Every finding on record at Cedar Hill Health Care Center

Based on the interview and record review, the facility failed to monitor and respond appropriately to a hyperglycemic event for 1 of 12 residents (Resident #38), who had a known diagnosis of diabetes mellitus and chronic kidney disease. Specifically, the facility failed to monitor blood glucose levels and vital signs following a critically elevated glucose reading of 567 mg/dL and failed to reassess the resident's condition after insulin administration. These failures were inconsistent with professional standards of practice and the facility's own diabetes care policy and resulted in the resident being found deceased approximately ten hours after the event, without documented follow-up monitoring. Per review of Resident #38's medical diagnosis, Resident #38 had type 2 diabetes with diabetic chronic kidney disease, and long-term use of insulin.Per record review, Resident #38 is care planned for diabetic management and the monitoring and treatment of medications for side effects and their effectiveness dated [DATE].Per record review of a progress note dated [DATE], Resident #38 was noted to be nauseous, vomiting, and diaphoretic, This writer was called in to see resident at about 2200 [10:00 PM]. Resident was complaining of feeling nauseous and diaphoretic. Resident reports that [s/he] had thrown up too. FSBG [Fingerstick Blood Glucose] taken. FSBG was 555. Repeat check performed. Follow up was 567. At 2202 [10:02 PM], call was placed to on call provider. It was noted that resident has not received any diabetic medication in over 48 hours. Verbal orders received for glargine insulin [long acting] 3 units now and 3 units at 9 am on [DATE]. On call provider requested [his/her] FSBG to be checked before the 9am dose of glargine. Orders placed. Resident made aware. See MAR [Medication Administration Record] for details. The resident #38 had critical blood sugar (glucose) levels (hyperglycemia (high): above 400 mg/dL) of 567 mg/dL. Additionally, Resident #38 was presenting possible Diabetic Ketoacidosis (DKA) symptoms of nausea, vomiting, and diaphoresis, which is a medical emergency (referenced from Diabetes and Endocrinology of Dangerous Blood Sugar Levels (2023), https://sahyadrihospital.com/blog/dangerous-blood-sugar-levels-understanding-symptoms-and-management/).Review of a progress note dated [DATE] states Initially the MAR was not showing insulin orders, but another nurse on day shift was able to see the orders and administrations for the diabetes medications. MAR administration records shows that [Resident #38] had received [his/her] medications on 7/8 and 7/9. During the initial assessment, resident noted that [s/he] had been feeling poorly since lunch time on [DATE] and had mentioned it to several staff members.Resident #38's Electronic Health Record (EHR), revealed no evidence that the Resident received monitoring and further treatment after the nurse identified an elevated blood glucose level of 567 mg/dL and administered a long-acting insulin medication. The EHR shows no evidence that Resident #38 had any follow up blood glucose monitoring or monitoring of vital signs after this event.Per record review of the progress notes on [DATE], approximately ten hours after a hyperglycemic event went unmonitored, a physician pronounced Resident #38 as dead with the time of death at 8:32 AM. A progress note dated [DATE], it states Resident resting at shift change. [S/he] was approached by [Physician], he came out stating that resident had passed (08:32). This writer found the resident was unresponsive to verbal or tactile stimuli, apneic [not breathing], unresponsive pupils, and an absence of heart sounds.Per review of the facilities policy titled Nurse Care of the Resident with Diabetes Mellitus dated 2025, it states under the section titled Glucose Monitoring that .Residents whose blood sugar is poorly controlled or those taking insulin may require more frequent monitoring, depending on n the situation.Per interview with the Director of Nursing (DON) on [DATE] at 11:29 AM, she confirmed that the nurse told the provider that Resident #38 had not received any diabetic medications in 48 hours, when they had, and the provider ordered 3 units of glargine insulin (a long acting insulin that takes about 2 hours to work) On [DATE] when Resident #38 had a last known blood glucose level of 567 mg/dL. When asking the DON about standard orders pertaining to monitoring blood glucose levels, she reported they have them for all residents. When asked about why Resident #38 wasn't monitored after having an extremely elevated blood glucose level, she reported that she wasn't there and couldn't say, she confirmed that Resident #38 was not monitored. The DON stated that if she were there at the time of this event, she would have monitored Resident #38 and documented that in the EHR.

Based on interview and record review the facility failed to ensure that the dietary manager possessed the required qualifications for the position. This deficient practice has the potential to affect all residents. Findings include: Per interview with the Dietary Manager on 9/24/2025 at 3:10 PM she had been enrolled in a Dietary Manager class but had to put it on hold due to the Dietician being away. The Dietary Manager confirmed that the Registered Dietician is not employed on a full-time basis and that she does not have the required qualifications to meet the regulatory requirements. During a phone interview on 9/24/2025 at 3:25 PM, the Facility Owner stated that due to the hardship of hiring a qualified Dietary Manager she hired the current manager with plans for her to become certified.

Based on observation, interview, and policy review the facility failed to ensure resident medications were securely stored for 1 of 1 treatment carts observed. Findings include:During an observation on 9/23/25 at 12:05 PM, an unattended treatment cart was observed unlocked, and the Licensed Medication Nurse's Aide (LMNA) confirmed that medicated ointments were inside the cart. The cart was then locked.During an observation on 9/23/25 at 1:39 PM, an unattended treatment cart was found to be unlocked. Per interview with the LMNA at 1:39 PM, stated, Thank you for letting me know, and then locked the treatment cart. The LMNA confirmed that the treatment cart contained prescribed medications for multiple residents and should always remain locked; however, it was not. Per the facility's Administering Medications policy [last revised 4/2019] states .medication cart is kept closed and locked when out of sight of the medication nurse or aide.

Based on interview and record review the facility failed to identify and provide treatment and services related to dementia for one of twelve residents in the sample (Resident #3). Findings include:Per record review Resident #3 has a diagnosis of dementia with behavioral disturbances including becoming resistive and combative with care.The facility policy titled Dementia- Clinical Protocol states For the individual with confirmed dementia, the IDT will identify a resident-centered care plan to maximize remaining function and quality of life.Review of Resident #3's care plan revealed that there was no care plan for dementia care, and the care plan did not identify dementia related care needs or what to do when Resident #3 was refusing, resistive, or combative. The only intervention related to combativeness with care was implemented on 9/8/2025 of If resident is combative with care, give [her/him] space and reattempt. This intervention is under the focus of Resident has a hematoma on [her/his] right forearm and a bruise on his left side when s/he sustained an injury of unknown origin.Further record review reveals that on 6 different occasions nursing staff documented that Resident #3 was refusing and resistive to care, at times becoming combative, hitting staff and yelling out. There were no documented resident centered approaches implemented during these occasions of behavioral expressions of distress however, psychotropic medications were added and increased between 8/26/25 and 9/11/2025. A Nursing Note Narrative dated 8/11/2025 states Resident was very upset with nighttime care this shift. [S/He] was yelling at staff, swearing and attempts made to pull out [her/his] supra pubic [catheter]. Settled after care was given. There are no resident-centered approaches to care documented in this progress note. A geriatric psychiatric consult dated 8/26/2025 reflects that Resident #3 has a history of dementia with behavioral disturbances and states that the Resident continues to have days when [s/he] is combative punches and hits with care-worse on afternoon and evening shift. A recommendation was made to increase Sertraline (Antidepressant) from 50 mg to 75 mg daily.A Nursing Narrative Note dated 8/27/2025 states that Licensed Nursing Assistants (LNAs) providing care after lunch reported that resident was calling out and swinging fists. LNAs attempted to calm [her/him], but [s/he] was resistive to care. Care was completed with no further complications. [S/He] is resting in bed at this time. An Alert Note dated 9/02/2025 states Resident cursing and hitting LMN/s [Licensed Medication Nursing Assistants] doing care. Resident not easily redirected. Continues behavior doing care. A communication note written by the facility Social Worker dated 8/28/2025 states Worker met with [Durable Power of Attorney, (DPOA)] to go over [their] questions about [the Resident's] emerging resistance to care seen as being combative physically and or verbally. [DPOA] has approved [the Resident's] change in medication of returning the Sertraline to 75mg per day and adding Trazadone 25mg BID [twice daily] for depression/anxiety to address associated behaviors. [DPOA] asked questions to be sure [the Resident] was not being sedated due to [their] behaviors. Reaffirmed that we cannot medicate as a restraint. We also reviewed [Resident's] dementia has having increased with time since admission. Worker offered education on dementia to [DPOA] during this meeting. [DPOA] states [s/he] has been kept abreast of [Resident #3's] need for medication changes and wanted to clarify with our DON [Director of Nursing] what behaviors are emerging, what time of day, what staff is working with [the Resident] and is there enough staffing to allow [her/him] extra time to process what is asked of [her/him] i.e. ADL [activities of daily living] care needs. [DPOA] acknowledged that [s/he] still needs to get a new battery charger for [the Resident's] hearing aids which may be contributing to any potential behaviors if [the Resident] can't hear/understand what is asked of [her/him] in the moment. [DPOA] asked if [s/he] could get copies of [the Resident's] documents to better understand the changes in [the Resident]. Worker guided [her/him] to [the DON] for further discussion on [the Resident's] behaviors and [her/his] request for documentation. Worker escorted [DPOA] down to meet with [DON] and discuss [their] concerns/questions. Review of Resident #3's care plan reveals that s/he does not have care planned interventions that address allowing extra time to process what is being asked of her/him and no interventions related to hearing loss or hearing aids that may improve her/his understanding. Another geriatric psychiatric consult dated 9/11/2025 states that the Resident is on the concern list for ongoing behaviors. Sertraline was increased from 50mg to 75mg 0n 8/28/25. [S/he] continues to have days when [s/he] is combative, punches and hits with care-worse on afternoon and evening shift. Yells out with Hoyer transfers. The recommendations made at this consult were to increase trazodone to 25mg three times per day and in 2 weeks increase sertraline to 100mg daily. There were no behavioral interventions recommended at either consult. A Nursing Narrative Note dated 9/16/2025 reveals that Resident #3 continued with refusals of care becoming resistive and combative stating PRN [as needed] trazadone was given at [6:00 PM]. Resident had behaviors during HS [hour of sleep/evening] care. Screaming, swearing and combative. There was no documented evidence that staff implemented any non-pharmacological interventions, gave her/him space, or reattempted. Another Nursing Narrative note dated 9/17/2025 states Resident had behavior's during HS care. [S/He] did receive PRN trazadone prior to. A 9/23/2025 Nursing Note Narrative states, [S/He] had behaviors during HS care. Screaming, swearing, uncooperative. Striking out at staff members. [S/He] was incontinent of BM [bowel movement]. Dressing was changed on sacrum. [S/He] did receive prn Trazadone prior to care. There is no documented evidence that staff gave her/him space and reattempted as directed in the care plan. Per interview with the MDS (Minimum Data Set, an assessment used to identify care plan needs) Coordinator on 9/24/2025 at 2:18 PM she confirmed that Resident #3's care plan did not identify the diagnosis of dementia, or Resident's dementia specific care needs. Ref. F-656

Based on interview and record review the facility failed to create a comprehensive care plan related to anxiety. depression, dementia care, psychotropic medication use, and hearing impairment for one of 12 residents in the sample (Resident #3). Findings include:Per record review Resident #3 has diagnoses that include anxiety, depression, and dementia with behavior disturbance, is prescribed psychotropic medications for behavioral management, and has had multiple psychotropic medication changes to manage refusals of care, resistive, and combative behaviors. Review of Resident #3's care plan revealed that Resident #3 was not care planned for psychotropic medications, anxiety, depression, or dementia care and the care plan did not identify interventions related to the Resident's behavioral or dementia related care needs or what to do when Resident #3 was refusing, resistive, or combative. The only intervention related to combativeness with care was implemented on 9/8/2025 of If resident is combative with care, give [her/him] space and reattempt. This intervention/approach is under the focus of Resident has a hematoma on [her/his] right forearm and a bruise on his left side when s/he sustained an injury of unknown origin. There is no documented evidence that this approach was used as indicated. A communication note written by the facility Social Worker dated 8/28/2025 states Worker met with [Durable Power of Attorney, (DPOA)] to go over [their] questions about [the Resident's] emerging resistance to care seen as being combative physically and or verbally. [DPOA] has approved [the Resident's] change in medication of returning the Sertraline to 75mg per day and adding Trazadone 25mg BID [twice daily] for depression/anxiety to address associated behaviors. [DPOA] asked questions to be sure [the Resident] was not being sedated due to [their] behaviors. Reaffirmed that we cannot medicate as a restraint. We also reviewed [Resident's] dementia has having increased with time since admission. Worker offered education on dementia to [DPOA] during this meeting. [DPOA] states [s/he] has been kept abreast of [Resident #3's] need for medication changes and wanted to clarify with our DON [Director of Nursing] what behaviors are emerging, what time of day, what staff is working with [the Resident] and is there enough staffing to allow [her/him] extra time to process what is asked of [her/him] i.e. ADL [activities of daily living] care needs. [DPOA] acknowledged that [s/he] still needs to get a new battery charger for [the Resident's] hearing aids which may be contributing to any potential behaviors if [the Resident] can't hear/understand what is asked of [her/him] in the moment. [DPOA] asked if [s/he] could get copies of [the Resident's] documents to better understand the changes in [the Resident]. Worker guided [her/him] to [the DON] for further discussion on [the Resident's] behaviors and [her/his] request for documentation. Worker escorted [DPOA] down to meet with [DON] and discuss [their] concerns/questions. Per review the facility policy titled Care Plans, Comprehensive Person-Centered the Policy Statement reads 1. The interdisciplinary team (IDT), in conjunction with the resident and his/her family or legal representative, develops and implements a comprehensive person-centered care plan for each resident. Further review of the Resident's care plan reveals that it does not address the need for hearing aids or interventions related to hearing loss that may help the Resident to understand. Per interview with the MDS (Minimum Data Set, an assessment used to identify resident care plan needs) Coordinator on 9/24/2025 at 2:18 PM she confirmed that care plan did not address the use of psychotropic medications and interventions to meet the behavioral health needs of Resident #3, including the Resident's dementia specific care needs.

Based on interview and record review, the facility failed to ensure a resident was not administered psychotropic medications without implementation of person-centered, non-pharmacological approaches to manage behavioral expressions of distress for one of two residents in the sample (Resident #3). Findings include:Per record review Resident #3 has diagnoses that include anxiety, depression, and dementia with behavioral disturbances. Further review of the record revealed that the Resident had been having behavioral expressions of distress when receiving care including refusals, resistive, and combativeness with care. On 6 different occasions nursing staff documented that Resident #3 was refusing and resistive to care, at times becoming combative, hitting staff and yelling out. There were no documented resident centered approaches implemented during these occasions of behavioral expressions of distress and the Resident's care plan did not address resident specific care needs. However, psychotropic medications were added and increased between 8/26/25 and 9/11/2025. A Nursing Note Narrative dated 8/11/2025 states Resident was very upset with nighttime care this shift. [S/He] was yelling at staff, swearing and attempts made to pull out [her/his] supra pubic [catheter]. Settled after care was given. There is no documentation that supports that the Resident was offered any therapeutic intervention. A geriatric psychiatric consult dated 8/26/2025 reflects that Resident #3 has a history of dementia with behavioral disturbances and states that the Resident continues to have days when [s/he] is combative punches and hits with care-worse on afternoon and evening shift. A recommendation was made to increase Sertraline (Antidepressant) from 50 mg to 75 mg daily. A Nursing Narrative Note dated 8/27/2025 states that Licensed Nursing Assistants (LNAs) providing care after lunch reported that resident was calling out and swinging fists. LNAs attempted to calm [her/him], but [s/he] was resistive to care. An Alert Note dated 9/2/2025 states Resident cursing and hitting LMN/s [Licensed Medication Nursing Assistants] doing care. Resident not easily redirected. Continues behavior doing care. A physicians visit note dated 9/9/2025 states .for the past week or 2 nurses have documented some agitation, yelling, swearing, trying to bite, spit grab usually starting around 4 pm or so. No issues in the day or at night (none documented). Trazodone was added 8/14 bid [twice daily] but staff still states mid second shift [s/he] is agitated. Noted to have a large hematoma on his [right] forearm over the weekend. No known trauma. Under the Assessment/Plan section of the visit note it states, Will schedule the trazodone for 8 am 4pm to see if this helps with agitation. Another geriatric psychiatric consult dated 9/11/2025 states that the Resident is on the concern list for ongoing behaviors. Sertraline was increased from 50mg to 75mg 0n 8/28/25. [S/he] continues to have days when [s/he] is combative, punches and hits with care-worse on afternoon and evening shift. Yells out with Hoyer transfers. The recommendations made at this consult were to increase trazodone to 25mg three times per day and in 2 weeks increase sertraline to 100mg daily. There were no behavioral interventions recommended at either consult. Review of Resident #3's care plan revealed that Resident #3 had not been care planned for psychotropic medications, depression, anxiety, or dementia care including the identification of person-centered non-pharmacological interventions when refusing, resistive, or combative. The only intervention related to combativeness with care was implemented on 9/8/2025 that states If resident is combative with care, give [her/him] space and reattempt. This intervention is under the focus of Resident has a hematoma on [her/his] right forearm and a bruise on [his/her] left side when s/he sustained injuries of unknown origin.A Nursing Narrative Note dated 9/16/2025 reveals that Resident #3 continued with refusals of care becoming resistive and combative stating PRN [as needed] trazadone was given at [6:00 PM]. Resident had behaviors during HS [hour of sleep/bedtime] care. Screaming, swearing and combative. There was no documented evidence that staff implemented any non-pharmacological interventions, gave her/him space, or reattempted. Another Nursing Narrative note dated 9/17/2025 states, Resident had behavior's during HS care. [S/He] did receive PRN trazadone prior to. A 9/23/2025 Nursing Note Narrative [S/He] had behaviors during HS care. Screaming, swearing, uncooperative. Striking out at staff members. [S/He] was incontinent of BM [bowel movement]. Dressing was changed on sacrum. [S/He] did receive prn Trazadone prior to care. There is no documented evidence that staff gave her/him space and reattempted as directed in the care plan. Per interview with the MDS (Minimum Data Set, an assessment used to identify resident care plan needs) Coordinator on 9/24/2025 at 2:18 PM she confirmed that care plan did not address the use of psychotropic medications or non- pharmacological interventions to meet the behavioral health needs of Resident #3. Ref. F656

Based on interview and record review, the facility failed to notify the resident's representative of a change in condition relating to an episode of hyperglycemia that required physician's orders for additional medical treatment for 1 of 12 sampled residents (Resident #38). Findings include:Per record review of Resident #38's medical diagnosis, s/he has a diagnosis of type II diabetes mellitus with diabetic chronic kidney disease. A document titled Resident Representative Notification of Incidents dated 2/20/25, indicated that Resident #38's Representative wanted to be contacted for any incidents that occurred between the hours of 9 PM and 7 AM. Per record review of a progress note on 7/9/25, Resident #38 was noted to be nauseous, vomiting, and diaphoretic. The nurse took Resident #38's blood glucose level and the Resident's glucose level was 555 mg/dL. The nurse retook Resident #38's blood glucose level and the Resident's glucose level was 567 mg/dL. The nurse then contacted the provider and obtained an order for additional insulin but did not notify the family of the elevated blood glucose level or the new physician order due to this change in condition. Per interview with the Director of Nursing (DON) on 9/24/25 at 11:47 AM, when asked if the resident representative was notified of the change in condition and treatment, the DON confirmed that they were not notified.

Based on interview and record review the facility failed to inform in advance of the risks and benefits of the proposed care, the treatment alternatives or other options for 1 of 5 sampled residents (Resident #3). Findings include: Per record review Resident #3 has diagnoses that include anxiety, depression, and dementia with behavioral disturbance and was experiencing increased behavioral expressions of refusing care, resistive, and combative in the evening. Resident #3 has a Durable Power of Attorney (DPOA, a person responsible for financial legal and medical decisions). A provider visit note dated 8/14/2025 states will add some trazodone 25 [mg] bid [twice daily] as needed (PRN) to see if this helps rather than adding a standing med or change dose of sertraline Reassess in 2 weeks for prn use Discussed with DPOA [name omitted] about change in meds and [s/he] will get back [to] us. Further record review reveals that the trazodone was started however, there is no evidence of response from the DPOA related to the implementation of PRN trazodone. An alert note dated 8/21/2025 reflects that trazodone 25 mg by mouth two times a day and 25 mg by mouth as needed for agitation related to depression was ordered. There is no documented evidence in the record that the DPOA was aware of the new scheduled order or offered informed consent of the risks and benefits of this increase in trazodone. A provider visit note dated 8/27/25 states On sertraline 50mg PO [by mouth] daily Indication: depression at this time Sertraline will be increased to 75mg PO daily per Geriatric Psych recommendations . On trazodone 25mg PO BID Indication: agitation at this time benefits outweigh the risks, and this med will be continued. A Nursing Note Narrative dated 8/27/2025 states POA is aware of the increase in [his/her] medication and gave consent. However, this was 12 days after the implementation of the initial trazodone and 6 days after the implementation of the scheduled trazodone. A communication note written by the facility Social Worker dated 8/28/2025 states Worker met with [Durable Power of Attorney, (DPOA)] to go over [their] questions about [the Resident's] emerging resistance to care seen as being combative physically and or verbally. [DPOA] has approved [the Resident's] change in medication of returning the Sertraline to 75mg per day and adding Trazadone 25mg BID [twice daily] for depression/anxiety to address associated behaviors. [DPOA] asked questions to be sure [the Resident] was not being sedated due to [their] behaviors. Reaffirmed that we cannot medicate as a restraint. We also reviewed [Resident's] dementia has having increased with time since admission. Worker offered education on dementia to [DPOA] during this meeting. [DPOA] states [s/he] has been kept abreast of [Resident #3's] need for medication changes and wanted to clarify with our DON [Director of Nursing] what behaviors are emerging, what time of day, what staff is working with [the Resident] and is there enough staffing to allow [her/him] extra time to process what is asked of [her/him] i.e. ADL [activities of daily living] care needs. [DPOA] acknowledged that [s/he] still needs to get a new battery charger for [the Resident's] hearing aids which may be contributing to any potential behaviors if [the Resident] can't hear/understand what is asked of [her/him] in the moment. [DPOA] asked if [s/he] could get copies of [the Resident's] documents to better understand the changes in [the Resident] . A Nursing Note Narrative dated 9/11/2025 states Resident seen by [Doctor] today for [her/his] dementia with behavior disturbances with ongoing behaviors on 3p-11p shift. Recommendations increase Trazodone to 25mg three times a day at [8:00am, 1:00pm, 5:00pm]. In 2 weeks increase Sertraline to 100mg daily in the morning. [Primary Physician] agrees with the recommendation and the orders have been entered. [Primary Physician] will call and speak with DPOA, about the changes. There is no documented evidence that the Resident's DPOA was informed of this increase in or the risks and benefits of increasing the trazodone. Per facility policy titled Requesting, Refusing, and/or Discontinuing Care or Treatment the Policy Statement reads Residents and resident representatives have the right to request, refuse and/or discontinue treatment. Treatment refers to medical care, nursing care, and interventions provided to maintain or restore health and well-being, improve functional level, or relieve symptoms. The policy also states Residents/representatives are informed (in advance) of: a. the care that will be furnished or made available to the resident based on his or her assessment or plan or care; b. the risks and benefits of the proposed care, treatment, treatment alternatives or treatment options; During an interview with a Registered Nurse (RN) on 9/24/2025 at 1:09 PM she confirmed that there was no documented evidence that Resident #3's DPOA had consented for the initial trazadone order on 8/14/2025 and the increase on 8/21/2025. The RN stated that they only implement informed consent forms for antipsychotic medications. She confirmed that informed consent was not in the progress notes and there was no consent form.

Based on interview and record review, the facility failed to maintain hospice records and coordinate care services for 1 of 1 residents in the sample (Resident #10). Findings include:Per review of the facilities policy titled Hospice Program dated 2025, it states that it is the responsibility of the facility to meet the resident's personal care and nursing needs in coordination with the hospice representative and ensure that the level of care provided is appropriately based on the individual resident's needs. These include . Administering prescribed therapies, including those therapies determined appropriate by the hospice and delineated in the hospice plan of care.communicating with the hospice provider (and documenting such communication) to ensure that the needs of the resident are addressed and met 24 hours per day.obtaining the following information from the hospice. The most recent hospice plan of care specific to each resident.hospice election form.physician certification and recertification of the terminal illness specific to each resident. Names and contact information for hospice personnel involved in hospice care of each resident. instruction on how to access the hospice's 24 hour on-call system. Hospice medication information specific to each resident. Hospice physical and attending physician (if any) orders specific to each resident. Coordinated care plans for residents receiving hospice services will include the most recent hospice plan of care as well as the care and services provided by our facility. in order to maintain the resident's highest practicable physical, mental and psychosocial well-being.Per review of the facilities hospice agreement with Resident #10's hospice provider titled Nursing Facility Services Agreement For Respite Care marked effective starting on 7/1/16, it states that hospice shall communicate with the facility and At a minimum, Hospice shall provide the following information to Facility for each Hospice Patient resident at Facility. Plan of care, Medications, and Orders. The most recent Plan of care, medication information and physician orders specific to each Hospice Patient residing at Facility. Names and contact information for Hospice personnel involved in providing Hospice services. Instruction on how to access Hospice's 24-hour on-call system.Per review of Resident #10's Electronic Health Record (EHR), the Resident is on hospice services. Review of Resident #10's EHR revealed that they did not have a hospice care plan in their EHR or in the facilities paper hospice binder.Per interview with a Licensed Nurse on 9/23/25 at 1:42 PM, when asked how she knows Resident #10's hospice goals, she reported they usually follow the facility's care plan. When asked how often hospice was supposed to come in, she reported she wasn't sure. She confirmed that there was no hospice documentation other than the sign-in sheet in Resident #10's hospice binder.Per interview with the Director of Nursing (DON) on 9/23/25 at 1:27 PM, she reported they do not have access to any hospice records.Per interview with the DON on 9/23/25 at 4:04 PM, she confirmed that they did not have the hospice care plan for Resident #10 or any documents in their hospice binder other than the hospice sign in sheet. She reported she was unsure of how to access the hospice documents but does have access and confirmed that the hospice care plan should have been in the binder and wasn't.

Based on observation, interview, and record review the facility failed to ensure that each resident had access to an effective call system at their bedside for 2 of 21 residents sampled (Resident #1 and #7). This deficient practice has the potential to affect all residents who reside in the facility. Findings include: 1. During unit observations and resident interview on 6/17/24 at 3:03 PM, Resident #1 was observed sitting in a recliner in their room trying to get assistance to go to the bathroom. Resident #1 was asked by the Surveyor if they could ring their call bell to alert staff that s/he needed assistance. The Resident stated that s/he had been ringing and ringing and nobody was coming. The Surveyor pushed the call light button, and nothing happened. Resident #1 was pleading for help to get to the bathroom. The Surveyor went to get a Licensed Nursing Assistant (LNA) to assist. The LNA stated that s/he was not aware that Resident #1 was in need of assistance. The LNA also stated that the call lights don't work a lot of the time, and that the residents have been given hand bells to ring for help if the call light doesn't work. Upon looking for the hand bell in Resident #1's room the LNA discovered and confirmed that there was no hand bell available for Resident #1. The LNA said that s/he would get Resident #1 a hand bell and tell maintenance that the call light was not working after they assisted the resident to the bathroom. Per interview with the Administrator and Director of Nursing on 6/17/24 at approximately 5:15 PM they were unaware of Resident #1's light not working. The Administrator stated that they do have this issue on occasion, and they provide hand bells so the Residents can summon staff. 2. During unit observations on 6/18/24 at 10:44 AM while in Resident #7's room the Surveyor pushed the call light button that was attached to the wall. The call light indicator (a box that lights up when the call button is pushed) in the hall did not light up and there was no audible signal that occurs when the call light is activated. Per interview with the Administrator and the Assistant Administrator on 6/19/24 at 9:00 AM there are times when call lights get pulled from the wall a bit and need to be repositioned to work. When a call bell is not working, and staff are unable to fix it they must complete a TELS (Maintenance) request. The Assistant Administrator stated that about 10 call light checks are done weekly to ensure that they are working, and there has been a significant improvement. However, when asked if there was a system in place to check all call lights to ensure that residents could always call for assistance the Assistant Administrator and Administrator both confirmed that there was not. When asked if staff had made them aware that Resident #1's call light was not working on 6/17/24 the Assistant Administrator confirmed that the LNA had not informed anyone to fix it.

Based on interview and record review the facility failed to ensure that 1 of 4 sampled licensed nursing assistants (LNAs) and 2 of 2 sampled Licensed Practical Nurses (LPNs) were assessed for competency in the skills required to care for the resident needs based on resident care plans. Findings include: 1. Review of 1 LNA education and competency file revealed an orientation checklist that was signed off by another LNA; however, there was no evidence that the LNA was assessed for competency by a licensed nurse. 2. Review of the education and competency file for 1 LPN who was hired on 5/29/2024 revealed no evidence that they were assessed for competency in the skills needed to care for the residents. 3. Review of the education and competency file for 1 LPN who was hired on 8/23/17 revealed no evidence of annual competency evaluation of the skills needed to care for the residents. Durning interview on 6/19/2024 at 2:04 PM the Director of Nursing and the Human Resource Director confirmed that there was no evidence that the above LNAs and LPNs had been assessed for competency.

Based on resident and staff interviews and record review the facility failed to report an incident of alleged abuse to the state licensing agency for 1 resident (Resident #30) of 21 sampled residents. Findings include: Per resident interview on 6/19/24 at 11:36 AM Resident #30 stated that a staff member on the overnight shift had made a fist at her/him and stated, You can't even walk. I can knock the shit out of you. Resident #30 stated that s/he had reported this incident to a Licensed Nursing Assistant (LNA) that morning. Per record review of the facility's Abuse, Neglect, and Exploitation policy [last reviewed on 1/27/23], Reporting of all alleged violations are brought to the charge nurse and then the nurse on call. The nurse on call notifies the director of nursing and the administrator. The Director of Nursing, administrator, or designate will notify the state agency ([NAME]), Adult Protective Services [APS] . On 6/19/24 at 12:02 an interview was conducted with the DON [Director of Nursing] and the facility Administrator [ADM]. The DON and facility administrator confirmed that Resident #30 had reported the incident to a staff member and the staff did not inform the DON and ADM. The DON confirmed the incident was not reported as required to APS or the state agency.

Based upon interview and record review, the facility failed to revise resident care plans related to fall prevention for 1 resident [Res.#25] of 21 sampled residents. Findings include: Per review of the facility's Falls-Clinical Protocol policy, the staff and physician will identify pertinent interventions to try to prevent subsequent falls. [Nursing Services Policy and Procedure Manual for Long Term Care- revised March 2018] Review of the facility's Nursing Floor Communication Resource reveals under 'Falls' Update the resident's care plan with a new intervention EVERY time a fall occurs with the resident. An interview was conducted with the facility's Director of Nursing [DON] on 6/19/24 at 9:09 AM. The DON stated that the facility's procedure after a resident fall is to update the resident's care plan with new intervention[s] to prevent future falls. The DON confirmed that incident reports and Nursing Notes documented Res.#25 suffering falls on 12/8/23, 12/10/23, 1/8/24, 1/10/24 and 3/24/24. The DON confirmed that Res.#25's care plan contained no new interventions to prevent future falls after falls on 12/8, 1/8, 1/10. The DON confirmed that after the falls in January with no new interventions, the resident fell again on 3/24/24. Nursing Notes dated 3/24/24 record staff reported to this nurse that resident was lying on the floor of [h/her] room . Did begin to complain of pain in [h/her] Left wrist. Tender to touch or move . DON made aware and an x-ray of Left wrist will be ordered tomorrow (Monday 3/25/24). Nursing Notes dated the next day, 3/25/24, reveal Results of Xray returned and show acute, nondisplaced fracture of the left wrist. Per interview and record review, the DON confirmed that new interventions should have been added to Res.#25's care plan after each fall to prevent future falls and injury but were not.

Based on staff interview and record review, the facility failed to ensure that records are complete, readily accessible, and systematically organized related to a resident's required pharmacy review for 1 out of 5 sampled residents (Resident # 3). Findings include: Per record review, Resident # 3 was admitted to the facility on [DATE]. There was no evidence in the record that pharmacist conducted a monthly medical record review since admission. During an interview with the Director of Nursing (DON) on 06/18/2024 at approximately 3:30 PM s/he stated that the facility recently changed pharmacy providers. The new pharmacist visited the facility and removed the previous pharmacy recommendations from paper charts and brought them home to review. The DON confirmed at the time of interview that the pharmacy recommendations were not on site or in Resident # 3's medical record. The DON stated that the pharmacist was currently on vacation and was unsure if s/he would be able to obtain the reviews. The DON was able to produce a copy of the pharmacy review form prior to the end of the survey however, s/he did confirm that the pharmacy reviews should have been in the medical record.

Based on staff interview and record review the facility failed to provide facility transfer notices prior to transfer for residents and/or their representatives, and to send the same transfer notice (or a copy of it) to a representative of the Office of the State Long-Term Care Ombudsman for 10 out of 10 sampled residents (Residents #1, #2, #3, #7, #8, #10, #11, #13, #18 and #38). Findings include: Record review on 04/18/23 of a hospitalization for Resident #18 shows this resident was transferred to the emergency room (ER) on the date of 01/14/23 with no evidence found of a transfer notice being provided to the resident or resident representative. Interview with the Director of Nursing (DNS) on 04/18/23 revealed that the facility has not provided transfer or discharge notices to any of their residents or to the Ombudsman in the past year. The DNS stated this was, an oversight maybe due to staffing changes. On 04/19/23 An Action Summary list was provided to this surveyor showing ten ER transfers from 04/17/22 through 04/18/23. The list was comprised of all resident ER transfers in this time period. The DNS stated, none of the residents on the list, or their representatives, or the Ombudsman had been provided with a transfer notice at any time. On 04/20/23 the regulatory requirements for transfer and discharge notices were discussed with the DNS, the regulation was shown to her/him, and the DNS confirmed Residents #1, #2, #3, #7, #8, #10, #11, #13, #18 and #38 were not provided with a transfer notice at any time, nor were their representatives or the local Long-Term Care Ombudsman.

Based on staff interview and record review the facility failed to provide a written copy of a Bed-Hold notice to residents and/or their representatives prior to transfer or discharge or in case of emergency, within 24 hours for 3 of 10 sampled residents (Residents #18, #8, and #7). Findings include: Record review on 04/18/23 of a hospitalization for Resident #18 shows this resident was transferred to the emergency room (ER) on the date of 01/14/23 with no evidence found of a written Bed-Hold notice being given to the resident or resident representative. At the time of the record review the Director of Nursing was asked if s/he could provide evidence of the required Bed-Hold Notice but s/he could not produce this. It was noted that the Bed-Hold Notice is provided in the facility's admission packet and reviewed with residents or their representatives upon admission, however Federal regulations require facilities to issue two notices related to bed-hold policies. On 04/19/23 An Action Summary list was provided to this surveyor showing ten ER transfers since April of 2022. Two additional resident ER transfers were performed without the required Bed-Hold Notice; the additional residents were Resident #8 who was transferred to theER on [DATE], and Resident #7 who was transferred to theER on [DATE]. On 04/19/23 at 12:55 PM, the Director of Nursing (DON) confirmed there was no documentation to show that the required Bed-Hold notices for Residents #18, #8, and #7 had been given to the residents and/or their representatives at the time of the ER transfers, or within 24 hours of those transfers.

Based on observations and interviews the facility failed to update the required posted staffing information at the beginning of each shift. Findings include: On 4/19/23 at 9:30 am, 11:00 am and 12:18 pm, observation of the facility's staffing posting in the lobby revealed that the schedule posted was dated for 4/18/23. The posting was not updated at the beginning of each shift as required.

Based on staff interview and record review, the facility failed to provide notice of changes in coverage by Medicare for three of three sampled residents (Residents #11, #30, and #4). Findings include: Per record review, Residents #11, #30, and #4 were provided with the Skilled Nursing Facility Advanced Beneficiary Notice (SNF ABN) for services that would no longer be covered by Medicare due to no longer being necessary. These 3 Residents did not receive a Notification of Medicare Non-Coverage (NOMNC). All 3 Residents remained in the facility after coverage ended. Per interview on 4/18/23 at approximately 11:30 AM, the Director of Financial Services confirmed that Residents who remained in the facility after the coverage end date had not been receiving a NOMNC to date.

Based on observation, staff interview, and record review the facility failed to ensure that resident personal and medical information was maintained in a secure and confidential manner, so that others would not have access to it for 1 of 19 sampled residents and 1 of 2 medication carts with identifying information for all residents. Findings include: 1. Per observation on 4/20/2022 at 2:11 PM a sign was posted on the outside of the door, toward the hallway of room [ROOM NUMBER] that stated: Infection Prevention and Control Policy for Suspected or Confirmed Coronavirus (COVID 19); Room log: Residents with suspected or confirmed Coronavirus (COVID 19); Residents name: [The resident's name was written in]; Employee or Visitor Name: Date: Time In: Time Out: An employee had signed in on 4/19/22 at 7:20 AM and 9:30 AM. This sign in sheet was located on the door next to a sign that stated STOP: Modified DROPLET PRECAUTIONS. Visitors MUST report to Nursing Station before entering. visitors and staff must: Wear a mask Wear eye protection (goggles or face shield) when entering room On 4/20/22 at 3:09 PM when asked about the signs and documentation, the Director of Nursing (DNS) stated that the sign in sheet should not be on the door as it is not necessary for staff to sign in and out of the room. The DNS confirmed that the resident's name should not be posted on the sign in sheet for others to see, which discloses a potential health condition. 2. Observation on 4/20/22 10:50 AM - 11:03 AM revealed an unlocked medication cart, and upon the medication cart was noted a 24 hour report that included resident names, and room numbers. A computer that was on top of the medication cart was left open at a the Clinical and Current residents screen. It showed a list of resident names and room numbers - this allowed access to all residents medical records. The nurse was observed behind a tall wall in the nurses station that separated the nurses station from the medication carts and prohibited a constant visual of the medication cart. Upon the nurses return to the medication cart at 11:03 AM, s/he immediately locked the medication cart, closed out of the patient care records screen on the computer and, turned over the 24 hour report sheet so the information on that sheet was not upright and available for others to see. Interview with the nurse at 11:04 AM, confirmed that the medication cart should not have been left unlocked, and all resident information should not have left out in the open for anyone passing by or standing at the medication cart to have easy access to.

Based on observations, interviews, and record reviews, the facility failed to ensure the plan of care for 2 of 19 sampled residents in a standard survey sample were revised to reflect necessary care and services. (Residents #9, and #15). Findings include: 1. Observation on 4/18/2022 at 11:50 am, Resident #9 was sitting in the common area in a wheelchair without footrests. A licensed nursing assistant (LNA) asked her/him to pick up her/his feet and began to push the resident to the dining room. The resident did lift her/his feet up while the LNA pushed her/him to the dining room although she/he did put her/his feet down a few times during the transport. Observation on 4/18/22 at 11:52 AM, revealed a pair of wheelchair foot pedals on top of Resident #9's dresser in her/his room. Review of Resident #9's care plan revealed, has limited physical mobility r/t [related to] [CONDITION(S)], dementia and a non-repaired left [CONDITION(S)] with the following intervention Resident needs assistance with moving [pronoun omitted] scoot w/c [wheelchair] but can also self-propel short distances. Per interview on 4/20/2022 at 10:34 AM, a licensed practical nurse (LPN) stated that foot pedals are in the resident's room. The LPN explained that staff know when to use foot pedals by referring to the sheet on the resident's closet door (Physical Mobility Sheet) and the resident's care plan. Reviewed of Resident #9's Physical Mobility Sheet with the LPN, s/he confirmed the I on Resident's Physical Mobility sheet indicated that the resident was independent in her/his wheelchair. There was no direction indicated on the Physical Mobility Sheet explaining when to use foot pedals. Upon review of Resident #9's care plan with this LPN, s/he confirmed that the care plan does not direct staff when to use foot pedals. Interview on 4/20/2022 at 10:55 AM, a licensed nurse aid (LNA) stated that each resident has a mobility sheet on the inside of their closet door that's shows when to use wheelchair foot pedals. S/he would put foot pedals on the wheelchair while bringing a resident for a walk outside, if their feet/legs are swelling, or they can't keep their feet up. Some foot pedals would be considered a restraint. The LNA confirmed that the use of foot pedals would also be in the care plan. On 4/20/2022 at 11:40 AM during an interview with the Director of Nursing, she/he confirmed the use of foot pedals should be on the care plan and that Resident #9's care plan did not provide direction as to when staff would need to use the residents foot pedals. S/he stated that Resident #9's care plan needed to be updated to include when to use foot pedals. The DON also confirmed that the use of foot pedals should be listed on the Physical Mobility Sheet, which is on the inside of the residents closet door and on each residents care plan. Review of Resident #9's Physical Mobility Sheet revealed no indication for use of his/her foot pedals and there was no mention of foot pedals on the residents care plan. 2. Per observation on 4/18/2022 at 11:52 am, Resident #15 was sitting in the common area in a wheelchair without footrests. A licensed nursing assistant (LNA) asked him/her to pick up his/her feet and began to push the resident to the dining room. The resident lifted his/her feet approximately an inch off the ground for a couple seconds and then began to drag his/her feet while being pushed down the hall. Review of Resident #15's medical record lists history of falling, muscle weakness (generalized), and other abnormalities of gait and mobility as diagnoses. Per review of Resident #15's care plan revealed, the resident is able to complete wheelchair mobility for short distances independently, dependent on staff for purposeful movement and requires vocal cues to lift feet when staff are assisting with WC [wheelchair] mobility. Per review of ADL (Activities of Daily Living) documentation for the month of April, of the 68 instances of locomotion documented for Resident #15, 50 were extensive assistance or total dependence. Per observation on 4/19/2022 at 11:36 AM, Resident #15 was seen sitting in his/her wheelchair and was being pushed to the dining room by a staff member. It was noted that his/her feet were dragging on the floor while being pushed down the hall to the dining room. Per interview on 4/20/2022 at 10:34 AM, a licensed practical nurse (LPN) stated that foot pedals are in the Resident's room. The LPN explained that staff know when to use foot pedals by referring to the sheet on the resident's closet door (Physical Mobility Sheet) and the resident's care plan. Reviewed of Resident #15's Physical Mobility Sheet with the LPN, s/he confirmed the I on Resident #15's Physical Mobility sheet indicated that the resident was independent in his/her wheelchair, and it did not explain when to use foot pedals. Upon review of Resident #15's care plan with this LPN, s/he confirmed that the care plan does not direct staff when to use foot pedals. Per interview on 4/20/2022 at 10:55 AM, a LNA stated that each resident has a mobility sheet on the inside of their closet door that's shows when to use wheelchair foot pedals. S/he would put foot pedals on the wheelchair while bringing a resident for a walk outside, if their feet/legs are swelling, or they can't keep their feet up. Some foot pedals would be considered a restraint. The LNA confirmed that the use of foot pedals would also be in the care plan. On 4/20/2022 at 11:40 AM during an interview with the Director of Nursing (DON), he/she confirmed the use of foot pedals should be on the care plan and that Resident #15's care plan did not provide direction as to when staff would need to use the residents foot pedals. S/he stated that Resident #15's care plan needed to be updated to include when to use foot pedals.

Based on observations, record review and staff interview, the facility failed to ensure that 1 of 25 residents in the applicable sample (Resident #13), received person-centered care and treatment that meets professional standards of practice and the delivery of that care is as identified on the comprehensive care plan. The findings include the following: Per medical record review, Resident #13 was admitted on [DATE]. The comprehensive care plan noted that Resident #13 was admitted with significant altered skin integrity to include skin tears. On 9/5/17 the resident developed a skin tear to the right lower leg during transfer, and on 9/11/17 developed skin tears on upper arms. The written plan of care was then revised to include the application of Derma-Savers to both legs (protective leggings) while out of bed and Geri-Sleeves to bilateral upper arms to decrease skin tears. On 10/10/17 during surveyor observation, Resident #13 developed a skin tear to the right upper thigh while staff struggled to dress the resident without protecting his/her lower extremities with Derma-Savers as directed in the care plan. Per observation by the State Surveyor on 10/10/17 at approximately 3:41 PM, two Licensed Nurse Aides (LNA #1 and #2) were to transfer Resident #13 via a mechanical lift. The resident only needed to have his/her lower body dressed before the transfer from bed to chair. LNA #1 identified that the resident did not have Derma-Savers on his/her legs and stated they were here last night. LNA #1 tried to locate the protective leg coverings, but could not find any available, and she/he voiced they must be in the laundry. LNA #1 and #2 proceeded to dress the resident with a pair of jean pants with an elastic waist band. The resident was observed to be stiff, have dressings to the lower legs, and did not have the ability to assist with the care. The resident did demonstrate periods of anxiety evidenced by yelling. Much difficulty and struggling was observed as the LNA pulled and tugged from side to side on the waist band while donning the pants. On completion of the task, LNA #2, identified blood located on the resident's pants at the right thigh area and stated stop. Both LNA's acknowledged they should not have dressed the resident. LNA #1, identified she needed to have the derma-savers on for protection. The Licensed Practical Nurse (LPN) was notified and the wound was cleansed and dressed. On 10/10/17 at 4:54 PM, in the presence of the Director of Nurses, both LNA's and the LPN, confirmation was made that the care plan was not followed, that the Derma-Savers were not available, and that the facility did not have a back up pair of Derma-Savers. The LNA staff acknowledged that they had the instinct to not dress the resident without the Derma-Savers, but the need to get the resident out of bed for the evening meal seemed to be the priority. This resulted in an avoidable skin tear to the upper right thigh measuring 5 cm. x 3 cm

Based on observation, record review and staff interview, the facility failed to provide services as outlined in the comprehensive care plan for 1 of 25 residents in the applicable sample (Resident #13), The findings include the following: Per review of the comprehensive care plan, Resident #13 was admitted with significantly altered skin integrity, to include skin tears. Resident #13 developed skin tears on 9/5 and 9/11/17. Plan of care initiatives to prevent further skin tears were: Derma-Savers (protective leggings) to both legs while out of bed, 9/6/17; and Geri-Sleeves (protective sleeves) to the upper arms, 9/22/17. On 10/10/17 during surveyor observation, the resident developed a skin tear to the right upper thigh while staff struggled to dress him/her without protecting the lower extremities with Derma-Savers. At 3:41 PM, two Licensed Nurse Aides (LNA #1 and #2) were to transfer Resident #13 via a mechanical lift. The resident was in bed and only needed to have his/her lower body dressed before the transfer. LNA #1, identified that the resident did not have Derma-Savers on his/her legs and stated they were here last night. LNA #1 tried to locate the protective leg coverings, but could not find any available, she/he voiced they must be in the laundry. Through the process of dressing the resident, an avoidable skin tear developed on the resident's right upper thigh measuring 5 cm. x 3 cm. On 10/10/17 at 4:54 PM, in the presence of the Director of Nurses, the Licensed Practical Nurse, and the two LNA's, confirmation was made that the care plan was not followed regarding the Derma-Savers. The LNA staff acknowledged that they had the instinct to not dress the resident, but the need to get the resident out of bed for the evening meal seemed to be the priority. This resulted in an avoidable skin tear to the right upper thigh measuring 5 cm. x 3 cm. See also F309.