Every finding on record at Charlottesville Health & Rehabilitation Center

Based on staff interviews and facility document review, the facility failed to ensure resident preferences were met regarding showers for one of two units (unit one), which did not provide showers due to low weekend staffing. The findings include:Review of the facilities PBJ (Payroll Based Journal) indicated weekend staffing excessively low for the January through March 2025 quarter.Review of the as worked weekend scheduled for March 2025 revealed on March 8th and 9th (Saturday and Sunday) that there were two certified nursing assistants scheduled on unit one for 7 a.m. through 7 p.m. Review of the resident census log for these dates indicated a census of 59 residents on unit one.On 9/2/25 at 2:30 the director of nursing (DON) was interviewed regarding scheduling nursing staff. The DON verbalized not having a staff coordinator at the present time, but that typically there are four to five certified nurse assistants (CNA's) on unit one on both day/evening shift and evening/night shift. On 9/3/25 at 4:20 p.m. CNA #1 (aide that worked the weekend in question) was interviewed. CNA #1 verbalized that the unit should have four CNA's each shift. CNA #1 said that during that weekend the aides had thirty residents each and showers were not completed. CNA #1 said the other aide and herself helped each other and were able to provide hygiene and a shortened bed bath to residents, was able to feed residents with the help of other nursing staff and keep all the residents safe. CNA #1 said when a situation like that occurs that the staff prioritize what needs to be done and things like showers are not considered. On 9/4/25 at 9:00 a.m. license practical nurse (LPN #4-unit manager) was interviewed. LPN #4 the goal is to staff four CNAs on each twelve-hour shift, which does not always occur. LPN #4 verbalized when the unit is that short on help, the CNAs will do what is important for the resident. The above finding was presented to the DON and administrator on 9/3/25. No other information was presented prior to the exit conference on 9/4/25

Based on staff interview, clinical record review, and facility documentation review, the facility staff failed to ensure that unnecessary psychotropic medications were not administered to one resident, Resident #5 (R5) out of a survey sample of six residents. The findings included:Staff completed the admission medication reconciliation using the resident's at-home medications rather than the physician-verified hospital discharge orders, resulting in the administration of two antipsychotic medications, Amitriptyline 10 mg at bedtime and Trazodone 100 mg at bedtime, that were not prescribed upon discharge. This failure placed R5 at risk for chemical restraint related to receiving unnecessary antipsychotic medications.Unable to conduct an interview with R5 due to R5 was no longer a resident at the facility.On 9/3/25 at 9:50 a.m., an interview was conducted with a licensed practical nurse, unit two manager, LPN#2 (LPN2). LPN2 stated that the discharge summary from the hospital was used for the admission orders. She stated the discharge medications on the summary was used and not the at home medications. She stated that if the orders were unclear that the hospital or the doctor was contacted for clarification. On 9-3-25 at 10:05 a.m., an interview was conducted with LPN#3 (LPN3). LPN3 stated that the facility follows the hospital's discharge summary for medication orders. He explained that if at-home medications were administered while the resident was in the hospital, they are entered into the facility's system; otherwise, the facility relies on the hospital discharge summary. LPN3 further stated that at-home medications may or may not be included in the discharge summary. On 9-3-25 at 10:28 AM, an interview was conducted with the Director of Nursing (DON). The DON stated that the facility follows the hospital discharge summary and the medications listed at the time of discharge. She stated that the at home medication list was not discharge medications. She explained that the pharmacy reviews new medications, and the nurse practitioner is notified if there is documentation in the chart related to starting new medications. On 9-3-25 at 11:45 AM, an interview was conducted with the DON and the Regional Director of Clinical Services. Both confirmed that when Resident #5 was admitted to the facility, staff entered medications from the at-home medication list rather than following the hospital discharge summary orders. They further confirmed that medications from the at-home list were entered into the record even though the resident was not discharged on those medications. The DON and Regional Director also acknowledged that the nurse practitioner documented in her progress notes that the resident's son had requested these medications be discontinued, and while her intent was to discontinue them, this was not completed.On 9-3-25 at 1:41 PM, an interview was conducted with the nurse practitioner. She stated that her intent was to discontinue the medications in response to the son's request. She explained that on 8-11-25 the resident was somewhat confused, and on 8-13-25 the resident was noted to be less confused, so the medications were continued after being placed on hold. The nurse practitioner stated that she did not feel the medications made a difference and confirmed that her intent was to discontinue the antipsychotic medications per the son's request, but this was not completedOn 9-3-25, a clinical record review was conducted. The hospital discharge summary was reviewed, and it was determined that staff used the at-home medication list for admission orders rather than following the discharge summary. The facility staff did not complete the admission process according physician's discharge orders. As a result, the resident received Amitriptyline 10 mg at bedtime and Trazodone 100 mg at bedtime from 8/4/25 to his discharge on [DATE]. R5 had delirium in the hospital due to hospital setting, medications, narcotics and a head strike when he fell. The discharge summary had R5's delirium had resolved but the facility was still monitoring delirium with each visit from the provider. During the clinical record review, the nurse practitioner's progress notes were reviewed. On 8-11-25, the nurse practitioner documented that the resident's son expressed concerns and requested that psychotropic medications be discontinued. On 8-13-25, the nurse practitioner again documented the son's request to discontinue the antipsychotic medications due to the resident experiencing increased confusion, agitation, and anxiety over the weekend. The nurse practitioner documented her intent to discontinue these medications; however, the medications were not discontinued.During the clinical record review, a progress note dated 8/9/25 by a nurse practitioner indicated that R5 exhibited an altered level of consciousness. The resident's son reported that R5 was experiencing confusion, and the nurse observed R5 asking if his son was inside the mirror he was looking at. On this date, the son requested that three medications, Amitriptyline, Trazodone and Seroquel to be discontinued due to concerns that they cause delirium. The medications were held for three days, and then restarted after the three-day hold, and lab work was obtained. Labs that were obtained were within normal limits and no concerns.On 9-3-25, a facility documentation review was conducted. The policy titled, General Guidelines for Medication Administration, read in part, medications are to be administered only by licensed nursing, medical, pharmacy, or other personnel authorized by state laws and regulations to administer medications, and that medications must be administered in accordance with written orders of the prescriber.On 9-4-25 at 10:00 a.m., an interview was conducted with the Therapy Director. He stated that R5 participated well in therapy and received all three disciplines-speech therapy, occupational therapy, and physical therapy. He explained that the resident ambulated several times a day, used NuStep, and completed exercises. The Therapy Director stated that although the resident became fatigued, he participated well and completed his therapy sessions.On 9/4/24 at 11:00 AM, the Administrator, Regional Director of Clinical Services, and Director of Nursing were informed of the concerns described above. They were advised that discharge orders had not been followed, resulting in two antipsychotic medications being added to the admission paperwork that were not on the discharge medication list. They were also informed that the resident's son had requested on 8/9, 8/11, and 8/12 that the three antipsychotic medications (Amitriptyline, Trazodone and Seroquel) be discontinued due to causing delirium. Additionally, they were informed of two progress notes written by the nurse practitioner indicating that while there was intent to discontinue these medications as requested, the medications were not actually discontinued. A request for a policy for antipsychotic medication use was requested. The regional director of clinical services stated there was no policy related to psychotropic medications. On 9/4/25, a review of facility documentation was conducted. The policy titled, Physician Visits, read in part, that a discharging physician will provide patient information and orders to the facility at the time of admission. The patient's admission information is to be reviewed, and orders approved by the attending physician. The physician, nurse practitioner, or physician assistant is to review the patient's medical plan of care at each visit and provide documentation for the medical record'.No additional information was provided.

Based on staff interviews and facility document review, the facility failed to ensure sufficient staffing in accordance with the facility assessment on one of two units (unit one), which had excessively low weekend staff. The findings include: Review of the facilities PBJ (Payroll Based Journal) indicated weekend staffing excessively low for the January through March 2025 quarter. Review of the as worked weekend scheduled for March 2025 revealed on March 8th and 9th (Saturday and Sunday), there were two certified nursing assistants scheduled on unit one for 7 a.m. through 7 p.m. Review of the resident census log for these dates documented a census of 59 residents on unit one. On 9/2/25 at 2:30 the director of nursing (DON) was interviewed regarding scheduling adequate nursing staff. The DON verbalized not having a staff coordinator at the present time and was currently taking on that role, but typically there are four to five certified nurse assistants (CNA's) on unit one on both day/evening shift and evening/night shift (7:00 a.m. to 7:00 p.m. and 7:00p.m. to 7:00 a.m.). Review of current as worked schedules indicated no staffing concerns. On 9/3/25 at 4:20 p.m. CNA #1 (an aide that worked the weekend in question) was interviewed. CNA #1 verbalized that unit one should have four CNA's each shift. CNA #1 said during that weekend the aides had thirty residents each and showers were not completed. CNA #1 said the other aide and herself helped each other and were able to provide hygiene and a shortened bed bath to residents, was able to feed residents with the help of other nursing staff and keep all the residents safe. CNA #1 said when this occurred, the staff prioritized what needed to be done and showers are not considered. CNA #1 verbalized there were no incidents (such as falls or needs not being met) during this time period. CNA #1 verbalized this was an isolated incident and has been better since agency has been allowed to come into the facility. The above finding was presented to the DON and administrator on 9/3/25. The administrator verbalized that the facility has had a lot of turnovers in employment and call outs especially on weekends. The administrator said that recently the facility has started using agency staff to fill in vacancies when needed and is working towards hiring more staff.On 9/4/25 at 9:00 a.m. license practical nurse (LPN #4-unit manager) was interviewed. LPN #4 the goal is to staff four CNAs on each twelve-hour shift, which does not always occur. LPN #4 verbalized when the unit is that short on help, the CNAs will do what is important for the residents. On 9/4/25 the administrator presented the facility assessment and verbalized. Based on our census, acuity, and budget, the facility should be between four and five nursing assistants per shift.Review of incident logs, grievance logs, and resident council minutes did not evidence concerns regarding needs of residents or incident/accident concerns related to low staffing.The survey team conducted interviews regarding getting showers as scheduled with four residents in the survey sample, identified as R1, R2, R3, and R4. There were no concerns expressed except for R1(resident council president) who wanted to change shower schedule to be done early in the morning prior to breakfast, because of handing out daily menus to residents just after breakfast. This information was presented to LPN #4, LPN #4 verbalized being aware of the preference and had just gone into effect. No other information was presented prior to the exit conference.

Based on staff interviews, clinical record review, and facility document review, the facility failed to ensure an appropriate discharge for one of six residents, resident #6.The findings include:The facility did not set up home health therapy per discharge instructions for Resident #6 (R6).Diagnoses for R6 included spinal stenosis, diabetes, sepsis upon admission, scoliosis, status post spinal fusion. The most recent MDS (Minimum Data Set) was a 5-day assessment dated [DATE], R6 was assessed with a cognitive score was 10, indicating moderately cognitively impaired. Review of R6's clinical record indicated R6 was admitted to the facility due to status post-surgery for spinal fusion and was at the facility for skilled services requiring therapy.Review of R6's discharge instructions indicated R6 was scheduled to discharge home on 3/13/25 and receive home health services for therapy (physical and occupational). The record did not indicate that the facility initiated home health services. The discharge instructions evidenced that R6 signed the instructions on 3/13/25. On 9/2/25 at 3:00 p.m. the social worker (OS #5) was interviewed. OS #5 said typically she would talk with the resident or family and asked what their needs might be regarding equipment and home health is automatically set up unless the resident declines the service. OS #5 verbalized not remembering if she was working the week of R6's discharge but would review the discharge plan. On 9/2/25 at 3:30 p.m. OS #5 presented a progress note written by OS #5 dated 3/13/25 at time of discharge that read in part discharged on 3/13/2025 at 1:00 pm and was picked up by family to take home. Declined Home Health services. A progress note dated 3/13/25 preceding OS #5's discharge note read discharged home with health, DC summary and scripts reviewed. No concerns voiced. On 9/3/25 at 9:00 a.m. the therapy rehab. Director (other staff, OS #3) was interviewed. OS #3 verbalized that R6 was receiving therapy for strength training and self-transfers. Per insurance R6 would receive the therapy for six weeks and then be discharged . OS #3 reviewed the therapy notes and verbalized because R6 was not back to his baseline of functional abilities (prior to surgery) home health would be set up. OS #3 verbalized that according to therapy notes R6 needed partial assistance for transfers and home health would be working with R6 to achieve this. On 9/3/25 at 10:15 a.m. R6's emergency contact (EC) was interviewed by phone. EC verbalized that R6 did not come home on home health and R6's son was staying with R6 and helping R6 with his needs. The EC said that R6 did start receiving home health after going for a follow up appointment with R6's primary care provider.On 9/3/25 at 11:50 a.m. registered nurse (RN #2) was interviewed. RN #2 verbalized being the nurse that discharged R6 on 3/13/25. RN #2 verbalized going over all discharge instructions including home health care. RN #2 said that R6 agreed with all instructions, including home health, and signed the bottom of the discharge instructions. On 9/3/25 at 1:30 p.m. the facility nurse practitioner (OS #1) was interviewed. OS #1 said that if therapy felt like R6 needed more therapy after going home and R6 declined the therapy, then either the physician or OS #1 should have been notified to ensure a proper discharge. On 9/3/25 at 1:50 p.m. OS #5 and Nurse consultant (administrative staff, AS #3) were interviewed regarding discharge. The surveyor explained there was no documentation of the physician or OS #1 being notified of R6 declining therapy services from home health or that home health was contacted prior to discharge. AS #3 verbalized it's not typical that the physician is notified of a resident declining home health service, however if home health is needed and a resident declines it, then APS (Adult Protective Services) should be contacted to ensure the residents safety. OS #5 said that home health is typically contacted two days prior to discharge to ensure they know when the resident will be at home. The surveyor questioned, if home health is contacted two days prior to being discharged and R6 declined home health on the day of discharge there should be evidence that home health was set up. OS #5 said she could not recall all the details and was not sure what home health agency was contacted and was not sure about working the week R6 was discharged . On 9/3/25 at 4:50 p.m. AS #3 verbalized after calling home health agencies in the area where R6 resided, AS #3 was able to evidence that R6 started receiving home health care on 3/27/25 after being seen by R6's primary care physician and making the referral and not the facility. On 9/3/25 at 5:30 p.m. the above finding was presented to the administrator, director of nursing and nurse consultant.The facilities Discharge Instruction policy read in part Discharge planning will be initiated and coordinated by the social service department who will assist the patient/family to make arrangements for transportation, care equipment, Home Health Services, etc. (the social service department and/or therapy will take responsibility for completion of arrangements).No other information was provided prior to the exit conference on 9/4/25.

Based on staff interview, clinical record review, and facility documentation review the facility staff failed to follow physician orders for one resident, Resident #5 (R5) out of a survey sample of six residents. The findings included:The facility staff did not follow the physician discharge orders for R5's admission to the facility.On 9/3/25 at 9:50 a.m., an interview was conducted with a licensed practical nurse, unit two manager, LPN#2 (LPN2). LPN2 stated that the discharge summary from the hospital was used for the admission orders. She stated the discharge medications on the summary was used and not the at home medications. She stated that if the orders were unclear that the hospital or the doctor was contacted for clarification. LPN3 stated that when pharmacy alerts come up with medication orders that it was discussed with the doctor. She said, I would hope the nurses would document the alerts.On 9-3-25 at 10:05 a.m., an interview was conducted with LPN#3 (LPN3). LPN3 stated that the facility follows the hospital's discharge summary for medication orders. He explained that if at-home medications were administered while the resident was in the hospital, they are entered into the facility's system; otherwise, the facility relies on the hospital discharge summary. LPN3 further stated that at-home medications may or may not be included in the discharge summary. He explained that when drug alerts appear, the pharmacy is contacted, and the pharmacy clears the alerts rather than the physician. He also stated that staff review the resident's medication history from the discharging hospital when admitting the resident.On 9-3-25 at 10:28 AM, an interview was conducted with the Director of Nursing (DON). The DON stated that the facility follows the hospital discharge summary and the medications listed at the time of discharge. She stated that the at home medication list was not discharge medications. She explained that the pharmacy reviews new medications, and the nurse practitioner is notified if there is documentation in the chart related to starting new medications. On 9-3-25 at 11:45 AM, an interview was conducted with the DON and the Regional Director of Clinical Services (RDCS). Both confirmed that when Resident #5 was admitted to the facility, staff entered medications from the at-home medication list rather than following the hospital discharge summary orders. They further confirmed that medications from the at-home list were entered into the record even though the resident was not discharged on those medications. The DON and Regional Director also acknowledged that the nurse practitioner documented in her progress notes that the resident's son had requested these medications be discontinued, and while her intent was to discontinue them, this was not completed. The RDCS said, the facility staff was not familiar with the discharge summary from this hospital and was different than what we are used to seeing.On 9-3-25, a clinical record review was conducted. The hospital discharge summary was reviewed, and it was determined that staff used the at-home medication list for admission orders and there were two medications (amitriptyline and trazodone) from the at home list that was not on the medication discharge orders. The facility staff did not complete the admission process according physician's discharge orders. The discharge summary medications were followed but the facility added the at home medications also.On 9-3-25, a facility documentation review was conducted. The policy titled, General Guidelines for Medication Administration, read in part, medications are to be administered only by licensed nursing, medical, pharmacy, or other personnel authorized by state laws and regulations to administer medications, and that medications must be administered in accordance with written orders of the prescriber.On 9/3/25 at 5:15 p.m., an end of day meeting was conducted. The administrator, DON and the regional director of clinical services were made aware of the above concerns.On 9/4/25 at 9:40 a.m., an interview with the nurse practitioner (NP) was conducted. The NP stated that the nursing staff completed the medications and the diagnosis on admission, and she signs off on the admission. She stated that she was not aware there were wrong entries for the medications and diagnosis. She stated her intent was to discontinue the three medications the son requested.On 9/4/25, a review of facility documentation was conducted. The policy titled, Physician Visits, read in part, that a discharging physician will provide patient information and orders to the facility at the time of admission. The patient's admission information is to be reviewed, and orders approved by the attending physician. The physician, nurse practitioner, or physician assistant is to review the patient's medical plan of care at each visit and provide documentation for the medical record'.No additional information was provided.

Based on staff interview, clinical record review, and facility documentation review the facility staff failed to ensure medication review was performed by physician services on admission for one resident, Resident #5 (R5) out of a survey sample of six residents. The findings included: On 9/3/25, a clinical record review of Resident #5 was conducted. The review showed the residents did not have a diagnosis of depression or delirium on the diagnosis list; however, amitriptyline was documented for depression without a corresponding diagnosis. A nurse practitioner's progress notes dated 8/11/25 and 8/13/25 documented the son's request for the antipsychotic medications (amitriptyline, trazodone and Seroquel) to be discontinued. The nurse practitioner stated it was her intent to discontinue the medications, but she did not complete the discontinuation. The medications were ordered on admission, 8/4/25 and continued until R5 was discharged on 8/15/25.On 9/4/25 at 9:00 a.m., an interview was conducted with the Minimum Data Set (MDS) Coordinator, LPN#1 (LPN1). LPN1 stated she reviewed Resident #5's diagnoses and was unable to find depression, or delirium. She stated the facility's nurse practitioner had assigned the diagnosis of depression, although there was no history of depression in the resident's hospital record. LPN1 further stated that delirium was noted in the nurse practitioner's progress notes, but the hospital discharge summary showed it had resolved; therefore, it was not placed on the diagnosis list. The MDS Regional Director, who participated by phone, stated the medication Amitriptyline was listed on the hospital record, but no diagnosis was documented with it.On 9/5/25 at 9:40 a.m., an interview was conducted with the nurse practitioner. The nurse practitioner stated the diagnosis of depression came from the hospital. She reported that when reviewing the history and physical and the hospital paperwork, she was unable to find the diagnosis of depression, but believed that was how she obtained it. When asked about the diagnosis of depression being linked to the antidepressant medication, she stated the nursing staff entered that diagnosis with the medication on admission, and she did not catch that the resident had no history of depression when she signed off on the paperwork.On 9/4/25, a review of facility documentation was conducted. The policy titled, Physician Visits, read in part, that a discharging physician will provide patient information and orders to the facility at the time of admission. The patient's admission information is to be reviewed, and orders approved by the attending physician. The physician, nurse practitioner, or physician assistant is to review the patient's medical plan of care at each visit and provide documentation for the medical record'.On 9/4/25 at 11:00 a.m., the administrator, director of nursing and the regional clinical care coordinator was made aware of the above concerns.No additional information was provided.

Based on staff interviews and clinical record review, the facility failed to ensure a complete and accurate record for two of six residents. The findings include: 2. The facility staff failed to complete R5's admission medications correctly and had a diagnosis of depression and R5 had no history of depression. On 9/3/25 at 1:41 p.m., a phone interview was conducted with the nurse practitioner (NP). The NP stated she saw the resident on 8/11/25 with some confusion and again on 8/13/25 with less confusion. She reported that two other providers also noted improvement in his confusion. She stated she only heard the concern once about the son wanting the antipsychotic medications discontinued. She explained that it was her intent to discontinue the medication, but she did not do so. On 9/3/25, a clinical record review of Resident #5 was conducted. The review showed the residents did not have a diagnosis of depression or delirium on the diagnosis list; however, amitriptyline was documented for depression without a corresponding diagnosis. A nurse practitioner's progress notes dated 8/11/25 and 8/13/25 documented the son's request for the antipsychotic medications (amitriptyline, trazodone and Seroquel) to be discontinued. The nurse practitioner stated it was her intent to discontinue the medications, but she did not complete the discontinuation. On 9/4/25 at 9:00 a.m., an interview was conducted with the Minimum Data Set (MDS) Coordinator, LPN#1 (LPN1). LPN1 stated she reviewed Resident #5's diagnoses and was unable to find depression, or delirium. She stated the facility's nurse practitioner had assigned the diagnosis of depression, although there was no history of depression in the resident's hospital record. LPN1 further stated that delirium was noted in the nurse practitioner's progress notes, but the hospital discharge summary showed it had resolved; therefore, it was not placed on the diagnosis list. The MDS Regional Director, who participated by phone, stated the medication Amitriptyline was listed on the hospital record, but no diagnosis was documented with it. On 9/5/25 at 9:40 a.m., an interview was conducted with the nurse practitioner. The nurse practitioner stated the diagnosis of depression came from the hospital. She reported that when reviewing the history and physical and the hospital paperwork, she was unable to find the diagnosis of depression, but believed that was how she obtained it. When asked about the diagnosis of depression being linked to the amitriptyline medication, she stated the nursing staff entered that diagnosis with the medication on admission, and she did not catch that the resident had no history of depression when she signed off on the paperwork. On 9/4/25 at 11:00 a.m., the administrator, director of nursing and the regional clinical care coordinator was made aware of the above concerns. No additional information was provided. 1. Resident #6 (R6) progress notes and skin assessments failed to show documentation of a pressure ulcer. Diagnoses for R6 included spinal stenosis, diabetes, sepsis upon admission, scoliosis, status post spinal fusion. The most recent MDS (Minimum Data Set) was a 5-day assessment dated [DATE]. R6 was assessed with a cognitive score of 10, indicating moderately cognitively impaired. Review of R6's clinical record documented (via a skin assessment dated [DATE]) indicated that R6 had a stage three pressure ulcer upon admission. The clinical record documented treatments were put in place and a wound care company began to monitor and treat the wound. Further review of the daily skilled assessment progress notes dated 1/31/25 through 2/3/25 and weekly skin assessments dated 2/7/25 and 2/14/25 had inconsistent documentation of R6 having a pressure ulcer either by documenting No on the progress notes or no documentation regarding a stage three pressure ulcer on skin assessments. On 9/3/25 at 8:30 a.m. the director of nursing (DON) and nurse consultant (administrative staff, AS #3) were interviewed. AS #3 reviewed R6's clinical record and agreed there were discrepancies in the skin assessments and progress notes. A facility policy titled Wounds/Skin Impairments read in part, The Skin and Observation Tool will be completed by a licensed nurse [.], detailing any wounds/skin impairments. No other information was provided prior to the exit conference on 9/4/25.

Based on observation, resident interview, staff interview, and facility documentation review, the facility staff failed to follow the menu for both meals observed, affecting multiple residents, including Resident #2-R2, Resident #3 - R3, Resident #4 -R4, and Resident #5-R5, who resided on two of two nursing units. The findings included: 1. The facility staff failed to prepare and serve foods in accordance with the posted menu. On 3/18/25, the daily menu was observed to be posted on each of the nursing units and outside the main dining room. The menu indicated breakfast included: scrambled eggs, sausage patty, cranberry muffin, orange juice, hot coffee or tea, and assorted milk options. On 3/18/25, at approximately 8:00 a.m., observations were conducted on each of the units. Residents were noted to be served sausage patty, scrambled eggs, toast, and oatmeal. Residents were also noted to be eating breakfast with no beverages on their tray. A certified nursing assistant was observed taking a beverage cart down the hallway and serving residents beverages which consisted of one cup of coffee or a cup of juice. There was no milk noted. Several residents' meal trays and tickets were observed, which included but were not limited to, Resident #3 and Resident #4. Each of the meal/tray tickets noted cranberry muffin, which none of the residents were served. On 3/18/25 at approximately 8:20 a.m., the surveyor went to the kitchen and spoke with the cook (Other Employee #1- OE #1). When asked about the cranberry muffin, OE #1 stated that he had not prepared it and had substituted it with toast. When asked how he knows what to substitute items with, OE #1 said, I don't know, whatever I can pull out of there. When asked about a substitution log, OE #1 stated that he had not seen a substitution log. On 3/18/25, observations were conducted of the lunch meal/tray line service in the kitchen. The posted menu indicated that the menu was to include baked ham, carrots, scalloped potatoes, dinner roll, dessert: chocolate cake, hot coffee or tea, and assorted milk options. On 3/18/25, at approximately 11:30 a.m., observations in the kitchen noted the cook pouring mixed vegetable blend out of a bag into the pan and placing it on the steam table. The dietary aide (Other employee #3- OE #3) was observed with a sheet pan of yellow cake at a food preparation table. OE #3 had a gloved hand and was scooping handfuls of the cake into bowls that she placed a dollop of whipped cream on top. When asked about the cake, OE #3 said, I messed it up. On 3/18/25 at 11:45 a.m., the dietary staff started meal service on the tray line. It was noted that no scalloped potatoes were prepared, diced red potatoes were being served. The meal tickets indicated that the dessert was a chocolate cake with chocolate frosting, which also was not being served. Multiple resident meal trays were identified to indicate a heart healthy diet, and the protein was listed as a baked pork chop. When asked about the baked pork chop, OE #1 stated that he didn't prepare it, and all those residents were observed to be served the ham. Multiple residents were listed to have large portions and/or double portions. The cook did provide extra vegetables on some of the plates, on one he provided extra potatoes, and some received no extra servings. When asked about the double portions and what that means, the cook said, I was told to only give 3 oz of meat, and this is more than 3 oz. So its whatever I can get on the plate. Continued observations revealed that the residents listed with a diabetic diet were listed to receive a half serving of the cake. None of those residents received a half portion, instead it was a full bowl of the crumbled cake served. Part way through the meal service they ran out of cake and the remaining trays, which was approximately thirty residents, received a sherbert cup for dessert. Several resident trays were observed to not receive a roll. The dietary aides put the trays onto the meal delivery cart without making any adjustments or questioning the cook when the plate/meal served did not match the meal slip. For residents that had orders for chopped meats, the cook was observed to take a slice of ham to a food preparation table, place the ham on a cutting board and use a knife to cut the ham into large chunks and strips that were not consistent in size. Most of the chunks of ham averaged the size of a quarter. On 3/18/25, interviews were conducted with the two dietary aides, (other employee #2 - OE #2 and other employee #3 - OE #3). Both dietary aides stated that the cook (OE #1) didn't do like he was supposed to and cooked whatever, not following the menu and didn't prepare alternates, unless a manager was present, at which time he did better. OE #2 said, The cook knows what he is supposed to cook but when no manger is here, he does his own thing, but when the manager is here, he does what he is supposed to. On 3/18/25 at 10 a.m., an interview was conducted with the registered dietician (RD). The RD reported that he is at the facility once or twice weekly. The RD confirmed that a lot of the residents had expressed concerns about the diabetic diets, and that he had met with the residents recently. The RD explained that the facility doesn't prepare different foods for diabetics, they do a carbohydrate-controlled diet, and said, Every meal should get the same amount of carbs. It is less carbs than the regular diet and less calories. The RD went on to explain that the diabetic diets are controlled through portions and sometimes a substitution, such as a roll or pasta dish may be substituted for another vegetable or fruit. The RD explained that the meal/tray tickets would correspond with the system and show the serving sizes. The RD confirmed that the kitchen maintains a log of menu substitutions made that he reviews periodically. The RD was then made aware by the surveyor that the dietary staff had reported no knowledge of a substitution log or where to find it. The surveyor accompanied the RD to the kitchen and noted that he was not able to find a substitution log. The RD also confirmed that the facility had an interim dietary manager, who is not on-site daily. On 3/18/25, in the afternoon, an interview was conducted with the evening cook, (other employee #4 - OE #4). When asked about the cranberry muffins, OE #4 explained that they have a muffin mix and that the fruit must be added. OE #4 explained that the cooks look ahead at the menu so they can thaw frozen items for the next day. OE #4 explained that they do not have muffin pans and usually use a sheet pan and have to cut it into slices. Observations revealed that muffin mix was available, cranberries were in the freezer, as was the carrots and pork chops. On 3/18/25, the facility administrator was made aware of the above observations and provided the surveyor with a listing of residents on each diet. The facility provided report indicated that four residents were on a heart healthy diet and two were ordered a heart healthy/diabetic diet, of which none received the baked pork chop at lunch. The listing noted that eleven residents were ordered a diabetic diet that were not served portion controlled foods during the lunch meal service. According to the resident council minutes reviewed from November 2024-February 2025, the residents expressed concerns each month about meal tickets not matching what was served and two of the four months residents expressed concerns about diabetic diets not being followed/provided. According to the grievance log, nine residents filed a grievance with regards to food, which included food preferences and concerns about served items not matching the meal ticket. On 3/19/25 at 8:27 a.m., the activities director (AD) was interviewed. The AD stated that she works closely with resident council and started posting the daily menus because residents expressed concerns that they were not getting posted. The AD reported that the residents have had ongoing complaints regarding the menu/meal tickets not matching what is served and the lack of diabetic diets. The AD reported she has set-up meetings with the contracted dietary company and with the dietician and residents to help resolve the concerns. When asked about alternates, the AD stated that the alternates include a ham or turkey sandwich and said, Yesterday, I had several residents that couldn't eat the ham. So I got them a sandwich. The AD reported, Frequently, they don't get what is on the menu. Yesterday, they didn't have scalloped potatoes, carrots, or the chocolate cake at lunch. The AD went on to explain that she had arranged a meeting with the regional director from dietary and the residents but said, He wasn't actively listening to them. He was very dismissive. The AD explained that the residents were talking about not being provided a diabetic diet and the AD said she told the dietary regional manager, That day they had a plate full of biscuits and gravy for breakfast and at lunch had beef stroganoff, it was a full plate of noodles. It's not that they can't have those items, but it is too many carbohydrates, and it is intense portions. The AD stated that the regional director suggested the registered dietician (RD) educate the residents. The AD explained that the RD had held a meeting with the residents and the residents explained that they know they can eat the foods served but not a plate full. On 3/19/25, the activities director provided the surveyor with email communications she had made with the contracted dietary company management and the dietician. Among the emails, one dated 2/5/25, to the regional dietary manager read, My residents would like to meet with you. I was informed that you were visiting us February 12th. Do you have time in mind that you could have a meeting with them? The response from the regional dietary manager included, . I am happy to spend a small amount of time with the residents but understandably it would need to be quick. The AD responded with, I am available to facilitate a meeting at 11 a.m. However, I cannot guarantee that this meeting will be quick. The problems with residents and the kitchen have escalated to an extreme level. If changes aren't made, we may face significant issues ahead. I have a resident council president who is eager to approach our ombudsman and gather signatures for a petition to remove [contracted dietary company name redacted] from the building. If the ombudsman gets involved, this could potentially lead to APS [adult protective services] concerns. According to another email dated 2/15/25-2/18/25, following the regional dietary manager's meeting with the residents, he reached out to the RD. The email to the RD read in part, . There was a trend among the comments with which I hoped you could help. Comments suggest that diabetic information regarding our menu design and how items on the menu are appropriate. Residents shared that 'my doctor told me to never eat ___ (pasta, rice, any type of starch).' . According to an email from the RD dated 3/6/25, to the activity's director, it read in part, I met with the residents today to discuss the issues with the menu, diabetic diets, and overall complaints. I have a whole list of changes/issues that I will send to [name redacted/kitchen manager] and my big bosses to see what we can change . On 3/18/25, the activities director sent the regional dietary manager another email requesting a follow-up meeting to . assess dietary progress and review menu choices . The response from the regional dietary manager included, . Given the turnover in the kitchen, it would be wise to wait until we have a new manager in position (recruiting ongoing) to introduce the residents. I'll keep in touch with you when this happens so that it can be one of the first things on their list. 2. The facility staff failed to serve the food on the menu to Resident #2 (R2). On 3/18/25 at 12:15 p.m., an observation was made of R2's lunch meal. The meal tray was served in R2's room. The menu was baked pork chop for heart healthy diets, mixed vegetables, scalloped potatoes, dinner roll, chocolate cake with chocolate frosting, 8 oz of 2% milk hot coffee or hot tea. R2's meal tray was observed to contain ham, white cake with cool whip on top, no scalloped potatoes, and no milk. On 3/18/25 at 12:30 p.m. an interview was conducted with R2. R2 said, I usually get a pork chop and not ham. When asked about the beverages not being on the meal tray, R2 stated that beverages were served after the trays and sometimes when the meal is completed. R2 said, Not sure what this dessert is but it's not chocolate. On 3/18/25 at 2:00 p.m. a review of R2's clinical record was conducted. On 9/3/24, a diet order was written, which read, Regular diet with thin liquids. 3. The facility staff failed to serve the meal as listed on the meal ticket to Resident #5 (R5). On 3/18/25 at 12:20 p.m., an observation was made of R5's lunch meal. The meal tray was served in R5's room. R5's meal ticket noted the lunch meal as mechanical advanced chopped baked ham, mixed vegetables, scalloped potatoes, dinner roll, chocolate cake with chocolate frosting, 8 oz 2% milk, hot coffee or hot tea. R5's meal tray was observed with no dinner roll, no chocolate cake with chocolate frosting, no scalloped potatoes, and no milk. On 3/18/25 at 12:40 p.m., an interview was conducted with R5. When asked, R5 stated that the food was good, but it was observed that R5 had only eaten the dessert at lunch meal. On 3/18/25 at 2:30 p.m., a review of the clinical record was conducted. R5's diet order on 11/12/24 read, Regular Dysphagia Advanced thin liquids. On 3/18/25 at 4:00 p.m., a review of facility documentation was conducted. The Resident Council Meeting minutes were reviewed. The meal tickets not matching the meal being served was an ongoing issue in the minutes from November 2024 until present. On 3/18/25 at 4:30 p.m., an end of day meeting was conducted with the administrator, the director of nursing, and the regional clinical director, during which the above concerns were discussed. On 3/19/25 at 10:00 a.m. a review of facility documentation was conducted. The policy titled, Menus, read in part, .2. Menu cycles will be developed and tailored to the needs and requirements of the center . 6. Menus are served as written, unless changed in response to preference, unavailability of an item, or a special meal. 7. A menu substitution log will be maintained on file . No further information was provided prior to the conclusion of the survey.

Based on observation, resident and staff interviews, and facility documentation review, the facility staff failed to provide liquids consistent with resident needs and preferences affecting multiple residents on two of two units. The findings included: 1. For residents on each of the two units, the facility staff failed to provide milk and other liquids in a quantity sufficient to maintain hydration. On 3/18/25, the daily menu was observed to be posted on each of the nursing units and outside the main dining room. The menu indicated breakfast included: scrambled eggs, sausage patty, cranberry muffin, orange juice, hot coffee or tea, and assorted milk options. On 3/18/25 at approximately 8:00 a.m., observations were conducted on each of the units. Residents were noted to be served sausage patty, scrambled eggs, toast and oatmeal. Residents were also noted to be eating breakfast with no beverages on their tray. A certified nursing assistant was observed taking a beverage cart down the hallway and serving residents beverages which consisted of one cup of coffee or a cup of juice for each resident. There was no milk noted. Several residents' meal trays and tickets were observed, which included but were not limited to Resident #3 and Resident #4. Both residents' meal tickets noted orange juice- 4 oz, hot coffee or hot tea- 8 oz and milk 8 oz. Resident #3's meal tray was observed having only had a cup of juice. Resident #4's meal tray was observed having had not received any beverages yet. On 3/18/25 at approximately 8:20 a.m., an interview was conducted with certified nursing assistant #2 (CNA #2). When asked about milk, CNA #2 said, We just do cream for the coffee in the morning, it's easier. No milk was observed on the beverage cart. On 3/18/25 at 8:20 a.m., the residents residing on unit one, the hallway consisting of rooms 20-33, were just receiving their beverages for their meal, when trays had been distributed at 8 a.m. On 3/18/25 at approximately 8:25 a.m., an interview was conducted with another certified nursing assistant (CNA #5), who reported that milk was put on the trays from the kitchen and they only distributed the juice and coffee from the beverage cart. On 3/18/25 at approximately 8:30 a.m., an interview was conducted with a dietary aide, (other employee #2- OE #2). When asked about milk being on the resident's meal ticket but no one was observed to have received milk at breakfast, OE #2 reported they put milk on the trays in the kitchen but added, Normally when it says that they don't drink it and it goes to waste, so we only put it on a select few that ask for it. On 3/18/25 at 10 a.m., an interview was conducted with the registered dietician (RD). The RD indicated that residents were to receive all items as listed on their meal/tray tickets. The RD was notified of the observation of no residents receiving milk at breakfast and the comments from staff. The RD said, I don't know why they are not getting milk. On 3/18/25, interviews were conducted with residents to include resident #3 and resident #4, both who stated they don't get milk and just one cup of juice with meals. According to the resident grievances, filed on 1/25/25 and 2/3/25, residents expressed a desire to have milk with meals. Both grievances were noted as having been resolved. On 3/18/25 at 11:45 a.m., observations were conducted in the kitchen of the lunch meal service. Trays were observed being prepared, food plated and being put on the delivery carts which were taken to each unit. Resident's meal/tray tickets were observed which included milk and another beverage for each of the residents. None of the residents were served any milk. On 3/18/25 at 4 p.m., observations were conducted in the kitchen, and it was noted that they had 9 milk crates filled with individual cartons of milk, in addition to two, gallon jugs of milk. On 3/18/25, during an end of day meeting, the facility administrator was made aware of the above findings. On 3/19/25 at 8:27 a.m., an interview was conducted with the facility's activity director (AD). The AD reported that residents who eat in the dining room are served their food by the dietary staff, but then the staff in the dining room must prepare their beverages from the hydration station [a counter with various beverages in the dining room] for each resident. The AD went on to state, The hydration station is not done [set up] a lot of times. When asked what is done when there is no hydration station, the AD said, I have to put on a hair net and go in the kitchen to fix it. A lot of times, residents in the dining room get their food but not beverage. A facility policy regarding beverages was requested but the facility stated they had no such policy. No additional information was provided.

Based on observation, resident interview, staff interview, and facility documentation review, the facility staff failed to follow the menu for both meals observed, affecting multiple residents who resided on two of two nursing units. The findings included: 1. The facility staff failed to prepare and serve foods in accordance with physician ordered therapeutic diets affecting seventeen residents. On 3/18/25 at 10 a.m., an interview was conducted with the registered dietician (RD). The RD reported he is at the facility once or twice weekly. The RD confirmed that a lot of the residents had expressed concerns about the diabetic diets, and he had met with the residents recently. The RD explained that the facility doesn't prepare different foods for diabetics, they do a carbohydrate-controlled diet, and said, every meal should get the same amount of carbs, it is less carbs than the regular diet and less calories. The RD went on to explain that the diabetic diets are controlled through portions and sometimes a substitution, such as a roll or pasta dish may be substituted for another vegetable or fruit. The RD explained that the meal/tray tickets would correspond with the system and show the serving sizes. On 3/18/25 at 11:45 a.m., observations were conducted of the lunch meal/tray line service in the kitchen. The posted menu indicated that the menu was to include baked ham, carrots, scalloped potatoes, dinner roll, dessert: chocolate cake, hot coffee or tea and assorted milk options. Multiple resident meal trays were identified to indicate a heart healthy diet, and the protein was listed as a baked pork chop. The cook was asked about the baked pork chop and stated he didn't prepare it, and all those residents were observed to be served the ham. Multiple residents were listed to have large portions and/or double portions. The cook did provide extra vegetables on some of the plates, on one he provided extra potatoes, and some received no extra servings. When asked about the double portions and what that means, the cook said, I was told to only give 3 oz of meat, and this is more than 3 oz., so its whatever I can get on the plate. Continued observations revealed that the residents listed with a diabetic diet were listed to receive a half serving of the cake. None of those residents received a half portion, it was a full bowl of the crumbled cake served. Part way through the meal service they ran out of cake and the remaining trays, which was approximately thirty residents, received a sherbert cup for dessert. Several resident trays were observed to not receive a roll. The dietary aides put the trays onto the meal delivery cart without making any adjustments or questioning the cook when the plate/meal served did not match the diet. For residents that had orders for chopped meats, the cook was observed to take a slice of ham to a food preparation table, place the ham on a cutting board and use a knife to cut the ham into large chunks and strips that were not consistent in size. Most of the chunks of ham averaged the size of a quarter. On 3/18/25, interviews were conducted with the two dietary aides, (other employee #2- OE #2 and other employee #3- OE #3). OE #2 said, the cook knows what he is supposed to cook but when no manger is here, he does his own thing, but when the manager is here, he does what he is supposed to. On 3/18/25, the facility administrator was made aware of the above observations and provided the surveyor with a listing of residents on each diet. The facility provided report indicated that four residents were on a heart healthy diet and two were ordered a heart healthy/diabetic diet, that did not receive the baked pork chop at lunch. The listing noted that eleven residents were ordered a diabetic diet that were affected during the lunch meal service. According to the resident council minutes reviewed from November 2024-February 2025, the residents expressed concerns on two of the four months about diabetic diets not being followed/provided. According to the grievance log, nine residents filed a grievance with regards to food which included food preferences and concerns about items served not matching the meal ticket. On 3/19/25 at 8:27 a.m., the activities director (AD) was interviewed. The AD stated that she works closely with resident council and started posting the daily menus because residents expressed concerns that they were not getting posted. The AD reported that the residents have had ongoing complaints regarding the menu/meal tickets not matching what is served and the lack of diabetic diets. The AD reported she has set-up meetings with the contracted dietary company and with the dietician and residents to help resolve the concerns. When asked about alternates, the AD stated that the alternates include a ham or turkey sandwich and said, yesterday I had several residents that couldn't eat the ham, so I got them a sandwich. The AD reported that frequently they don't get what is on the menu, yesterday they didn't have scalloped potatoes, carrots or the chocolate cake at lunch. The AD went on to explain that she had arranged a meeting with the regional director from dietary and the residents but said, he wasn't actively listening to them. He was very dismissive. The AD explained that the residents were talking about not being provided a diabetic diet and the AD said she told the dietary regional manager, That day they had a plate full of biscuits and gravy for breakfast and at lunch had beef stroganoff, it was a full plate of noodles. It's not that they can't have those items, but it is too many carbohydrates, and it is intense portions. The AD stated that the regional director suggested the registered dietician (RD) educate the residents. The AD explained that the RD held a meeting with the residents and the residents explained they know they can eat the foods served but not plate full. On 3/19/25, the activities director provided the surveyor with email communications she had made with the contracted dietary company management and the dietician. According to the emails, one dated 2/5/25, to the regional dietary manager read, My residents would like to meet with you. I was informed that you were visiting us February 12th. Do you have time in mind that you could have a meeting with them? The response from the regional dietary manager included, . I am happy to spend a small amount of time with the residents but understandably it would need to be quick. The AD responded with, I am available to facilitate a meeting at 11 a.m., However, I cannot guarantee that this meeting will be quick. The problems with residents and the kitchen have escalated to an extreme level. If changes aren't made, we may face significant issues ahead. I have a resident council president who is eager to approach our ombudsman and gather signatures for a petition to remove [contracted dietary company name redacted] from the building. If the ombudsman gets involved, this could potentially lead to APS [adult protective services] concerns. According to another email dated 2/15/25-2/18/25, following the regional dietary manager's meeting with the residents, he reached out to the RD. The email to the RD read in part, . There was a trend among the comments with which I hoped you could help. Comments suggest that diabetic information regarding our menu design and how items on the menu are appropriate. Residents shared that 'my doctor told me to never eat ___ (pasta, rice, any type of starch).' . According to an email from the RD dated 3/6/25, to the activity's director, it read in part, I met with the residents today to discuss the issues with the menu, diabetic diets, and overall complaints. I have a whole list of changes/issues that I will send to [name redacted/kitchen manager] and my big bosses to see what we can change . On 3/18/25, the activities director sent the regional dietary manager another email requesting a follow-up meeting to . assess dietary progress and review menu choices . The response from the regional dietary manager included, . Given the turnover in the kitchen, it would be wise to wait until we have a new manager in position (recruiting ongoing) to introduce the residents. I'll keep in touch with you when this happens so that it can be one of the first things on their list. 2. The facility failed to provide R5 with a mechanically altered diet. On 3/18/25 at 12:20 p.m. an observation was made of R5's lunch meal. The meal tray was served in R5's room. The meal ticket noted the resident was to receive mechanical advanced chopped baked ham, and the ham was not chopped. The ham was served cut in long strips. On 3/18/25 at 2:30 p.m. a review of the clinical record was conducted. R5's diet order on 11/12/24 read, Regular Dysphagia Advanced thin liquids. Dietician notes on 2/13/25 read in part. .Nutrition Rec-cont w/[continue with] current mech. diet + supplement order. To cont POC [plan of care], comfort care. Wt (weight) loss anticipated, wt maintenance desired. MD [medical doctor], Nursing, RP [responsible party] notified & aware. On 3/18/25 at 4:00 p.m. a review of facility documentation was conducted. The Resident Council Meeting minutes were reviewed. The minutes had that mechanical diets were not being given. The concern about the mechanically altered foods was voiced in the meeting held in January 2025. On 3/18/25 at 4:30 p.m. an end of day meeting was conducted with the administrator, the director of nurses and the regional clinical director. The above concerns were discussed. On 3/19/25 at 10:00 a.m. a review of facility documentation was conducted. The policy titled, Therapeutic Diets, read in part, Therapeutic diet is defined as a diet ordered by a physician or delegated registered or licensed dietician as part of the treatment for a disease or clinical condition, to eliminate or decrease specific nutrients in the diet, or to increase specific nutrients in the diet, or to provide food that a resident is able to eat. Mechanically altered diet means one in which the texture of the diet is altered. When the texture is modified, the type of texture must be specific and part of the physicians or delegated registered or licensed dietitian's order . Action Steps . 3. Diets are prepared in accordance with the guidelines in the approved diet manual and the individualized plan of care. No further information was provided prior to the conclusion of the survey.

Based on observation, staff interview, and facility documentation review, the facility staff failed to maintain essential equipment in safe, operating condition the main kitchen. The findings included: 1. The facility staff failed to maintain the kitchen's walk-in freezer in operating condition. On 3/18/25 at approximately 4 p.m., during observations of the kitchen, it was noted that the freezer door was damaged and did not close completely. When the freezer door was opened, a significant amount of ice buildup was observed around the door jamb, which extended about 4 inches up the door frame. The food packages closest to the door had a buildup of frost. The gasket on the door was not attached at the bottom, about 12 inches of the gasket moved when the door was opened. On the back wall of the freezer was frozen streams of ice and the rear floor was incapsulated with ice build-up that covered the back 1/3 of the walk-in freezer floor. The ice incapsulated a milk crate that was sitting in the floor. On 3/18/25 at 4:05 p.m., an interview was conducted with the cook (other employee #4- OE #4). OE #4 reported that the freezer door had been messed up for a long time. On 3/19/25 at approximately 9:30 a.m., an interview was conducted with the facility's maintenance director (other employee #11- OE #11). OE #11 was asked about the walk-in freezer and stated, The freezer door was in bad shape forever, before I got here. It had a bad seal. We got a new seal, but the door is so bent up, it doesn't close properly. The freezer has always held temperature, so it wasn't a priority until about 3 weeks ago, a drain line burst. So now there are massive chunks of ice everywhere. OE #11 reported he had reached out to a vendor and sent them measurements of the door to see if they can find a replacement door or if they would have to build onto what is there to install a new door and is waiting to hear back. On 3/19/25, the facility administrator provided the survey team with emails that showed communication with a vendor regarding the freezer door. The email was dated 3/5/25 and was communication between OE #11 and a vendor. It read in part, . As you said, you have an old Southern Stainless walk-in freezer that the door has completely gone bad and needs to be replaced. I personally have never heard of Southern Stainless WIF [walk-in freezer] and as you said they're out of business . If you could supply us with dimensions, photos, etc. we might be able to supply you with a replacement option which might be a bump-out . On 3/11/25, OE #11 responded with measurements and photos. No additional information was provided. 2. The facility staff failed to maintain the main kitchen pellet warmer in operating condition. On 3/18/25, during the lunch meal service, observations were conducted in the kitchen of the meal service/tray line. It was observed that facility staff were not using the pellets to sit the plate on to keep the food warm. The plate of food was sat directly onto the meal tray with a pellet lid to cover it. When asked why the pellets were not being used, two dietary aides reported that it wasn't working. On 3/18/25 at 4 p.m., upon a return visit to the kitchen, an interview was conducted with the evening cook, OE #4. When asked about the pellet warmer, OE #4 reported the pellet warmer had been out of service for about two months. She went on to report, It had a burning smell and wasn't getting warm. On 3/18/25, a review of the resident council minutes from November 2024 through February 2025 were reviewed. Each month there were dietary concerns noted. According to the resident council meeting minutes dated 12/19/24 and 2/20/25 noted that residents repeatedly complained of cold food. The administrator's response was that meetings were held and/or communication with the contracted dietary management staff and that dietary had a new manager. On 3/18/25, a review of the grievance log was conducted and grievances related to food services were requested and received. According to a grievance dated 12/16/24, a resident reported concern with food temperature when getting meals in the room. The response included, pellet warmer fixed . On the afternoon of 3/18/25, during an end of day meeting held at approximately 4 p.m., the facility administrator was made aware of the above concerns and asked to provide any evidence he had with regards to the pellet warmer and repairs made to it. On 3/19/25 at 8:27 a.m., the activities director (AD) was interviewed. The AD arranges and coordinates the resident council meetings and reported, Resident council was talking about cold food and there was an issue with the plate warmer. I keep asking about it and the last time was 2 1/2 weeks ago and was told it is not fixed; they are still waiting on a part. On 3/19/25 at approximately 9:30 a.m., an interview was conducted with the facility's maintenance director (other employee #11- OE #11). When asked about the pellet warmer, OE #11 stated that the pellet warmer had been fixed 2-3 times. OE #11 said, It is not set to run indefinitely. I have replaced the thermostat, wire, and switch. It is only like 6 parts, and I have replaced everything in it. They kept plugging it in, hours ahead of time, and when it reaches 220 degrees, it would trip the switch inside of it and shut it off. OE #11 said that he had checked, and it reaches 190 degrees in 25 minutes. OE#11 stated that he told the kitchen staff to not cut it on until they are putting food on the steam table, . but they kept cutting it on and letting it run too long, and it would cut off. OE #11 stated that he had reached out to the company with about five phone calls and an email and then got a response that the technician had come out. OE #11 reported that he didn't even know the technician had come, . they never told me. On 3/19/25, the facility administrator provided an email that was between OE #11 and a vendor for the pellet warmer. The email was dated 3/18/25 and read in part, . We have spoken with tech support, our corporate parts department, and we have any searched online [sic] and cannot find the part information that is needed. Do you have the original purchase order or equipment information that has the model and serial number. This will help him to get what is needed, but we have searched for weeks and contacted our corporate parts department. I have added the technician notes to this work order . Tech notes: 2/21/25 Arrived to look at the plate warmer. I have to put this call on hold to find information on it. Date plate sticker is worn and only has serial number visible. Have to do some digging to find the correct info and parts . On 3/19/25 at approximately 10 a.m., the Regional Director for the contracted dietary services management company was made aware of the above findings. No additional information was provided.

2. For R10, the facility staff failed to uphold the resident's meal preference for a salad and sandwich. On 3/18/25, during the lunch meal, R10's meal tray was observed as the kitchen staff prepared it. According to the meal ticket, R10 was to receive deli sandwich, tossed salad, dressing, mixed vegetables, scalloped potatoes, chocolate cake with chocolate frosting. R10's meal included a slice of ham, mixed vegetables, diced red potatoes, and a roll. On 3/18/25 at approximately 12:20 p.m., R10 was observed in the dining room eating his lunch meal of the ham. When asked, R10 reported that the meal was not what he wanted. According to the facility policy titled, Menus read in part, . 6. Menus are served as written, unless changed in response to preference, unavailability of an item, or a special meal. On 3/18/25, during an end of day meeting, the facility administrator, director of nursing, and regional director of clinical services were made aware of the above findings. No additional information was provided. Based on observation, resident interviews, staff interviews, clinical record reviews, and facility documentation reviews, the facility staff failed to provide meals in accordance with resident preference for 2 residents (Resident #2 - R2 and Resident #10 - R10) out of a survey sample of 8 residents. The findings included: 1. The facility staff failed to serve R2's choice of an entree and a lidded cup with the lunch time meal. On 3/18/25 at 12:15 p.m. an observation was made of R2's lunch meal. R2's meal ticket read that a baked pork chop was the entree requested, but it was observed that she received the flat baked ham and no lidded cup for R2's beverage was observed on her meal tray. On 3/18/25 at 12:30 p.m. an interview was conducted with R2. R2 said, I usually get a pork chop and not ham. R2 stated that she liked a lidded cup but was never given a lid on the cup with meals. On 3/18/25 at 2:00 p.m. a review of the clinical record was conducted. R2's care plan was reviewed and documented that R2 preferred lidded cups with meals. On 3/18/25 at 4:00 p.m. a review of resident council meeting minutes was conducted. The minutes had several dietary concerns that had not been resolved over several months. The documented resident concerns about the food, included meal tickets not being followed, resident choices not being granted,and needing more snacks to be offered. On 3/18/25 at 4:30 p.m. an end of day meeting was conducted with the administrator, the director of nursing, and the regional clinical director. The above concerns were discussed. No further information was provided prior to the conclusion of the survey.

Based on staff interview and clinical record review, the facility staff failed to notify the responsible party of a change in condition for one of four residents in the survey sample, (Residents #3). Resident #3's (R3) responsible party was not notified of a fall with injury. This was a closed record review. The findings include: According to the clinical record, diagnoses for R3 included; Encephalopathy, fractured right pubis, dementia, pneumonia, and aseptic necrosis of the left femur. The most current MDS (minimum data set) was a significant change assessment with an ARD (assessment reference date) of 11/22/23. R3 was assessed with a cognitive score of 3 out of 15, indicating severely cognitively impaired. On 12/3/24 R3's clinical record was reviewed regarding a fall incident occurring on 11/12/23. The note indicated R3 got up out of wheelchair with right leg still crossed behind left foot. Before the nurse could catch R3, R3 landed on knees and obtained a skin tear to the left elbow. Review of the SBAR (Situation Background Appearance Review) notification section; it was documented the person notified was self own rp. R3's clinical record documented a friend as the RP indicating R3 was not his own RP. On 12/3/24 at 3:00 p.m. license practical nurse (LPN #1) was interviewed regarding notification of change of condition (fall). LPN #1 verbalized anytime there is a change of condition or fall with injury the physician and RP should be notified, if the resident has an RP then documentation of the notification should be documented on the eINTERACT assessment form. LPN #1 then reviewed the form for notification. After seeing documentation on the form indicating R3 was his own RP, LPN #1 verbalized that is not correct, verbalizing R3 had an RP and that person should have been notified. On 12/4/24 at 9:15 a.m. the above finding was presented to the director of nursing (DON). The DON also reviewed the documentation and agreed that R3 was not his own RP and the RP should have been notified. No other information was provided prior to exit conference on 12/4/24.

Based on staff interview and facility record review, the facility staff failed to have a surety bond to assure the security of all personal funds of residents deposited with the facility, which affected 72 residents who had funds deposited with the facility. The findings included: On 7/10/24 the facility staff provided a surety bond which was in the amount of $165,000. On 7/10/24, a review of the resident trust accounts revealed that there were 72 residents with funds deposited at the facility. The total balance was $180,783.50. The surety bond did not have sufficient coverage to cover the funds deposited with the facility. On 7/10/24, during an end of day meeting, the facility administrator was made aware of the above findings. Following the end of day meeting, the administrator came to the conference room and a list of residents that she said the business office said they needed to close the accounts for. The surveyor then went to the business office manager's (BOM) office. The BOM said she had just started at the facility and had identified several accounts that need to be closed, but that had not been done yet. No additional information was provided.

Based on resident interviews, staff interviews, and facility documentation review, the facility staff failed to maintain sufficient nurse staffing to assure resident safety and highest practicable well-being of each resident, to meet their daily needs in accordance with the facility assessment, for 2 of 2 nursing units. The findings included: On 7/8/24, during initial tour of the facility and interviews with the residents, numerous residents expressed concerns about the facility staffing. The residents reported having to wait long periods of time, that they described as over an hour, for call bell responses. On 7/8/24 at 2:20 p.m., the Ombudsman met with the survey team. The Ombudsman reported, staffing is horrible. I think it is dangerous. Especially on weekends, people feel like they can just call out, it is like a revolving door. I worry, they don't have an intercom system, if they put their call light on, it is on for an hour. If someone has fallen, this is dangerous. On 7/8/24 at 3:07 p.m., a group meeting was held with the resident council and survey team. Five residents were in attendance. They reported concern with call bell responses and said, sometimes we have to wait a long time, up to an hour. When asked if this was specific times of the day, they said, it's just anytime . I need help with bathroom and can't hold it. The resident council went on to say, some days there are only 2 aides on the floor [unit]. On 7/8/24-7/10/24, interviews were conducted with various staff, which included: CNA #11 (certified nursing assistant). CNA #11 reported that staffing was not good, that people call out all the time. CNA #9 reported staffing was horrible and said she can't provide the care Residents need. CNA #9 reported that 95% of the time I have over 20 residents to take care of, they are supposed to get showers twice a week but 95% of the time we don't have enough staff to do them. CNA #10 reported, staffing is very short, especially on weekends, a few weeks ago there was only 2 CNAs for the entire unit. It's not always that bad, but it is hard to get everything done. CNA #7 confirmed staffing was challenging and reported she can't provide all the care residents needs due to lack of staff. LPN #2 described the staff as, rachet and went on to say, do they get the care they need and deserve, no. When asked if there are times there is only one CNA for the entire unit, LPN #2 said, yes, the weekends are really bad. On 7/10/24, a review was conducted of the resident council minutes from November 2023-June 2024. The minutes revealed the following complaints directly related to nursing staffing and lack of care/services due to staffing: November 2023, concerns were shared regarding call bell response times. December 2023, concerns were shared regarding lack of showers. January 2024, staffing and staff leaving at 3 p.m., and leaving the unit short. CNA's complaining to residents about being short staffed, long call bell wait times, not seeing staff for a 4-hour period, and rounds not being conducted. February 2024- call lights not being answered in a timely manner. March 2024, long call bell wait time, staff turning off light [call bell], especially bad at night, 2 CNAs per unit, . beds not made, and sheets not changed. April 2024, staffing being an issue . Under the section G. titled, Administration is read, Asking for more staff and what can we do to keep the staff we have. May 2024, read in part, The weekdays staffing has increased. However, weekends are still bad . June 2024, read in part, . Nursing: back to call light being on long [sic]. Some residents not getting there showers [sic]. Staff on the weekend is really bad . Administration: Residents wanting to know about the staffing shortage . On 7/10/24, the facility assessment was reviewed. According to that document, the facility needed 34.2 FTE's (full time equivalents) for nurse aides, per day. Which would equate to 16 CNAs per unit, per 24-hour period. Also noted as 5 nursing assistants per shift, per unit. The document went on to say, department heads are responsible for staff review. Needs are discussed daily . On 7/10/24, the facility staffing/nursing assignment sheets were reviewed from June 1, 2024-July 8, 2024. This review revealed on multiple instances there were only 3 CNAs to care for all residents on one of the two units. Those dates included, but were not limited to: 6/1/24, 6/2/24, 6/3/24, 6/4/24, 6/6/24, 6/8/24, 6/9/24, 6/10/24, 6/11/24, 6/12/24, 6/13/24, 6/14/24, 6/17/24, 6/20/24, 6/21/24, 6/24/24, 6/27/24, 6/29/24, 7/1/24, 7/3/24, 7/6/24, 7/7/24, 7/8/24, and 7/9/24. Additional details according to the staffing assignment sheets included: On 6/1/24, units 1 and 2, each only had 2 CNA's from 7 pm-7 am. On 6/2/24, unit 2 only had 2 CNA's from 7 pm-7am. On 6/8/24, unit 2 only had 2 CNAs on the over-night shift. On 6/13/24, on unit 2 after 3 p.m., there was only 1 CNA until 7 pm. On 6/14/24, unit 2 from 3-7 p.m., there was only 2 CNAs for the unit. On 6/15/24, unit 1 only had two CNA's from 7 am-7pm. On 6/19/24, unit 2 only had 2 CNAs for the 7am-7pm shift. On 6/21/21, unit 2 only had 2 CNA's from 7am until 5 pm, and from 7pm-7am, there was only 2 CNA's. On 6/22/24, both units only had 2 CNA's from 7am-3pm. On 6/23/24 unit 2 only had 2 CNAs for first shift, 7am-3pm. On 6/24/24, unit 2 only had 2 CNAs for the 12-hour shift from 7am-7pm. On 6/29/24, unit 2 had a nurse work the floor as a CNA to make 2 staff to provide for all resident needs on the unit from 7am-7pm. On 6/30/24 there were 4 total CNAs for the entire facility from 7am-3pm and 7pm-7am. On 7/5/24, unit 2 only had 2 CNA's from 7am-7pm. On 7/6/24, unit 1 only had 2 CNA's. On 7/10/24 at 10:28 a.m., an interview was conducted with the Director of Nursing (DON). The DON was asked about nurse staffing of each nursing unit. The DON confirmed that standard staffing is 4 CNAs on each side during day shift, we come as close to that as we can with the staffing, we have available. We would rather over staff than under staff, not to mention call outs, when we can, go up to 5 and 5 [5 CNAs per unit]. During the above interview, the DON was asked about agency staffing and how they manage when people call out for their scheduled shift. The DON explained that they have been using agency since 2019. The company will only allow them to use one staffing agency, which is also owned by the same company, so they are limited in agency staff available. He went on to say, they are unreliable, they are just no shows [do not call or show up for their scheduled shift], but it all we have, and I can't do anything to hold them accountable. As for call outs, the DON said, It is difficult, I did some research recently and found that majority of the time when people call out, they had worked the previous 6 days because we are so low on staffing. I have a really hard time writing them up when they bailed me out in the week and picked up 12-hour shifts. I [NAME] these CNA's they bail us out and bail us out, but then call out because they are tired. The DON went on to say, Staffing has got me, that's the enemy in this place. When asked if there are times there are only 2 CNAs for a unit, he said, Oh yeah, it's happening but that's my worst days, I will come in and help do what I can, my unit manager comes in. We lost a unit manager recently because she got sick of coming in. I agree with you, staffing is bad. The DON further confirmed that the facility's average census runs around 100, which equates to 60 on one unit, and 40 on another. He explained that unit 2, where 40 residents are, is skilled, with families, the families more involved, they are scared, the residents are more needy and are more demanding, the residents more complicated and a higher acuity, so they need just as many staff as the other unit. On 7/10/24, during an end of day, pre-decision making meeting, the above findings were discussed. No further information was provided.

Based on observation, staff interview, and facility documentation review, the facility staff failed to store, prepare, and serve food accordance with professional standards for food safety in the main kitchen, which has the potential to affect multiple residents on 2 of 2 nursing units. The findings included: 1. The facility staff failed to store food at an appropriate temperature in the walk-in refrigerator. On 7/8/24 at 11 a.m., a tour of the kitchen was conducted with a dietary aide and cook (other employee #11- OE11), in the absence of the dietary manager. On 7/8/24 at 11 a.m., upon entry into the walk-in cooler, it was noted that the temperature did not feel cool enough to ensure food safety. The internal thermometer located within the fridge was observed to be reading 55 degrees Fahrenheit. OE11 was asked about the cooler, and he reported, It feels cold enough to me. When asked about the temperature readings and records, OE11 said, maintenance checks that, and said the logs should be hanging on the wall. There were no temperature logs available for any of the food storage areas, to include the walk-in cooler, walk-in freezer, the stand alone cooler or stand-alone freezer. The following items were noted to be in the cooler: approximately 12 cartons of milk, sliced sandwich ham, boiled eggs, ground beef, macaroni salad, cups of sliced watermelon, tossed garden salad, sandwiches, and macaroni salad, cases of margarine, cheese, whipped topping, various items of produce to include fruits and vegetables. The cook (other employee #10- OE10) was asked about temperature logs and he also said, maintenance checks them daily. On 7/8/24 at 11:47 a.m., OE11 was asked to take the temperature of foods on the steam table. OE11 went to the dietary manager's office to obtain a thermometer, the surveyor followed him. While in the dietary manager's office, it was observed that other employee #12 (OE12) was sitting at a desk filling in the temperature logs. When asked, OE12 said, I am catching them up. When the surveyor asked how she knew what the temperatures were on those days, no response was given. On 7/8/24 at 11:55 a.m., the dietary manager arrived in the kitchen. The dietary manager was asked about the walk-in cooler and reported they had been having problems with the cooler for a few weeks. When notified that they surveyor wanted the temperature of the milk taken, the dietary manager and surveyor walked into the walk-in cooler. When asked if she felt it was cool enough, the manager said, yes. The thermometer was pointed out that it was reading 56 degrees. The dietary manager did take the temperature of the milk stored in the walk-in cooler and the temperature was 52 degrees. The dietary manager said, that's not good, it should be way lower than that. When asked about temperatures of the food storage areas, she said that the dietary staff take temperatures twice daily. She was notified that each of the dietary employees had reported maintenance did this and there were no logs of temperature monitoring. On 7/8/24 at 2:44 p.m., the dietary manager accompanied the surveyor into the walk-in cooler. It was noted that there was a rack containing 3 shelves of fruit cups and tuna stored in the walk-in cooler, in addition to the previously identified items. The dietary manager replaced the thermometer in the walk-in cooler, and it was now reading 55 degrees. On 7/8/24 at 2:50 p.m., the surveyor observed the even cook preparing a ground beef dish that was to be served as a taco salad. The cook was asked where she got the ground beef being prepared from and responded that it was in the walk-in cooler and had come on the truck delivery that morning. The dietary manager was asked what was going to be done with the remaining ground beef, she said it had just been delivered that morning and she was sure it was ok. The surveyor asked the ground beef, which was still stored in the walk-in cooler to have the temperature taken. The dietary manager took the temperature of the ground beef, and it was 47 degrees. On 7/9/24 at 8:55 a.m., an interview was conducted with the maintenance director. The maintenance director reported that his department checked the temperature of the walk-in cooler and freezer daily, but dietary staff were to do it twice daily. The maintenance director went on to say that their department doesn't work on weekends, and therefore no temperatures are taken those days. When asked about the walk-in cooler, the maintenance director reported that when they check the temperature in the mornings the temperature is in the 30's. He accompanied the surveyor into the walk-in cooler and confirmed the thermometer was reading 53 degrees. The maintenance director then used a laser thermometer to check the temperature of the air coming from the cooling fans, it registered 50-degree air coming from the left fan and 48-degree air from the right fan. Review of the facility policy titled, Food Storage: Cold, was conducted. That policy read in part, . 2. The dining services director/cook(s) ensure that all perishable foods will be maintained at temperature of 41 degrees F [farenheight] or below except during necessary periods of preparation and service . 4. The dining services director/cook(s) ensures that an accurate thermometer will be kept in each refrigerator and freezer. A written record of daily temperatures is recorded . On 7/9/24 at 4:45 p.m., during an end of day meeting, the facility administrator and director of nursing were made aware of the above findings. 2. The facility staff failed to label and date foods that had been opened and failed to store food in a manner to prevent contamination. On 7/8/24 at 11 a.m., a tour of the kitchen was conducted with a dietary aide and cook (other employee #11- OE11), in the absence of the dietary manager. On 7/8/24 at 11 a.m., upon entry into the walk-in cooler, it was noted that a bag of onions was sitting on the floor of the walk-in cooler. There were multiple items that were not labeled with the date of when they were prepared, or when to be used by, which included but were not limited to: left over pureed eggs in a bag tied closed, boiled eggs in a liquid appearing to be water, covered with saran wrap, which had no date. There was a garden salad on a plate, which had no date(s). There was a zip lock bag, which was open and not closed and contained sliced sandwich ham. There was a container of macaroni salad, container of what appeared to be stewed tomatoes, macaroni and cheese, and multiple sandwiches all of which had no label or date of when they were prepared or to be used by. Additionally there were approximately 50 cups of cut watermelon that were open to air, not covered and had no date. Under one of the food preparation tables in the kitchen was a box of hotdog buns on the floor. OE11 was asked if this is where bread is normally stored and he said, when in a rush we put it there and put it up later. In the walk-in freezer there was a case of diced carrots and a case of green peas, that were open to air and not secured or dated of when opened. In the stand-alone cooler there was a container of egg salad that was covered with saran wrap and had no date of when it was prepared. There were multiple bottles of apple and cranberry juices that had been opened and not dated. On 7/8/24 at approximately 11:55 a.m., the dietary manager arrived and was asked about food storage. The dietary manager said, everything is to be labeled and dated. When asked why, the dietary manager said, we don't want anyone getting food poison. On 7/8/24 at 2:44 p.m., during a follow up visit to the kitchen, it was noted that in the walk-in cooler tuna salad was stored without any date. There were 3 racks of bowls of fruit cocktail. The dietary manager said they had just made them and would make a label for them. The walk-in freezer had a case of bacon that was not secured, was open to air and had no date as to when it was opened. There were also rolls and green peas that were observed to not be secured and were stored open to air and had no date of when opened. On 7/9/24 at 4:20 p.m., during a follow-up visit to the kitchen, observations were conducted with the dietary manager. In the walk-in cooler, the bag of onions remained stored on the floor of the cooler. The stand-alone cooler had 3 pitchers of juice that had no label of contents or date of when prepared. A review was conducted of the facility policy titled, Food Storage: Cold. The policy read in part, . 1. The dining services director is responsible for storing all items 6 inches above the floor and 18 inches below the sprinkler unit . 5. The dining services director/cook(s) ensures that all food items are stored properly in covered containers, labeled and dated and arranged in a manner to prevent cross contamination. The CFR [Federal code] read, 3-305.11 Food Storage .D. A date marking system that meets the criteria . (2) Marking the date or day of preparation, with a procedure to discard the food on or before the last date or day by which the food must be consumed on the premises, sold, or discarded . According to the 2017 Food Code published by the U.S. Public Health Service, FDA U.S. Food & Drug Administration chapter 3, section 3-302.15, page 64 stated: Package Integrity. Food packages shall be in good condition and protect the integrity of the contents so that the food is not exposed to adulteration or potential contaminants. On 7/9/24 at 4:45 p.m., during an end of day meeting, the facility administrator and director of nursing were made aware of the above findings. No additional information was provided. 3. The facility staff failed to wash dishes in a manner to prevent micro-organism growth, by wet nesting dishes. On 7/8/24 at approximately 11:15 a.m., observations were conducted of the facility staff washing dishes. It was noted that a dietary aide, (other employee #9-OE9) was observed removing dishes from the dish washer and immediately stacking them, while wet. This included tulip bowls and plates. When asked about the silverware that was wet, OE9 said she was going to get a towel and dry them. A few minutes later, OE9 was observed to have one towel that she was using to dry the eating utensils. On 7/8/24 at 2:50 p.m., OE9 was again observed to be stacking dishes directly out of the dishwasher that were still wet. This included trays and plate warmer bottoms. Another dietary aide, OE11 was observed taking silverware directly from the rack that go through the dishwasher on and putting them into a container where the spoons were stacked in a manner that they could not air dry. Joining this surveyor, the dietary manager observed the items and confirmed that water was in them. The dietary manager stated that this was wet nesting, which could allow the growth of bacteria. The dietary manager said that all items are to be air dried. Review of the facility policy titled, Ware Washing read in part, . 4. The dining services director ensure that all dishware is air dried and properly stored. According to the 2017 Food Code published by the U.S. Public Health Service, FDA U.S. Food & Drug Administration chapter 4, section 4-901.11, titled Equipment and Utensils, Air-Drying Required pages 151-152 stated: After cleaning and sanitizing, equipment, and utensils: (A) Shall be air-dried or used after adequate draining as specified in the first paragraph of 40 CFR 180.940 Tolerance exemptions for active and inert ingredients for use in antimicrobial formulations (food-contact surface sanitizing solutions), before contact with food; and (B) May not be cloth dried except that utensils that have been air-dried may be polished with cloths that are maintained clean and dry. On 7/9/24 at 4:45 p.m., during an end of day meeting, the facility administrator and director of nursing were made aware of the above findings. No additional information was provided. 4. The facility staff failed to sanitize food preparation areas and dishes washed in the 3-compartment sink. On 7/8/24 at 11 a.m., during the initial tour of the kitchen, the following was observed. OE11, who was a dietary aide was at the food preparation table preparing a rice pudding for the meal. Following the completion, OE11 used a rag from a green bucket to wipe down the food prep table. Sanitizer strips were used, and the solution had no sanitizer in it and registered a reading of 0 ppm [parts per million]. On 7/8/24, during the above observation in the initial kitchen tour, the cook was observed removing dishes from the 3 compartment sink and putting them on storage racks to dry and be available for use. It was noted that the gallon jug of sanitizer solution was empty, and the hose and plunger were hanging on the outside of the container. The cook was asked about the sanitizer, and he stated he didn't know where it was kept and did not know how long it had been empty. Review of the Sanitizer Dispenser Log which was posted on the wall to the left of the 3-compartment sink had not been filled out since 6/4/24 at 7:30 a.m. On 7/8/24 at 11:55 a.m., when the dietary manager arrived, she was made aware of the above findings. The dietary manager confirmed that the green buckets are used for soapy water to clean food prep area and then a red bucket is used to have sanitizer which is used to sanitize the food prep areas. The dietary manager was made aware that there were no red buckets nor any sanitizer available for use in the kitchen. Review of the facility policy titled, Ware Washing read in part, . It is the center policy that all dishware and service ware will be cleaned and sanitized after each use . 3. The dining services director is responsible for insuring appropriate completion of temperature and/or sanitizer concentration logs as appropriate . On 7/9/24 at 4:45 p.m., during an end of day meeting the facility administrator and director of nursing were made aware of the above findings. No further information was provided. 5. The facility staff failed to monitor and record the temperature of foods to ensure they were cooked to appropriate internal temperatures and failed to monitor and record the temperatures foods were held at, on the steam table, to ensure temperatures prevent the growth of food-borne illness causing bacteria. On 7/8/24 at approximately 11:30 a.m., during initial tour of the kitchen, the cook (OE10) had prepared the food for the lunch meal and had it on the steam table. OE10 was asked about temperatures and OE10 reported that he had already taken temperatures of the food. OE10 was asked where the record of food temperatures was located and OE10 went to the dietary managers office and started shuffling through papers and reported he could not find where he had written it. On 7/8/24 at approximately 11:45 a.m., the surveyor was provided a 3-ring binder that had food temperature logs. Review of this log revealed that food temperatures were recorded May 1-17, and June 2-June 6, 2024. Additionally temperatures were recorded for the breakfast meal on 6/7/24. There was no evidence of food temperatures cooked temperature or holding temperatures being monitored since 6/7/24. On 7/8/24 at approximately 12 noon, when the dietary manager arrived, she was made aware of the above findings and reported facility staff are to record food temperatures at every meal on the log. Review of the policy titled, Food: Preparation was conducted. This policy read in part, . 9. The cook(s) will prepare all cooked food items, in a fashion that permits rapid heating to appropriate minimum internal temperature. 10. Time/Temperature control for safety (TCS) hot food items will be heated according to the following guidelines: poultry and stuffed foods 165 degrees, ground meat 155 degrees, fish, and other meats 145 degrees for 15 seconds, . 11. The cook(s) ensure that all foods are held at appropriate temperatures, greater than 135 degrees (or as state regulation requires) for hot holding and less than 41 degrees for cold food holding. 12. Temperature for Time/Temperature Control for Safety (TCS) foods recorded at time of service, and monitored periodically during meal service periods as indicated . On 7/9/24 at 4:45 p.m., during an end of day meeting, the facility administrator was made aware of the above findings. No further information was provided. 6. The facility staff failed to ensure that dietary staff wore proper hair restraints while in the kitchen. On 7/8/24 at 11:05 a.m., upon the surveyor's entry to the kitchen, a dietary aide/other employee #11- OE11, was observed in the kitchen/food preparation area without a hair net on. OE11 was observed to walk to the back of the kitchen and obtained a hair net and put on. On 7/8/24 at approximately 12 noon, a nursing employee was observed to enter the kitchen and start to put juice into a pitcher from the juice machine and did not put on a hair net. The employee was advised by kitchen staff and then returned to the doorway to put on a hair net. On 7/8/24 at approximately 12:15 p.m., a dietary aide- other employee #13 (OE13) was observed to enter the kitchen through the back door and walk through the food service area without a hair net or beard guard. On 7/8/24 at 2:44 p.m., on a follow-up visit to the kitchen, two dietary staff (OE11 and OE13) were observed in the kitchen without any hair net on. During the above observation of OE11 and OE13, the dietary manager was asked about hair nets. The dietary manager was asked about hair restraints. The dietary manager stated that all staff are to put on hairnets before entering the kitchen. The dietary manager observed OE11 and OE13 and directed them to put on a hair nets. On 7/9/24, during an end of day meeting, the facility administrator and director of nursing were made aware of the above findings. 7. The facility staff failed to maintain the kitchen and kitchen equipment in a clean and sanitary manner. On 7/8/24 at approximately 11:15 a.m., during an initial tour of the kitchen the following was observed: Under the food steamer was a black pan approximately 8 inches deep that was filled with a liquid that had a grease film across the top. A dietary aide/other employee 11 (OE11), who was touring with the surveyor in the absence of the dietary manager, confirmed it was grease. OE11 stated that it is supposed to be dumped each day but could not answer why it had not been dumped from the previous day. There was a blender canister that was observed on the shelf beside the hand washing sink. The blender canister had a liquid in it, that was clear in color. When the cook, OE10 was asked about it and the contents, OE10 said, honey, I don't know. There was a metal 2 shelf cart beside a food prep table near the oven that had a hammer on the shelf that had left a brown, rust colored area of the claw hammer. There was significant debris on the cart, and it was observed that food service utensils/scoops and other food storage containers were stored on the cart. On 7/8/24 at 2:50 p.m., during a follow-up visit to the kitchen, observations revealed the pan of grease under the food steamer was still in place. The metal cart with the hammer, containing a rust stain and debris remained. Under the oven was a disposable fork. Under the 3-compartment sink was a copious amount of debris and dirt build-up that was black in color around the wall. The front of the oven had food spills down the front doors. On 7/9/24 at 4:20 p.m., during a return visit to the kitchen, the cart with the claw hammer was still present. The dietary manager was asked about it and shown the brown rust stain and she said maintenance must have left it there. She was asked about the cleaning of equipment and said her manager was going to get her a check list, but that equipment and floors are to be cleaned daily. When it was pointed out that the disposable fork under the oven had been observed yesterday and was still present, she confirmed the observation but made no comment. She was shown that under the 3 compartment sink it was significant debris build-up, and the oven had food spills down the front. The dietary manager said they are to clean the ovens every 2 months but are to wipe them down daily. A review was conducted of the facility policy titled, Equipment. This policy read in part, 1. The dining services director will ensure that all equipment is routinely cleaned and maintained in accordance with manufacturer directions and training materials. 2. The dining services director will ensure that all staff members are properly trained in the cleaning and maintenance of all equipment. 3. The dining services director ensure that all food contact equipment is cleaned and sanitized after every use. 4. The dining services director ensures that all non-foods contact equipment is clean . On 7/9/24 at 4:45 p.m., during an end of day meeting, the facility administrator and director of nursing were made aware of the above findings. No further information was provided.

Based on observation, resident interview, staff interviews, facility documentation review and clinical record review, the facility staff failed to assess and determine if a Resident was safe to self-administer medications that were at the bedside, for one Resident (Resident #28) in a survey sample of 26 Residents. The findings included: For Resident #28 (R28), who had multiple medications stored on the over bed table and bedside table, in their room, the facility staff failed to assess if the resident was safe to self-administer medications. On 7/8/24 at 12:42 p.m., observations were conducted in R28's room and an interview with R28 was conducted. During the interview, it was observed that R28 had prescription nasal spray which was Ipratropium Bromide and had a pharmacy label with an RX # and date of 4/16/24. Also at the bedside was sterile eye drops and a toothache cream on the over bed table which was positioned at the bedside. When asked, R28 said she is supposed to use the nasal spray 3 times a day, but most days only uses it twice. R28 also said, she uses the eye drops routinely and when asked about the toothache cream, she reported she had dentures but that she wipes her mouth a lot and gets sores in the corners of her mouth. R28 reported she used the cream on the corners of her mouth. Additional observations revealed a tube of Bengay on the over bed table. On 7/8/24 at 1:15 p.m., a clinical record review was conducted of R28's chart, which included physician orders. The orders included an active order that was started on 5/16/23, and read, Ipratropium Bromide Nasal Solution 0.03 % (Ipratropium Bromide (Nasal) 2 sprays in both nostrils three times a day for allergies . and an order dated 3/3/24, for Visine Dry Eye Relief Ophthalmic Solution 1 % (Polyethylene Glycol 400 (Ophth)) Instill 2 drop in both eyes in the morning for dry eyes. There were no orders for toothache cream, Bengay, or voltaren. During the clinical record review, R28's care plan was reviewed. There was no indication that R28 had been assessed for the ability to, nor had been approved by the interdisciplinary team that it was clinically appropriate for the resident to self-administer medications. Review of the assessment tab of the clinical record, revealed no evidence of an assessment having been conducted to assess the resident's ability to self-administer medication. On 07/08/24 at 03:27 p.m., observations revealed all the above noted medications still at the bedside. On 07/08/24 at 03:57 p.m., an interview was conducted with LPN #1 (licensed practical nurse), who was assigned to and routinely cares for R28. LPN #1 was asked about residents who are permitted to self-administer medications. LPN #1 explained that all medications are kept in the medication cart, which is maintained by the nurses and locked for safety. LPN #1 went on to say that if the resident is able, she will allow them to use inhalers and things of that nature while she is in the room and watching. LPN #1 went on to say at times families come and sneak stuff in. When asked what they do when this happens, LPN #1 said that they remove the items if they see them and tell the family. On 7/8/24, at approximately 4 p.m., following the above interview, LPN #1 accompanied the surveyor into R28's room. LPN #1 confirmed that the nasal spray was an item that had come from the facility's pharmacy. LPN #1 removed the nasal spray, Bengay, and voltaren gel that was also at the bedside. LPN #1 then asked the surveyor to accompany her to the medication cart and showed the surveyor where she had the prescription nasal spray for R28 in the medication cart that she said she administers. On 7/9/24 at 8:03 a.m., LPN #1 was observed performing medication administration with R28. Following the administration, R28 did not want to give LPN #1 the nasal spray back. LPN #1 had to engage the unit manager and said, We are going to get an order from the doctor, she is a strong woman. On 7/9/24 at 12:23 p.m., the facility conducted an assessment titled, Medication Self-Administration Safety Screen, to determine if R28 could self-administer the nasal spray and Voltaren Gel. According to the assessment it was determined that R28 could self-administer these two medications and store them at the bedside. On 7/9/24 at 2:38 p.m., the director of nursing (DON) was interviewed. The DON said that if a resident can self-administer medications, they can get them a lock box to keep the medications in. When asked why the medications are stored in a lock box, the DON said, so other residents can't access it. The DON confirmed that the facility does have residents that wander. When asked what the expectation is if families bring in over-the-counter medications, the DON said, if they see, they will take them and give to the nurse. The facility's policy regarding medication storage and self-administration of medications was requested. On 7/9/24, in the afternoon, it was noted that R28 had a box at the bedside that was locked for the medications to be stored in. It was also noted that the facility had obtained a physician order for the Voltaren which included unsupervised self-administration and updated the order for the nasal spray to include, . unsupervised self-administration. A review was conducted of the facility policy titled, Self-Administration of Medication at Bedside, which had an effective date of 1/29/24. Excerpts from the policy read, 1. The patient may request to keep medications at bedside for self-administration in a lock box. 2. Complete Medication Self-Administration Safety Screen Assessment. 3. The Interdisciplinary Team will review the assessment and together, use clinical judgement to determine if the patient is eligible. 4. If eligible, medications that are ordered by a provider to be self-administered will be identified in the medical record . On 7/9/24, in the late afternoon, during an end of day meeting, the facility Administrator and director of nursing were made aware of the above findings. No further information was provided.

Based on family interview, staff interview, facility document review and clinical record review, the facility staff failed to provide advance written notice of a room change for one of twenty-six residents in the survey sample (Resident #77). The findings include: Resident #77 (R77) nor R77's responsible party were provided a written notice prior to a room change. R77 was admitted to the facility with diagnoses that included adult failure to thrive, deep vein thrombosis, insomnia, severe protein-calorie malnutrition, major depressive disorder, cancer, and gastroesophageal reflux disease. The minimum data set (MDS) dated [DATE] assessed R77 with moderately impaired cognitive skills. On 7/8/24 at 2:30 p.m., R77's family member (other #7) was interviewed. R77's family member stated the facility moved the resident to a different room on 7/1/24 and that there had been no advance notice of the room change. The family member stated she was not aware of any written notice provided about the room change. R77's clinical record documented the resident changed rooms on 7/1/24. A note written by the admissions coordinator documented verbal notification to the resident on the same day as the room change. The admissions coordinator note dated 7/1/24 at 2:49 p.m. documented, .[R77] notified of room change on 07/01/2024 12:00 AM. Family/Responsible party notified of change . R77's clinical record documented a room change notification form dated 7/1/24 listing the reason for R77's room change and indicated the resident and/or responsible party were provided with a copy of the room change notification. On 7/9/24 at 10:30 a.m., the admissions coordinator (other staff #5) was interviewed about any written, advance notice of R77's room change. The admissions coordinator stated she notified R77 verbally on the day of the room change. The admissions coordinator stated, We looked at her as her own responsible party. The admissions coordinator stated she called the resident's listed responsible party (RP) and left a voice message that the resident was moving rooms. The admissions coordinator stated the notifications were made on the same day as the room change and no written notice of the change was provided to the resident or the RP. When asked about the documentation on the room change notification form indicating that a copy had been provided, the admission coordinator stated that no actual copy was provided. The admissions coordinator stated, I just marked yes about the notification. The admissions coordinator stated she asked the resident about the move on 7/1/24 and left a voice message for the RP. The admissions coordinator stated, There was no piece of paper. The admission director stated the current protocol was to complete the room change form in the electronic health record and that the facility no longer provided paper copies of the room change notice. The facility's current admissions/business contract documented residents had a right to advance notice of room and/or roommate changes. This finding was reviewed with the administrator, director of nursing and regional nurse consultant during a meeting on 7/9/24 at 4:30 p.m. with no further information provided prior to the end of the survey.

Based on facility staff interview, clinical record review and facility documentation review, the facility staff failed to obtain and incorporate the recommendations from a level II PASARR (preadmission screening and resident review) into the Resident's assessment and care plan for one Resident (Resident #46) in a survey sample of 26 Residents. The findings included: For Resident #46 (R46), who had a level II PASARR, the facility staff were unaware until requested by the survey team, that the Resident had a level II screening and failed to incorporate the recommendations into the Resident's assessment and care planning. On 7/8/24, a clinical record review was conducted of R46's electronic health record. The census tab of the clinical record revealed R46 was initially admitted to the facility on [DATE]. R46 did have several hospitalization s and the most recent readmission was on 10/7/23. R46's diagnosis included but were not limited to hemiplegia and hemiparesis following other cerebrovascular disease affecting right dominant side, paranoid schizophrenia, schizoaffective disorder, bipolar type, major depressive disorder/recurrent/moderate, other symptoms, and signs involving cognitive functions and awareness, and generalized anxiety disorder. During the above review, the surveyor was unable to find a PASSAR. The care plan did not address that R46 had a level II PASARR, nor any recommendations contained within the assessment. According to the care plan, it read in part, The resident has signs and symptoms of depression and is at risk for adverse reactions secondary to major depressive disorder, recurrent, anxiety disorder and schizoaffective disorder, bipolar type. Another focus area read, The resident exhibits adverse behavioral symptoms such as restlessness (agitation), hitting, increase in complaints, delusions, hallucinations, psychosis, aggression, refusing care. According to the documents tab of R46's chart, a document with an upload date of 10/29/2018, that was titled, UAI (uniform assessment instrument) 102918, was a one-page document which contained the Medicaid Funded Long-Term Care Service Authorization Form. On this document it indicated that a level II PASARR was referred, active treatment not needed. On 7/10/24 at 11:44 a.m., an interview was conducted with Other Employee #8 (OE8), who was the discharge planner/social services director. OE 8 was asked about the PASARR for R46. OE8 provided the surveyor with a level I PASARR that was completed 10/8/2023, that indicated, No referral for Level II evaluation for active treatment needs required because individual: Has a severe physical illness (e.g. documented evidence of coma, functioning at brain-stem level, or other conditions which results in a level of impairment so severe that the individual could not be expected to benefit from specialized services.) OE 8 also said that R46 had been admitted from a sister facility and they did not have the PASARR either. A review was conducted of the discharge summary from the hospital dated 10/7/23. The document read in part, . Reason for Admission: . Suicidal ideation, schizoaffective disorder. Hospital Course: . Suicidal Ideation/Schizoaffective disorder. Patient has a history of SI [suicidal ideation] and schizoaffective disorder. Patient initially endorse SI but denies on day of discharge. Psychiatry consulted and has evaluated patient to be at low risk to act on SI and does not require suicide precautions at this time, in terms of his chronic mental illness, patient's home facility meds has been reconciled and restarted while admitted . Recommendations: Melatonin 10 mg nightly, Mirtazapine 7.5 mg nightly, Olanzapine 10 mg daily, Risperdal 2mg BID [twice daily], Buspirone 10 mg BID, Clonazepam 0.5 mg BID, Valproic acid 250 mg morning, 375mg nightly . On 7/10/24 at approximately 12 noon, OE 8 confirmed he had completed the PASARR form dated 10/8/23. When asked what severe physical illness the resident had that made him not qualify for a Level II? OE 8 stated, he is pretty low functioning and bed bound. The surveyor explained that R46 was alert and had been able to communicate with the surveyor and impaired physical functioning was not reason to not perform a PASARR. Review of the facility policy titled, Level II PASRR- Virginia was conducted. Excerpts from this policy read, 1. Prior to center admission, the admission director will review preadmission information to determine if a Level II PASRR has been triggered by a completed Level I PASRR. a. If a Level II PASRR was triggered, and results are included in preadmission documents, the patient can be admitted to the center. No later than five (5) days after admission confirm that the Level II PASRR is uploaded into PCC and ensure that any requirements outlined in the Level II determination are incorporated into the care plan for the patient. 2. If a Level II PASRR was triggered by the Level I PASRR provided by the transferring hospital and the patient was admitted without a completed Level II PASRR, the center Social Work and Discharge Planner will initiate the discharge planning process by contacting: [name of company that performs Level II PASRR assessments redacted and phone number redacted] . On 7/10/24, during an end of day meeting, the facility Administrator was made aware of the above findings. No further information was provided.

Based on observation, staff interview, clinical record review and facility documentation review, the facility staff failed to ensure that residents receive devices to prevent accidents for one resident (Resident #28- R28), in a survey sample of 26 residents. The findings included, For R28, who had a recent fall, the facility staff failed to ensure the resident had fall interventions in place to prevent further accidents. On 07/08/24 at 1:19 p.m., an interview was conducted with R28. R28 reported that she has had several falls while at the facility. When asked what interventions were put in place to prevent future falls, the resident said she didn't know. Observations revealed no fall mat within the room. On 7/8/24, a clinical record review was conducted of R28's chart. According to the Post Fall Investigation document in the assessment tab of the chart, it indicated that R28's most recent fall was on 6/16/24. There were also Post Fall Investigation assessments completed on 12/15/23, 10/26/23, 9/19/23, 9/18/23, and 9/14/23. According to the care plan R28 had a focus area initiated on 5/15/23, which was the day of admission that read, the resident is at risk for falls due to history of falls with injury with impaired gait and mobility. The care plan was last revised on 6/7/24. Interventions to prevent falls and injuries included but were not limited to: fall mats to side of bed (left), which was initiated 10/26/23, and concave mattress to help with bed parameters, which was initiated 9/14/23. On 07/08/24 at 12:42 p.m., and again at 3:27 p.m., observations were conducted in R28's room. It was observed that R28 had a regular mattress, not a concave mattress and there was no fall mat present. On 07/09/24 at approximately 8:00 a.m., R28 was visited in her room. R28 was in bed, lying on a regular mattress and there was no fall mat at the bedside. R28 was asked about the fall mat, and she reported they didn't put anything on the floor by the bed to prevent injury in the event of a fall. On 7/9/24 at 03:01 p.m., an interview was conducted with LPN #1 (licensed practical nurse), who routinely cares for R28. LPN #1 was asked about R28's fall history. LPN #1 reported R28 had been treated for pneumonia recently and had some confusion and during that time had a fall. LPN #1 was shown R28's care plan which indicated she was to have a fall mat and concave mattress. On 7/9/24 at 3:03 p.m., LPN #1 accompanied the surveyor into R28's room and confirmed there was no fall mat present in the room to be used. LPN #1 also confirmed that R28 did not have a concave mattress and went on to say that the resident had not had that since she moved to her current room. LPN #1 reported that R28 transfers in and out of bed independently and was concerned that a fall mat would post more of a risk to the resident and was not aware why that would have been a part of the resident's care plan. Review of the facility policy titled, Fall Management Program, was conducted. The policy read in part, The center considers all patients to be at risk for falls and provides an environment as safe as practicable for all patients. The center utilizes a systematic approach to a falls management program that facilitates an interdisciplinary approach with evidence-based interventions to develop individual care strategies . Prevention: . 2. Discuss fall risks and interventions with patient and/or responsible party. 3. Incorporate any identified interventions into the care plan as applicable Fall Occurrence: 2. Complete the Post-Fall Investigation to determine, to the extent possible, the cause of patient fall . 3. A licensed nurse will review, revise, and implement interventions to the care plan . On 6/9/24, during the end of day meeting, the facility administrator and director of nursing were made aware of the above findings. No additional information was provided.

Based on observation, staff interview, clinical record review, facility document review, and in the course of a complaint investigation, the facility staff failed to ensure that two of three residents in the survey sample did not develop avoidable pressure ulcers. Resident #2 developed an avoidable facility acquired Stage III pressure ulcer on her right buttock. Resident #3 developed five avoidable facility acquired unstageable pressure ulcers, one of which was not identified by the facility until eschar (dark scab) was present over the area. This was identified as harm. Findings were: During the entrance conference on 08/03/2021 at approximately 9:15 a.m., the DON (director of nursing) was asked for a list of all residents in the facility with facility acquired pressure ulcers. The DON was asked if there was a wound nurse at the facility. She stated, We have a nurse practitioner (NP), that has her own business (name of business). She comes in every week and sees our residents with pressure. She was here this morning around 6:30 (a.m.). She makes rounds and does all the dressing changes, she measures everything, and writes the orders. Also requested during entrance was the facility policy and procedure regarding pressure ulcers. The DON presented a list with four resident names. Two of the four, Resident #2 and Resident #3 were added to the survey sample. 1. Resident #2 was admitted to the facility on [DATE] with the following diagnoses, including but not limited to: [CONDITION(S)] (chronic obstructive pulmonary disease), [CONDITION(S)], bilateral foot drop, protein-calorie malnutrition, dementia without behavioral disturbances. The most recent MDS (minimum data set) was an annual assessment with an ARD (assessment reference date) of 04/16/2021. Resident #2 was assessed as severely impaired in her cognitive status with a summary score of 07. The DON was interviewed on 08/03/2021 at approximately 12:25 p.m. regarding the list of residents with facility acquired pressure ulcers. When asked about Resident #2, she stated, She was seen for the first time today (08/03/2021) by [name of wound NP (nurse practitioner)]. The area was initially found at a Stage III. The clinical record was reviewed. A Weekly Skin Evaluation dated 07/26/2021 was observed and made no mention of any areas on Resident #2's buttocks. A progress noted dated 07/27/2021 at 19:38 [7:38 p.m.] documented: Resident w/ [with] no changes to baseline. RP [responsible party] .notified that resident remains at baseline. Resident eats very little at times but is supplemented w/ house supplement nutrition drink, which she likes a lot. Resident responds to verbal stimulation and is normally cooperative with staff providing care. Will refuse medications at times, but usually able to be redirected. Treatment to lower extremities continues . There was no other documentation in the clinical record regarding the resident's skin until the Weekly Skin Evaluation note for 07/31/2021 which documented the following regarding a new area on the gluteal fold: Observations: 1. Is Skin Intact without impairment? No 2. Wound(s) present: Yes 3. Are any wounds pressure related? Yes 4. Site: 55 Right gluteal fold Type: Pressure Length: 2cm Width: 2 cm Depth: 0 Stage: NOT ANSWERED 5. Notes: open area noted to right gluteal fold, slough tissue noted in wound bed . Wound 1. Location of wound: R [right] gluteal fold 2. Indicate whether this site was acquired during the residents stay or whether it was present on admission: Acquired 2a. Date acquired: 07/31/2021 3. Wound healed? No 4. Visible/Observation of Tissue: slough tissue present . 4b. Percentage of wound involvement (describe): NOT ANSWERED 5. Drainage present? No 6. Tunneling present? No 7. Undermining present? No 8. Description of peri-wound tissue: Pink 9. Describe wound edges and shape: Well defined 10. Surgical Wound Edges: na 11. Enter the number of sutures/staples present: 0 12. Infection suspected: No TREATMENT 13. Current treatment plan: [MEDICAL RECORD OR PHYSICIAN ORDER] EVALUATION 15. Wound progress: new, worsening, stalled improving- nothing documented 16. Care Plan reviewed/revised: Yes no- nothing documented 17. Comments: NONE ENTERED18. Another wound present: No Resident #2 was referred to the wound NP and seen on 08/03/2021. The progress note from the NP dated 08/03/2021 documented the following: Wound HPI: [Name of Resident #2] is a [AGE] year-old frail appearing white female .some recent decrease in mobility, and fecal incontinence. Staff noted ulceration at buttock region 2 days ago. Patient denies pain at site .Current treatment includes: foam dressing PMHx [Past medical history/PSHx [past symptom history]: [CONDITION(S)], foot drop of bilateral feet, GERD [gastroesophageal reflux disease], poor mobility, dementia, fecal incontinence Review of Systems: .(-) [negative] lower extremity [CONDITION(S)] (+) [positive] fecal incontinence (+) urinary incontinence (+) ambulation difficulty (-) ability to self reposition .(-) weight loss .Wound (+) full thickness ulceration of the right buttock that measures 1.8 X 1.5 X 0.2 cm. Wound base 55% slough and 45% granular before debridement and 25% slough and 75% granular after. Edges adherent to wound base, moderate non-odorous serous drainage, periwound without [CONDITION(S)], induration, or [CONDITION(S)]. Patient does not demonstrate evidence of pain when area is palpated. Plan: Stage III right buttock-contributing factors are poor mobility, fecal incontinence. Wound care to right buttock as follows: -cleanse with normal saline or wound cleanser, pat dry -Apply honey fiber to wound bed -Cover with bordered foam dressing -Change dressing QD [every day] and as needed for saturation or soilage. Turn/reposition at least every 2 hours when in bed and every hour when OOB [out of bed] to chair. HOB [head of bed] at 30 degrees or less as able, Float heels off bed with pillows or off loading boots, minimize the number of /layers beneath patient, Pressure redistribution cushion in chair when OOB to chair and pressure redistribution mattress for bed. Limit time OOB to chair. Education/Instructions: Plan of care and treatment recommendation discussed with patient and nursing staff, verbalized understanding. Performed excisional Debridement of right . ttock wound consisted of: Ulceration site was prepped and conservative sharp debridement was performed. Depth of debridement was at level of subcutaneous tissue, and within wound margins. Removal of devitalized necrotic tissue with a 5mm curette. There was scant bleeding that quickly subsided with light pressure and cleansing, Patient appeared to tolerate procedure without pain or signs of discomfort. A progress note on 08/03/2021 21:24 [8:24 p.m.] documented: Resident seen on wound rounds by wound NP, wound changed by NP, new order placed .supplement added X 30 days, RP stated he would bring outside food for extra supplement. On 08/04/2021 at approximately 8:30 a.m., the DON and nurse consultant were interviewed. The DON stated, We identified an increase in pressure ulcers in July. We did education with staff in July .we had a number of new staff so we did education on turning and repositioning. The inservice information for staff was reviewed. The education included: Subject: Pressure Ulcers and Skin breakdown, repositioning and floating heels. Objectives: Prevent Pressure Ulcers and Skin Breakdown. Summary of Content: Repositioning, turning, and floating heels, use of air mattress, Demonstrate proper use of air mattress. The DON stated, All the staff were educated. Concerns were voiced to the DON and the nurse consultant regarding the number of facility acquired pressure ulcers and that after the inservice had been done, Resident #2 had developed a stage III pressure area. On 08/04/2021 at approximately 9:00 a.m., the care plan was reviewed. The following information was observed: Focus: .has an ADL self-care performance deficit r/t [related to] weakness, [CONDITION(S)], limited ROM [range of motion], age, impaired mobility. Interventions included but were not limited to: Assist with all ADL tasks .Resident do not get out of bed BED MOBILITY: Extensive staff assist for bed mobility .TOILET USE: .is incontinent and requires total/extensive staff assist. Provide peri-care after incontinent episodes . Focus: SKIN: Is at risk for skin impairment/pressure ulcer development r/t incontinence & immobility Interventions included but were not limited to: Keep skin clean and dry, pericare with incontinence episodes. Wears briefs ., Pressure reduction mattress, treatment to wounds as ordered, weekly skin assessments .Focus: The resident has a skin tear/potential for skin tear of the (right lower leg). resident with a Stage 3 to left buttock. Interventions were: Air mattress, The resident needs her nails kept short to reduce the risk of scratching or injury from picking at skin. Weekly skin assessments. At 9:25 a.m., the NP providing wound care at the facility was interviewed. She was asked about her role at the facility. She stated, I come every week on Tuesday mornings and provide care for the wounds in the facility. She was asked if she had seen Resident #2. She stated, Yes, I saw her for the first time yesterday .I don't know her well. She hasn't had any pressure in the past. She presented with what the facility said was a Stage 2 pressure area, it was really a stage 3. I debrided the area and gave them treatment orders. The NP was asked if Resident #2's pressure ulcer had been avoidable. She stated, Well, it's not unavoidable. She was asked to explain. She stated, I reviewed her record, she hasn't had a significant weight loss, or a decline that would indicate the area is unavoidable .if I think an area is unavoidable I write that in my note, I didn't write that .she is totally dependant on the staff to turn and reposition her and provide incontinence care this area was avoidable if she had been repositioned and received good incontinence care. At approximately 10:15 a.m., RN (registered nurse) #2 was observed providing wound care to Resident #2. The old dressing was removed, the area was measured. RN #2 stated, The whole area is 2 cm X 2.5 cm. The area of slough is 1 X 1.5 cm, the depth is about .5 cm. The wound was observed with a reddish bright pink outer area. Yellow slough was observed in the center with a small area of reddish skin in the center of the slough. The entire wound was cleaned with wound cleanser. A small piece of calcium alginate was placed over the area of slough, and a border gauze was placed over the entire area. RN #2 stated that the facility did not have the honey fiber ordered by the NP and had gotten the okay to use the calcium alginate until they could obtain it. The facility policy Pressure Ulcer Monitoring &Documentation was reviewed and contained the following: Policy: All pressure ulcers will be monitored. Procedure: 1. A licensed nurse will assess patients for the presence of pressure ulcers/injuries; if a pressure ulcer/injury is present, the nurse will evaluate for complications. 2. Provide pain management prior to pressure ulcer/injury treatment as indicated. 3. The Skin Wound Evaluation will be completed weekly by a licensed nurse for any patient with pressure ulcers/injuries. 4. There will be a Wound Evaluation for each site. The DON, the administrator, and the nurse consultant were interviewed at approximately 11:35 a.m., the above information was discussed. The DON was asked if the were any other policies regarding pressure ulcer assessment, staging, etc. She stated, No. The nurse consultant stated, The skin evaluation has information regarding staging. The DON was asked how wounds were identified. She stated, If the CNA sees it they notify the charge nurse, they also have an option in their system to do a stop and watch charting. The nurse then does an assessment, a skin evaluation is done, the doctor is called, treatment is applied and the orders are initiated it is standard nursing practice. The DON was asked how the NP who takes care of the pressure areas became involved. She stated, [Name of Medical Director] is okay with [name of NP] evaluating the residents .all the pressure areas automatically go to [NP name] .not always the stage one but the others do . At approximately 2:20 p.m., the care plan interventions for Resident #2 were discussed with the DON, the administrator, and the nurse consultant. The DON was asked if interventions such as off loading boots, air mattresses, heelz up devices, floating heels, etc. were physician orders. She stated, No, those are nursing interventions. She was asked how staff was reminded to look at those things, or the nursing staff to check to see if they were in place if they were not on the TAR (treatment administration record) to remind them. She stated, They are on the care plan. The interventions listed for Resident #2 were read. The DON was asked where the interventions for Resident #2 regarding turning and repositioning were on the care plan. She stated, Bed mobility .she is extensive assistance. She was asked what that meant. She stated, Extensive assistance means she needs someone to turn and reposition her, it doesn't say turn and reposition is says extensive assistance. The administrator stated, Extensive assistance is defined as turn and reposition. The DON stated, That's standard nursing practice to turn the resident every 2 hours .and treat the wounds as ordered. The DON, the nurse consultant, and the administrator were informed that based on the documentation, and the interview with the NP who stated the pressure area on Resident #2's buttocks was avoidable, harm was identified. Any additional information available was requested. The DON and the nurse consultant stated, We identified the area, we treated it, she's [AGE] years old. It was reiterated that per the wound care nurse practitioner, the area was incorrectly staged by the facility as a Stage 2 when it was a Stage 3, and the area would have been avoided with repositioning and good incontinence care. No further information was obtained prior to the exit conference. 2. Resident #3 was originally admitted to the facility on [DATE] and readmitted on [DATE]. Her diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The most recent completed MDS was significant change assessment with an ARD of 06/01/2021, six days after her return from the hospital. Resident #3 was assessed as severely impaired in her cognitive status with a summary score of 03. However, the electronic health record included an MDS in progress and not yet completed, with an ARD of 07/17/2021, that assessed Resident #3 as moderately impaired in her cognitive status with a summary score of 09. When Resident #3 was readmitted from the hospital on 05/25/2021 she had a Stage III pressure area to her sacrum and DTI (deep tissue injury) to both her right and left heel. Weekly skin assessents and the wound NP notes through 06/24/2021 documented that both heels had healed, that the sacral pressure ulcer was improving, and no additional skin issues. Beginning on 06/28/2021, weekly skin assessment and NP wound notes documented new and worsening pressure areas as follows: Weekly skin assessment on 06/28/202: Left ankle (outer) Pressure Length 2.1cm Width 1.3cm Depth 0.5cm Stage II .Notes: Open area right ankle .acquired, date acquired 06/27/2021, scant amount serous drainage, no tunneling or undermining . Weekly skin assessment on 06/30/2021: Sacrum: 0.5 x 0.7 x 0.1 Stage III Notes: R hand is contracted, Popped blister to left outer ankle healed, nitrated by wound NP. Sacrum 100 % granulation, small amount serous drainage . Wound NP note on 07/06/2021: .pt is seen for evaluation and management of pressure injury at sacrum. Patient also with new wound at left lateral ankle. Patient hit the area on the foot pedal of her wheelchair. The area initially blistered, and now has opened .Wound: (+) Full thickness ulceration of the sacrum that measures 3.0 x 3.5 x 0.2 cm. Wound base 45% slough and 55% granular before debridement and 15% slough, 85% granular after. Edges adherent to wound base, small non-odorous serous drainage .(+) Full thickness ulceration of the left lateral ankle that measures 2.5 x 1.8 x 0.2 cm. Wound base is 10% slough and 90% granular. Edges adherent to wound base, moderate non-odorous serous drainage .Blanchable [CONDITION(S)] noted at the left lateral heel. Plan: Stage 3 pressure injury at sacrum, abrasion at left lateral ankle, resolved DTI left heel, resolved DTI right heel-contributing factors are recent acute illness, poor mobility, recent acute illness, type 2 diabetes, incontinence .Site enlarged continue care x 1 week and if no improvement will change POC next week Wound care to left lateral ankle as follows: -Cleanse with normal saline or wound cleanser, pat dry -Apply calcium alginate to wound bed -Cover with gauze and kerlix -Change dressing Q 3 days and as needed for saturation or soilage . Weekly skin assessment on 07/07/2021: Sacrum 3.0 x 3.5 x 0.2 Stage III Left lateral ankle-abrasion- 2.5 x 1.8 x 0.2 Sacrum: 15% slough and 85% granular, moderate amount serous drainage, no tunneling or undermining, special equipment: air mattress. Wound progress: Worsening . Left lateral ankle: Acquired. 10% slough and 90% granular, moderate amount serous drainage . Wound NP note on 07/13/2021: .pt is seen for evaluation and management of pressure injury at sacrum, pressure injury to left lateral ankle, left hip, and left heel. Initially the left ankle wound was defined as an abrasion last week, however, site has increased in size and patient has had increased pressure to the area now defined as a stage III pressure injury. Staff has been repositioning patient often, continues to use air mattress and offloading heels with foam boots .Wound: (+) Full thickness ulceration of the sacrum that measures 9.5 x 3.5 x 0.2 cm. Wound base 20% eschar, 50% slough and 30% granular. Edges adherent to wound base, small non-odorous serous drainage . (+) Full thickness ulceration of the left lateral ankle that measures 5.0 x 4.5 x 0.2 cm. Wound base with some peeling skin from unroofed blister, 25% slough and 75% granular before debridement, and 100% granular after. Edges adherent to wound base, small non-odorous serous drainage .Blanchable [CONDITION(S)] noted at the left lateral heel. (+) Full thickness wound of the left lateral heel that measures 4.0 x 3.5 x 0.0 cm. Wound base 100% area of purple deep ecchymosis, (+) surface induration, edges adherent to wound base. No drainage .(+) Full thickness wound of the left hip that measures 3.0 x 3.0 x 0.0 cm. Wound base 100% area of deep purple ecchymosis. (+) surface induration, edges adherent to wound base. No drainage . Plan: Stage 3 pressure injury at sacrum, stage 3 pressure injury to left lateral ankle, recurrent DTI left heel, DTI at left hip, resolved DTI right heel, contributing factors are recent acute illness, poor mobility, recent acute illness, type 2 diabetes, incontinence, [CONDITION(S)]. Site enlarged CHANGE care- Wound care to sacrum as follows: -Cleanse wound with normal saline or wound cleanser -Apply calcium alginate to wound bed -Cover with bordered foam dressing -Change dressing daily and as needed for saturation or soilage Site enlarged CHANGE care- Wound care to left lateral ankle as follows: -Cleanse with normal saline or wound cleanser, pat dry -Apply xeroform to wound bed -Cover with gauze and Kerlix -Change dressing daily and as needed for saturation or soilage Wound care to left hip and left heel as follows: -Cleanse with normal saline or wound cleanser, pat dry. -Apply skin prep/barrier film to wound bed -Provide this care daily. Apply [NAME] cream to bilateral feet/heels daily to prevent xerosis Assist to- Turn/reposition at least every 2 hours when in bed and every hour when OOB [out of bed] to chair. HOB [head of bed] at 30 degrees or less as able, Float heels off bed with pillows or off loading boots, minimize the number of layers beneath patient, Pressure redistribution cushion in chair when OOB to chair and pressure redistribution mattress for bed. Limit time OOB to chair. Education/Instructions: Plan of care and treatment recommendation discussed with patient and nursing staff, verbalized understanding . Weekly skin assessment on 07/14/2021: Sacrum: 9.5 x 3.5 x 0.2 Stage III; Left hip Pressure 3 x 3 0 Suspected DTI; Lt [left] lateral heel Pressure 4 x 3.5 x 0 Suspected DTI; Left lateral ankle Pressure 5 x 4.5 x 0.2 Stage III Sacrum: Wound base 20% eschar 50% slough and 30% granular, moderate amount serous drainage- cleanse with wound cleanser, pat dry, apply calcium alginate to wound bed, cover with bordered foam dressing. Wound progress: Worsening Left lateral ankle: Acquired (NO DATE), wound base with some peeling skin from unroofed blister 25% slough and 75% granular before debridement and 100% granular after. Small amount serous drainage. Treatment: Cleanse, apply xerform to wound bed and cover with gauze wrap with kerlix. Wound Progress: New Left hip: Date acquired 07/13/2021, 100% purple ecchymosis, no drainage. Treatment: Skin Prep. Wound Progress: New Left lateral heel: Date acquired 07/13/2021, wound base 100% area of purple deep ecchymosis, no drainage. Treatment: Skin prep. Wound Progress: New. Wound NP note on 07/20/2021: Patient is seen for evaluation and management of pressure injury to sacrum, pressure injury at left lateral ankle, right and left hip, left medial great toe, and left heel. Patient continues to deny complaints, states she is very comfortable. Appetite has been good, intake is good. Staff has been repositioning her frequently and patient has air mattress and foam boots. Wound: (+) Full thickness ulceration of the sacrum that measures 8.2 x 3.5 x 0.2 cm. Wound base 75% slough and 25% granular before debridement and 65% granular and 35% slough after. Edges adherent to wound base, moderate non-odorous serous drainage . (+) Full thickness ulceration of the left lateral ankle that measures 4.0 x 2.5 x 0.0 cm. Wound base 5% slough and 95% slightly moist eschar. Edges adherent to wound base, scant non-odorous serous drainage . (+) Full thickness wound of the left lateral heel that measures 3.0 x 2.5 x 0.0 cm. Wound base 100% area of purple deep ecchymosis, (+) surface induration, edges adherent to wound base. No drainage . (+) Full thickness wound of the left hip that measures 2.5 x 3.8 x 0.2 cm. Wound base 100% slightly moist eschar, edges adherent to wound base. Scant serous drainage. (+) Full thickness ulceration of the right hip measures 7.0 x 3.0 x 0.0 cm. Wound base 100% slightly moist eschar. edges adherent to wound base, scant non-odorous serous drainage . (+) Full thickness wound of the left medial great toe that measures 2.0 x 1.5 x 0.0 cm. Wound base 100% stable eschar, edges adherent to the wound base. No drainage. Plan: Stage 3 pressure injury at sacrum, unstageable pressure injury to left lateral ankle, recurrent DTI left heel, unstageable pressure injury to left hip, unstageable pressure injury at right hip, unstageable pressure injury to left medial great toe, resolved DTI right heel, contributing factors are recent acute illness, poor mobility, recent acute illness, type 2 diabetes, incontinence, [CONDITION(S)]. Site Improved Continue Care- Wound Care to Sacrum . (Dressing change described is unchanged from previous note) Wound Care to Left lateral ankle and left hip: Apply alginate and coversite Q3days in an attempt to keep the site dry and help it stabilize. Wound Care to left medial foot and left heel as follows: (Dressing change described is unchanged from previous note) (NOTE: There was no mention of treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] Weekly skin assessment on 07/21/2021: Sacrum Pressure 8.2 x 3.5 x 0.2 Stage III; Left Hip Pressure 2.5 x 3.8 x 0.2 Unstageable; Lt great toe Pressure 2 x 1.5 x 0 Unstageable; Lt lateral heel Pressure 3 x 2.5 x 0 Suspected DTI; Left lateral ankle Pressure 4 x 2.5 x 0 Unstageable; Right hip Pressure 7 x 3 X 0 unstageable. Sacrum: wound base 75% slough, 25% granular before debridement and 65% granular 35% slough after, Moderate amount serous drainage. Wound edges adherent to base. Wound progress: Improving Left lateral Ankle: Acquired, (NO DATE), wound base with 5% slough and 95% slightly moist eschar, Scant serous drainage, wound edges adherent, Treatment: Cleanse, apply calcium alginate to wound bed and cover with coversite dressing. Wound progress: New. Left hip: Date acquired: 07/13/2021 100% slightly moist eschar, scant amount serous drainage, Wound Progress: worsening Left lateral heel: Date acquired 07/13/2021 Wound base 100% area of deep purple ecchymosis; Wound Progress: Improving Right hip: Date Acquired: 07/20/2021 100% slightly moist eschar, scant amount serous drainage, wound edges adherent to base. Treatment: Cleanse with wound cleanser, pat dry, and apply silicone border. Wound Progress: New. Left Great Toe: Date acquired: 07/20/2021 100% stable eschar, no drainage. Treatment: Cleanse,Apply Skin prep. Wound Progress: New. Weekly skin assessment on 07/29/2021: Sacrum Pressure 7 x 3.5 x 0.2 Stage III; Left hip Pressure 2.5 x 2.8 X 0.2 Unstageable; Left great toe Pressure 2 x 1.5 x 0 Unstageable; Left lateral heel Pressure 3 x 2.5 x 0 Suspected DTI; Left lateral ankle Pressure 4 x 2.5 x 0 Unstageable; Right hip Pressure 7 x 3 x 0 Unstageable. The rest of the skin evaluation was identical to the weekly skin evaluation completed on 07/21/2021. Wound NP note on 08/03/2021: Patient is seen for evaluation and management of pressure injury to sacrum, left lateral ankle, right and left hip, left medial great toe, and left heel. Patient denies complaints, appetite and intake are good. Patient has air mattress and is using foam boots to offload heels. Review of Systems: (-) ability to self-reposition, (+) poor bed mobility, (+) intermittent appetite loss, (-) weight loss. Besides meals, drinks ensure daily. Wound: (+) Full thickness ulceration of the sacrum that measures 3.1 x 3.6 x 0.2cm x 3.5 x 0.2 cm. Wound base 85% slough and 15% granular before debridement and 60% granular and 40% slough after. Edges adherent to wound base, moderate non-odorous serous drainage . (+) Full thickness ulceration of the left lateral ankle that measures 4.0 x 2.6 x 0.2 cm. Wound base 5% slough- this is the only area of depth, and 95% slightly moist eschar. Edges adherent to wound base, scant non-odorous serous drainage . (+) Full thickness wound of the left lateral heel that measures 1.0 x 0.8 x 0.0 cm. Wound base 100% stable eschar,edges adherent to wound base. No drainage . (+) Full thickness wound of the left hip that measures 2.5 x 3.2 x 0.2 cm. Wound base 100% slightly moist eschar, edges adherent to wound base. Scant serous drainage. (+) Full thickness ulceration of the right hip measures 6.6 x 3.4 x 0.0 cm. Wound base 100% slightly moist eschar. Edges adherent to wound base, scant non-odorous serous drainage . (+) Full thickness wound of the left medial great toe that measures 1.0 x 1.0 x 0.0 cm. Wound base 100% stable eschar, edges adherent to the wound base. No drainage. Plan: Stage 3 pressure injury at sacrum, unstageable pressure injury to left lateral ankle, now unstageable pressure injury with stable eschar at the left heel, unstageable pressure injury at left hip, unstageable pressure injury at right hip, unstageable pressure injury to left medial great toe, resolved DTI right heel, contributing factors are recent acute illness, poor mobility, recent acute illness, type 2 diabetes, incontinence, [CONDITION(S)]. Site Improved Continue Care- Wound Care to Sacrum . (Dressing change described is unchanged from previous note) Site Stable/Improved, continue care- Wound care to left lateral ankle and left hip, and right hip: -Cleanse with NS or wound cleanser, pat dry -Apply alginate Then apply coversite OR border foam dressing Provide this care q 3 days, and as needed for saturation or soilage. Site improved, continue care- Wound Care to left medial foot and left heel as follows: . (Dressing change described is unchanged from previous note) Weekly skin assessment on 08/03/2021: Sacrum: 3.1 x 3.6 x 0.2 Stage III; Lt lateral heel Pressure 1 x 0.8 x 0 Unstageable; Left great toe: Pressure 1 x 1 x 0 Unstageable; Left hip pressure 2.5 x 3.2 x 0.2 Unstageable; Left lateral ankle Pressure 4 x 2.6 x 0.2 Unstageable; Right hip pressure: 6.6 x 3.4 x 0 Unstageable. Sacrum: Wound base 85% slough and 15% granular before debridement and 60% granular and 40% slough after. Moderate amount serous drainage. Wound edges adherent to base. Wound Progress: Improving. Left lateral ankle: Acquired (NO DATE), wound base with 5% slough and 95% slightly moist eschar, scant amount serous drainage. Treatment: Cleanse, apply calcium alginate to wound bed and cover with coversite. Wound Progress: (NOT ANSWERED) Left hip: Date acquired 07/13/2021, 100% slightly moist eschar, scant amount serous drainage. Wound edges adherent to base. Treatment: Cleanse with wound cleanser, pat dry and apply calcium alginate to wound bed and cover with coversite dressing Q3D and prn. Wound Progress: Improving Left lateral heel: Date acquired 07/13/2021, Wound base 100% stable eschar, no drainage, Wound Progress: Improving Right hip: Date Acquired: 07/20/2021 100% slightly moist eschar, scant amount serous drainage, wound edges adherent to base. Wound Progress: Improving. Left Great Toe: Date acquired: 07/20/2021 100% stable eschar, no drainage. Wound Progress: (NOT ANSWERED). At approximately 12:15 p.m., Resident #3 was observed sitting up in a chair in her room. She was interviewed about her care at the facility including her wounds. She stated, I don't know how I got them but I got them. She was asked if she was able to move herself from side to side in the bed. She stated, No, I can't turn myself. They do it for me .sometimes it's a long time between times. She was asked to clarify a long time. She stated, I don't know about the time on the clock, but sometimes it's two hours before they come .I call and call and they don't come. They are busy, I know. Resident #3 was asked about her diet. She stated, My food is pureed .I don't like it. My daughter brings me chicken and greens, I like that. She was asked if she had difficulty swallowing. She stated, No. Resident #3's bed was observed with an air mattress in place. A pump for the mattress was hanging on the foot of her bed. A green light was lit up on the side. There were no lights illuminated on the display screen on top of the pump. At approximately 1:00 p.m., the DON was asked about the multiple new wounds that had been identified on Resident #3. She stated that Resident #3 was turned every two hours, and she had an air mattress in place. She stated, She has a wound on her sacrum, she's been positioned on her sides to off load the pressure on her sacrum and she developed deep tissue injuries on her hips. Concerns were voiced that per the documentation the wound on the right hip was not discovered until it was 100% eschar. The DON was asked about staffing. She stated, Like everyone in the area we have staffing challenges, we have open positions, we have PRN staff, and we are covering the facility at appropriate staffing levels. Copies of the July as worked schedule for Resident #3's unit were requested. At 2:35 p.m., Resident #3 was observed lying in bed on the right side. The air mattress pump on the footboard of her bed was observed. The green light on the side of the pump was lit up, [TRUNCATED]

Based on a complaint investigation, resident interview, staff interview, clinical record review, and facility document review, the facility staff failed to ensure adequate safety and supervision for the prevention of an accident, which resulted in harm for one of one resident (Resident #1) in the survey sample. Resident #1 was taken outside of the of the facility on (MONTH) 20, 2019 via wheelchair by a CNA (certified nursing assistant) #1. The CNA left the resident outside and failed to return. The resident attempted to return to the facility on her own, but rolled off the sidewalk and out of the wheelchair onto the pavement, which resulted in a right humeral head and neck fracture with impaction. Findings include: Resident #1 was admitted to the facility originally on 11/12/18. [DIAGNOSES REDACTED]. The most current MDS (minimum data set) was a quarterly assessment dated [DATE]. This MDS assessed the resident as 15 cognitively, indicating the resident was intact for daily decision making skills. The resident was also assessed as requiring extensive assistance for transfers, dressing, hygiene and bathing with assistance of one staff person. The resident was assessed as having no ambulation in the look back period. The resident was assessed as a 7/2 for locomotion (on and off the unit), meaning this activity occurred only once or twice and the resident required physical assistance from one staff member for locomotion. In section G0300. (Balance during transitions and walking) the resident was assessed as not steady, only able to stabilize with staff assistance for moving on and off the toilet and surface to surface transfers. The resident was assessed as an 8/8 (activity did not occur) for walking (with assistive device if used) and turning around and facing the opposite direction while walking. Resident #1's clinical record was reviewed and revealed the resident was a long term hospice patient due to end stage [MEDICAL CONDITION]. Resident #1 had been on hospice for over a year. Resident #1 also had a history of [REDACTED].#1 had unwitnessed falls on 01/02/19, 01/09/19, 02/22/19, and on 06/21/19 (which resulted in a [MEDICAL CONDITION]). These falls were documented as unwitnessed and as failure on Resident #1's part to call for assistance and/or use a walker. The fall that occurred on 06/21/19 resulted in the resident's [MEDICAL CONDITION], which ultimately led to the resident being bed/chair bound. Resident #1's CCP (comprehensive care plan) was reviewed prior to the fall on 12/20/19. The CCP documented, .ADL (activities of daily living) self-care performance deficit related to end stage [MEDICAL CONDITION], activity intolerance, and right [MEDICAL CONDITION] .dressing .staff assist .transfers .assist with transfers .personal hygiene .assist with personal hygiene .encourage resident to use bell to call for assistance .The resident had a fall with major injury on 06/21/19 related to gait/balance problems .anticipate and meet the resident's needs .assistive devices: Assist bars .be sure the resident's call light is within reach .use it for assistance as needed .educate the resident/family/caregivers about safety reminders and what to do if a fall occurs .ensure that the resident is wearing appropriate footwear when ambulating or mobilizing w/c .Non weight bearing to right leg per order .PT (physical therapy) to evaluate and treat PRN (as needed) . The complainant was interviewed on 01/07/20 at 7:45 PM. The complainant stated that she came to the facility on [DATE] at approximately 10:40 AM and the CNA was already outside with the resident. The complainant stated that she went on into the facility and about 45 minutes later walked by Resident #1's room and the resident wasn't there. The complainant stated that she then walked toward the lobby of the facility where she saw an RN (Registered Nurse) bringing the resident in from outside. The complainant stated that Resident #1 had some blood on her arm and that she complained of right shoulder pain. The complainant stated that talked to Resident #1 and told her that she got cold and the CNA didn't come back to get her so she tried to come back herself and rolled off the curb. On 01/08/20 at 9:55 AM, Resident #1 was interviewed regarding her fall on 12/20/19. Resident #1 stated that she could push her self. Resident #1 then stated, that she did not want to get anyone in trouble or get anyone fired and that she couldn't remember the name of the CN[NAME] When Resident #1 was asked if it was CNA #1 the resident stated yes. Resident #1 stated that CNA #1 pushed her outside in her wheelchair on (MONTH) 20, 2019. Resident #1 stated that CNA #1 left her out there and did not come back to check on her. Resident #1 stated that she became cold and attempted to maneuver herself back down the sidewalk, when she rolled off the sidewalk, and tipped over out of her wheelchair onto the pavement face down. Resident #1 stated that her arm was hurting at that time and she didn't know why staff didn't get an x-ray at that time. Resident #1 then stated that she was tired of talking about the incident. On 01/08/20 at 10:00 AM, CNA #2 was interviewed and stated that she knew Resident #1. CNA #2 stated that after the resident fell in (MONTH) and broke her hip, she was pretty much in the bed all the time. CNA #2 stated that she was moved to the other hall at that time and didn't work with her much after that. On 01/08/20 at 10:05 AM, CNA #3 was interviewed. CNA #3 stated that she was working the day that CNA #1 took Resident #1 outside. CNA #3 stated that CNA #1 was assigned to Resident #1 that day and had asked CNA #3 to help her get Resident #1 out of bed. CNA #3 stated that it was rare for Resident #1 to be out of the bed and that Resident #1 was a hoyer lift. CNA #3 stated that she and CNA #1 got the resident up in the wheelchair and then CNA #1 told her that she was taking Resident #1 outside. CNA #3 stated that a little while later someone said that Resident #1 had fell outside. CNA #3 then stated, Later CNA #1 came and said 'Oh my God, I'm the one who pushed her (Resident #1) outside.' CNA #3 stated that she asked CNA #1 why did you do that and CNA #1 stated, she didn't know. CNA #3 stated that the CNAs get report on their residents before each shift and that she didn't know why she took the resident outside because that wasn't normal for that resident. On 01/08/20 at 10:00 AM, LPN (Licensed Practical Nurse) #1 was interviewed. LPN #1 stated that she was the resident's nurse that day and that she didn't know exactly what happened, but that Resident #1 was trying to get back inside and she tipped over that's why she fell . LPN #1 stated that CNA #1 took her out and that she didn't know why she took her out and didn't see her take Resident #1 out. LPN #1 stated that she went outside after it happened and that Resident #1 complained of pain, but not much, and she was given pain medication, but really didn't complain much until the next day. LPN #1 stated that it was not a normal occurrence for Resident #1 to go out, that she stayed in the bed a lot and would occasionally get up in her wheelchair in the facility, but not go outside. On 01/08/20 at 10:25 AM, the administrator and corporate nurse were asked for the investigation for Resident #1's fall with injury. The investigation was presented and documented that the resident was found on the ground on her stomach with her wheelchair tipped over. The investigation determined that CNA #1 took the resident outside of the facility around 10:30 AM and left her at the far end of the building and that Resident #1 had a cell phone on her (this was not confirmed). Resident #1 fell and sustained a fracture to the right arm as a result. Resident #1 was found by an employee, OS #1 (Other Staff #1) who was leaving the facility to run errands. CNA #1 was interviewed and the statement documented, .the resident wanted to go outside and told her (CNA #1) that she could bring herself back in so she left her out there .around 10:45 AM . CNA #1 stated in the statement that she was on her way to check on Resident #1 when she heard people yelling that the resident had fell . CNA #1 stated in the statement that the she locked the wheels on the wheelchair and that Resident #1 was able to wheel herself. A nursing note dated 12/24/19 (late entry follow up to incident on 12/20/19) documented, Res (resident) had been escorted outside by CNA, res had an unwitnessed fall, was found laying on stomach with w/c (wheelchair) tipped over . On 01/08/20 at 12:05 PM, the PT (physical therapist) manager was interviewed. The PT stated that Resident #1 was on hospice and has been since she has been a patient here. The PT looked in the computer and stated that Resident #1 had not been seen by therapy while a resident at this facility and therapy doesn't normally see patients on hospice, unless nursing has identified a concern that therapy may be able to help a resident. On 01/08/20 at 12:10 PM, CNA #1 was interviewed via phone. CNA #1 stated that Resident #1 wanted to go outside and she got her up and dressed pushed her outside. CNA #1 stated, she told me that she could, so I just left her out there. CNA #1 stated that she had worked with the resident before, but she was not very familiar with the resident. CNA #1 stated that the resident never really got out of bed, but she (CNA) had seen her (resident) by herself. An interview with OS #1 was conducted on 01/08/20 at 12:30 PM. OS #1 stated that she was in her car and getting ready to leave the facility parking lot when she saw Resident #1 on the ground. OS #1 stated no one was with Resident #1, she was by herself. OS #1 stated she immediately assisted by getting out of the car and running to the resident to see if she was ok and calling for help inside of the facility via her personal cell; she did not leave the resident. OS #1 stated that it had to have been around 11:00 or 11:15 AM because she was going shopping for a party at the facility and that as soon as she ensured help and assistance for Resident #1 she left. OS #1 had a receipt which documented the time of check out and gave an approximate estimate of how long Resident #1 was outside, which would have been anywhere from 30 to 45 minutes according to the documentation and interviews. Resident #1's Kardex (used by CNAs) prior to the fall on 12/20/19 was reviewed and documented, .assistive devices: assist bars .be sure call light is in reach .encourage use .non weight bearing right leg per order . On 01/08/20 at 3:30 PM, the administrator, DON and corporate nurse were made aware of the serious concerns regarding the lack of safety and supervision, which resulted in harm to Resident #1. No further information and/or documentation was presented prior to the exit conference on 01/08/20 at 4:00 PM to evidence that the facility staff provided appropriate and adequate supervision for the prevention of an accident, which resulted in actual harm for Resident #1. This is a complaint deficiency.

Based on staff interview, clinical record review and facility document review, the facility staff failed to ensure that one of 16 residents, Resident #7, was free from a significant medication error. During a hospital admission in July 2017, it was determined that Resident #7 who had a history of [REDACTED]. This resulted in altered mental status and hospitalized from [DATE] through 07/11/2017. Resident #7 received IV (intravenous) [MEDICATION NAME] (a medication to replace [MEDICAL CONDITION] hormones) upon admission to the hospital and had improvement in her mental status by the following morning. The lack of [MEDICAL CONDITION] replacement therapy from June 1, 2017 until her hospitalization on [DATE] was identified as harm by the survey team. Findings were: Resident #7 was originally admitted to the facility on [DATE] and was most recently readmitted on [DATE]. Her [DIAGNOSES REDACTED]. The most recent MDS (minimum data set) was quarterly assessment with an ARD (assessment reference date) of 09/21/2017. Resident #7 was assessed as having a cognitive summary score of 15, indicating she was cognitively intact. On 10/31/2017 at approximately 1:00 p.m., this surveyor reviewed Resident #7's clinical record (paper chart). Contained in the clinical record was information from Resident #7's most recent hospitalized from [DATE] through 07/11/2017, including but not limited to hospital discharge summary, hospital course and labs obtained at the hospital. Information on the hospital reports had been highlighted in yellow. The reports were reviewed and the following information was obtained: General Medicine Discharge Summary and Progress Note for 7/11/17 .Principal [DIAGNOSES REDACTED].Additional [DIAGNOSES REDACTED].Grave's Disease s/p (status [REDACTED].Grave's disease s/p [MEDICAL CONDITION] .who presents with altered mental status .On the night of 07/09/2017, the patient's nurse was unable to arouse her to give her PM meds. A blood glucose was 140 at this time. Per staff .the patient can sometimes be difficult to arouse. On the evening of presentation, however, she would not arouse to sternal rub or cold water on her face .ED (emergency department) course: In the ED (resident name) was somnolent, and a clear history was unable to be obtained .A TSH ([MEDICAL CONDITION] stimulating hormone) checked was 162 (normal range is 0.4 - 4.0) and free T 4 level (free [MEDICATION NAME]) was less than 0.4 (normal range is 4.5 -11.2) .The patient was admitted to General Medicine for altered mental status. MICU (medical intensive care unit) was consulted given her profound somnolence, but she was protecting her airway and awoke to sternal rub. Endocrinology was consulted given TSH (140's) and undetectable T 4 out of concern for [MEDICAL CONDITION] coma. She was also noted to be hypercarbic (a condition of abnormally elevated carbon [MEDICATION NAME] levels in the blood) .She was given [MEDICATION NAME] 25 mcg IV and had improvement in her mental status by the following morning Per the patient's SNF (skilled nursing facility), she had not been receiving [MEDICATION NAME] (had fallen off MAR (medication administration record)) .She was restarted on [MEDICATION NAME] 100 mcg every morning at 6 am .Given patient's recovery after resumption of [MEDICATION NAME] and report that she was not on any [MEDICAL CONDITION] replacement at baseline, her symptoms were attributed to [MEDICAL CONDITION]. The patient needs [MEDICAL CONDITION] replacement given her history of [MEDICAL CONDITION] The electronic record was reviewed. The MARs were reviewed from April 2017 through July 2017. In April 2017 the MAR indicated [REDACTED]. The medication was checked off as given every day. The May MAR indicated [REDACTED]. The June MAR indicated [REDACTED]. Further review of the electronic record was conducted. An additional General Discharge Summary and Daily Progress Note from a local hospital was observed. The discharge date was 05/02/2017. The following information was contained within the documentation. Principal [DIAGNOSES REDACTED].bus to go to [MEDICAL TREATMENT] earlier today, when she had a syncopal episode while in [MEDICAL TREATMENT] center waiting room .Hospital Course: (Problem #1) [MEDICAL CONDITION]ly due to polypharmacy and orthostasis improved: .She also had a low AM [MEDICATION NAME] and [MEDICAL CONDITION] studies consistent with [MEDICAL CONDITION] .for which endocrine was consulted. They felt her [MEDICATION NAME] was likely due to [MEDICAL CONDITION] and discovered medication non-compliance at home with [MEDICATION NAME]. After talking with (name of facility) pharmacist, Endocrine discovered patient was documented to be taking her [MEDICATION NAME] as prescribed. Endocrine then recommended increasing [MEDICATION NAME] regimen. Plan: .[MEDICATION NAME] ([MEDICATION NAME]) 100 mcg po daily X 3 days (through 5/4/17), then starting 5/5/17 increase to [MEDICATION NAME] 125 mcg po daily X 4 wks. Follow-up with PCP on Thursday May 4. (Problem #2) [MEDICAL CONDITION] s/p [MEDICAL CONDITION] for Grave's disease tx: 4/29 labs c/w (consistent with) [MEDICAL CONDITION] (TSH 39, free T 4 0.59). Concern that patient was not taking [MEDICATION NAME] 125 mcg daily as prescribed (even while at (name of facility) center). Improvement in blood pressure after restarting [MEDICATION NAME] 50 mg (sic: mcg) daily. Endocrine was consulted, evaluated patient, and agreed that [MEDICATION NAME] levels likely low 2/2 (sic:d/t due to) [MEDICAL CONDITION]. Random [MEDICATION NAME] on admit was 3.2 but follow-up morning [MEDICATION NAME] level returned to 8.2, indicating presentation unlikely due to [MEDICAL CONDITION]. Endocrine confirmed no need for further workup .After talking with (name of facility) pharmacist, Endocrine discovered patient was documented to be taking her [MEDICATION NAME] as prescribed. Endocrine then recommended increasing [MEDICATION NAME]. Plan: [MEDICATION NAME] ([MEDICATION NAME]) 100 mcg po daily X 3 days (thru 5/4/17), then starting 5/5/17 increase to [MEDICATION NAME] 125 mcg po daily X 4 wks. Per endocrine f/u with PCP in 4-6 wks for repeat [MEDICAL CONDITION] studies and titration of [MEDICATION NAME]. Discharge medications were listed and included, but were not limited to: [MEDICATION NAME] 100 mcg .take 1 tablet by mouth daily at 6 am for 2 days .[MEDICATION NAME] 125 mcg .take 1 tablet by mouth daily . There was no stop date on the [MEDICATION NAME]. The physician orders [REDACTED]. The order was dated 05/03/2017, the start date was 05/04/2017 and the end date was 06/01/2017. The physician notes were reviewed. A note written on 06/07/2017 from the nurse practitioner was reviewed and contained the following information: Asked to see -family concerned that she is very lethargic at night .A/P (assessment/plan)- lethargic at night hx of [MEDICAL CONDITION], no changes in meds .[MEDICAL CONDITION]- check TSH -labs @ [MEDICAL TREATMENT] today . The lab section of the clinical record was reviewed There were no TSH or T 4 levels results in the clinical record for June. Within the electronic clinical record was a screen similar to the MAR but dedicated to lab orders only The June lab orders were reviewed. an order for [REDACTED]. All the dates for the month of June had an X marked except for 06/07/2017 and 06/08/2017. Those two dates were blank. The nurse's notes were reviewed for June. There were no entries regarding labs being drawn or attempted to be drawn for Resident #7. The [MEDICAL TREATMENT] records were reviewed. A 6 Month Cumulative Report showing all values for the month was in the clinical record. All labs drawn at the [MEDICAL TREATMENT] center were listed on the report which covered March 2017 through August 2017. There were no results listed for TSH or T 4 levels. The Medication Regimen Review sheet was reviewed. The review for May, dated 05/05/2017, contained the following information: Readmit - 5/3- [MEDICAL CONDITION]/hypothyr .Levo ([MEDICATION NAME]) 125 (mcgs). The June review, dated 6/19/2017, contained the following: Levo DC'd (discontinued) See report for any noted irregularities and/or recommendations. Out to the side in the margin was written TSH. The review for August, dated 08/10/2017, contained the following: Levo 100 (mcgs) added- TSH 162 in hosp At approximately 3:30 p.m., the administrator, the corporate QA nurse, and two corporate nurse consultants were asked to come to the conference room. The above information was presented. Neither the administrator nor the corporate nurse's were aware of any of the above information. They were asked to obtain, if available any TSH or T4 levels obtained for Resident #4 after her [MEDICATION NAME] was stopped. This surveyor also asked how orders were transcribed at the facility. The corporate nurse consultant stated, The nurse's take the orders off of the hospital information, the physician reviews it and signs it. The facility team was asked where the pharmacy recommendations that were referred to on the June review would be located. The corporate nurse consultant stated, That could be a couple of places .it may be scanned in or it may be in the doctor's box. This surveyor requested a copy of the pharmacy recommendations as it was not observed in either the paper record or the electronic record. On 11/01/2017 at approximately 11:45 a.m., one of the corporate nurses came to the conference room and stated, the nurse who took the orders off the chart when (name of resident) was admitted back her in May is no longer working here it doesn't look like the TSH ordered in June was ever obtained. On 11/01/2017 a meeting was held with the DON (director of nursing), the administrator and the corporate nurse consultants. The pharmacy recommendations for Resident #4 were again requested. The DON stated that the recommendations had been missed. Per the DON and the corporate nurse consultants, the recommendations come to the facility via email to the DON the recommendations are then printed out and given to the physician to approve or deny. The recommendations then go to the unit manager. The Consultation Report (pharmacy recommendations) written for Resident #4 on 06/19/2017 were: (Name of Resident) was taking [MEDICATION NAME] 125 mcg qd (everyday) before going out to the hospital. Upon return, the [MEDICATION NAME] was not reordered. Recommendations: Please consider obtaining a TSH Level on the next convenient lab day. On 11/02/2017 at approximately 9:15 a.m., Resident #4's attending physician was interviewed. He was asked about the discontinuation of the [MEDICATION NAME] for Resident #4. He stated, I don't know why the gal put it in like that .I don't scrutinize the orders .I trust the nurse's to write down what the hospital doctors recommend and I trust the hospital doctors to be [MEDICATION NAME] good medicine .I don't go through every single order .I look at insulins and anticoagulants .I didn't specifically look at the [MEDICATION NAME] .she shouldn't have gone without it ([MEDICATION NAME]) .the labs weren't done as I ordered them. The physician was asked how orders at the time of admission were obtained. He stated, The orders are written within twenty-four hours after the resident arrives .sometimes we don't see them for a couple of days later and the medications are started .we have to trust that the hospital is [MEDICATION NAME] good medicine .I expect my orders to be followed .I don't know why the labs weren't done, but that would have certainly identified the problem. The hospital discharge report dated 05/02/2017 was reviewed with the physician. The area under Plan that discussed the discontinuation of the [MEDICATION NAME] after four weeks was pointed out. He stated, I see that, but under the discharge medication orders there is no stop date for the [MEDICATION NAME], that's what the nurse should have gone by. An end of survey meeting was held with the DON, the administrator and the corporate nurse consultants on 11/02/2017 at approximately 10:00 a.m. They were informed that the survey team was looking at possible harm for Resident #4. A copy of the facility policy regarding lab testing and admission orders [REDACTED] The policy Admitting physician's orders [REDACTED]. [REDACTED]. No further information was obtained prior to the exit conference on 11/02/2017.

Based on staff interview, clinical record review and facility document review, the facility staff failed to ensure physician ordered laboratory services were obtained for three of 16 residents, Resident #7, Resident #2 and Resident #3. 1. Resident #7 did not have a physician ordered TSH ([MEDICAL CONDITION] stimulation hormone) level obtained in June. Resident #7, who had a history of [REDACTED]. Failure of the facility to obtain the TSH level resulted in a continued lapse in hormone replacement therapy with subsequent hospitalization for altered mental status from 07/09/2017 through 07/11/2017. This was identified as harm by the survey team. 2. The facility staff failed to obtain a physician ordered TSH level on Resident #2. 3. The facility staff failed to obtain a physician ordered [MEDICATION NAME] level for Resident #3. Findings were: 1. Resident #7 was originally admitted to the facility on [DATE] and was most recently readmitted on [DATE]. Her [DIAGNOSES REDACTED]. The most recent MDS (minimum data set) was quarterly assessment with an ARD (assessment reference date) of 09/21/2017. Resident #7 was assessed as having a cognitive summary score of 15, indicating she was cognitively intact. On 10/31/2017 at approximately 1:00 p.m., this surveyor reviewed Resident #7's clinical record (paper chart). Contained in the clinical record was information from Resident #7's most recent hospitalized from [DATE] through 07/11/2017, including but not limited to hospital discharge summary, hospital course and labs obtained at the hospital. Information on the hospital reports had been highlighted in yellow. The reports were reviewed and the following information was obtained: General Medicine Discharge Summary and Progress Note for 7/11/17 .Principal [DIAGNOSES REDACTED].Additional [DIAGNOSES REDACTED].Grave's Disease s/p (status [REDACTED].Grave's disease s/p [MEDICAL CONDITION] .who presents with altered mental status .On the night of 07/09/2017, the patient's nurse was unable to arouse her to give her PM meds. A blood glucose was 140 at this time. Per staff .the patient can sometimes be difficult to arouse. On the evening of presentation, however, she would not arouse to sternal rub or cold water on her face .ED (emergency department) course: In the ED (resident name) was somnolent, and a clear history was unable to be obtained .A TSH ([MEDICAL CONDITION] stimulating hormone) checked was 162 (normal range is 0.4 - 4.0) and free T 4 level (free [MEDICATION NAME]) was less than 0.4 (normal range is 4.5 - 11.2) .The patient was admitted to General Medicine for altered mental status. MICU (medical intensive care unit) was consulted given her profound somnolence, but she was protecting her airway and awoke to sternal rub. Endocrinology was consulted given TSH (140's) and undetectable T 4 out of concern for [MEDICAL CONDITION] coma. She was also noted to be hypercarbic (condition of abnormally elevated carbon [MEDICATION NAME] levels in the blood) .She was given [MEDICATION NAME] 25 mcg IV and had improvement in her mental status by the following morning Per the patient's SNF (skilled nursing facility), she had not been receiving [MEDICATION NAME] (had fallen off MAR (medication administration record) .She was restarted on [MEDICATION NAME] 100 mcg every morning at 6 am .Given patient's recovery after resumption of [MEDICATION NAME] and report that she was not on any [MEDICAL CONDITION] replacement at baseline, her symptoms were attributed to [MEDICAL CONDITION]. The patient needs [MEDICAL CONDITION] replacement given her history of [MEDICAL CONDITION] The electronic record was reviewed. The MARs were reviewed from April 2017 through July 2017. In April 2017 the MAR indicated [REDACTED]. The medication was checked off as given every day. The May MAR indicated [REDACTED]. The June MAR indicated [REDACTED]. Further review of the electronic record was conducted. An additional General Discharge Summary and Daily Progress Note from a local hospital was observed. The discharge date was 05/02/2017. The following information was contained within the documentation. Principal [DIAGNOSES REDACTED].bus to go to [MEDICAL TREATMENT] earlier today, when she had a syncopal episode while in [MEDICAL TREATMENT] center waiting room .Hospital Course: (Problem #1) [MEDICAL CONDITION]ly due to polypharmacy and orthostasis improved: .She also had a low AM [MEDICATION NAME] and [MEDICAL CONDITION] studies consistent with [MEDICAL CONDITION] .for which endocrine was consulted. They felt her [MEDICATION NAME] was likely due to [MEDICAL CONDITION] and discovered medication non-compliance at home with [MEDICATION NAME]. After talking with (name of facility) pharmacist, Endocrine discovered patient was documented to be taking her [MEDICATION NAME] as prescribed. Endocrine then recommended increasing [MEDICATION NAME] regimen. Plan: .[MEDICATION NAME] ([MEDICATION NAME]) 100 mcg po daily X 3 days (through 5/4/17), then starting 5/5/17 increase to [MEDICATION NAME] 125 mcg po daily X 4 wks. Follow-up with PCP on Thursday May 4. (Problem #2) [MEDICAL CONDITION] s/p [MEDICAL CONDITION] for Grave's disease tx: 4/29 labs c/w (consistent with) [MEDICAL CONDITION] (TSH 39, free T 4 0.59). Concern that patient was not taking [MEDICATION NAME] 125 mcg daily as prescribed (even while at (name of facility) center). Improvement in blood pressure after restarting [MEDICATION NAME] 50 mg (sic: mcg) daily. Endocrine was consulted, evaluated patient, and agreed that [MEDICATION NAME] levels likely low 2/2 (sic:d/t due to) [MEDICAL CONDITION]. Random [MEDICATION NAME] on admit was 3.2 but follow-up morning [MEDICATION NAME] level returned to 8.2, indicating presentation unlikely due to [MEDICAL CONDITION]. Endocrine confirmed no need for further workup .After talking with (name of facility) pharmacist, Endocrine discovered patient was documented to be taking her [MEDICATION NAME] as prescribed. Endocrine then recommended increasing [MEDICATION NAME]. Plan: [MEDICATION NAME] ([MEDICATION NAME]) 100 mcg po daily X 3 days (thru 5/4/17), then starting 5/5/17 increase to [MEDICATION NAME] 125 mcg po daily X 4 wks. Per endocrine f/u with PCP in 4-6 wks for repeat [MEDICAL CONDITION] studies and titration of [MEDICATION NAME]. Discharge medications were listed and included, but were not limited to: [MEDICATION NAME] 100 mcg .take 1 tablet by mouth daily at 6 am for 2 days .[MEDICATION NAME] 125 mcg .take 1 tablet by mouth daily . There was no stop date on the [MEDICATION NAME]. The physician orders [REDACTED]. The order was dated 05/03/2017, the start date was 05/04/2017 and the end date was 06/01/2017. The physician notes were reviewed. A note written on 06/07/2017 from the nurse practitioner was reviewed and contained the following information: Asked to see -family concerned that she is very lethargic at night .A/P (assessment/plan)- lethargic at night hx of [MEDICAL CONDITION], no changes in meds .[MEDICAL CONDITION]- check TSH -labs @ [MEDICAL TREATMENT] today . The lab section of the clinical record was reviewed There were no TSH or T 4 levels results in the clinical record for June. Within the electronic clinical record was a screen similar to the MAR but dedicated to lab orders only The June lab orders were reviewed. an order for [REDACTED]. All the dates for the month of June had an X marked except for 06/07/2017 and 06/08/2017. Those two dates were blank. The nurse's notes were reviewed for June. There were no entries regarding labs being drawn or attempted to be drawn for Resident #7. The [MEDICAL TREATMENT] records were reviewed. A 6 Month Cumulative Report showing all values for the month was in the clinical record. All labs drawn at the [MEDICAL TREATMENT] center were listed on the report which covered March 2017 through August 2017. There were no results listed for TSH or T 4 levels. The Medication Regimen Review sheet was reviewed. The review for May, dated 05/05/2017, contained the following information: Readmit - 5/3- [MEDICAL CONDITION]/hypothyr .Levo ([MEDICATION NAME]) 125 (mcgs). The June review, dated 6/19/2017, contained the following: Levo DC'd (discontinued) See report for any noted irregularities and/or recommendations. Out to the side in the margin was written TSH. The review for August, dated 08/10/2017, contained the following: Levo 100 (mcgs) added- TSH 162 in hosp At approximately 3:30 p.m., the administrator, the corporate QA nurse, and two corporate nurse consultants were asked to come to the conference room. The above information was presented. Neither the administrator nor the corporate nurse's were aware of any of the above information. They were asked to obtain, if available any TSH or T4 levels obtained for Resident #4 after her [MEDICATION NAME] was stopped. This surveyor also asked how orders were transcribed at the facility. The corporate nurse consultant stated, The nurse's take the orders off of the hospital information, the physician reviews it and signs it. The facility team was asked where the pharmacy recommendations that were referred to on the June review would be located. The corporate nurse consultant stated, That could be a couple of places .it may be scanned in or it may be in the doctor's box. This surveyor requested a copy of the pharmacy recommendations as it was not observed in either the paper record or the electronic record. On 11/01/2017 at approximately 11:45 a.m., one of the corporate nurses came to the conference room and stated, the nurse who took the orders off the chart when (name of resident} was admitted back her in May is no longer working here it doesn't look like the TSH ordered in June was ever obtained. On 11/01/2017 a meeting was held with the DON (director of nursing), the administrator and the corporate nurse consultants. The pharmacy recommendations for Resident #4 were again requested. The DON stated that the recommendations had been missed. Per the DON and the corporate nurse consultants, the recommendations come to the facility via email to the DON the recommendations are then printed out and given to the physician to approve or deny. The recommendations then go to the unit manager. The Consultation Report (pharmacy recommendations) written for Resident #4 on 06/19/2017 were: (Name of Resident) was taking [MEDICATION NAME] 125 mcg qd (everyday) before going out to the hospital. Upon return, the [MEDICATION NAME] was not reordered. Recommendations: Please consider obtaining a TSH Level on the next convenient lab day. On 11/02/2017 at approximately 9:15 a.m., Resident #4's attending physician was interviewed. He was asked about the discontinuation of the [MEDICATION NAME] for Resident #4. He stated, I don't know why the gal put it in like that .I don't scrutinize the orders .I trust the nurse's to write down what the hospital doctors recommend and I trust the hospital doctors to be [MEDICATION NAME] good medicine .I don't go through every single order .I look at insulins and anticoagulants .I didn't specifically look at the [MEDICATION NAME] .she shouldn't have gone without it ([MEDICATION NAME]) .the labs weren't done as I ordered them. The physician was asked how orders at the time of admission were obtained. He stated, The orders are written within twenty-four hours after the resident arrives .sometimes we don't see them for a couple of days later and the medications are started .we have to trust that the hospital is [MEDICATION NAME] good medicine .I expect my orders to be followed .I don't know why the labs weren't done, but that would have certainly identified the problem. The hospital discharge report dated 05/02/2017 was reviewed with the physician. The area under Plan that discussed the discontinuation of the [MEDICATION NAME] after four weeks was pointed out. He stated, I see that, but under the discharge medication orders there is no stop date for the [MEDICATION NAME], that's what the nurse should have gone by. An end of survey meeting was held with the DON, the administrator and the corporate nurse consultants on 11/02/2017 at approximately 10:00 a.m. They were informed that the survey team was looking at possible harm for Resident #4. A copy of the facility policy regarding lab testing was requested. The facility policy, Laboratory/Diagnostic Testing, included the following: A licensed nurse will monitor and track all physician or physician extender ordered laboratory, radiology, and other diagnostic tests; ensure that tests are complete as ordered and communicate results to the physician or the physician extender. No further information was obtained prior to the exit conference on 11/02/2017. 2. The facility staff failed to obtain a TSH ([MEDICAL CONDITION] stimulating hormone) level on Resident # 2, as ordered by the physician. Resident #2 was admitted to the facility on [DATE] originally, with the most current readmission on 09/19/17. [DIAGNOSES REDACTED]. The most current MDS (minimum data set), a significant change assessment dated [DATE] assessed the resident as having a cognitive score of 7, indicating the resident had severe impairment in daily decision making skills. This MDS also assessed the resident as requiring extensive to total assistance for most ADL's (activities of daily living). A quarterly MDS assessment, dated 04/26/17 was reviewed for comparison. This MDS assessed the resident as having a cognitive score of 1, indicating the resident had severe impairment in daily decision making skills. This MDS also assessed the resident as requiring extensive to total assistance for most ADL's (activities of daily living). During clinical record review 10/31/17 and 11/01/17, a nursing note dated 12/12/16 documented, that the resident's TSH was drawn and was 0.053. The resident's lab results were reviewed and documented the value above, as L (LOW). The TSH lab range on was listed as 0.270-4.200. The resident's [MEDICAL CONDITION] medication was adjusted and an order was written to obtain another TSH on 01/23/17. This TSH lab could not be found. an order for [REDACTED]. This TSH lab could not be located. an order for [REDACTED]. an order for [REDACTED]. Again the resident's [MEDICAL CONDITION] medication was adjusted and another TSH level was ordered for 09/06/17. This TSH lab level could not be located. Resident #2's current CCP (comprehensive care plan) was reviewed. The resident's CCP documented, .lab work as ordered .Give [MEDICAL CONDITION] replacement therapy as ordered . On 11/01/17 at approximately 1:15 p.m., administrator and administrative staff # 3 and # 4 were made aware of the above concerns in a meeting with the survey team. The staff were asked if they could locate the missing labs for Resident # 2. On 11/02/17 at 7:55 a.m., administrative staff # 3 stated, As far as the labs, we don't have anything. The staff member was asked if there was a policy on how the lab process should be done to ensure lab tests are not missed. The admin staff stated, they would get the policy. The policy was presented a short time later. The policy titled, Laboratory/Diagnostic Testing documented, .nurse will obtain laboratory .or other diagnostic services to meet the needs of its patients as ordered by the physician .nurse will monitor and track all physician .ordered laboratory .tests; ensure that test are complete as ordered and communicate results to the physician in a timely manner . No further information and/or documentation was presented prior to the exit conference on 11/02/17. 3. The facility staff failed to obtain a laboratory test for a [MEDICATION NAME] level for Resident # 3. Resident # 3 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The most current MDS (minimum data set) was a significant change assessment dated [DATE], which assessed the resident as having cognitive score of 10, indicating the resident had moderate impairment in daily decision making skills. During clinical record review on 10/31/17 and 11/01/17, Resident # 3's physician's orders [REDACTED]. Resident # 3's [MEDICATION NAME] labs were reviewed. [MEDICATION NAME] levels for Resident # 3 could not be located for the week of 02/20/17 and 03/06/17. No [MEDICATION NAME] levels could be located from 03/20/17 through 06/26/17. Further review of the clinical record revealed a physician's orders [REDACTED]. A one time order for a [MEDICATION NAME] level was ordered on [DATE] and 06/07/17, which neither were completed. An order was again put into the system for weekly [MEDICATION NAME] levels on 06/19/17, after this order was put in a [MEDICATION NAME] level was drawn on 06/26/17, 10/02/17 and 10/18/17. The resident's CCP (comprehensive care plan) was reviewed and documented, .[MEDICAL CONDITION] disorder related to disease process and history of [MEDICAL CONDITION] and [MEDICAL CONDITION] .give medications as ordered .monitor labs as ordered . On 11/01/17 at approximately 1:15 p.m., administrator and administrative staff # 3 and # 4 were made aware of the above concerns in a meeting with the survey team. The staff were asked if they could locate the missing labs for Resident # 3. On 11/02/17 at 7:55 a.m., administrative staff # 3 stated, As far as the labs, we don't have anything. The staff member was asked if there was a policy on how the lab process should be done to ensure lab tests are not missed. The admin staff stated, they would get the policy. The policy was presented a short time later. The policy titled, Laboratory/Diagnostic Testing documented, .nurse will obtain laboratory .or other diagnostic services to meet the needs of its patients as ordered by the physician .nurse will monitor and track all physician .ordered laboratory .tests; ensure that test are complete as ordered and communicate results to the physician in a timely manner . Concerns were again raised regarding the above information in a meeting with the administrator, DON (director of nursing) and the admin staff # 3 and # 4, that this resident had not been having [MEDICATION NAME] levels completed as ordered by the physician for an extended amount of time and that this resident had a history of [REDACTED]. No further information and/or documentation was presented prior to the exit conference on 11/02/17 at 11:00 a.m.

Based on resident interview, family interview, staff interview, clinical record review, and during the course of a complaint investigation, the facility staff failed to ensure physician's orders for immediate care for one of 25 residents was provided, resulting in harm for Resident # 14. The facility staff failed to provide immediate care orders for Resident # 14 regarding [MEDICAL CONDITION]; a [DIAGNOSES REDACTED]. Findings include: Resident # 14 was admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. The most current full MDS (minimum data set), with CAAS (care area assessment summary) was an admission assessment dated [DATE]. This MDS assessed the resident with a cognitive score of "15", which indicated the resident was cognitively intact. The resident was also assessed on this MDS as requiring supervision with assistance from one staff member for most ADL's, including transfers, ambulation, and hygiene. Resident # 14's clinical record was reviewed and revealed the resident's hospital records prior to admission to the nursing facility. The resident's hospital ED (emergency department) notes were reviewed and documented: "...(Name of Resident # 14) ...with a PMH (past medical history) of [MEDICAL CONDITION]: [MEDICAL CONDITION] medications: [REDACTED] The resident's hospital discharge summary was reviewed and documented: "DISCHARGE SUMMARY admitted : [DATE] discharge date : [DATE]...Hospital Course: (Name of Resident # 14) with [MEDICAL CONDITION] went well without complications...discharged in stable condition...Plan of treatment after discharge: ...Discharge medications: [REDACTED]" Resident # 14's progress notes were reviewed from [DATE] (date of admission) through [DATE] (date of discharge). The progress notes documented the following: [DATE] (1:16 a.m.)-"Resident alert & oriented times 4...no neurological impairment noted..." [DATE] (4:32 p.m.)-"...verbal cues for energy conservation...with mild fatigue post session..." [DATE] (3:55 p.m.)-"...Patient stating that she felt a bit more tired today than previously..." [DATE] (4:07 p.m.)-"...mild complaints of fatigues..." [DATE] (11:10 a.m.)-"...patient complained of feeling sluggish all morning and not being able to wake up...patient stating she had just never gotten rid of logy feeling..." [DATE] (11:12 a.m.)-"...admitted with a non-healing surgical [MEDICAL CONDITION]" [DATE] (2:04 p.m.)-"Patient discovered that she is not getting her [MEDICAL CONDITION] replacement meds and that would explain the...lethargy she feels and this writer was aware yesterday...Patient with complaints of fatigue and returning to room to rest..." [DATE] (5:07 p.m.)-"Patient discovered that she is not getting her [MEDICAL CONDITION] meds and apologizes for not being able to engage in full session of rehab due to increased concern and anxiety. Nursing is aware and providing care for patient...focus on energy conservation...as patient was feeling "low" today...Patient stating that PT (physical therapy) was the part of the day she most looks forward to and again apologizes for not being able to complete session..." [DATE] (6:45 a.m.)-"...Resident voiced "she will feel better as soon as she gets her [MEDICAL CONDITION] under control"..." [DATE] (10:09 a.m.)-"...Patient stating that she woke up in a sweat this AM and still did not feel her self or energetic..." [DATE] (1:55 p.m.)-"Patient seen in PM for There ex but still fatiguing easily...tiring easily..." [DATE] (12:15 p.m.)-"...Patient stating [MEDICAL CONDITION] meds had been doubled, but she was not feeling any peppier (sic)...tiring and sitting..." [DATE] (12:20 p.m.)-"...weekly summary...patient fatiguing associated with cessation of [MEDICAL CONDITION] meds status [REDACTED]. [DATE] (6:00 p.m.)-"...discontinue summary...patient fatiguing associated with cessation of [MEDICAL CONDITION] meds status [REDACTED]. Resident # 14's physician's admission orders [REDACTED]. New orders were written for the resident's [MEDICATION NAME] on [DATE] by the nurse practitioner (9 days after admission), after the resident discovered and informed the facility staff she had not been getting her daily dose of [MEDICATION NAME]. Resident # 14 did not receive her regularly scheduled daily dose of [MEDICATION NAME] for a total nine days, as a result the resident became lethargic with low energy levels and was unable to completely participate in physical therapy; the resident also became "jittery" and anxious, resulting in the facility prescribing [MEDICATION NAME] ( a benzodiapine) in attempt to manage the side effects of the resident not having her regularly daily dose of [MEDICATION NAME]. A physician's progress note dated [DATE] documented that the physician was aware that the resident had a history of [REDACTED]. The progress note did not address medications/laboratory testing or specific care instructions relating to Resident # 14's [MEDICAL CONDITION] or the care and services to be provided for the resident's chronic condition. A physician's progress note dated [DATE] documented: "...doing [MEDICAL CONDITION]-[MEDICATION NAME] had not been ordered, start now-obtain TSH level..." A physician's progress note dated [DATE] documented that the resident was feeling "weak" and feeling anxious and that the resident was now back on [MEDICATION NAME]. The note also documented that with a TSH this high, the resident "likely must not have had it" for awhile or it (medication) was "unfortunately" missed. On [DATE] at approximately 9:30 a.m., the resident's daughter was interviewed and stated that her mother had become less cognitive while off of the [MEDICATION NAME], stating having difficulty concentrating. The daughter also stated that her mother was on the medication while at the hospital prior to admission to the nursing facility. Additionally, the daughter stated that the facility had put her mother on [MEDICATION NAME] to try to manage the effects of doing without the [MEDICATION NAME]. At approximately 9:45 a.m., Resident # 14 was interviewed. Resident # 14 stated that she had been taking [MEDICATION NAME] daily for over [AGE] years and that her TSH "was enormous." The resident also stated, "I could have died -you can't live without a [MEDICAL CONDITION]" The resident stated that she become nervous and anxious, "jittery" while off of her [MEDICATION NAME] and they gave me [MEDICATION NAME] to help with that. At approximately 2:10 p.m. on [DATE], CS (Corporate Staff) # 6 was interviewed regarding the above. CS # 6 was informed that the resident had not been ordered her [MEDICATION NAME] upon admission and went without it for 9 days. CS # 6 stated that the physician must not have wanted the resident to have the it, because what was ordered was signed for by the physician. CS # 6 was made aware that the physician did not sign the admission orders [REDACTED]. CS # 6 was asked about the admission process in general and was asked if the facility has any type of check to ensure that resident's are receiving the correct medications, care and services, as intended by the physician. CS # 6 stated, "No." Any additional information/documentation regarding the above was requested at this time. Resident # 14's CCP (comprehensive care plan) was reviewed and documented: "...Pain...encourage anxiety reducing activities...Fall...Remind resident to rise slowly to prevent dizziness and/or [MEDICAL CONDITION], Observe for adverse reaction to medications (dizziness, drowsiness, orthostatic [MEDICAL CONDITION], changes in behavior...etc.) and report..." The CCP for Resident # 14 had no documentation whatsoever regarding the resident's [DIAGNOSES REDACTED]. The administrative staff were asked for assistance in locating any additional information at this time, to evidence that Resident # 14's admission orders [REDACTED]. On [DATE] at approximately 3:30 p.m., the administrator, DON (director of nursing), and nurse consultants were, again made aware the allegations and concerns regarding Resident # 14. CS # 6 stated that no other documentation or information could be found. No further information or documentation was provided prior to the exit conference on [DATE] at 7:30 p.m. THIS IS A COMPLAINT DEFICIENCY.

Based on resident interview, family interview, staff interview, clinical record review, and during the course of a complaint investigation, the facility staff failed to ensure one of 25 residents was free of a significant medication error, resulting in harm for Resident # 14. The facility staff failed to administer [MEDICATION NAME] 100 mcg (micrograms) to Resident # 14 for 9 days. Resident # 14 had a history of [REDACTED].# 14 became symptomatic and a TSH ([MEDICAL CONDITION] stimulating hormone) laboratory test result showed Resident #14 had an abnormally high TSH level at 60.140. The normal reference range is 0XXX,[DATE].200. Findings include: Resident # 14 was admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. The most current full MDS (minimum data set), with CAAS (care area assessment summary) was an admission assessment dated [DATE]. This MDS assessed the resident with a cognitive score of "15", which indicated the resident was cognitively intact. The resident was also assessed on this MDS as requiring supervision with assistance from one staff member for most ADL's, including transfers, ambulation, and hygiene. Resident # 14's clinical record was reviewed and revealed the resident's hospital records prior to admission to the nursing facility. The resident's hospital ED (emergency department) notes were reviewed and documented: "...(Name of Resident # 14) ...with a PMH (past medical history) of [MEDICAL CONDITION]: [MEDICAL CONDITION] medications: [REDACTED]" The resident's hospital discharge summary was reviewed and documented: "DISCHARGE SUMMARY admitted : [DATE] discharge date : [DATE]...Hospital Course: (Name of Resident # 14) with [MEDICAL CONDITION] went well without complications...discharged in stable condition...Plan of treatment after discharge: ...Discharge medications: [REDACTED]" Resident # 14's progress notes were reviewed from [DATE] (date of admission) through [DATE] (date of discharge). The progress notes documented: [DATE] (1:16 a.m.)-"Resident alert & oriented times 4...no neurological impairment noted..." [DATE] (4:32 p.m.)-"...verbal cues for energy conservation...with mild fatigue post session..." [DATE] (3:55 p.m.)-"...Patient stating that she felt a bit more tired today than previously..." [DATE] (4:07 p.m.)-"...mild complaints of fatigues..." [DATE] (11:10 a.m.)-"...patient complained of feeling sluggish all morning and not being able to wake up...patient stating she had just never gotten rid of logy feeling..." [DATE] (11:12 a.m.)-"...admitted with a non-healing surgical [MEDICAL CONDITION]" [DATE] (2:04 p.m.)-"Patient discovered that she is not getting her [MEDICAL CONDITION] replacement meds and that would explain the...lethargy she feels and this writer was aware yesterday...Patient with complaints of fatigue and returning to room to rest..." [DATE] (5:07 p.m.)-"Patient discovered that she is not getting her [MEDICAL CONDITION] meds and apologizes for not being able to engage in full session of rehab due to increased concern and anxiety. Nursing is aware and providing care for patient...focus on energy conservation...as patient was feeling "low" today...Patient stating that PT (physical therapy) was the part of the day she most looks forward to and again apologizes for not being able to complete session..." [DATE] (6:45 a.m.)-"...Resident voiced "she will feel better as soon as she gets her [MEDICAL CONDITION] under control"..." [DATE] (10:09 a.m.)-"...Patient stating that she woke up in a sweat this AM and still did not feel her self or energetic..." [DATE] (1:55 p.m.)-"Patient seen in PM for There ex but still fatiguing easily...tiring easily..." [DATE] (4:54 p.m.)-"...prn (as needed) dose of [MEDICATION NAME], stated she was feeling nervous and anxious..felt like she needed a nap more relaxed..." [DATE] (3:35 p.m.)-"LATE ENTRY for [DATE]...medicated with prn [MEDICATION NAME] ,[DATE]...feeling jittery/anxious..." [DATE] (3:40 p.m.)-"...medicated with prn [MEDICATION NAME] x 2 (twice) due to feeling anxious..." [DATE] (12:15 p.m.)-"...Patient stating [MEDICAL CONDITION] meds had been doubled, but she was not feeling any peppier (sic)...tiring and sitting..." [DATE] (12:20 p.m.)-"...weekly summary...patient fatiguing associated with cessation of [MEDICAL CONDITION] meds status [REDACTED]. [DATE] (5:19 p.m.)-"...received report from ,[DATE] nurse that patient had left for an appointment, later the patients daughter came in to collect her mothers belongings and to have patient discharged home, patient discharged from facility at 11:00 a.m. to go home..." [DATE] (6:00 p.m.)-"...discontinue summary...patient fatiguing associated with cessation of [MEDICAL CONDITION] meds status [REDACTED]. Resident # 14's physician's admission orders [REDACTED]. The following was revealed. 1. "{START [DATE] (entered on [DATE] at 9:40 a.m.)}- [MEDICATION NAME] 100 mcg tablet 1 tab by mouth daily Daily 6:30 a.m. {END [DATE] D/C-CHANGE}" 2. "{START [DATE] (entered on [DATE] at 8:30 a.m.)}-[MEDICATION NAME] 100 mcg tablet 1 tab by mouth 1 X (time) order now for 1 day Daily 6:30 a.m. {END [DATE] EXPIRED}" 3. "{START [DATE] (entered on [DATE] at 8:34 a.m.)-[MEDICATION NAME] 150 mcg tablet 1 tablet by mouth Daily 6:30 a.m. {END [DATE] EXPIRED}" 4. "{START [DATE] (entered on [DATE] at 8:38 a.m.)-[MEDICATION NAME] 100 mcg tablet 1 tablet by mouth Daily 6:30 a.m. {[DATE] ACTIVE New Order}" A TSH ([MEDICAL CONDITION] stimulating hormone) laboratory test was collected and received on [DATE] for Resident # 14. The lab result was abnormally high at: 69.080 , the normal reference range: 0XXX,[DATE].200 . Resident # 14's MAR's (medication administration records) were reviewed from admission ([DATE]) through discharge ([DATE]). Resident # 14 was administered two doses of [MEDICATION NAME] 100 mcg on [DATE]. The total amount of [MEDICATION NAME] administered on [DATE] was 200 mcg. Resident # 14 then received [MEDICATION NAME] 150 mcg on September the 5th, 6th, 7th, 8th, and 9th. Another TSH ([MEDICAL CONDITION] stimulating hormone) laboratory test was collected and received on [DATE] for Resident # 14. The lab result was abnormally high at: 60.140, the normal reference range: 0XXX,[DATE].200 . Resident # 14 did not receive her regularly scheduled daily dose of [MEDICATION NAME] for a total nine days, as a result the resident became lethargic with low energy levels and was unable to completely participate in physical therapy; the resident also became "jittery" and anxious, resulting in the facility prescribing [MEDICATION NAME] (a benzodiazepine) in attempt to manage the side effects of the resident not having her regularly daily dose of [MEDICATION NAME]. A physician's progress note dated [DATE] documented that the physician was aware that the resident had a history of [REDACTED]. A physician's progress note dated [DATE] documented: "...doing [MEDICAL CONDITION]-[MEDICATION NAME] had not been ordered, start now-obtain TSH level..." A physician's progress note dated [DATE] documented that the resident was feeling "weak" and feeling anxious and that the resident was now back on [MEDICATION NAME]. The note also documented that with a TSH this high, the resident "likely must not have had it for awhile" or was "unfortunately" missed. On [DATE] at approximately 9:30 a.m., the resident's daughter was interviewed and stated that her mother had become less cognitive while off of her medication. The daughter also stated that her mother was on the medication while at the hospital prior to admission to the nursing facility. Additionally, the daughter stated that the facility had put her mother on [MEDICATION NAME] to try to manage the effects of doing without the [MEDICATION NAME]. At approximately 9:45 a.m., Resident # 14 was interviewed. Resident # 14 stated that she had been taking [MEDICATION NAME] daily for over [AGE] years and that her TSH "was enormous." The resident also stated, "I could have died -you can't live without a [MEDICAL CONDITION]" On [DATE] at approximately 1:40 p.m., RN (Registered Nurse) # 4 was interviewed on the facility's process for accepting patients from the hospital, specifically regarding making sure the resident gets the prescribed medications. RN # 4 presented a packet with multiple forms and stated that when they (residents) get here, they will either have a discharge summary or one is faxed to the facility and the discharge summary contains the orders. The nurse then calls the Dr. to confirm which medications are to be ordered and then they are entered into the computer. RN # 4 stated that nothing is written or checked off, it's just put into the computer. The RN also stated that after that the Dr. will come in and sign the orders. RN # 4 was asked if there is a check of some sort to ensure that the right medications are entered and ordered correctly. The RN stated that we (the facility) have a check list, that we go through called the 24 hour audit. RN # 4 stated that "ideally" what should happen is the nurse, should call the Dr. go through all the orders, write a verbal order "saying approved", then write a nursing notes confirming that. The RN was made aware that an admission/nursing assessment form had been completed for Resident # 14, but did not have any information whatsoever regarding Resident # 14's medications. The RN was also made aware that the first nursing note written on Resident # 14 was on [DATE] at 1:16 a.m. in the morning and was basically an admission assessment; nothing related to contacting the resident's physician and nothing related to the resident's medications. At approximately 2:10 p.m., CS (Corporate Staff) # 6 was interviewed regarding the above. CS # 6 was shown the 24 audit check list that RN # 4 was referring to and was made aware at that time, that Resident # 14's could not be located in the clinical record. CS # 6 was asked for assistance in locating it. CS # 6 stated, "That's not an official (initials of facility) form." CS # 6 was asked if the facility had a check to ensure that medications do not get missed. CS # 6 stated, "No." CS # 6 was asked if a nursing note should be written showing that the nurse had in fact spoke with the physician regarding the medications. CS # 6 stated, "...not necessarily" and further commented that the Dr. must have approved the medications, because he had signed the POS (physician's orders [REDACTED].# 6 was informed that although, the physician wrote a progress note dated [DATE] (the day after admission), there was no signature on the POS and that the physician's electronic signature was dated [DATE] (timed after 1:15 p.m.), the date that Resident # 14 was discharged (resident discharged at approximately 11:00 a.m.) CS # 6 and CS # 3 were informed at this time that this was a complaint investigation and that allegations were going to be substantiated unless the facility had additional information to evidence otherwise. The staff were made aware of the serious concerns of the resident not getting her regularly daily medication while at the facility and the fact that the resident had a decline in condition, as a result. Resident # 14's CCP (comprehensive care plan) was reviewed and documented: "...Pain...encourage anxiety reducing activities...Fall...Remind resident to rise slowly to prevent dizziness and/or [MEDICAL CONDITION], Observe for adverse reaction to medications (dizziness, drowsiness, orthostatic [MEDICAL CONDITION], changes in behavior...etc.) and report..." The CCP for Resident # 14 had not documentation whatsoever regarding the resident's [DIAGNOSES REDACTED]. The administrative staff were asked for assistance in locating any additional information at this time, to evidence that Resident # 14 was not suppose get the regularly scheduled daily dose of [MEDICATION NAME]. On [DATE] at approximately 3:30 p.m., the administrator, DON (director of nursing), and nurse consultants were made aware of the concerns regarding Resident # 14. CS # 6 stated that no other documentation or information could be found. No further information or documentation was provided prior to the exit conference on [DATE] at 7:30 p.m. THIS IS A COMPLAINT DEFICIENCY.