transplant (anti-rejection) [MEDICATION NAME] 2 mg po (by mouth) q (every) AM (morning) and 3 mg. Q HS for renal transplant [MEDICATION NAME] 750 mg. BID (2 times a day) for renal transplant (anti-rejection) [MEDICATION NAME] 25 mg. [MEDICAL CONDITION](high blood pressure) [MEDICATION NAME] ,[DATE] q day HTN/Chol (cholesterol) [MEDICATION NAME] 0.5 - 1 mg. BID PRN (as needed) [MEDICATION NAME] Insulin TID/AC (Sliding scale for [MEDICATION NAME] administration for blood sugars in the range of:)150 - 200 2 (units of insulin); 201 - 250 5 (units); 251 - 300 8 (units); 301 - 350 10 (units); 351 - 400 12 (units)" 1. The Interim Plan of Care dated [DATE] revealed, "Diabetic Alert, Goal: Manage Symptoms with a check mark by Meds (medications), Diet, Monitor S/S (signs and symptoms) of hypo/ (low) [MEDICAL CONDITION] (high blood sugar), FSBS (finger stick blood sugar) and Labs as ordered." 2. Record review of a "Treatments Record" (used for medication administration, including name and dose of medication, date ordered, diagnosis, and time for administration) dated [DATE], for Resident #10 revealed all of the physician ordered medications were on the treatment sheet with an order date of [DATE]. All medications had an "X" from [DATE] through [DATE], indicating the medications were not given from the time of admission on Friday, [DATE] until Monday, [DATE]. 3. Record review of Resident #10's History and Physical dated [DATE] revealed, "History of Present Illness: The patient is ... admitted with two episodes of apparent [MEDICAL CONDITION] (difficulty with speech) probably representing [MEDICAL CONDITION] (TIA). ... Another problem is his elevated creatinine (blood work to show kidney function) of 2 (normal = 1.5) ... he has been following with a nephrologist (kidney doctor)... He had a cadaveric (taken form an expired body) renal (kidney) transplant in 2005. ... He continues to faithfully take his immunosuppressive drugs. He has not missed any and his wife manages his medications. I spoke with (name of physician) about this. ... for his diabetes, he uses an insulin pump and glucoses have generally been below 200. Past Medical History: ... 2. He had a below knee amputation of the left leg in [DATE] .... 3. History of hypertension. 4. Diabetes mellitus since his age 30's. 5. Renal transplant in 2005 with a cadaveric kidney and [MEDICAL CONDITION] (low blood supply to the legs) that led to the gangrene and his below knee amputation. Assessment and Plan: 1. [MEDICAL CONDITION]. 2. Renal transplant. Creatinine of 2 may be a little high for him ... 3. Diabetes mellitus, uncertain control but probably fair if not ideal control with the insulin pump. ... Since she (wife) will not be here all the time to manage the insulin pump with the patient, we have agreed to take him off the insulin pump and use [MEDICATION NAME] and [MEDICATION NAME]. ... We calculated a value of 15 units of [MEDICATION NAME] which will be given tonight and then we will use [MEDICATION NAME] 5 units before meals plus a correction dose if the insulin is quite high. This is a complex patient with multiple issues as noted above. ..." 4. The "Diabetic Record" for Resident #10 revealed no Glucose Test Results (blood sugar tests) were performed between Friday [DATE] and Monday [DATE] at 11:00 am when the test results were "HI." (Test results of High are above what the machine can register.) 5. Daily Skilled Nurse's Note at 12:00 pm on [DATE] revealed, "Checked residents blood sugar read HI called and reported to (Name of Nurse Practitioner) on voicemail. 12:15 pm (Name of Nurse Practitioner) ordered 14 units [MEDICATION NAME] (insulin) and make changes to MAR (Medication Administration Record) please see MAR." B. On [DATE] at 10:50 am, the Initial Physician order [REDACTED]. These orders revealed the order for [MEDICATION NAME]TID/AC with sliding scale. When asked if the order for the [MEDICATION NAME] with a sliding scale would be an order to check the blood sugar levels prior to administering the insulin, the DON stated, "Yes, that would be an order for [REDACTED]. 1. On [DATE] at 11:40 am, Registered Nurse (RN) #1 was interviewed. When shown the treatment record for documentation of medication administration for [DATE], RN #1 stated, "The 'X' from [DATE]th to the 17th (admitted [DATE]th) would indicate no medications were given until 11 am on Monday ([DATE])." 2. On [DATE] at 1:20 pm, a telephone interview was conducted with Family Member (FM) #1. When FM #1 was asked about medication administration for Resident #10 at the facility, FM #1 stated, "I was very concerned about him not getting the anti-rejection medications because the doctor had told us it was looking like he might be starting to reject the kidney. I had left his pill box at the facility so the meds could be given and thought they (the facility) would give them. The nurses did not tell me they could not give the pills because they (the pills) were not labeled." 3. On [DATE] at 1:35 pm, FM #2 was interviewed by telephone. When asked if medications were given to Resident #10, FM #2 stated, "I was with him Saturday night ([DATE]) from about 4:00 pm until midmorning Sunday ([DATE]) and never saw his blood sugar tested or any meds given. The blood sugar was tested on ce, when I asked about it on Monday evening, and it was over 300, and insulin was given then. I asked them every day if the meds had arrived and I was told on Saturday and Sunday they had not come in." 4. On [DATE] at 1:45 pm, FM #3 was interviewed by telephone. When asked about the facility giving Resident #10's medications, FM #3 stated, "My family and I were at the facility on Saturday ([DATE]) from about 11:00 am, until 6:30 or 7:00 pm. When we arrived, I asked the nurse if his meds had come in yet and was told they should come in that day. I asked the nurse if his blood sugar had been checked that day and was told, 'No, he seems fine.' I did not witness any medications being given or blood sugar level being checked. We visited again on Monday ([DATE]) from 10:30 am until about 4:00 pm. On arrival, I asked if the meds had arrived yet and was told 'No.' I asked the nurse if his blood sugars had been checked and was told that the machine read HI and the nurse was calling the doctor." 5. On [DATE] at 2:30 pm, the DON stated that the pharmacy was having problems locating information about order and delivery times for Resident #10, but the pharmacy thought the meds were sent on Monday [DATE]th. 6. On [DATE] at 2:45 pm, the DON was asked when medications were received by the facility for Resident #10. The DON stated, "No medications, including insulin were sent to the facility from Friday until Monday about mid morning." When asked if there were any stock medications to give Resident #10, the DON stated, "No, we did not have any of his meds available to give him. The nurses did not call the administrator or nurse on call to inform them of the facility not having the medications that the resident needed."

Based on record review and interview, the facility failed to provide quality care to Resident #10, an insulin dependent diabetic, from Friday, [DATE] to Monday, [DATE] by not giving insulin, high blood pressure medications, anti-rejection medications for a kidney transplant, a blood anti-clotting medication after Resident #10 had been in the hospital for mini [MEDICAL CONDITION]. The facility failed to check the blood sugar levels of Resident #10. On [DATE] the resident was found to have blood sugar levels so high that the machine could not register a level. This resulted in an immediate jeopardy at a scope of level K. An immediate jeopardy was called on [DATE] at 3:10 pm. At that time, the Administrator, Director of Nursing (DON), and Regional Corporate Director were informed. The letter of confirmation of substandard quality of care was presented to the Administrator. A Plan of Removal was accepted by the survey team [DATE] at 5:20 pm. Acceptance of the Plan of Removal lowered the scope and severity to a level H, which included the following interventions: Immediate Plan: 1. New admissions from today [DATE] are being reviewed to ensure weekend medications are received. 2. Ensure all diabetics have their insulin today and for the weekend. This audit is being conducted now 4:15 pm [DATE] and will be completed by 5:15 pm [DATE]. 3. The pharmacy number will by posted at each nurse's station and at the FAX machine. Which will include day time and after-hours numbers (sic - incomplete sentence). 4. A nurse manager will be in over the weekend [DATE]-[DATE] to ensure medications are here and will review diabetic residents for insulin administration. 5. The nurse manager will review the in-service (stated below) again with licensed nurses. Education Plan: 1. Licensed nurses will be in-serviced tonight [DATE] and at 6:00 am on [DATE] on procedures to ensure all medications arrive for the residents from the pharmacy timely. Further, nurses will be re-educated on blood sugar checks per physician orders. 2. Each licensed staff will be educated on the proper number and procedure to call in medications to the pharmacy such as proper procedure for after-hours medication orders. 3. If the nurse is having trouble getting medication ... he/she is to call the on-call nurse and/or administrator for immediate action. 4. Nurses will monitor Medication Administration Records (MARs) to ensure there are no missed doses. Based on record review and interview, the facility failed to provide quality care by not administering medications for 1 (#10) of 3 (#10, 15, 17) residents sampled for the availability of medications during a complaint survey. Resident #10 was admitted on a Friday night, [DATE], and went without insulin, blood-thinning medications, blood pressure medications, kidney anti-rejection medications until Monday [DATE] at 11:00 am. The facility failed to test Resident #10's blood sugar levels that rose to a level so high the testing machine could not register the results until [DATE] at 11:00 am. This caused harm to Resident #10 by increased blood sugar levels, likelihood of organ rejection, and risk of additional TIAs ([MEDICAL CONDITION]). The findings are: A. On [DATE], record review of Resident #10's physician "Initial Orders" dated [DATE] revealed, "Primary Diagnoses: [REDACTED]." Medications orders included the following: "[MEDICATION NAME] 20 units subq (under the skin) q (every) day for DM [MEDICATION NAME] Insulin 5 units subq TID (3 times a day) AC (before meals) for diabetes [MEDICATION NAME] 10 mg. (milligrams) q day for depression ASA (Aspirin) 81 mg. q day for TIA [MEDICATION NAME] 2 mg. q day Q HS (at bedtime) for [MEDICAL CONDITION] [MEDICATION NAME] 5 mg. q day for renal transplant (anti-rejection) [MEDICATION NAME] 2 mg po (by mouth) q AM (every morning) and 3 mg. Q HS for renal transplant (anti-rejection) [MEDICATION NAME] 750 mg. BID (2 times a day) for renal transplant (anti-rejection) [MEDICATION NAME] 25 mg. [MEDICAL CONDITION] [MEDICATION NAME] ,[DATE] q day HTN/Chol (cholesterol) [MEDICATION NAME] 0.5 - 1 mg. BID PRN (as needed) [MEDICATION NAME] Insulin TID/AC (Sliding scale for [MEDICATION NAME] administration for blood sugars in the range of): 150 - 200 2 (units) 201 - 250 5 (units) 251 - 300 8 (units) 301 - 350 10 (units) 351 - 400 12 (units)" 1. The Interim Plan of Care dated [DATE] revealed, "Diabetic Alert, Goal: Manage Symptoms" There was a check mark by "Meds (medications), Diet, Monitor S/S (signs and symptoms) of hypo/ (low) [MEDICAL CONDITION] (high blood sugar), FSBS (finger stick blood sugar) and Labs as ordered." 2. Review of Resident #10's [DATE] "Treatment Record" (used for medication administration, including name and dose of medication, date ordered, diagnosis, and time for administration) revealed all of the physician-ordered medications were on the treatment sheet with an order date of [DATE]. All medications had an "X" from [DATE] through [DATE], indicating the medications were not given from the time of admission on Friday, [DATE] until Monday, [DATE]. 3. The "Diabetic Record" for Resident #10 revealed that no Glucose Test Results were obtained between Friday [DATE] and Monday [DATE] at 11:00 am, when the test results were "HI" (machine unable to calculate blood sugar level)." 4. Daily Skilled Nurse's Note at 1200 pm on [DATE] revealed, "Checked residents blood sugar read HI called and reported to (Name of Nurse Practitioner) on voicemail. 1215 pm (Name of Nurse Practitioner) ordered 14 units [MEDICATION NAME] (insulin) and make changes to MAR (Medication Administration Record) please see MAR." 5. Daily Skilled Nurse's Notes dated [DATE] through [DATE] revealed no documentation related to medications not being available or blood sugar testing not being done. 6. Record review of Resident #10's [DATE] History and Physical revealed, "History of Present Illness: The patient is ... admitted with two episodes of apparent [MEDICAL CONDITION] (difficulty with speech) probably representing [MEDICAL CONDITION] (TIA). ... Another problem is his elevated creatinine (blood work to indicate kidney function) of 2 (normal = 1.5) ... he has been following with a nephrologist (kidney doctor)... He had a cadaveric (taken from an expired body) renal (kidney) transplant in 2005. ... He continues to faithfully take his immunosuppressive drugs. He has not missed any and his wife manages his medications. I spoke with (name of physician) about this.... for his diabetes, he uses an insulin pump and glucoses have generally been below 200. Past Medical History: ... 2. He had a below knee amputation of the left leg in [DATE] ... has been using prosthesis without difficulty. 3. History of hypertension. 4. Diabetes mellitus since his age 30's. 5. Renal transplant in 2005 with a cadaveric kidney and [MEDICAL CONDITION] (decreased blood suppley to the legs) that led to the gangrene and his below knee amputation. Assessment and Plan: 1. [MEDICAL CONDITION]. 2. Renal transplant. Creatinine of 2 (normal 1.2) maybe a little high for him ... 3. Diabetes mellitus, uncertain control but probably fair if not ideal control with the insulin pump. ... Since she (wife) will not be here all the time to manage the insulin pump with the patient, we have agreed to take him off the insulin pump and use [MEDICATION NAME] and [MEDICATION NAME]. ... We calculated a value of 15 units of [MEDICATION NAME] which will be given tonight and then we will use [MEDICATION NAME] 5 units before meals plus a correction dose if the insulin is quite high. This is a complex patient with multiple issues as noted above. ..." B. On [DATE] at 10:35 am, the interim Director of Nurses (DON) was interviewed. When asked about the admission process to prepare for the arrival of Resident #10, the DON stated, "The resident arrived about 7:,[DATE]:45 on a Friday night. The meds (medications) should have been ordered as soon as the nurses received the faxed orders that morning. The admission orders [REDACTED]. I will call the pharmacy and see when they received the orders and when the meds were shipped. As far as the anti-rejection meds, if those are very expensive, the pharmacy probably would not have sent them until they had approval from the DON or Administrator. I talked to the nurse who was working that night and she told me that she called the pharmacy several times to get the meds ordered. The family brought his meds in from home but they were in a pill box, not in labeled containers from the pharmacy, and so we could not give them." 1. On [DATE] at 10:50 am, the physician "Initial Orders" dated [DATE] were shown to the DON. These orders revealed the order for [MEDICATION NAME]TID/AC with sliding scale. When asked if the order for the [MEDICATION NAME] with a sliding scale would be an order to check the blood sugar levels prior to administering the insulin, the DON stated, "Yes, that would be an order for [REDACTED]. 2. On [DATE] at 11:40 am, Registered Nurse (RN #1) was interviewed. When shown the Physician Initial Orders for [MEDICATION NAME] TID/AC with sliding scale, RN #1 stated, "That would mean to check the blood sugar prior to giving the insulin to see if he needed more than the scheduled dose." When asked if the facility had stock insulins to give in an emergency, RN #1 stated, "No, each resident has his own bottle." When shown the treatment record for documentation of medication administration, RN #1 stated, "The X to the 17th would indicate no medications were given until 11 am, on Monday ([DATE])." 3. On [DATE] at 1:20 pm, a telephone interview was conducted with Family Member (FM) #1. When FM #1 was asked about the medications being given at the facility, FM #1 stated, "I was very concerned about him not getting the anti-rejection medications because the doctor had told them it was looking like he might be starting to reject the kidney. I had left his pill box at the facility so the meds could be given and thought they (the facility) would give them. The nurses did not tell me they could not give the pills because they (the pills) were not labeled." 4. On [DATE] at 1:35 pm, FM #2 was interviewed by telephone. When asked if medications were given to Resident #10, FM #2 stated, "I was with him Saturday night ([DATE]) from about 4:00 pm until mid-morning Sunday ([DATE]) and never saw his blood sugar tested or any meds given. The blood sugar was tested on ce, when I asked about it on Monday evening ([DATE]), and it was over 300. Insulin was given then. I asked them every day if was the meds had arrived and I was told on Saturday and Sunday that they had not come in." 5. On [DATE] at 1:45 pm, FM #3 was interviewed by telephone. When asked about the facility giving Resident #10's medications, FM #3 stated, "My family and I were at the facility on Saturday ([DATE]) from about 11:00 am, until 6:30 or 7:00 pm. When we arrived, I asked the nurse if his meds had come in yet and was told they should come in that day. I asked the nurse if his blood sugar had been checked that day and was told, 'No, he seems fine.' I did not witness any medications being given or blood sugar level being checked. We visited again on Monday ([DATE]) from 10:30 am, until about 4:00 pm. On arrival, I asked if the meds had arrived yet and was told, 'No'. I asked the nurse if his blood sugars had been checked and was told that the machine read HI and the nurse was calling the doctor." 6. On [DATE] at 2:30 pm, the DON stated that the pharmacy was having problems locating information about order and delivery times, but the pharmacy thought the meds were sent on Monday [DATE]th. She stated, "The facility nurse did call the pharmacy Friday, Saturday and Sunday, but called the wrong number, so the pharmacy did not get the order until Monday morning. There is a number to call to get meds sooner from the local pharmacy, but that was not done." 7. On [DATE] at 2:45 pm, the DON was asked when medications were received by the facility for Resident #10. The DON stated, "No medications, including insulin were sent to the facility from Friday until Monday about mid morning." When asked if there were any stock medications to give Resident #1, the DON stated, "No, we did not have any of his meds available to give him. The nurses did not call the administrator or nurse on call to inform them of the facility not having the medications that the resident needed."

Based on record review and interview, the facility failed to acquire and administer a minimum of 10 doses of insulin to Resident #10, an insulin dependent diabetic, from Friday, 07/15/11 until Monday, 07/18/11. The facility failed to provide to Resident #10 high blood pressure medication, anti-rejection medication for a kidney transplant, a blood anti-clotting medication from Friday, 07/15/11 to Monday, 07/18/11 after Resident #10 had been in the hospital for mini strokes. The facility also failed to provide blood sugar testing supplies for Resident #10. On 07/18/11, after biologicals and medications were supplied the resident was found to have blood sugar levels so high that the machine could not register a level. This resulted in an immediate jeopardy at a scope and level K. An immediate jeopardy was called on 10/14/11 at 3:10 pm. At that time, the Administrator, Director of Nursing (DON), and Regional Corporate Director were informed. The letter of confirmation of substandard quality of care was presented to the Administrator. A Plan of Removal was accepted by the survey team 10/14/11 at 5:20 pm. Acceptance of the Plan of Removal lowered the scope and severity to a level H, and included the following interventions: Immediate Plan: 1. New admissions from today 10/14/11 are being reviewed to ensure weekend medications are received. 2. Ensure all diabetics have their insulin today and for the weekend. This audit is being conducted now 4:15 pm 10/14/11 and will be completed by 5:15 pm 10/14/11. 3. The pharmacy number will by posted at each nurse's station and at the FAX machine. Which will include day time and after-hours numbers (sic - incomplete sentence). 4. A nurse manager will be in over the weekend 10/15/11-10/16/11 to ensure medications are here and will review diabetic residents for insulin administration. 5. The nurse manager will review the in-service (stated below) again with licensed nurses. Education Plan: 1. Licensed nurses will be in-serviced tonight 10/14/11 and at 6:00 am on 10/15/11 on procedures to ensure all medications arrive for the residents from the pharmacy timely. Further, nurses will be re-educated on blood sugar checks per physician orders. 2. Each licensed staff will be educated on the proper number and procedure to call in medications to the pharmacy such as proper procedure for after hours medication orders. 3. If the nurse is having trouble getting medication ... he/she is to call the on-call nurse and/or administrator for immediate action. 4. Nurses will monitor Medication Administration Records (MARs) to ensure there are no missed doses. Based on record review and interview, the facility failed to provide all medications for 1 (#10) resident of 3 (#10, 15, 17) reviewed for medication availability. Resident #10 was admitted on Friday, 07/15/11 at 7:30 pm, and no medications were provided by the facility until Monday, 07/18/11 at 11:00 am. Physician orders [REDACTED]. This caused harm to Resident #10 by increasing the blood sugar levels, the likelihood of organ rejection, and the risk of additional TIAs (transient ischemic attacks). The findings are: A On 10/14/11, record review of Resident #10's Physician Initial Orders, dated 07/15/11, revealed, "Primary Diagnoses: [REDACTED]." Medications ordered included the following: "Lantus Insulin 20 units subq (under the skin) q (every) day for DM Novolog Insulin 5 units subq TID (3 times a day) AC (before meals) for diabetes Celexa 10 mg. (milligrams) q day for depression ASA (Aspirin) 81 mg. q day for TIA Terazosin 2 mg. q day Q HS (at bedtime) for BPH Prednisone 5 mg. q day for renal (kidney) transplant (anti-rejection) Prograf 2 mg po (by mouth) q (every) AM (morning) and 3 mg. Q HS for renal transplant (anti-rejection) Cellcept 750 mg. BID (2 times a day) for renal transplant (anti-rejection) Metoprolol 25 mg. bid HTN Caduet 10/40 q day HTN/Chol (cholesterol) Ativan 0.5 - 1 mg. BID PRN (as needed) Novolog Insulin TID/AC (Sliding scale for Novolog administration for blood sugars in the range of): 150 - 200 2 (units of insulin); 201 - 250 5 (units); 251 - 300 8 (units); 301 - 350 10 (units); 351 - 400 12 (units)" 1. Review of the July 2011 "Treatments Record" (used for medication administration, including name and dose of medication, date ordered, diagnosis, and time for administration) for Resident #10 revealed all of the physician ordered medications were on the treatment sheet with an order date of 07/15/11. All medications had an "X" from 07/01/11 through 07/17/11, indicating the medications were not given from the time of admission on Friday, 07/15/11 until Monday, 07/18/11. 2. Daily Skilled Nurse's Note at 12:00 pm on 07/18/11 revealed, "Checked residents blood sugar read HI called and reported to (Name of Nurse Practitioner) on voicemail. At 12:15 pm (Name of Nurse Practitioner) ordered 14 units Novolog (insulin) and make changes to MAR (Medication Administration Record) please see MAR." B. On 10/14/11 at 1:20 pm, a telephone interview was conducted with Family Member (FM) #1. When FM #1 was asked about the medications being given at the facility, FM #1 stated, "I was very concerned about him not getting the anti-rejection medications because the doctor had told them it was looking like he might be starting to reject the kidney. I had left his pill box at the facility so the meds could be given and thought they (the facility) would give them. The nurses did not tell me they could not give the pills because they (the pills) were not labeled." 1. On 10/14/11 at 1:35 pm, FM #2 was interviewed by telephone. When asked if medications were given to Resident #10, FM #2 stated, "I was with him Saturday night (07/16/11) from about 4:00 pm until midmorning Sunday (07/17/11) and never saw his blood sugar tested or any meds given. The blood sugar was tested on ce, when I asked about it on Monday evening (07/18/11), and it was over 300. Insulin was given then. I asked them every day if was the meds had arrived and I was told on Saturday and Sunday that they had not come in." 2. On 10/14/11 at 1:45 pm, FM #3 was interviewed by telephone. When asked about the facility giving Resident #10's medications, FM #3 stated, "My family and I were at the facility on Saturday (07/16/11) from about 11:00 am, until 6:30 or 7:00 pm. When we arrived, I asked the nurse if his meds had come in yet and was told they should come in that day. I asked the nurse if his blood sugar had been checked that day and was told 'No, he seems fine.' I did not witness any medications being given or blood sugar level being checked. We visited again on Monday (07/18/11) from 10:30 am, until about 4:00 pm. On arrival, I asked if the meds had arrived yet and was told 'No'. I asked the nurse if his blood sugars had been checked and was told that the machine read HI and the nurse was calling the doctor." 3. On 10/14/11 at 2:30 pm, the interim Director of Nurses (DON) stated that the pharmacy was having problems locating information about order and delivery times, but the pharmacy thought the meds were sent on Monday July 18th. The DON stated, "The facility nurse did call the pharmacy Friday, Saturday and Sunday, but called the wrong number, so the pharmacy did not get the order until Monday morning. There is a number to call to get meds sooner from the local pharmacy, but that was not done." 4. On 10/14/11 at 2:45 pm, the interim DON was asked when medications were received by the facility for Resident #10. The DON stated, "No medications, including insulin were sent to the facility from Friday (07/15/11) until Monday (07/18/11) about mid morning." When asked if there were any stock medications(medications available in the facility medication room) to give Resident #10, the DON stated, "No, we did not have any of his meds available to give him. The nurses did not call the administrator or nurse on call to inform them of the facility not having the medications that the resident needed."