Every finding on record at Colonnades Health Care Center

Based on observation, resident interview, staff interviews, clinical record review, and facility documentation review, the facility staff failed to ensure the environment was free of accident hazards and failed to assess residents to determine who was at risk, having the potential to affect multiple residents on one of one nursing units. Two residents (Resident #105 and Resident #109) spilled coffee onto their lap, which resulted in R105 requiring first aide intervention, which constituted harm. Immediate Jeopardy (IJ) and substandard care was identified. Once IJ was abated, the scope and severity was lowered to a level three, isolated. The findings included: For all of the residents residing on the one nursing unit in the facility, the facility staff had not assessed the residents ability to manage hot liquids, when hot coffee was available and accessible to residents in the lobby, and the facility failed to maintain a consistent system in place to monitor temperatures of hot liquids being served in the dining room, which resulted in two residents spilling coffee and one resident (Resident #105) sustaining redness that required first aide treatment. On 1/7/25 at 2:30 p.m., during a review of facility documentation, it was noted that on 12/22/24, Resident #105 (R105) spilled hot coffee onto her lap, which required medical treatment to include first aide (application of cold compress). According to the nursing note dated 12/22/24 at 12:37 p.m., it read, It was reported to writer that patient spilled hot coffee on her lap during lunch. Assessed guest skin and redness noted to thighs. Cold compress applied. Resident denies pain/discomfort when asked. Resident's son [name redacted] notified and Dr. [physician's name redacted] is made aware. Will continue to assess patient for any blister s/sx [signs and symptoms] of skin irritation. Patient is now to have cup with lid for all meals. According to R105's physician orders, the physician ordered occupational therapy to evaluate for upper extremity strengthening. On 12/24/24, occupational therapy (OT) initiated therapy for R105 to work on self-feeding and alternate cup options. According to a dietary employee (Other Employee #2-OE2), the dietary manager (Other Employee #6-OE6) and a registered nurse (RN #3), R105 had been previously identified with issues/concerns in her ability to feed herself. According to the dietary manager/OE6 and R105's clinical record, the previously identified concern prompted on 8/10/24, a physician order that R105 was to have light weight mugs at meals. On 1/7/25 at 2:40 p.m., an observation was conducted of the kitchenette where the coffee is prepared. The dietary aide (other employee #1- OE1) said that the coffee temperature is checked once it's prepared, but they let the coffee sit and cool down before serving it. The dietary aide also stated that sometimes ice must be added, prior to serving. As requested, the dietary aide measured the temperature of the coffee from the dispensing machine, and it was observed that the temperature measured 173 degrees Fahrenheit. The dietary aide then said that the service technician had just come and turned it down, as it previously was around 179 degrees. According to the meal service temperature logs from 12/30/24-1/7/25, there were multiple omissions that demonstrated that the temperature of the hot liquids was not recorded during each meal. When questioned about the prior temperature logs on 1/8/25, the dietary manager and dining director stated that the prior monitoring form did not include beverages, and they had not been recording or monitoring the temperature of hot liquids. On 1/8/25, approximately 8:15 am, an interview with a licensed practical nurse (LPN #2), it was identified that Resident #109 had also had an incident where she spilled coffee. Review of the clinical record revealed that on 12/27/24, R109 spilled lukewarm coffee into her lap and sustained no injury. On 1/8/25, interviews were conducted with LPN #2 and a certified nursing assistant (CNA #1), both of whom stated that if residents want coffee between meals, they obtain it from the lobby coffee station. On 1/8/25 at approximately 8:50 a.m., the dietary manager measured the temperature of the coffee in the lobby, which was noted to be 156 degrees Fahrenheit. On 1/8/25 at 3:20 p.m., an interview was conducted with two dietary staff (OE#1 and OE #2). Both of whom stated when they arrive, they obtain coffee from the coffee machine, fill the coffee dispensers, and take them to the front lobby around 7:30 a.m. Both dietary staff stated that they do not take the temperature of the coffee that is placed in the lobby, and it is not cooled down prior to placing in the lobby. At this time, the temperature of the coffee was again obtained, directly from the coffee machine as it would be put into the dispensers in the lobby and was measured at 165 degrees Fahrenheit. Both the dietary aides and dietary managers confirmed that the repair technician was onsite and had decreased the temperature of the machine on 1/7/25. On the afternoon of 1/8/25, an interview was conducted with the facility's interim administrator, interim Director of Nursing (DON), and general manager, to identify the facility response to the spilled coffee incidents. The facility DON reported that they had initiated a PIP (performance improvement plan) which included that all residents with a BIMs (brief interview for mental status score) of 12 or less, and those who are visually impaired, were evaluated by therapy for hot liquids and were actively working to develop an assessment tool to be used to assess resident's ability to safely manage hot liquids. The DON stated that the PIP was still in process and had not been completed. On 1/8/25, in the afternoon, an interview was conducted with the therapy director (Other Employee #9- OE #9). As of 1/8/25, there were three residents with a BIMs of 12 or less, that had not yet been evaluated for their ability to handle hot liquids safely. There was no evidence that the facility made any attempt to identify residents at risk with causative factors, other than cognitive or visual impairments, were evaluated for their ability to manage hot liquids safely. On 1/8/25 at 5:15 p.m., Immediate Jeopardy was identified and was noted to have begun on 12/22/2024, when R105 spilled her coffee, and first aid had to be provided. A meeting was held with the facility's interim administrator, interim director of nursing, and general manager to notify of the immediate jeopardy. On 1/8/25 at 7:40 p.m., the facility submitted an accepted IJ removal plan. The plan read as follows: Residents #105 and #109 were assessed for hot liquid safety and referred to Occupational Therapy. On 1/8/25 the Director of Nursing will conduct an assessment of all current residents for accident hazards such as risk of burns from hot liquids. Residents identified at risk; nursing will initiate a care plan with interventions to mitigate hazards such as risk of burns from hot liquids. Residents identified at risk will be evaluated by occupational therapy. Director of Nursing will educate all current team members on hazards such as the risk of burns from hot liquids and appropriate serving temperature prior to being permitted to work. Dietary manager will educate dietary team members on the importance of completing and documenting temperatures on hot liquids during each meal prior to being permitted to work. New admissions will be assessed for hazards such as risk of burns from hot liquids, with interventions initiated and a referral to occupational therapy. Hot beverage station located at the concierge's desk will be removed. Any concerns identified will be addressed as per our policy and procedures. Completion Date: 1/9/25 11:00 a.m. On 1/9/25 at 11:05 a.m., interviews were conducted with both certified nursing assistants (CNA #1 and CNA #2) working, the licensed practical nurse (LPN #2), a registered nurse (RN #3), the activity assistant, a housekeeper, the medical records employee, two therapy staff, and the two dietary employees. Each of the employees were able to verify they had received education and were able to answer questions with regards to the serving temperature of hot liquids, how to obtain coffee for a resident outside of mealtimes, and how to know what precautions had to be taken for residents identified to be at risk for burns from hot liquids. The two nurses were also able to verbalize knowledge of when and how the assessment of residents with regards to hot liquids would be completed. An audit was conducted which included comparison of the daily census, to ensure that 100% of residents had been screened/assessed for the risk of injury from hot liquids. The care plan was reviewed for the eleven residents identified to be at risk to ensure interventions had been implemented in the care plan. The therapy evaluation for each of the eleven residents noted to be at risk was reviewed to ensure that therapy had assessed the residents. The staff education was reviewed and the sign in sheet was compared to the as worked schedule to ensure that all staff were trained. Interviews were conducted with various staff to confirm they received education and had knowledge of the risks, interventions, etc. The education for the dietary staff was reviewed and compared to the as worked schedule to ensure that the dietary staff working had been educated. The temperature logs for breakfast were reviewed to ensure that that temperatures had been taken and were noted to be in the facility's acceptable serving range of 140-155 degrees Farenheight. The dietary staff were then interviewed to confirm receipt of the education and to verify their knowledge of the risk, importance of ensuring appropriate temperatures and the interventions for residents identified to be at risk. The census was reviewed to identify if any new admissions had been admitted since IJ was identified. No admissions had been received at the facility. On 1/9/25 at 12:10 p.m., observations were conducted in the kitchenette. Dietary staff were observed to obtain the temperature of all food items to include hot water and coffee. All temperatures were verified by the surveyor to ensure they were within appropriate serving temperature. Observations were conducted of the entire meal delivery to residents in the dining room. It was noted that none of the residents in the dining room received any hot liquids. The meal set-up and delivery of meals to residents eating in their rooms was observed. It was noted that Resident #106 (R106) was served hot coffee in a disposable cup with a lid. According to R106's meal ticket which was on the tray and accompanied the food into the resident's room was observed and was noted to read, . Preferences: Handled cup & lid for hot [NAME] [beverage] . At 1:30 p.m., R106 was served the meal which included the coffee in the disposable cup. The surveyor then returned to the Administrator's office, reviewed R106's hot liquid assessment which indicated that the resident was at risk and the care plan intervention read, Handled cup with lid for hot beverages. The facility administrator and director of nursing services (DON) were asked to accompany the surveyor to R106's room. The surveyor notified them of the observations and findings. The DON then entered R106's room and confirmed the observation. The facility administrator and DON were made aware at 1:40 p.m., they had been unable to abate IJ. The facility then presented the surveyor with notification that they had re-educated all the staff and were ready for the surveyor to attempt to verify IJ removal as of 3 p.m. on 1/9/25. On 1/9/25 at the evening meal, observations were again made. The observations included dietary staff obtaining temperatures of the foods and hot liquids and verification that they were within appropriate temperature for service. The dietary staff were observed to record the temperatures obtained. Meal service/delivery to residents was observed. One resident, R106 received coffee at the meal, and it was served in a mug with a handle and a lid. IJ was abated at 5:40 p.m. on 1/9/25, and the scope and severity was lowered to a level three, isolated. No additional information was provided.

Based on observation, resident interview, staff interviews, clinical record review, and facility documentation review, the facility staff failed to ensure the environment was free of accident hazards and failed to assess residents to determine who was at risk, having the potential to affect multiple residents on one of one nursing units. Two residents (Resident #105 and Resident #109) spilled coffee onto their lap, which resulted in R105 requiring first aide intervention, which constituted harm. Immediate Jeopardy (IJ) and substandard care was identified. Once IJ was abated, the scope and severity was lowered to a level three, isolated. The findings included: For all of the residents residing on the one nursing unit in the facility, the facility staff had not assessed the residents ability to manage hot liquids, when hot coffee was available and accessible to residents in the lobby, and the facility failed to maintain a consistent system in place to monitor temperatures of hot liquids being served in the dining room, which resulted in two residents spilling coffee and one resident (Resident #105) sustaining redness that required first aide treatment. On 1/7/25 at 2:30 p.m., during a review of facility documentation, it was noted that on 12/22/24, Resident #105 (R105) spilled hot coffee onto her lap, which required medical treatment to include first aide (application of cold compress). According to the nursing note dated 12/22/24 at 12:37 p.m., it read, It was reported to writer that patient spilled hot coffee on her lap during lunch. Assessed guest skin and redness noted to thighs. Cold compress applied. Resident denies pain/discomfort when asked. Resident's son [name redacted] notified and Dr. [physician's name redacted] is made aware. Will continue to assess patient for any blister s/sx [signs and symptoms] of skin irritation. Patient is now to have cup with lid for all meals. According to R105's physician orders, the physician ordered occupational therapy to evaluate for upper extremity strengthening. On 12/24/24, occupational therapy (OT) initiated therapy for R105 to work on self-feeding and alternate cup options. According to a dietary employee (Other Employee #2-OE2), the dietary manager (Other Employee #6-OE6) and a registered nurse (RN #3), R105 had been previously identified with issues/concerns in her ability to feed herself. According to the dietary manager/OE6 and R105's clinical record, the previously identified concern prompted on 8/10/24, a physician order that R105 was to have light weight mugs at meals. On 1/7/25 at 2:40 p.m., an observation was conducted of the kitchenette where the coffee is prepared. The dietary aide (other employee #1- OE1) said that the coffee temperature is checked once it's prepared, but they let the coffee sit and cool down before serving it. The dietary aide also stated that sometimes ice must be added, prior to serving. As requested, the dietary aide measured the temperature of the coffee from the dispensing machine, and it was observed that the temperature measured 173 degrees Fahrenheit. The dietary aide then said that the service technician had just come and turned it down, as it previously was around 179 degrees. According to the meal service temperature logs from 12/30/24-1/7/25, there were multiple omissions that demonstrated that the temperature of the hot liquids was not recorded during each meal. When questioned about the prior temperature logs on 1/8/25, the dietary manager and dining director stated that the prior monitoring form did not include beverages, and they had not been recording or monitoring the temperature of hot liquids. On 1/8/25, approximately 8:15 am, an interview with a licensed practical nurse (LPN #2), it was identified that Resident #109 had also had an incident where she spilled coffee. Review of the clinical record revealed that on 12/27/24, R109 spilled lukewarm coffee into her lap and sustained no injury. On 1/8/25, interviews were conducted with LPN #2 and a certified nursing assistant (CNA #1), both of whom stated that if residents want coffee between meals, they obtain it from the lobby coffee station. On 1/8/25 at approximately 8:50 a.m., the dietary manager measured the temperature of the coffee in the lobby, which was noted to be 156 degrees Fahrenheit. On 1/8/25 at 3:20 p.m., an interview was conducted with two dietary staff (OE#1 and OE #2). Both of whom stated when they arrive, they obtain coffee from the coffee machine, fill the coffee dispensers, and take them to the front lobby around 7:30 a.m. Both dietary staff stated that they do not take the temperature of the coffee that is placed in the lobby, and it is not cooled down prior to placing in the lobby. At this time, the temperature of the coffee was again obtained, directly from the coffee machine as it would be put into the dispensers in the lobby and was measured at 165 degrees Fahrenheit. Both the dietary aides and dietary managers confirmed that the repair technician was onsite and had decreased the temperature of the machine on 1/7/25. On the afternoon of 1/8/25, an interview was conducted with the facility's interim administrator, interim Director of Nursing (DON), and general manager, to identify the facility response to the spilled coffee incidents. The facility DON reported that they had initiated a PIP (performance improvement plan) which included that all residents with a BIMs (brief interview for mental status score) of 12 or less, and those who are visually impaired, were evaluated by therapy for hot liquids and were actively working to develop an assessment tool to be used to assess resident's ability to safely manage hot liquids. The DON stated that the PIP was still in process and had not been completed. On 1/8/25, in the afternoon, an interview was conducted with the therapy director (Other Employee #9- OE #9). As of 1/8/25, there were three residents with a BIMs of 12 or less, that had not yet been evaluated for their ability to handle hot liquids safely. There was no evidence that the facility made any attempt to identify residents at risk with causative factors, other than cognitive or visual impairments, were evaluated for their ability to manage hot liquids safely. On 1/8/25 at 5:15 p.m., Immediate Jeopardy was identified and was noted to have begun on 12/22/2024, when R105 spilled her coffee, and first aid had to be provided. A meeting was held with the facility's interim administrator, interim director of nursing, and general manager to notify of the immediate jeopardy. On 1/8/25 at 7:40 p.m., the facility submitted an accepted IJ removal plan. The plan read as follows: Residents #105 and #109 were assessed for hot liquid safety and referred to Occupational Therapy. On 1/8/25 the Director of Nursing will conduct an assessment of all current residents for accident hazards such as risk of burns from hot liquids. Residents identified at risk; nursing will initiate a care plan with interventions to mitigate hazards such as risk of burns from hot liquids. Residents identified at risk will be evaluated by occupational therapy. Director of Nursing will educate all current team members on hazards such as the risk of burns from hot liquids and appropriate serving temperature prior to being permitted to work. Dietary manager will educate dietary team members on the importance of completing and documenting temperatures on hot liquids during each meal prior to being permitted to work. New admissions will be assessed for hazards such as risk of burns from hot liquids, with interventions initiated and a referral to occupational therapy. Hot beverage station located at the concierge's desk will be removed. Any concerns identified will be addressed as per our policy and procedures. Completion Date: 1/9/25 11:00 a.m. On 1/9/25 at 11:05 a.m., interviews were conducted with both certified nursing assistants (CNA #1 and CNA #2) working, the licensed practical nurse (LPN #2), a registered nurse (RN #3), the activity assistant, a housekeeper, the medical records employee, two therapy staff, and the two dietary employees. Each of the employees were able to verify they had received education and were able to answer questions with regards to the serving temperature of hot liquids, how to obtain coffee for a resident outside of mealtimes, and how to know what precautions had to be taken for residents identified to be at risk for burns from hot liquids. The two nurses were also able to verbalize knowledge of when and how the assessment of residents with regards to hot liquids would be completed. An audit was conducted which included comparison of the daily census, to ensure that 100% of residents had been screened/assessed for the risk of injury from hot liquids. The care plan was reviewed for the eleven residents identified to be at risk to ensure interventions had been implemented in the care plan. The therapy evaluation for each of the eleven residents noted to be at risk was reviewed to ensure that therapy had assessed the residents. The staff education was reviewed and the sign in sheet was compared to the as worked schedule to ensure that all staff were trained. Interviews were conducted with various staff to confirm they received education and had knowledge of the risks, interventions, etc. The education for the dietary staff was reviewed and compared to the as worked schedule to ensure that the dietary staff working had been educated. The temperature logs for breakfast were reviewed to ensure that that temperatures had been taken and were noted to be in the facility's acceptable serving range of 140-155 degrees Farenheight. The dietary staff were then interviewed to confirm receipt of the education and to verify their knowledge of the risk, importance of ensuring appropriate temperatures and the interventions for residents identified to be at risk. The census was reviewed to identify if any new admissions had been admitted since IJ was identified. No admissions had been received at the facility. On 1/9/25 at 12:10 p.m., observations were conducted in the kitchenette. Dietary staff were observed to obtain the temperature of all food items to include hot water and coffee. All temperatures were verified by the surveyor to ensure they were within appropriate serving temperature. Observations were conducted of the entire meal delivery to residents in the dining room. It was noted that none of the residents in the dining room received any hot liquids. The meal set-up and delivery of meals to residents eating in their rooms was observed. It was noted that Resident #106 (R106) was served hot coffee in a disposable cup with a lid. According to R106's meal ticket which was on the tray and accompanied the food into the resident's room was observed and was noted to read, . Preferences: Handled cup & lid for hot [NAME] [beverage] . At 1:30 p.m., R106 was served the meal which included the coffee in the disposable cup. The surveyor then returned to the Administrator's office, reviewed R106's hot liquid assessment which indicated that the resident was at risk and the care plan intervention read, Handled cup with lid for hot beverages. The facility administrator and director of nursing services (DON) were asked to accompany the surveyor to R106's room. The surveyor notified them of the observations and findings. The DON then entered R106's room and confirmed the observation. The facility administrator and DON were made aware at 1:40 p.m., they had been unable to abate IJ. The facility then presented the surveyor with notification that they had re-educated all the staff and were ready for the surveyor to attempt to verify IJ removal as of 3 p.m. on 1/9/25. On 1/9/25 at the evening meal, observations were again made. The observations included dietary staff obtaining temperatures of the foods and hot liquids and verification that they were within appropriate temperature for service. The dietary staff were observed to record the temperatures obtained. Meal service/delivery to residents was observed. One resident, R106 received coffee at the meal, and it was served in a mug with a handle and a lid. IJ was abated at 5:40 p.m. on 1/9/25, and the scope and severity was lowered to a level three, isolated. No additional information was provided.

Based on resident interview, staff interview, clinical record review, and facility documentation review, the facility staff failed to protect the residents' right to be free from mental abuse/verbal abuse/ and physical abuse by a staff member for four residents, (Resident #5 (R5), Resident #7 (R7) Resident #20 (R20) and Resident #177 (R177)) out of a survey sample of 20 residents, which resulted in psychosocial harm for R20. Immediate jeopardy (IJ) and substandard quality of care in the area of abuse was identified. The findings included: 1. For R5 and R20, the facility staff failed to protect the resident's right to be free from physical abuse, mental abuse and verbal abuse. On 10/29/24, a clinical record review was conducted of R5's chart, which noted she had been discharged and was no longer a resident of the facility. Therefore, an interview could not be conducted with R5. On 10/29/24 at 9:08 a.m., an interview was conducted with R20. R20 said, [Certified nursing assistant #1 (CNA 1)'s name redacted] treated me like slapping the pigs. I reported it to the social worker and talked with her about it. R20 said, The aide was rough with me, and I didn't like it. R20 stated they [facility staff] were responsive to her concern, and she never saw CNA1 again after the incident. R20 said, I am limited to what I can do due to my broken leg. On 10/30/24 at 11:00 a.m. an interview was conducted with the social service director (SSD). The SSD stated she had interviewed R5 and R20, who were roommates. SSD stated that R20 had stated that CNA1 was rough with her during daily care and in the shower room. The SSD stated that R5's complaint was that CNA1 was being rough with her during morning care while applying her back brace. The SSD said, [R5's name redacted] and [R20's name redacted] verbalized that they were not scared or nervous, just didn't want [CNA1's name redacted] as an aide anymore. On 10/31/24 at 8:40 a.m. another interview was conducted with the SSD. The SSD stated she documented her interviews with R5 and R20 in a word document but was unable to locate the document. When asked if other residents had complained about CNA1, the SSD stated she was unable to recall the names of the other residents, but others had complained previously about CNA1 and reported the residents were on the same hallway as R5 and R20. The SSD had no evidence of any interviews she conducted with any of the residents nor a record of their concerns and confirmed she had not documented any of the information in the resident's clinical record. The SSD said, [Administrator name redacted] asked me to interview the other residents who had complained about [CNA1's name redacted] being rough with them with care. The SSD stated that she reported the interviews to the administrator, and she was unaware of what was done about the additional complaints. The SSD stated that the complaints and interviews with other residents were prior to the complaints received about R5 and R20's incident. On 10/30/24, the facility administrator was asked to provide all information/evidence they had with regards to R5 and R20's allegation of abuse. On 10/31/24 at 9:15 a.m. an interview with the administrator was conducted. The administrator was questioned about the facility documentation provided to the survey team with regards to R5 and R20's allegations of abuse. Included in the documents was evidence of staff education with regards to customer service, not abuse. The administrator said, Not all nursing staff is on the in-service, we are missing two part-time college students and some from the third shift that's not on this education. The administrator stated that after she came into work on 10/1/24, a dayshift aide, CNA#7 (CNA7) approached her and reported the allegation of abuse. The administrator stated CNA7 was a new aide and was scared and tearful over the incident. The administrator then stated that CNA7 came to her after breakfast to report the allegation of abuse. The administrator stated that she discussed the allegation with her supervisor and then CNA1 was pulled off the nursing unit. The administrator said, [CNA1's name redacted] could be abrupt with communication when she is upset. [CNA1's name redacted] was terminated for her behavior toward us [staff/administration]. When [CNA1's name redacted] was leaving, she was disruptive in the hallway on the nursing unit and in front of the residents. ***On 10/31/24 a clinical record review was conducted of R5 and R20's charts. There was no documentation within the clinical records with regards to the resident's allegation of abuse or having been interviewed. According to the activity of daily living (ADL) documentation, it indicated that CNA1 continued to provide care and documented in R5 and R20's charts on 9/30/24 and on 10/1/24 until 10:00a.m. According to CNA1's timecard she clocked out at 10:45 a.m. on 10/1/24. On 10/31/24 at 11:30 a.m. an interview was conducted with the MDS (minimum data set) coordinator, who was a registered nurse. The MDS coordinator had written a witness statement on 10/1/24 that read, While reviewing baseline care plan with resident, [R5's name redacted] on 9/30/24, she told me that her nurse's aide that morning had been rough with her. She stated that while putting her TLSO (thoracic-lumbar-sacral orthosis) brace on, she was rough. When asked, the MDS coordinator identified the CNA as CNA1. The MDS coordinator said, I told her I would talk to the person who supervises the CNAs about it, and she expressed fear of retribution from the CNA. I assured her that she was safe. The MDS coordinator stated that she reported this to the administrator on 9/30/24. According to the facility documentation and fax confirmations, R5 and R20's allegation of abuse was not reported to the regulatory agencies and adult protective services until 10/1/24 at 3:34 p.m. On 10/31/24 at 5:00 p.m. a follow-up interview was conducted with R20. R20 said, Early morning I like to go out and watch things come to life and [CNA1's name redacted] came out stood by me just looking at me and never spoke to me and I did feel intimidated by her. Then R20 said, During the bed bath [CNA1's name redacted] took a washcloth and slapped me, like you would take a mop and sling it down. I have dogs and would not wash them like that. Then R20 said, When she hit me with this washcloth, I felt I wasn't human, subhuman and I cannot understand anyone doing this to someone! This verbiage you can tell is coming from a teacher. R20 stated that the acting DON did complete a skin assessment and found two small bruises on her legs and back. Then R20 said, I cried and was trying to catch my breath. I was appalled that someone would be that way. The social worker let me talk and I reported it and thought it would end there, but the social worker said no. I wish the aide still had a job but not with humans. I cried when I told the social worker the story and didn't see any reason for this, over a bath. It was like a nightmare. On 10/31/24 a review of witness statements in CNA1's personnel file about the allegation of abuse was conducted. The first witness statement was from CNA7. CNA7's witness statement read in part, .this morning two residents stated to me that [CNA1's name redacted] has been very rough and hurting them during her care. The two residents were [R20's name redacted] and [R5's name redacted]. I brought [R5's name redacted] to the dining table for breakfast she was trying to talk to me about [CNA1's name redacted] and [CNA1 name redacted] said to the resident Do you have something you need to say to me, in a smart tone. The administrator had written a witness statement on 10/1/24 that read in part, .This writer had to suspend [CNA1's name redacted], pending an investigation after complaints from two separate residents regarding her care for them. The SSD wrote a statement and read, This writer spoke with [R5's name redacted] and [R20's name redacted]. [R5's name redacted] reported that [CNA1 name redacted] was 'rough' with her during morning care yesterday morning. She had to have a brace on while lying down and [CNA1's name redacted] wouldn't put it on, getting her dressed instead and was rough with her. [R20's name redacted] reported that [CNA1's name redacted] was rough with her during shower care, not gentle, slapping the washcloth on her and she felt intimidated by her standing there. On 10/31/24, CNA1's personnel file was reviewed. According to the document titled, Performance Counseling and Improvement Plan for Correction Action, read in part, .Termination Written. Reason for Counseling 1. Policy/company rules not followed: Abuse or neglect of a resident, Date and Time: [DATE]. 2. Policy/company rules not followed: Failure to work in a cooperative manner. Date and Time: 9/26/24 . This document was signed by the administrator, the general manager and a witness on 10/7/24. On 11/1/24 at 9:09 a.m. another interview was conducted with the SSD. The SSD said, The resident [R20] was tearful when telling me the story about what happened with the aide. The SSD stated that she never asked R20 how the actions from CNA1 made her feel. On 11/1/14 at 10:28 a.m. an interview was conducted with a physical therapist. The physical therapist said, [R5's name redacted] was more subjective and was guarded with her language. She [R5] stated to me that her roommate was upset about being struck in the shower which indicated physical contact to me. The physical therapist stated she questioned R5 about R20 striking the aide and R5 stated no, it was the other way around, the aide struck her. The physical therapist said, I told [R5's name redacted] I needed to report this to my supervisor, and she may want to speak with you to get your feedback. Facility documentation also revealed that on 10/1/24, Resident #20 (R20) and Resident #5 (R5) reported to facility staff, that CNA #1 was rough and hurting them during care. Following this, the administrator suspended CNA #1 at 10:45 am, reported the incident to regulatory agencies that afternoon, and initiated an investigation. The investigation included staff witness statements that confirmed that CNA #1 was verbally abusive, and statements from both R20 & R5 that alleged physical abuse by CNA#1. On 10/31/24 a review of facility documentation was conducted. The incident summary read in part, .based on the assessments and investigation, the allegations were unsubstantiated. The facility administrator failed to complete a thorough investigation, no additional resident or staff interviews were conducted, and concluded that the allegation of abuse had been unfounded. 2. The facility staff failed to report an allegation of abuse for R7, after it was reported by a surveyor to the acting director of nursing. On 10/29/24 at 10:47 a.m., during an interview with R7 she reported the staff are rough when they help you to stand up or change your diaper. When R7 was asked about the bruising to her right wrist, the resident said, they are very rough. On 10/29/24 at 10:51 a.m., following the above interview with R7, the surveyor was unable to locate the facility administrator to report the allegation. The surveyor then made the acting director of nursing (DON) aware of the allegation. On the evening of 10/29/24, a clinical record review was conducted of R7's chart. There was no documentation with regards to the bruising on the interior of R7's right wrist and the bruising noted. There was a progress note entry dated 10/29/24 at 11:14 a.m., by the DON that read, ADNS [acting director of nursing services] was asked to follow up on resident statement that when she was asked how she got the bruise on her wrist, she stated staff was sometimes rough with her during care. ADNS approached resident in her room; she was observed lying in bed with eyes closed. I asked her how she was feeling and she responded sleepy. When I asked her how she got the bruise on her wrist, she hesitated to answer and said, I don't know . I asked her if she wanted any covers and she said, No. I just want to rest. I ensured bed was in low position, fall mat on floor beside bed, wheelchair in locked position, and call bell within reach prior to leaving the room. Will follow up with resident when she is awake. On 10/30/24 at 11:12 a.m., a follow-up interview was conducted with the DON. When asked about any follow-up with regards to R7 and the allegation reported by the surveyor, the DON said, I think I put a note in, I went in and she had put herself to bed, I was trying to make sure she was centered on the bed better, she is very hard of hearing, I asked if felt ok, she said yes, I asked if she was sleepy she said yes. I asked her, can you tell me how you got that bruise? She said, I don't know, she was very tired and very lethargic, I left it alone, I lowered the bed and put the fall mat down. I went and checked on her later and she was in a meal. I talked to her, she was up this morning, she wasn't answering questions appropriately, she had a fall again last night, they are talking to hospice to see what else we can do to help her . On 10/30/24 at 3:17 p.m., an interview was conducted with the administrator. The surveyor asked the administrator if she was aware of the allegation reported by the surveyor to the DON involving R7, the administrator said, She [the DON] did say you [the surveyor] had talked to her about an area on [R7's name redacted]'s wrist or hand and she went and talked to [R7] and got a very different answer. I believe she went back and talked to her again and she had no complaints of staff. She brought all that to me. The administrator acknowledged that nothing involving R7 had been reported to the required agencies and nothing was in process. On 10/31/24 at 11:30 a.m., the survey team reviewed facility documentation, which indicated R7's report of an allegation of abuse was reported as an injury of unknown origin following the surveyor questioning the facility administrator about reporting the allegation of abuse involving R7 on 10/30/24. 3. The facility staff failed to respond to and report an injury of unknown origin for R177's skin tear to her left hand. On 10/31/24 at 11:13 a.m. an interview was conducted with a staff member who expressed a desire to remain anonymous. The anonymous staff (AS1) verbalized that she was called into R177's room by certified nursing assistant, CNA1. AS1 stated, I reported an incident with a resident to the Administrator, the resident had two skin tears to her left extremity. AS1 then stated, the skin tears were new. AS1 said, [CNA1's name redacted] said to the resident, I don't want to hear that apology, and the resident began to cry. On 10/31/24 at approximately 3:00 p.m. a clinical record review was completed. On 7/28/24 a physician order for treatment was noted. The order read, clean skin tear to left elbow and left hand with normal saline pat dry apply border gauze until healed. On 7/28/24 a skilled note was written and there was no mention of an incident or the skin tears. On 7/30/24 a weekly skin note was completed by RN1 and read in part, .skin tear to left hand steri strips applied and foam dressing applied. On 7/30/24 a doctor's progress note was written. The note read in part, the skin tear on the left elbow happened by rubbing on the arm of the wheelchair. The note did not mention the skin tear to the left hand. On 10/31/24 an employee that wanted to remain anonymous showed the surveyor a text message that was sent to the administrator on 7/28/24 and the text message read, I really need to talk to you. The anonymous employee stated, I reported the incident of [R177's name redacted] skin tears and of her complaining that CNA1 was rough with her. The employee stated that the administrator response was, to be careful of what you are saying and accusing people of. The anonymous employee then stated, I never heard anything else about the incident and assumed nothing was done. On 10/31/24 and again on 11/1/24 a request was made by the surveyor for the facility to provide evidence of an investigation for the skin tear that R177 obtained, or how the facility determined it was caused. On 11/1/24 the surveyor had not received any information. Another request for it was made to the administrator. Prior to the survey team's departure from the facility, no information was provided to the survey team. On 10/31/24, prior to calling IJ, the skilled nursing staff members were interviewed, and three out of six staff members interviewed knew who the abuse coordinator for the facility was. On 10/31/24, a facility document was reviewed. The titled document was, Abuse, Neglect and Exploitation-Prevention, Reporting and Investigation, read in part, .It is the policy of the community that: a) each resident has the right to be free from abuse, neglect, misappropriation of resident property, and exploitation. Team members must not engage in, nor permit anyone else to engage in, abuse, neglect, or exploitation of any resident. b) team members of the community are mandated reporters and have a duty to report known or suspected abuse, neglect and/or exploitation to local, state, and/or federal authorities in accordance with applicable law and regulations. c) in addition, team members who know of or suspect abuse, neglect, or exploitation of any resident must immediately notify the Executive Director/designee, to ensure appropriate action is timely taken for the safety of the resident and those potentially impacted .Training, the department coordinator/designee educates team members, through on-boarding and on-going training sessions on the prevention, reporting, and documentation of abuse, neglect, and exploitation. Training includes a) all team members are mandated reporters and are required to report allegations or known episode of abuse, neglect, and/or exploitation to applicable state authorities within the time frame established by law. h) steps to take to ensure the safety and protection of residents in situations of known or suspected abuse, neglect and/or exploitation, including escalation to the Executive Director/designee .Duty to report. Every team member is a mandated reporter and has a duty to report known or suspected abuse, neglect, and/or exploitation to local and state authorities in accordance with applicable law and regulation. a) these authorities may include law enforcement, the licensing regulator, the ling term care ombudsman, and/or adult protective services. The report of abuse, neglect or exploitation must be made within the timeframes and through the format required by applicable law and regulation. b) allegations of or suspicions of abuse, neglect and/or exploitation are to be reported .Protecting the resident. In addition, to initial Mandatory reporting, to ensure the safety and protection of residents, any team member who know of or suspect abuse, neglect or exploitation of a resident must also immediately notify the ED/SNA/designee. The SNA/designee: a) upon receiving notification of any known or suspected abuse, neglect, or exploitation of a resident contacts the licensed nurse who evaluates the resident and provides the necessary intervention, for example, calls 911 if emergent. b) Removes the individual alleged to be involved in the abuse, neglect or exploitation from the area. i. ensure that any team member alleged to be involved in the abuse, neglect or exploitation is placed on administrative leave, pending the results of the investigation. ii. Ensures that non-team members alleged to be involved in the abuse, neglect or exploitation will be asked to leave the resident area and await further instructions. c) ensures that the resident's (i) physician, (ii) legal representative and (iii) family member or other individual regularly involved in the residents day to day care are notified as soon as practicable within timeframes established within laws/regulations .Investigation: The SNA/designee: Validates that the mandatory report of known or suspected abuse, neglect or exploitation has been made to the applicable authorities in accordance with state/federal requirements. The SNA/designee manage and directs the investigation of all abuse, neglect and/or exploitation. The SNA/designee implements corrective actions as indicated by the results of the investigation. If a written report of the investigation 1findings is required by applicable law or regulation, the SNA completes such report and ensures that it is submitted timely. On 10/31/24 at 4:30 p.m., the survey team identified the facility was in immediate jeopardy (IJ) in the care area of Freedom from Abuse, Neglect, and Exploitation. The facility staff failed to implement interventions to prevent, protect, and respond to allegations of physical and verbal abuse. The survey team met with the facility administrator, acting director of nursing, social service director, the general manager and the regional director of resident care and reviewed the IJ findings and a copy of the IJ template was provided to the facility administrator. On 10/31/24 at 10:25 p.m., the facility administrator provided the survey team with an accepted IJ removal plan. The facility's plan to remove IJ read as follows: A. With respect to the specific resident/situation cited: On 10/31/24 upon notification of citation, the administrator and current on shift skilled team members will be educated by the regional director of resident care/designee to prevent, protect, respond to abuse reflected in the Abuse, Neglect, and Exploitation-Prevention, Reporting and Investigation policy. On 10/31/24 the administrator will complete a facility reportable incident for an allegation of abuse of Resident #7 to required agencies. B. With respect to how the facility will identify residents/situations for the identified concerns: On 10/31/24 the administrator and/or designee will interview resident #7 and have a nurse complete a physical assessment. An assessment will be conducted for current residents in skilled nursing by the administrator and/or designee who are alert and oriented for safety and care concerns in the community to include abuse. Beginning 10/31/24 the administrator and/or designee will place additional signage around the community advising of the abuse coordinator and grievance coordinator. 10/31/24 the regional director of resident care and/or the acting director of nursing will re-educate all skilled team members on how to prevent, protect, and how to respond to abuse reflected in the Abuse, Neglect, and Exploitation-Prevention, Reporting and Investigation policy. All skilled team members will be trained prior to them being able to work. Any concerns identified will be addressed as per our policy and procedures. The facility alleged they would have the IJ removal plan completed on 11/1/24 at 10:00 a.m. On 11/1/24 the survey team verified the removal of IJ. The survey team conducted interviews with all skilled team staff working how to prevent, protect, and how to respond to abuse as reflected in the Abuse, Neglect, and Exploitation-Prevention, Reporting and Investigating Policy. Interviewable resident interviews were reviewed, and no additional concerns of abuse were identified. Non interviewable resident families were interviewed. The interviews were reviewed, and no additional concerns were noted. Skin assessments conducted on non interviewable residents were reviewed. The skin assessments had no indication of when they were conducted, who conducted them and if the findings were areas of new concern or exiting issues. The facility staff were notified of the concern about the skin assessments and that the survey team would be unable to abate the IJ. The facility staff conducted new skin assessments on non interviewable residents. No new areas were noted, and all assessments had the initial date of identification. The survey team reviewed the revised skin assessments and confirmed that no new skin issues were identified. A sample of 20% of the skin assessment findings were verified through clinical record reviews to ensure skin impairments had been previously documented by the facility staff. The survey team reviewed and confirmed that the family of non interviewable residents were interviewed with no abuse related concerns noted. The survey team reviewed resident interviews, and no new areas of concern were identified. The survey team confirmed that the facility completed and reported R7's allegation of abuse. On 11/1/24 at 1:30 p.m. the survey team was able to confirm that the immediacy had been removed and IJ was abated. Following the removal of immediate jeopardy, the scope and severity was lowered to a level three isolated. No additional information was provided prior to exit.

Based on resident interviews, staff interviews, clinical record reviews, and facility documentation review, the facility staff failed to effectively administer the facility for residents to maintain their highest practicable well-being, which had the potential to affect all residents residing in the facility. The findings included: For the resident's residing in the facility, the facility administration failed to effectively and efficiently administer the facility to ensure residents were free from and protected from abuse. The facility administrator, who was the abuse coordinator, failed to implement the facility's abuse policy to ensure residents were protected, allegations were reported and investigated timely, and residents were free from abuse, which resulted in the identification of immediate jeopardy and substandard quality of care. 1. On 10/29/24 at 9:08 a.m., an interview was conducted with resident #20 (R20). R20 said, [Certified nursing assistant #1 (CNA 1)'s name redacted] treated me like slapping the pigs. I reported it to the social worker and talked with her about it. R20 said, The aide was rough with me, and I didn't like it. R20 stated they [facility staff] were responsive to her concern, and she never saw CNA1 again after the incident. R20 said, I am limited to what I can do due to my broken leg. On the evening of 10/29/24, a clinical record review was conducted of R20's chart, which revealed no information with regards to her allegation of abuse. On 10/30/24 at 11:00 a.m. an interview was conducted with the social service director (SSD). The SSD stated she had interviewed R5 and resident #20 (R20), who were roommates. SSD stated that R20 had stated that CNA1 was rough with her during daily care and in the shower room. The SSD stated that R5's complaint was that CNA1 was being rough with her during morning care while applying her back brace. The SSD said, [R5's name redacted] and [R20's name redacted] verbalized that they were not scared or nervous, just didn't want [CNA1's name redacted] as an aide anymore. On 10/31/24 at 9:15 a.m. an interview with the administrator was conducted. The administrator was questioned about the facility documentation provided to the survey team with regards to R5 and R20's allegations of abuse. Included in the documents was evidence of staff education with regards to customer service, not abuse. The administrator said, Not all nursing staff is on the in-service, we are missing two part-time college students and some from the third shift that's not on this education. The administrator stated that after she came into work on 10/1/24, a dayshift aide, CNA#7 (CNA7) approached her and reported the allegation of abuse. The administrator stated CNA7 was a new aide and was scared and tearful over the incident. The administrator then stated that CNA7 came to her after breakfast to report the allegation of abuse. The administrator stated that she discussed the allegation with her supervisor and then CNA1 was pulled off the nursing unit On 10/31/24 at 11:30 a.m. an interview was conducted with the MDS (minimum data set) coordinator, who was a registered nurse. The MDS coordinator had written a witness statement on 10/1/24 that read, While reviewing baseline care plan with resident, [R5's name redacted] on 9/30/24, she told me that her nurse's aide that morning had been rough with her. She stated that while putting her TLSO (thoracic-lumbar-sacral orthosis) brace on, she was rough. When asked, the MDS coordinator identified the CNA as CNA1. The MDS coordinator said, I told her I would talk to the person who supervises the CNAs about it, and she expressed fear of retribution from the CNA. I assured her that she was safe. The MDS coordinator stated that she reported this to the administrator on 9/30/24. According to the facility documentation and fax confirmations, R5 and R20's allegation of abuse was not reported to the regulatory agencies and adult protective services until 10/1/24 at 3:34 p.m. According to the activity of daily living (ADL) documentation, it indicated that CNA1 continued to provide care and documented in R5 and R20's charts on 9/30/24 and on 10/1/24 until 10:00a.m. According to CNA1's timecard she clocked out at 10:45 a.m. on 10/1/24. Therefore, following the administrator being made aware of the allegations on 9/30/24 by the MDS Coordinator, the facility administrator failed to take measures to protect the resident and initiate an investigation into the allegations. By failure to remove the alleged perpetrator CNA1 following the initial report, CNA1 was permitted to continue working with the residents and had the opportunity to further abuse the residents. On 10/31/24 a review was conducted of witness statements in CNA1's personnel file. The first witness statement was from CNA7. CNA7's witness statement read in part, .this morning two residents stated to me that [CNA1's name redacted] has been very rough and hurting them during her care. The two residents were [R20's name redacted] and [R5's name redacted]. I brought [R5's name redacted] to the dining table for breakfast she was trying to talk to me about [CNA1's name redacted] and [CNA1 name redacted] said to the resident Do you have something you need to say to me, in a smart tone. The administrator had written a witness statement on 10/1/24 that read in part, .This writer had to suspend [CNA1's name redacted], pending an investigation after complaints from two separate residents regarding her care for them. According to the document titled, Performance Counseling and Improvement Plan for Correction Action, which was in CNA1's personnel file, it read in part, .Termination Written. Reason for Counseling 1. Policy/company rules not followed: Abuse or neglect of a resident, Date and Time: [DATE] This document was signed by the administrator, the general manager and a witness on 10/7/24. 2. On 10/29/24 at 10:47 a.m., during an interview with resident #7 (R7), the resident reported facility staff are rough. When asked about bruises to the resident's right arm, the resident repeated, Staff are very rough! The allegation was immediately reported by the surveyor, to the facility's acting director of nursing when the administrator was not able to be located. On the evening of 10/29/24, a clinical record review was conducted of R7's chart. There was no documentation with regards to the bruising on the interior of R7's right wrist and the bruising noted. There was a progress note entry dated 10/29/24 at 11:14 a.m., by the DON that read, ADNS [acting director of nursing services] was asked to follow up on resident statement that when she was asked how she got the bruise on her wrist, she stated staff was sometimes rough with her during care. ADNS approached resident in her room; she was observed lying in bed with eyes closed. I asked her how she was feeling and she responded sleepy. When I asked her how she got the bruise on her wrist, she hesitated to answer and said, I don't know . I asked her if she wanted any covers and she said, no. I just want to rest. I ensured bed was in low position, fall mat on floor beside bed, wheelchair in locked position, and call bell within reach prior to leaving the room. Will follow up with resident when she is awake. On 10/30/24 at 11:12 a.m., a follow-up interview was conducted with the director of nursing (DON). When asked about any follow-up regarding R7's allegation, the DON stated that she had talked to R7 but she was sleepy and so she ensured the resident was centered in the bed, lowered the bed and put the fall mat in place. The DON stated she went back later to talk with R7, but she was in a meal and didn't interview the resident. On 10/30/24 at 3:17 p.m., an interview was conducted with the administrator. The administrator confirmed that she was the facility's abuse coordinator and stated, As soon as we are notified, we begin the questioning. When asked, what if the resident doesn't repeat what was reported? The administrator said, I would ask other residents if they had any issues, talk to team members. We can talk to their family and see if they mentioned it to them. When asked if any of this is reported, the administrator said, It should be because it is an allegation of abuse. When asked if she had any abuse reports in process, the administrator said, I do not. The administrator confirmed she was aware of R7's allegation that was reported to the director of nursing, but that she thought the DON had talked with the resident and no further action had been taken. According to facility documentation, the administrator reported R7's allegations to the state survey agency and adult protective services as an injury of unknown origin, following the surveyor's questioning of the administrator if any reports had been made. On 10/31/24, observations within the facility noted that postings were in place that indicated the administrator was the abuse coordinator. On 10/31/24 at 4:30 p.m., the survey team identified the facility was in immediate jeopardy within the care are of Free from Abuse, Neglect, and Exploitation, and substandard quality of care was identified. On 11/01/24 at 8:39 a.m., an interview was conducted with the attending physician and medical director of the facility. When asked about his role as medical director, the doctor said, I am responsible for overseeing the coordination of care and helping develop policies, provide education with staff on care, and dementia precautions. When asked, who the abuse coordinator is for the facility, the medical director stated the administrator. When asked, As medical director what are your expectation of what she would do? The medical director said, She covers a lot of different roles. I would expect her to gather the details and do a good investigation and report it up further. As far as the policy, she would coordinate gathering the information and doing the investigation. When asked if he would expect the administrator to take measures to protect the resident? He said, it depends on what the allegations are, it should be immediate if there is concern of mistreatment of a patient here. According to the Skilled Nursing Administrator (SNA) job description, it read in part, . Essential Duties: Skilled Nursing Center and Program Oversight. Plans, organizes, develops and leads the overall operation of the skilled nursing center in accordance with current federal, state, local laws and [company name redacted] standards, guidelines and regulations . Reviews and acts upon any complaint or concern as they arise . A review of the facility's policy titled, Abuse, Neglect & Exploitation- Prevention, Reporting and Investigation was conducted. The policy read in part, . team members who know of or suspect abuse, neglect, or exploitation of any resident must immediately notify the Executive Director /designee, to ensure appropriate action is timely taken for the safety of the resident and those potentially impacted . 8. The SNA/designee: a. Upon receiving notification of any known or suspected abuse, neglect or exploitation of a resident contacts the licensed nurse who evaluates the resident and provides the necessary interventions, for example, calls 911 if emergent. b. Removes the individual alleged to be involved in the abuse, neglect or exploitation from the area . 9. The SNA/designee: a. Validates that the mandatory report of known or suspected abuse, neglect or exploitation has been made to the applicable authorities in accordance with state/federal requirements. 10. The SNA/designee manages and directs the investigation of all abuse, neglect and/or exploitation . On 11/1/24 at 1:45 p.m., during a meeting with the facility administrator and other management staff, the above concerns were discussed. No additional information was provided.

Based on staff interview, clinical record review and facility documentation review, the facility staff failed to provide education and offer COVID immunizations, to 4 of 5 residents (resident #7-R7, resident #17-R17, resident #76- R76 and Resident #20-R20) sampled for immunizations and failed to have evidence of having provided staff education regarding COVID immunizations for 3 (licensed practical nurse #1- LPN #1, certified nursing assistant #6- CNA #6, and other employee #5- OE#5) of 3 staff sampled. The findings included: On 10/30/24, a sample of five residents was selected for review of immunizations. Review of the clinical records for each resident revealed the following: 1. R7 had no information noted with regards to the status of her COVID immunizations. There was no indication that the facility had offered any education with regards to COVID immunizations. 2. For R17, the clinical record indicated that the resident was eligible for the spike vaccination of COVID-19. 3. R76's clinical record indicated no information with regards to the COVID immunization status or that any offering or education had been provided. 4. R20's clinical record had no information with regards to immunizations. On 10/31/24 at 9:53 a.m., a meeting was held with the acting director of nursing (DON) in the presence of the regional director of resident care. The DON confirmed that she oversaw and oversaw the facilities immunization program and infection control. When asked about immunizations, the DON said, we offer flu, covid, and RSV. When asked about pneumonia, the DON said, we can. The DON was asked to explain the process for residents with regards to immunizations. The DON said, usually social work will ask them, they start the process and ask if they want the immunizations and get consents. Right now it is flu season, we did flu clinic last week, we get the consent and ordered from the pharmacy, get the orders, give the vaccines and do follow-up and documentation. When the DON was asked, why is important for residents to get immunized? The DON said, its personal preference to help with infection control and better for their health. The DON went on to explain that the social worker will give her, [the DON] the consent form and she will look into their record to see what they have had and when they received it. During the above interview the DON and Regional director of resident care were asked to access each resident's clinical record. They reported immunizations should be documented under the immunization tab and confirmed the above findings. The DON reported they attempt to get information regarding the resident's immunizations from the hospital. When asked how they know if the resident has received immunizations outside of the hospital and if they use the VIIS [Virginia Immunization Information System] portal, the DON stated, I know nothing about that and have never heard of it. The DON stated she had some consent forms in her office and obtained the following: 1. R7 had a signed consent to receive the COVID immunization dated 10/18/24. The DON confirmed it had not been administered as of 10/31/24. 2. R17 had a signed consent form for COVID, which was signed and dated 10/17/24. However, neither box had been checked to identify if the resident wanted the flu or pneumonia vaccine. The DON stated R17 wanted the COVID immunization, and she had failed to check the box. The DON also confirmed despite having the consent on file, the resident had not been immunized. 3. R76 had no information on file that the resident's COVID immunization status was known other than according to hospital records the last dose received was 10/20/21, which would make the resident eligible for the spike vaccination. There was no evidence that R76 had been educated or offered the vaccine. 4. R20 had signed a consent form indicating the desire to receive the COVID immunization on 10/17/24. The DON confirmed that as of 10/31/24, the immunization had not been given. When asked about the immunizations being signed 10/17-10/18 and had not been administered, the DON said, This is my first time doing any of this. It is a work in progress. When we were getting consent for the flu shots, we got consents for everything. The Regional Director of resident services stated, If they sign wanting it, we should schedule it immediately to prevent the spread of infection. On 10/31/24, in the early afternoon, the facility administrative staff were asked to provide evidence of COVID immunization status and education regarding COVID immunizations for the three staff being sampled, LPN #1, CNA #6 and OE #5. On 11/1/24 at 10:25 a.m., the general manager reported to the survey team, Costco comes in to provide education. We no longer require them [staff] to provide COVID immunization cards. The surveyor asked if they had any evidence of the staff being provided the education regarding immurations, such as a signed form, as the regulation continues to require evidence of staff education. The general manager said, they don't sign a copy, no and had no further information to provide. On 11/1/24 at 10:42 a.m., an interview was conducted with the social worker. The social worker was asked about consent forms for immunizations and reported when reviewing admission paperwork she had consent forms for flu, pneumonia and RSV vaccinations. The social worker stated that they get the hospital's immunization records for residents, she asks the residents and said, if they tell me I put it on the consent form and give it to [the DON's name redacted]. When asked about COVID immunizations, the social worker said, We did COVID this year when we asked about flu shots. It is not in my contract, and we just started it in October because it is flu season. Review of the facility policy titled, COVID-19: Education & Offering of Vaccine- Resident & Team Members was conducted. The policy read in part, . The skilled nursing administrator (SNA)/executive director (ED)/director of nursing (DNS)/designee will facilitate the education of residents or resident representatives and team members regarding the benefits and potential side effects associated with the COVID-19 vaccine in a manner they can understand . 2. It is the responsibility of the SNA/ED/DNS/designee to facilitate a. Vaccination, which will be conducted in accordance with CDC, ACIP, FDA, and manufacturer guidelines .b. Screening individuals prior immunization prior to offering the vaccination . d. Each resident and team member will be offered the COVID-19 vaccine unless the immunization is medically contraindicated as determined by a physician, or the resident or team member has already been immunized . 9. It is the responsibility of the SNA/ED/designee that the facility maintain documentation related to team member COVID-19 vaccination that includes at a minimum, the following: a. That team members were provided education regarding the benefits and potential risks associated with COVID-19 vaccine . The FDA (Food and Drug Administration) gives information about the 2023-2024 spike vaccine on their website, accessed at: https://www.fda.gov/vaccines-blood-biologics/coronavirus-covid-19-cber-regulated-biologics/novavax-covid-19-vaccine-adjuvanted. The guidance read, On October 3, 2023, the Food and Drug Administration amended the emergency use authorization (EUA) of Novavax COVID-19 Vaccine, Adjuvanted to include the 2023-2024 formula. The Novavax COVID-19 Vaccine, Adjuvanted, a monovalent vaccine, has been updated to include the spike protein from the SARS-CoV-2 Omicron variant lineage XBB.1.5 (2023-2024 formula). The Novavax COVID-19 Vaccine, Adjuvanted (Original monovalent) is no longer authorized for use in the United States. Novavax COVID-19 Vaccine, Adjuvanted (2023-2024 Formula) is authorized for use in individuals [AGE] years of age and older as follows: Individuals previously vaccinated with any COVID-19 vaccine: one dose of Novavax COVID-19 Vaccine, Adjuvanted (2023-2024 Formula) is administered at least 2 months after receipt of the last previous dose of an original monovalent (Original) or bivalent (Original and Omicron BA.4/BA.5) COVID-19 vaccine. Individuals not previously vaccinated with any COVID-19 vaccine: two doses of Novavax COVID-19 Vaccine, Adjuvanted (2023-2024 Formula) are administered three weeks apart . On 11/1/24 at 1:45 p.m., during an end of day meeting, the facility administrator, management staff and corporate staff was made aware of the above findings. No additional information was provided.

Based on observation, resident interview, staff interview, clinical record review and facility documentation review, the facility staff failed to ensure medications were securely stored in 1 of 2 medication carts and for 1 resident (resident #128) in a survey sample of 20 residents. The facility staff also failed to ensure that expired medications were not available for use in 1 of 1 medication rooms. The findings included: 1. For R128, the facility staff permitted the resident to have eye drops at the bedside which were not secured. On 10/29/24 at 9:49 a.m., observations were conducted in R128's room and an interview conducted with the resident. On R128's over bed table the surveyor noted a bottle with a prescription label. When asked, R128 said it was eye drops and I use them when my eyes get dry or itchy. R128 reported that he had received them when he was in the hospital. R128 handed the surveyor the bottle and it was noted to be Carboxymethylcellulose Refresh 1% a 15 ml container of ophthalmic gel. The instructions read, 1 drop both eyes. It had a hospital pharmacy label with a date 10/17/24. On 10/30/24 at 1:16 p.m., an interview was conducted with licensed practical nurse #1 (LPN #1), who was assigned as R128's nurse. LPN #1 said, [registered nurse #1- RN #1 name redacted] gave it to me [referring to the eye drops]. I let doctor [doctor's name redacted] know we have a patient who wants to self-administer. I've called the doctor, and I am waiting for him to respond back to me. LPN #1 said, all medications have to be locked up. On 10/30/24 at 1:18 p.m., an interview was conducted with RN #1. When asked about the eye drops, she found at R128's bedside, RN #1 said, my understanding is we have to talk to the physician and there is an evaluation that the nurses do to see if they understand the medication, are capable of administering, etc. When asked how she came to notice the eye drops, RN #1 she said, . I went in his room to ask him about something and found them in his belongings. I asked his permission to take them and told him why. He said yes I could take them. RN #1 was asked where mediations get stored if they can self-administer? RN #1 said, let me ask. When asked what the risk is of medications being left in the open and not secured, RN #1 said, someone who shouldn't have them could take them. On 10/30/24, a clinical record review was conducted of R128's chart. There was no indication that R128 was able to self-administer medications and keep medications stored at the bedside. Within the care plan for R128 was a focus area dated 10/19/24, which read, The resident is unable to self-administer their own medication. 2. The facility staff failed to ensure one medication cart, which contained over 75 cards of medications containing approximately 20-30 pills per card, was secured to prevent unauthorized access to medications. On 10/29/24 at 12:25 p.m., the surveyor arrived at the nursing station and noted no nursing staff were in sight. There was a medication cart in the hallway and the lock was protruding, which was an indication the cart was not locked. The surveyor talked with two maintenance staff that were at the nursing station and maintained eye contact of the medication cart. The surveyor then walked to the medication cart and was able to open each drawer. During the duration of observations of the unattended medication cart, the surveyor had noted numerous staff and residents pass by, who could have potentially accessed the medications. There were the two-maintenance staff that were just steps away at the nursing station, a housekeeper, activity staff member, laundry worker and certified nursing assistant. Two residents walked by the cart and another resident was pushed in a wheelchair by a staff member. On 10/29/24 at 1:13 p.m., another surveyor went to retrieve the nurse. When the licensed practical nurse #2 (LPN #2) arrived at the cart they surveyor showed her that she was able to open each drawer of the medication cart. The cart was observed to contain approximately 50 bottles of over-the-counter medications, which included pain medication such as Tylenol, vitamins, stool softeners, etc. There was another drawer which contained syringes with needles attached, lancets, eight lovenox injections and another drawer with approximately 75 cards of medications. Each of the cards contained 20-30 pills. The nurse stated she was sure she had locked the cart and didn't know what happened. The nurse also confirmed that no one else had keys and would have been able to unlock the medication cart. When asked why it is important to lock the cart, LPN #2 said, so no one can go in them, and it is a risk someone taking out of it. 3. Within the medication storage room, the facility staff failed to discard a box of tuberculin purified protein vial that was past the open date, making it expired, but available for use/administration. On 10/29/24 at 3:43 p.m., an inspection of the medication room was conducted with LPN #2 being present. The surveyor noted that within the refrigerator was two multi-dose vials of Tuberculin Purified Protein, both of which had been opened and accessed. The outer box of one had an open date of 4/30/24, and the second vial had an open date of 9/20/24, on the box. Following the above observation LPN #2 was asked about the dating of medication. LPN #2 explained that mediations are dated when opened because it determines the date of how long the product is good for. When asked about the tuberculin purified protein specifically, LPN #2 said, so you know when it is opened, and it is only good for 45 days. Review of the facility's policy titled; Storage of Medication was conducted. It read in part, . 3. In order to limit access to prescription medications, only licensed nurses, pharmacy staff, and those lawfully authorized to administer medications are allowed access to medication carts. Medication rooms, cabinets and medication supplies should remain locked when not in use or attended to by persons with authorized access . 14. Outdated, contaminated, discontinued or deteriorated medications and those in containers that are cracked, soiled, or without secure closures are immediately removed from stock, disposed of according to procedures for medication disposal . The facility policy and information provided titled, Abridged List of Medications with Shortened Expiration Dates was reviewed and did not address the use by date of the Tuberculin Purified Protein vials that had been opened. According to the Food and Drug Administration (FDA), the Tuberculin Purified Protein Derivative (Mantoux) TUBERSOL(R) package insert obtained online at: https://www.fda.gov/media/74866/download, was reviewed. It read in part, .A vial of TUBERSOL which has been entered and in use for 30 days should be discarded . On 10/30/24 at 5:01 p.m., during an end of day meeting, the facility administrator and director of nursing were made aware of the above concerns. No additional information was provided.

2. Four food bins containing rice, flour, sugar, and bread crumbs were labeled as expired and were accessible for distribution in the main kitchen. The findings included: On [DATE] at 8:40 a.m. during the initial tour of the main kitchen with dietary manager (other staff, OS #1) four large food bins containing rice, flour, sugar, and bread crumbs all with an expiration date of [DATE] were accessible for distribution. OS #1 also observed the food bins and verbalized that either a staff member had not relabeled the food bins when new food was added or the food is out of date, verbalizing the food will be removed and replaced along with new expiration dates. A policy titled Food Storage, Preparation and Service was obtained and read in part: General Food Handling [ .] d. All food items are labeled, dated and rotated to maintain a system of First In First Out. e. Expired food is discarded. On ,d+[DATE] at 5:01 p.m. the administrator and director of nursing (DON) were notified of the above finding. No other information was provided prior to exit conference on [DATE]. 49456 Based on observations, staff interviews and facility documentation the facility staff failed to store, prepare, and distribute food in a sanitary manner in the main kitchen and in the dining room. The findings included: 1. The facility staff wore the same pair of gloves in the main dining room while serving food and assisting residents with feeding and other activity of daily living needs. On [DATE] at 12:52 p.m. to 1:00 p.m. a certified nursing assistant, CNA#2 (CNA2), was observed with the same pair of gloves on in the main dining room, assisting a residents with repositioning in the wheelchairs., rearranging the chairs in the dining room, touching the cabinets, had his hand on the wall, removed a cup from the cabinet and served food to several residents without changing his gloves or using hand hygiene. CNA2 then sat down and was observed assisting a resident with feeding wearing the same gloves. On [DATE] at 1:04 p.m. an interview with CNA2 was conducted. CNA2 was asked why he wore gloves in the dining room and he stated, I feel it is more sanitary and I don't want to catch anything I try to stay clean. CNA2 was made aware about being observed with assisting the resident with positioning in the wheelchair, opening the cabinets to get a cup, handling food and then began assisting with feeding a resident with the same gloves on the entire time and he was never observed changing the gloves or performing hand hygiene. CNA2 stated, I have never changed them but technically I should, and I will keep that in mind for the future. On [DATE] at 1:15 p.m. an observation of CNA2 was conducted. CNA2 was observed on the nursing unit hallway assisting residents back to their rooms and was wearing a different colored pair of gloves. He assisted several residents to their rooms and never changed the pair of gloves he was wearing in the hallways. On [DATE] at approximately 3:00 p.m. a review of facility documentation was completed. The document titled, Infection Prevention and Control Program for Skilled Communities, read in part, .hand hygiene -one of the most effective ways to prevent the spread of infection. Gloves: wearing gloves is not a substitute for hand hygiene. Dirty gloves can soil hands. Always clean your hands after removing gloves. Remove gloves after contact with a resident and/or the surrounding environment. Failure to remove gloves after caring for a resident may lead to the spread of potentially deadly germs from one resident to another. Do not wear the same pair of gloves for the care of more than one resident. On [DATE] at approximately 5:15 p.m. an end of day meeting was conducted with the administrator, the acting director of nursing and the regional director of resident care services was conducted. The above concerns were discussed. No additional information was provided.

Based on staff interview and facility documentation review, the facility staff failed to ensure that the facility assessment involved the appropriate participants, which had the potential to affect all operations and residents within the facility. The findings included: The facility staff failed to ensure the active involvement of direct care staff and solicit input from residents, resident representatives and family members in the development of the facility assessment. On 10/31/24, a review of the facility assessment was conducted. This review revealed no evidence of direct care staff, residents, resident representatives or family members being involved and/or their input being solicited for the development of and/or review of the resident assessment. The facility assessment was updated 5/23/24 and reviewed with the governing body on 5/16/24. According to the persons involved in completing assessment it included the administrator, director of nursing, governing body representative, medical director, social services coordinator, resident assessment coordinator and dietary services manager. On 11/1/24 at 10:56 a.m., an interview was conducted with the facility administrator. When asked if there was any involvement of direct care staff in the development, the administrator stated, it is more so like the DON [director of nursing] and assistant director of nursing. When asked, are residents and families involved in the process or their input solicited? The administrator stated, we only have a few long-term residents and most of them are cognitively impaired. I would say no. On 11/1/24 at 1:45 p.m., during an end of day meeting, the facility administrator, management team and corporate staff were made aware of the recent regulatory changes that require direct care staff, resident and family involvement in the development of the facility assessment. The facility policy regarding facility assessment was requested. The facility policy titled, Facility Assessment Process was received and reviewed. The document read in part, . How do we collect the necessary information? We utilize the facility assessment tool to collect the necessary information in three important areas. The tool basically asks three questions: Who are our residents? What are their needs? and What do we have that meets their needs? Or what do we need to get or work to improve . No additional information was provided.

3. For R12, who had multiple falls and sustained a significant head injury, the facility failed to maintain a complete and accurate clinical record to include the details of the fall and the facility's response. On 10/29/24 at 11:03 a.m., during an interview with R12 and his spouse, the spouse reported, He had several falls here, which resulted in a head injury. The first one they called me, he hit his head badly and was bleeding and had to have some surgery on his brain. On the evening of 10/30/24, during a clinical record review, the following was noted. R12 had a fall on 6/10/24. The Fall Progress Note read, Fall was unwitnessed in residents room [ROOM NUMBER]/10/2024 8:00 PM. Residents description of event and how they were feeling: Guest stated that he was going to bed. He stated that he was ok before he fell .No injury noted at time of fall. [R12's spouse's name redacted] Your husband fell . He is ok. was notified on 06/10/2024 11:00 PM [Doctor's name redacted], MD was notified on 06/10/2024 9:00 PM with new orders received and entered in orders tab of record. Response: Care plan has been reviewed and updated. Guest requires extensive assistance for transfers and adls [activities of daily living]. On 6/23/24, R12 fell again. According to the fall progress note, it read, Fall was unwitnessed in residents room [ROOM NUMBER]/23/2024 8:00 PM. Resident unable to describe the event and how they felt just prior to falling .Fall resulted in an injury to the resident: guest noted to have bleeding from his right ear, right side of face reddened from fall with minor scrapes [R12's spouse's name redacted] was notified on 06/23/2024 8:15 PM [physician's name redacted] was notified on 06/23/2024 8:15 PM with new orders received and entered in orders tab of record. Response: Care plan has been reviewed; no updates needed at this time. There was a note entered at 1:30 a.m. on 6/24/24, that read, Received call from [hospital name redacted] ICU [intensive care unit] staff reporting that Guest has been admitted to the ICU. DX [diagnosis] Subarachnoid Hemorrhage and Parietal fracture. Medications reviewed with ICU nurse. On 9/9/24, R12 sustained another fall according to the progress notes. The fall progress note read in part, Fall event details: Fall was witnessed in hallway 09/09/2024 6:00 PM. Resident unable to describe the event and how they felt just prior to falling . Fall resulted in an injury to the resident: Left face laceration Our husband had a fall in front dining room door. was notified on 09/09/2024 6:15 PM [physician name redacted], MD was notified on 09/09/2024 6:30 PM with new orders received and entered in orders tab of record. Response: Care plan has been reviewed; no updates needed at this time. On 9/30/24, another fall progress note read in part, Fall event details: Fall was unwitnessed in residents' room [ROOM NUMBER]/29/2024 9:35 PM. Resident unable to describe the event and how they felt just prior to falling. Post fall evaluation: . [vital sign information redacted] .No injury noted at time of fall. wife was notified on 09/29/2024 9:40 PM Dr [name redacted] was notified on 09/29/2024 9:40 PM with no new orders received. Response: Care plan has been reviewed; no updates needed at this time. On 10/16/24, a fall progress note was entered into R12's chart that read in part, Fall event details: Fall was witnessed in residents room [ROOM NUMBER]/16/2024 10:00 PM Resident unable to describe the event and how they felt just prior to falling. Post fall evaluation: . [vital sign information redacted] .No injury noted at time of fall. [R12's wife's name redacted] was notified on 10/16/2024 10:00 PM [doctor's name redacted] was notified on 10/16/2024 10:00 PM with no new orders received. Response: Care plan has been reviewed and updated. Guest requires maximum assistance with his adls, bed mobility and transfers. On 10/25/24, another fall progress note was entered into R12's clinical record, which read in part, Fall event details: Fall was witnessed in residents room [ROOM NUMBER]/25/2024 12:00 AM. Resident unable to describe the event and how they felt just prior to falling. Post fall evaluation: .No injury noted at time of fall. [R12's wife's name redacted] was notified on 10/25/2024 9:30PM [doctor's name redacted], MD was notified on 10/25/2024 9:30 PM with no new orders received. Response: Care plan has been reviewed and updated. Guest requires maximum assistance with his adls. He limited assistance with bed mobility and ambulation. For each of the falls the clinical record failed to indicate the situational details of the fall, how the resident was found, and what the facility did in response to the falls. On 10/31/24, the facility staff were asked to provide the survey team with details of R12's falls and what was done in response to the falls. On the morning of 11/1/24, the survey team was provided with copies of R12's fall progress notes as noted above. The surveyor again asked for evidence to include the details of the falls and what interventions were put in place following the fall. On 11/1/24, in the early afternoon the survey team was provided with information and a document that had been typed to include the details of each fall and copies of the care plan which indicated appropriate interventions were put into place to prevent reoccurrence of falls following each incident. The resident assessment coordinator, who was a registered nurse was who had prepared the information with regards to R12's falls. When interviewed and asked if she had found the details within R12's clinical record, she said no. When asked if she would have expected such details to be part of the clinical record, she stated it should have been. On 11/1/24, in the afternoon an interview was conducted with the director of nursing (DON) and the surveyor shared the concern that R12's chart did not include the details of falls and the facility's response to show a clear picture of the events and the facility's response. The DON verbalized that she agreed, the details were not in the clinical record and should have been. The DON went on to state that she had provided education to nursing staff that they needed to be more descriptive and put the details of the falls/incidents in the clinical record of residents. On 11/1/24, about mid-afternoon, the administrator was made aware of the above findings. No additional information was provided. 4. For R7, who had eleven falls, some resulting in injury requiring transfer to the emergency room , the facility staff failed to document in the clinical record the details of the fall, how resident was found, and any contributing factors to the falls. On 10/29/24 at 10:47 a.m., during an interview with R7, the resident was observed to have bruising above her right eye and multiple bruises on her arms. On 10/30/24, during a clinical record review, it was noted that R7 had multiple falls and sustained significant injury on several occasions. The falls were noted to have occurred on 7/29/24, two on 8/5/24, 8/6/24, 10/4/24, 10/10/24, two on 10/14/24, 10/24/24, 10/25/24, and again on 10/30/24. Each of the falls documented that the fall was either witnessed or unwitnessed and the location of the fall such as living room, resident room, and dining room. The incidents gave no details as to contributing factors such as if the resident had shoes on, if the call bell had been engaged, or any interventions put in place to prevent reoccurrence. On 10/31/24, the facility administration was asked to provide the survey team with a timeline of R7's falls and the interventions implemented following each incident. On the morning of 11/1/24, the survey team was provided with copies of R7's fall progress notes, which noted no details. The surveyor again asked for evidence to include the details of the falls and what interventions were put in place following the falls. On 11/1/24, in the early afternoon, the resident assessment coordinator, who was a registered nurse, provided the survey team with a typed timeline of R7's falls. The information gave more detail to the incidents and provided R7's care plan with the associated interventions highlighted. The resident assessment coordinator, was asked if she had found the details within R7's clinical record, she said no. When asked if she would have expected such details to be part of the clinical record, she stated it should have been. On 11/1/24, in the afternoon an interview was conducted with the director of nursing (DON) and the surveyor shared the concern that R7's chart did not include the details of falls and the facility's response to show a clear picture of the events and the facility's response. The DON verbalized that she agreed, the details were not in the clinical record and should have been. The DON went on to state that she had provided education to nursing staff that they needed to be more descriptive and put the details of the falls/incidents in the clinical record of residents. On 11/1/24, about mid-afternoon, the administrator was made aware of the above findings. No additional information was provided. 49456 Based on resident interview, staff interview, clinical record review and facility documentation review the facility staff failed to ensure an accurate clinical record for 4 residents, Resident #20 (R20), Resident #177 (R177), Resident #7 (R7), and Resident #12 (R12), in a survey sample of 20 residents. The findings included: 1. The facility staff failed to complete an accurate care plan for Resident #20 (R20). On 10/30/24 in the evening, a review of the clinical record was conducted. During the review R20's care plan was to use a mechanical lift with bed mobility and transfers. R20's care plan also had that the resident could bear weight and transfer with the right boot on her lower extremity. On 10/31/24 at 10:31 a.m. an interview was conducted with R20. R20 stated, a mechanical lift had never been used here at this facility. On 10/31/24 at 10:32 a.m. an interview was conducted with the MDS (minimum data set) coordinator, RN#1 (RN1). RN1 accessed R20's care plan, reviewed it and verbalized that the care plan for R20 was not accurate with the transfer and bed mobility sections. RN1 stated, that this was not accurate and resolved the issue. On 10/31/24 at approximately 2:00 p.m. a review of the facility documentation was completed. The facility document titled, Individualized Care Plan, was read in part, .It is the policy of the community to develop a comprehensive, person-centered plan of care for each resident utilizing the information gathered during each assessment. The comprehensive care plan will include services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being. 2. The facility staff failed to document an injury of unknown origin in R177's clinical record. On 10/31/24 R177 was no longer a resident on the skill nursing unit, she had been discharged , so no interview was able to be conducted with her. On 10/31/24 at 11:13 a.m. an interview was conducted with licensed practical nurse #1 (LPN1). LPN1 verbalized that she was called into R177's room by certified nursing assistant #1 (CNA1). LPN1 stated, I reported an incident with a resident to the Administrator, the resident had two skin tears to her left extremity. LPN1 then stated, the skin tears were new. [name redacted] (CNA1) put in her notice and was cussing and yelling in front of the residents. LPN1 then verbalized that R177 said CNA1 was rough with her and the skin tears were fresh. LPN verbalized that CNA1 appeared mad at R177 about something and R177 apologized to CNA1. LPN1 stated, [name redacted] (CNA1) said to the resident, I don't want to hear that apology, and the resident began to cry. On 10/31/24 at 2:26 p.m. an interview was conducted with LPN1. LPN1 verbalized that when an incident was reported that you ask the staff and resident what happened, notify the family and doctor, put the incident in the risk connect, obtain an order for treatment, treat the area and do a health note in the clinical record. On 10/31/24 at 2:50 p.m. an interview was conducted with the acting director of nursing. The acting director of nursing stated, I expected all incidents to be charted in the clinical record by the nursing staff. On 10/31/24 at approximately 3:00 p.m. a clinical record review was completed. On 7/23/24 a weekly skin check note was completed and had no mention of any skin tears to left hand or elbow. On 7/28/24 an order for treatment was completed. The order reads, clean skin tear to left elbow and left hand with normal saline pat dry apply border gauze until healed. On 7/28/24 a skilled note was written by LPN1 and there was no mention of an incident with the skin tears. On 7/30/24 a weekly skin note was completed by RN1 and reads in part, .skin tear to left hand steri strips applied and foam dressing applied. On 7/30/24 a doctor's progress note was written. The note read in part, the skin tear on the left elbow happened by rubbing on the arm of the wheelchair. The note did not mention the skin tear to the left hand. On 11/01/24 at approximately 1:45 p.m. an end of day meeting was conducted with the administrator, the acting director of nursing, the general manager and the social worker. The above concerns were discussed. No additional information was provided.

Based on staff interview, clinical record review and facility documentation review, the facility staff failed to ensure residents were free from a significant medication error for one resident (Resident #7-R7) in a survey sample of 20 residents. The findings included: For R7, the facility staff failed to administer an antibiotic resulting in a two-day delay in the order being carried out and then resulting in multiple missed doses. On 10/29 and 10/30/24 a clinical record review was conducted of R7's chart. This review revealed R7 had a visit to the hospital on 10/25/24, following a fall where she sustained a laceration to the back of her head which required medical attention. R7 returned to the facility on [DATE]. According to the hospital records within R7's paper chart, the ED [emergency department] After Visit Summary dated 10/25/24, noted Reason for Visit: Fall. Diagnoses: Fall, initial encounter, Hematoma of scalp, initial encounter, Cystitis, Traumatic tear of thoracic aorta, initial encounter. That same form noted, Your medications have changed. Start taking: Cephalexin (Keflex). Pick up these medications from any pharmacy with your printed prescription. The actual prescription was in the chart and read, Cephalexin (Keflex) 250 mg/5ML suspension. Take 3 mL by mouth 4 times daily for 5 days. According to R7's medication administration record (MAR), the order was entered with a start date of 10/26/24. Two doses of the antibiotic on 10/26/24, were noted as not administered and had the code MD noted before the order was discontinued at 3:56 p.m. According to the Chart Codes/Follow Up Codes noted on the MAR, MD indicated medication pending delivery. According to the MAR and physician orders, the order for Cephalexin was entered again on 10/27/24, and indicated a stop date of 10/30/24 at 6:07 p.m., which indicated the antibiotic would be stopped after the resident received only 11 of the 20 scheduled doses. According to the MAR all four scheduled doses on 10/27/24, were coded as not given with the reason code medication pending delivery noted. On 10/25/24, there was a progress note entered by the medical director and attending physician of R7. According to the note, it read in part, .admitted to the hospital and treated for sepsis due to Staph epidermidis bacteremia. Patient was found to be hypothermic while hospitalized . Blood cultures were positive patient was started on vancomycin. Other etiologies of hypothermia were ruled out. Infectious disease was consulted who recommended 14-day course versus 6-week course of antibiotics. After goals of care discussion patient decided complete a 2- week course with PICC line placement . Patient seen today for follow-up . Additional Assessment and Plan: Patient is an [AGE] year-old female with past medical history of Parkinson's, MVC, recurrent falls, SAH, anemia, and osteoporosis who was admitted to the hospital and treated for sepsis due to Staph epidermidis bacteremia #. Sepsis due to staph bacteremia, - Complete antibiotics, - Monitor for symptoms . On 10/29/24 at 5:05 p.m., an interview was conducted with the acting director of nursing (DON). When asked what MD on the MAR indicated, the DON said, this means medication waiting for delivery. On 10/29/24 at 5:10 p.m., an interview was conducted with the registered nurse #3. When asked to explain the process when a resident returns from the emergency room or hospital, RN #3 said, a discharge summary comes with them, we call the doctor and go over it with him, we enter the orders in the computer. When we put the orders in the computer it sends to the pharmacy to be filled. When asked about the pharmacy, RN #3 stated that they send the discharge summary to the pharmacy via fax. The pharmacy has a STAT [urgent] run if you need them then, otherwise they deliver nightly, we have a box here that we can get some medications out of. RN #3 went on to say that we mark medicine pending delivery but when it comes, we go back and give it especially if it is a critical medicine, like an antibiotic, pain med or blood thinner. RN #3 was asked about R7's antibiotic for Cephalexin. LPN #1 explained that R7, was unresponsive when she first came back. During the above interview with RN #3, licensed practical nurse #1 (LPN #1) was present. LPN #1 went on to say, she [R7] was almost unresponsive when she left out of here, when she comes back, she is on puree diet, when arouses back up she wants her regular food. If medication is not available, we notify doctor it is not available, sometimes he will change to something we have, especially if antibiotic he will ask what you have available? LPN #1 went on to say that since R7 was ordered liquid antibiotics that would not be available in the on-site back-up supply of medications. The two nurses went on to report, [local retail pharmacy name redacted] didn't deliver it, so [facility contracted out of town pharmacy] was later getting it [the order]. We hate this pharmacy because they aren't local. On a good day they come twice a day, but if they don't have a driver, we get one delivery, on the weekends it is one delivery. We get the delivery about 6-7 p.m. and then night shift gets one around 12 midnight -1 am. On 10/30/24 at 8:26 a.m., an interview was conducted with the medical director/doctor (MD), who was also the attending physician for R7. When it was discussed that R7 had a delay in receiving the antibiotics, the MD said, the hospital ordered the antibiotic and sent it to [local retail pharmacy name redacted], they were waiting for it to be received. The surveyor discussed with the physician that due to the delay in starting the antibiotic the resident would not receive all ordered doses as the order was scheduled to end after only 11 of the 20 scheduled doses had been administered The MD said, I will have to extend the duration so that the resident receives all doses. On 10/30/24 at 5 p.m., during the end of day meeting, the facility administrator and DON were made aware of the above findings. The facility policy with regards to physician orders was requested. The DON went on to report that when the order for the antibiotic for R7 was entered into the electronic health record, the [local retail pharmacy name redacted] was selected as the pharmacy, so the order never actually made it to their pharmacy to fill. The DON stated that she had previously noticed that for some reason when some orders are entered, the system automatically defaults to the retail pharmacy versus the facility's contracted pharmacy. The DON stated that she has educated all nursing staff to be very mindful of this. When asked about the facility process to verify and/or review orders, the DON stated she reviewed them daily when she worked. On 10/31/24, the facility administration reported they had no policy regarding physician orders. The DON confirmed that the expectation would be that orders be carried out when given by the doctor. No additional information was provided.

Based on staff interviews and facility documentation review, the facility staff failed to provide as part of their Quality Assurance and Performance Improvement (QAPI) program mandatory training for five employees (certified nursing assistants- CNA #1, #4 and #5, licensed practical nurse LPN #4, and registered nurse RN #2) in a sample of five staff members reviewed for educational requirements. The findings included: On 10/31/24, a survey sample of five staff members was selected for review of their education and training. The sample included: CNA #1, CNA #4, CNA #5, LPN #4 and RN #2. The facility administration was given the names and asked to provide all evidence of education and training provided to those employees for the past two years. On 11/1/24, the general manager (GM) provided the survey team with transcript reports of education for each of the five sampled staff. The GM was asked if all the staff education is conducted as computer-based training and the GM stated that it was, and the facility used Relias for staff training. The GM also confirmed that they have a training calendar which included mandatory trainings staff had to complete each month. Review of the Annual Training Assignments/ 2024 Annual Training Calendar and Skilled Nursing Annual Training Online 2023 documents were reviewed. According to the 2023 training outline QAPI training was to be completed by all team members in January 2023. According to the 2024 training calendar, no QAPI training was listed. Review of the educational training for each of the five sampled employees was reviewed. None of the five employees had received any QAPI training in 2023 or 2024. On 11/01/24 at 11:21 a.m., an interview was conducted with the facility administrator. The administrator was asked to tell the surveyor about staff education with regards to their QAPI program and plan. The administrator said, we generally will have monthly meetings with them and go over pertinent topics such as if we have an increase in falls and ask for any input, they have with regards to possible ways to decrease them or ways to prevent them or if they have noticed anything. When asked when the monthly meetings were held, the administrator said, usually on Wednesday towards the end of the month. When the surveyor asked to see the minutes from the last six months of meetings, the facility administrator provided the surveyor with the QAPI book. It was noted that QAPI meetings were held monthly and included only management level staff and the medical director. A follow-up interview was conducted with the facility administrator who confirmed that only management level staff were in attendance at the QAPI meeting. When informed the surveyor was attempting to determine the facility's compliance with the regulation that the facility must include as part of its QAPI program mandatory training that outlines and informs staff of the elements and goals of the facility's QAPI program. On 11/1/24 at 1:45 p.m., the facility administrator and management staff were made aware of the above findings. No additional information was provided.

Based on staff interview and facility documentation review, the facility staff failed to respond timely to a clinical record request for 1 resident of 20 residents, resident #26 (R26). The findings included: For R26, whose power of attorney requested copies of the resident's clinical record, the facility staff failed to fulfil the request for over six weeks. On 11/1/24, a closed clinical record review was conducted of R26's chart. This review revealed no information with regards to a request for clinical records being made. On 11/1/24 at 9:49 a.m., an interview was conducted with the medical records employee. The medical records employee reported that the process when a person requests medical records is that they fill out a form, it is forwarded to the records management team and documents are uploaded for them to review. Once approval is received from the records management team, she releases the requested records. The medical records employee reported she had only been in the role about two months and therefore had no knowledge of a request for records involving R26. On 11/1/24 at approximately 10:15 a.m., the medical records employee reported to the surveyor that the social worker had handled the request for records involving R26. On 11/1/24 at approximately 10:30 a.m., an interview was conducted with the social worker. The social worker was able to go through her emails and confirmed that a request for records involving R26 was made 12/21/2023. The social worker also provided copies to the survey team where the records were shipped to R26 and received on 2/3/24. When asked about the timing of such requests the social worker said that the process of the request going through the records management and the legal team but we try to do it within a 2-week period. The Social worker confirmed that R26's family member who requested the records was the power of attorney and provided the surveyor with a copy of the power of attorney. On 11/1/24, the facility's policy regarding medical record requests was requested. The policy titled; Record Requests was reviewed. According to the policy as part of a foot note, it read, 42 CFR [code of federal regulation] 483.10(b)(2) states that access to records must be provided within 24 hours (excluding weekends and holidays) and copies within two business days. On 11/1/24 at 1:45 p.m., during an end of day meeting held with the facility administrator, acting director of nursing and corporate staff, the above findings were reviewed. No additional information was received.

Based on resident interview, staff interview, clinical record review, and facility document review, the facility failed to implement Quality Assurance and Performance Improvement (QAPI) policy for abuse and failed to implement abuse policy regarding an allegation of abuse and injury of unknown origin for one of 20 residents (Resident #7). The Findings Include: 1. The facility did not communicate or monitor feedback of allegations of abuse during QAPI meetings as directed in the QAPI policy. Review of facility reported incidents indicated that the facility reported an allegation of abuse between a staff member and two residents on 10/2/24. Review of the facility QAPI policy read in part 4. The SNA/designee [skilled nursing administrator] will maintain documentation and demonstrate evidence of its ongoing QAPI program. Documentation may include. but is not limited to: b. Systems and reports demonstrating systematic identification, reporting, investigation,analysis, and prevention of adverse events. [ .] The community maintains procedures for feedback,data collection systems, and monitoring, including adverse event monitoring [ .] Date sources may include, but not limited to: viii. Reportable events, including reports of adverse events or abuse, neglect, or exploitation. On 11/1/24, review of the facility QAPI meeting minutes conducted on 10/23/24 did not indicate abuse allegations were monitored or discussed during the meeting. On 11/1/24 at 10:50 a.m. the administrator was interviewed regarding the above finding. The administrator reviewed the QAPI meeting minutes and agreed there was no documentation evidencing communication or monitoring of abuse. No there information was provided prior to exit conference on 11/1/24. 41449 For resident #7 (R7) who reported an allegation of abuse, the facility staff failed to implement their abuse policy as evidenced by failure to report the allegation timely to the required regulatory agencies and other agencies, and to initiate an investigation. On 10/29/24 at 10:47 a.m., during an interview with R7 she reported the staff are rough when they help you to stand up or change your diaper. When R7 was asked about the bruising to her right wrist, the resident said, they are very rough. On 10/29/24 at 10:51 a.m., following the above interview with R7, the surveyor was unable to locate the facility administrator to report the allegation. The surveyor then made the acting director of nursing (DON) aware of the allegation. On the evening of 10/29/24, a clinical record review was conducted of R7's chart. There was no documentation with regards to the bruising on the interior of R7's right wrist and the bruising noted. There was a progress note entry dated 10/29/24 at 11:14 a.m., by the DON that read, ADNS [acting director of nursing services] was asked to follow up on resident statement that when she was asked how she got the bruise on her wrist, she stated staff was sometimes rough with her during care. ADNS approached resident in her room; she was observed lying in bed with eyes closed. I asked her how she was feeling and she responded sleepy. When I asked her how she got the bruise on her wrist, she hesitated to answer and said, I don't know . I asked her if she wanted any covers and she said, no. I just want to rest. I ensured bed was in low position, fall mat on floor beside bed, wheelchair in locked position, and call bell within reach prior to leaving the room. Will follow up with resident when she is awake. On 10/30/24 at 11:12 a.m., a follow-up interview was conducted with the DON. When asked about any follow-up with regards to R7 and the allegation reported by the surveyor, the DON said, I think I put a note in, I went in and she had put herself to bed, I was trying to make sure she was centered on the bed better, she is very hard of hearing, I asked if felt ok, she said yes, I asked if she was sleepy she said yes. I asked her, can you tell me how you got that bruise? She said, I don't know, she was very tired and very lethargic, I left it alone, I lowered the bed and put the fall mat down. I went and checked on her later and she was in a meal. I talked to her, she was up this morning, she wasn't answering questions appropriately . During the above interview with the DON, she was asked how they handle abuse allegations. The DON said, we investigate, we ask, we talk to the resident and then talk to whomever it involved and just kind of evidence based, if it was, they were rough with me, we would do a skin assessment as well. The DON asked, was that done for her [R7]? The DON said, yeah, she has had recent skin assessments. I looked at her yesterday and she has had the something there it wasn't anything new. On 10/30/24 at 3:17 p.m., an interview was conducted with the administrator. When asked how they respond to allegations of abuse, the administrator stated, As soon as we are notified, we begin the questioning. When asked, what if the resident doesn't repeat what was reported? The administrator said, I would ask other residents if they had any issues, talk to team members. We can talk to their family and see if they mentioned it to them. When asked if any of this is reported, the administrator said, It should be because it is an allegation of abuse. When asked if she had any abuse reports in process, the administrator said, I do not. The surveyor asked the administrator if she was aware of the allegation reported by the surveyor to the DON involving R7, the administrator said, She [the DON] did say you [the surveyor] had talked to her about an area on [R7's name redacted]'s wrist or hand and she went and talked to [R7] and got a very different answer. I believe she went back and talked to her again and she had no complaints of staff. She brought all that to me. The administrator acknowledged that R7's allegation had not been reported to the required agencies and nothing was in process. On 10/31/24 at 11:30 a.m., the survey team reviewed facility documentation, which indicated R7's report of an allegation of abuse was reported as an injury of unknown origin following the surveyor questioning the facility administrator about reporting the allegation of abuse involving R7 on 10/30/24. On 10/31/24, following identification of immediate jeopardy in another tag, the facility administrator reported R7's report of staff being rough as an allegation of abuse. Review of the facility's policy titled, Abuse, Neglect & Exploitation- Prevention, Reporting and Investigation was conducted. The policy read in part, . 4. Every team member is a mandated reporter and has the duty to report known or suspected abuse, neglect and/or exploitation to local and state authorities in accordance with applicable law and regulation. a. These authorities may include law enforcement, the licensing regulator, the long-term Care Ombudsman and/or adult protective services. The report of abuse, neglect or exploitation must be made within the time frames and through the format required by applicable law and regulation. b. Allegations of or suspicions of abuse, neglect and/or exploitation are to be reported . On 10/31/24 at 4:30 p.m., when the facility administrator, director of nursing and corporate staff was notified of the failure to implement their abuse policy with regards to R7. On 11/1/24, the survey team was provided evidence that the facility reported R7's allegation of abuse to the appropriate agencies to include the state survey agency and adult protective services. No further information was provided.

For Resident #7 (R7) who made an allegation of abuse/mistreatment, the facility staff failed to report the abuse allegation to the required agencies timely. On 10/29/24 at 10:47 a.m., during an interview with R7 she reported the staff are rough when they help you to stand up or change your diaper. When R7 was asked about the bruising to her right wrist, the resident said, they are very rough. On 10/29/24 at 10:51 a.m., following the above interview with R7, the surveyor was unable to locate the facility administrator to report the allegation. The surveyor then made the acting director of nursing (DON) aware of the allegation. On the evening of 10/29/24, a clinical record review was conducted of R7's chart. There was no documentation with regards to the bruising on the interior of R7's right wrist and the bruising noted. There was a progress note entry dated 10/29/24 at 11:14 a.m., by the DON that read, ADNS [acting director of nursing services] was asked to follow up on resident statement that when she was asked how she got the bruise on her wrist, she stated staff was sometimes rough with her during care. ADNS approached resident in her room; she was observed lying in bed with eyes closed. I asked her how she was feeling and she responded sleepy. When I asked her how she got the bruise on her wrist, she hesitated to answer and said, I don't know . I asked her if she wanted any covers and she said, no. I just want to rest. I ensured bed was in low position, fall mat on floor beside bed, wheelchair in locked position, and call bell within reach prior to leaving the room. Will follow up with resident when she is awake. On 10/30/24 at 11:12 a.m., a follow-up interview was conducted with the DON. When asked about any follow-up with regards to R7 and the allegation reported by the surveyor, the DON said, I think I put a note in, I went in and she had put herself to bed, I was trying to make sure she was centered on the bed better, she is very hard of hearing, I asked if felt ok, she said yes, I asked if she was sleepy she said yes. I asked her, can you tell me how you got that bruise? She said, I don't know, she was very tired and very lethargic, I left it alone, I lowered the bed and put the fall mat down. I went and checked on her later and she was in a meal. I talked to her, she was up this morning, she wasn't answering questions appropriately, she had a fall again last night, they are talking to hospice to see what else we can do to help her, she sustained a laceration on the back of her head, right wrist had an old bruise that had separated from the skin, asked how she got that and she didn't answer appropriate to the question. She mentioned something off the wall, I don't know what it was. During the above interview with the DON, she was asked how they handle abuse allegations. The DON said, we investigate, we ask, we talk to the resident and then talk to whomever it involved and just kind of evidence based, if it was, they were rough with me, we would do a skin assessment as well. The DON asked, was that done for her [R7]? The DON said, yeah, she has had recent skin assessments. I looked at her yesterday and she has had the something there it wasn't anything new. On 10/30/24, an additional clinical record review was conducted of R7's medical record. This review revealed a note dated 10/24/24, that was titled, Weekly Skin Check Note. The note read, Multiple bruising noted on face and head. Several staples noted on right side of head. Guest is currently resting in her room with no distress. Another skin check note dated 10/17/24 read, no new areas of concern to skin, has bruising to face from previous fall as well as skin tear with steri- strips to left hand from previous fall, skin otherwise intact, uncooperative with skin checks. There was no mention to a bruise to the interior of the right wrist. On 10/30/24 at 3:17 p.m., an interview was conducted with the administrator. When asked to define abuse, the administrator stated, anything that is physical, allegations of abuse can be physical, if being verbally talked down to or in a negative way. Of course there would be the misappropriation of funds. It is the resident's perception of anything negative that happens to them. When asked how they respond to such allegations, the administrator said, we initially go talk to the resident and ask them to define rough, it depends on their definition of rough. If their definition is rough, we talk to the team member, talk to other residents. Depending on the severity we may suspend them pending investigation. As soon as we are notified, we begin the questioning. When asked, what if the resident doesn't repeat what was reported? The administrator said, I would ask other residents if they had any issues, talk to team members. We can talk to their family and see if they mentioned it to them. When asked if any of this is reported, the administrator said, It should be because it is an allegation of abuse. When asked if she had any abuse reports in process, the administrator said, I do not. The surveyor asked the administrator if she was aware of the allegation reported by the surveyor to the DON involving R7, the administrator said, She [the DON] did say you [the surveyor] had talked to her about an area on [R7's name redacted]'s wrist or hand and she went and talked to [R7] and got a very different answer. I believe she went back and talked to her again and she had no complaints of staff. She brought all that to me. The administrator acknowledged that nothing involving R7 had been reported to the required agencies and nothing was in process. On 10/31/24 at 11:30 a.m., the survey team reviewed facility documentation, which indicated R7's report of an allegation of abuse was reported as an injury of unknown origin following the surveyor questioning the facility administrator, about reporting the allegation of abuse, involving R7 on 10/30/24. On 10/31/24 in the afternoon, following identification of immediate jeopardy in another tag, the facility administrator reported R7's report of staff being rough as an allegation of abuse. Review of the facility's policy titled, Abuse, Neglect & Exploitation- Prevention, Reporting and Investigation was conducted. The policy read in part, . 4. Every team member is a mandated reporter and has the duty to report known or suspected abuse, neglect and/or exploitation to local and state authorities in accordance with applicable law and regulation. a. These authorities may include law enforcement, the licensing regulator, the long-term Care Ombudsman and/or adult protective services. The report of abuse, neglect or exploitation must be made within the time frames and through the format required by applicable law and regulation. b. Allegations of or suspicions of abuse, neglect and/or exploitation are to be reported . On 10/31/24 at 4:30 p.m., when the facility administrator, director of nursing and corporate staff was notified of the failure to report R7's allegation of abuse timely and accurately. On 11/1/24, the survey team was provided evidence that the facility reported R7's allegation of abuse to the appropriate agencies to include the state survey agency and adult protective services. No further information was provided. 49456 Based on resident interviews, staff interviews, clinical record review, and facility documentation review, the facility staff failed to report an allegation of abuse and injuries of unknown origin involving two residents, Resident #177 (R177) and Resident #7 (R7), in a survey sample of 20 residents. 1. The facility staff failed to report a skin tear to R177's left hand, which was an injury of unknown origin. On 10/31/24 R177 was no longer a resident on the skill nursing unit, she had been discharged , so no interview was able to be conducted with her. On 10/31/24 at 9:15 a.m. an interview was conducted with the administrator. The administrator verbalized that all staff should know to report abuse immediately. The administrator was unable to recall any allegations reported to her pertaining to abuse prior to 10/1/24. The administrator did also state that injuries of unknown origin have to be reported and could be an indication that abuse has occurred. On 10/31/24 at 11:13 a.m. an interview was conducted with a staff member who expressed a desire to remain anonymous. The anonymous staff (AS1) verbalized that she was called into R177's room by certified nursing assistant, CNA1. AS1 stated, I reported an incident with a resident to the Administrator, the resident had two skin tears to her left extremity. AS1 then stated, the skin tears were new. AS1 said, [CNA1's name redacted] said to the resident, I don't want to hear that apology, and the resident began to cry. On 10/31/24 at 2:20 p.m. an interview was conducted with LPN1. LPN1 verbalized that when there was an allegation of abuse made, that they find out who was abusing them, would separate them, and if a staff member was the abuser, they would send the staff member home. LPN1 stated, I would report it to the administrator, or the acting director of nursing and that the administrator was the abuse coordinator. On 10/31/24 at 2:28 an interview was conducted with CNA#3 (CNA3). CNA3 verbalized that if she needed to report abuse that she would report to the charge nurse and to the administrator. CNA3 verbalized that if the administrator is not in the building that she would report it to the acting director of nursing. On 10/31/24 at 2:26 p.m. an interview was conducted with LPN1. LPN1 verbalized that when an incident was reported that you ask the staff and resident what happened, notify the family and doctor, put the incident in the risk connect, obtain an order for treatment, treat the area, and do a health note in the clinical record. On 10/31/24 at 2:51 p.m. an interview was conducted with the administrator and with the regional director of resident care. The administrator stated, we do our incidents in a separate portal, and it is not like a incident report. The regional director of resident care stated, we review all our incidents, falls, behaviors, medication errors, pressure ulcers and skin tears. The administrator verbalized that the incidents cannot be printed out from this portal. The regional director of resident care verbalized that we follow a process, and it is managed by our legal team. She stated, The legal team is our second QAPI [quality assurance and performance improvement] and monitor to make sure we do everything. The surveyor then requested proof of an investigation being conducted for the skin tear on R177's left hand. On 10/31/24 an employee that wanted to remain anonymous showed the surveyor a text message that was sent to the administrator on 7/28/24 and the text message read, I really need to talk to you. The employee stated, I reported the incident of [R177's name redacted] skin tears and of her complaining that CNA1 was rough with her. The employee stated that the administrator response was, to be careful of what you are saying and accusing people of. The employee then stated, I never heard anything else about the incident and assumed nothing was done. On 10/31/24 at approximately 3:00 p.m. a clinical record review was completed. On 7/23/24 a weekly skin check note was completed and had no mention of any skin tears to R177's left hand or elbow. On 7/28/24 an order for treatment was completed. The order read, clean skin tear to left elbow and left hand with normal saline pat dry apply border gauze until healed. On 7/28/24 a skilled note was written and there was no mention of an incident with the skin tears. On 7/30/24 a weekly skin note was completed by RN1, and it read in part, .skin tear to left hand steri strips applied and foam dressing applied. On 7/30/24 a doctor's progress note was written. The doctor's note read in part, .the skin tear on the left elbow happened by rubbing on the arm of the wheelchair . The note did not mention the skin tear to the left hand. On 11/1/24 at 10:00 a.m. an interview was conducted with the administrator. The administrator verbalized that she was never made aware of the allegation of abuse that happened on 7/28/24. The administrator stated, No one called me and made me aware. The general manager was manager on duty that day. Staff will contact me when I am not the manager on duty. On 11/1/24 at 10:37 a.m. an interview was conducted with LPN#3 (LPN3). LPN3 stated, If an allegation of abuse needed to be reported I would report it to the administrator, acting director of nursing and the social worker. If it is a weekend when they are off, I would call or text them to report it to them. On 10/31/24 and 11/1/24 a request was made by the surveyor for the facility to provide evidence that an investigation was conducted for the skin tear that R177 obtained. On 11/1/24, mid-morning, the surveyor had not received any information, so another request for it was made to the administrator. Upon departure of the facility, no evidence of an investigation was provided to the surveyor. On 10/31/24 a facility document was reviewed. The facility documentation was titled, Abuse, Neglect, and Exploitation-Prevention, Reporting and Investigation, read in part, Duty to report. Every team member is a mandated reporter and has a duty to report known or suspected abuse, neglect, and/or exploitation to local and state authorities in accordance with applicable law and regulation. a) these authorities may include law enforcement, the licensing regulator, the ling term care ombudsman, and/or adult protective services. The report of abuse, neglect or exploitation must be made within the timeframes and through the format required by applicable law and regulation. b) allegations of or suspicions of abuse, neglect and/or exploitation are to be reported. On 11/01/24 at approximately 1:45 p.m. an end of day meeting was conducted with the administrator, the acting director of nursing, the general manager and the social worker. The above concerns were discussed. No additional information was provided.

Based on resident interview, staff interview, facility documentation review, and clinical record review, the facility staff failed to complete a thorough investigation for an allegation of abuse for three residents, Resident #5 (R5), Resident #20 (R20), and Resident #177 (R177), in a survey sample of 20 residents. The findings included: 1. For R5 and R20 who reported an allegation of abuse, the facility staff failed to provide evidence that a thorough investigation to include interviews with other residents to determine if they may have been affected. According to the personnel records, the alleged perpetrator was terminated for abuse, but the facility administrator noted that the allegation of abuse was unsubstantiated. Following the abuse report, some facility staff were educated on customer service. On 10/29/24, a clinical record review was conducted of R5's chart, which noted the resident had discharged and was no longer a resident of the facility. Therefore, an interview could not be conducted with R5. On 10/29/24 at 9:08 a.m., an interview was conducted with R20. R20 said, [Certified nursing assistant #1's name redacted] treated me like slapping the pigs. I reported it to the social worker and talked with her about it. R20 said, The aide was rough with me and I didn't like it. R20 stated she was at the facility until her leg heals and she can get back to her home. R20 stated they [facility staff] were responsive to her concern, and she never saw CNA1 again after the incident. R20 said, I am limited to what I can do due to my broken leg. On 10/30/24 at 11:00 a.m., an interview was conducted with the social service director (SSD). The SSD stated she had interviewed R5 and R20, who were roommates. SSD stated that R20 had stated that CNA1 was rough with her during daily care and in the shower room. The SSD stated that R5's complaint was that CNA1 was being rough with her during morning care and in applying her brace. The SSD said, [R5's name redacted] and [R20's name redacted] verbalized that they were not scared or nervous, just didn't want [CNA1's name redacted] as an aide anymore. The SSD said, More residents complained about this aide over time, but not that specific day. On 10/30/24 at 11:15 a.m., an interview was conducted with the acting director of nursing (DON). The acting DON stated that she was not involved in the interview process with the residents. The acting DON stated that she completed a skin assessment on R5 and R20 and found no changes with their skin assessments. When asked about other residents to whom CNA1 had provided care, the acting DON stated that she only did skin checks on those two residents on the nursing unit. On 10/30/24 at 2:50 p.m. an interview was conducted with the administrator. When asked about the abuse allegations against CNA1, the administrator stated that an employee from third shift had reported the abuse allegation to her as soon as she entered the building on 10/1/24, adding that she arrives to work between 8:00 a.m. to 8:15 a.m. every morning. The administrator stated that she could not recall the identity of the third shift staff member that reported the allegation of abuse to her. The administrator stated, It was such an ordeal with CNA1. She was calling me all kinds of names. The administrator stated that she discussed the allegation of abuse with the administrative staff, so they would know what happened, and then sent CNA1 home, pending the results of the abuse investigation. The administrator that stated she had the acting DON to do skin checks on the two residents, provide education to staff, and had the SSD talk with R5 and R20 about the incident. On 10/31/24 at 8:40 a.m., another interview was conducted with the SSD. The SSD stated that she documented her interviews with R5 and R20 in a word document but was unable to locate the document. The SSD stated she was unable to recall the names of the other residents that had complained about CNA1, but that the residents were on the same hallway as R5 and R20. The SSD said, [Administrator name redacted] asked me to interview the other residents who had complaints about [CNA1's name redacted] being rough with them with care. The SSD stated that she reported the interviews to the administrator, and that she was unaware of what was done about those additional complaints. The SSD stated that the complaints and interviews with other residents were performed prior to the complaints received from R5 and R20's. The SSD was unable to recall who the residents were that had complained about CNA1 and had no evidence of the interviews she conducted with them nor any record of their concerns. On 10/31/24 at 9:15 a.m., an interview with the administrator was conducted. Providing requested facility documentation, the administrator said, Not all nursing staff is on this in-service; we are missing two part-time college students and some from the third shift that's not on this education. The administrator stated that after she came into work on 10/1/24, a dayshift aide, CNA#7 (CNA7) approached her and reported the allegation of abuse. The administrator stated CNA7 was a new aide and was scared and tearful over the incident. The administrator stated that CNA7 came to her after breakfast to report the allegation of abuse. The administrator stated that she discussed the allegation with her supervisor and then CNA1 was pulled off the nursing unit. CNA1's timecard was reviewed and showed that CNA1 clocked out of the facility at 10:45 a.m. on 10/1/24. The administrator said, [CNA1's name redacted] could be abrupt with communication when she is upset. [CNA1's name redacted] was terminated for her behavior toward us [staff/administration]. When [CNA1's name redacted] was leaving, she was disruptive in the hallway on the nursing unit and in front of the residents. On 10/31/24 at 11:30 a.m., an interview was conducted with the MDS (minimum data set) coordinator, who was a registered nurse. The MDS coordinator had written a witness statement on 10/1/24 that read, While reviewing baseline care plan with resident, [R5's name redacted] on 9/30/24, she told me that her nurse's aide that morning had been rough with her. She stated that while putting her TLSO (thoracic-lumbar-sacral orthosis) brace on, she was rough. When asked, the MDS coordinator identified the CNA as being CNA1. The MDS coordinator said, I told her I would talk to the person who supervises the CNAs about it, and she expressed fear of retribution from the CNA. I assured her that she was safe. The MDS coordinator stated that she reported this to the administrator on 9/30/24. No report was made for R5 and R20's allegation of abuse until 10/1/24 at 3:34 p.m. On 10/31/24 at 5:00 p.m., a follow-up interview was conducted with R20. R20 said, Early morning, I like to go out and watch things come to life and [CNA1's name redacted] came out stood by me just looking at me and never spoke to me. I did feel intimidated by her. Then R20 said, During the bed bath [CNA1's name redacted] took a washcloth and slapped me, like you would take a mop and sling it down. I have dogs and would not wash them like that. Then R20 said, When she hit me with this washcloth, I felt I wasn't human, subhuman, and I cannot understand anyone doing this to someone! This verbiage, you can tell, is coming from a teacher. R20 stated that the acting DON did complete a skin assessment and found two small bruises on her legs and back. Then R20 said, I cried and was trying to catch my breath. I was appalled that someone would be that way. The social worker let me talk. I reported it and thought it would end there, but the social worker said no. I wish the aide still had a job but not with humans. I cried when I told the social worker the story and didn't see any reason for this, over a bath. It was like a nightmare. On 10/31/24, a review of facility documentation was conducted. The incident summary of these allegations of abuse perpetrated by CNA1 read in part, .based on the assessments and investigation, the allegations were unsubstantiated. On 10/31/24, a review of witness statements in CNA1's personnel file about the allegations of abuse was conducted. The first witness statement was from CNA7. Dated 10/1/24, CNA7's witness statement read in part, .this morning two residents stated to me that [CNA1's name redacted] has been very rough and hurting them during her care. The two residents were [R20's name redacted] and [R5's name redacted]. I brought [R5's name redacted] to the dining table for breakfast she was trying to talk to me about [CNA1's name redacted] and [CNA1 name redacted] said to the resident, Do you have something you need to say to me, in a smart tone. The second witness statement was written by the administrator on 10/1/24 and read in part, .This writer had to suspend [CNA1's name redacted], pending an investigation after complaints from 2 separate residents regarding her care for them. The SSD also wrote a witness statement, which read, This writer spoke with [R5's name redacted] and [R20's name redacted]. [R5's name redacted] reported that [CNA1 name redacted] was 'rough' with her during morning care yesterday morning. She had to have a brace on while lying down and [CNA1's name redacted] wouldn't put it on, getting her dressed instead and was rough with her. [R20's name redacted] reported that [CNA1's name redacted] was rough with her during shower care, . not gentle, slapping the washcloth on her and she felt intimidated by her standing there. On 10/31/24, CNA1's personnel file was reviewed. The facility document titled, Performance Counseling and Improvement Plan for Correction Action, read in part, .Termination Written. Reason for Counseling 1. Policy/company rules not followed: Abuse or neglect of a resident, Date and Time: [DATE]. 2. Policy/company rules not followed: Failure to work in a cooperative manner. Date and Time: 9/26/24 . This document was signed by the administrator, the general manager, and a witness on 10/7/24. On 11/1/24 at 9:09 a.m., another interview was conducted with the SSD. The SSD said, The resident [R20] was tearful when telling me the story about what happened with the aide. The SSD stated that she never asked R20 how the actions from CNA1 made her feel. On 11/1/14 at 10:28 a.m., an interview was conducted with a physical therapist. The physical therapist said, [R5's name redacted] was more subjective and was guarded with her language. She [R5] stated to me that her roommate was upset about being struck in the shower, which indicated physical contact to me. The physical therapist stated that she questioned R5 about R20 striking the aide and R5 stated no, it was the other way around, the aide struck her. The physical therapist said, I told [R5's name redacted] I needed to report this to my supervisor, and she may want to speak with you to get your feedback. 2. The facility staff failed to investigate an injury of unknown origin for R177's skin tear to her left hand. On 10/31/24 at 11:13 a.m., an interview was conducted with a staff member who expressed a desire to remain anonymous. The anonymous staff (AS1) verbalized that she was called into R177's room by certified nursing assistant, CNA1. AS1 stated, I reported an incident with a resident to the Administrator, the resident had two skin tears to her left extremity. AS1 then stated, The skin tears were new. AS1 said, [CNA1's name redacted] said to the resident, I don't want to hear that apology, and the resident began to cry. On 10/31/24 at approximately 3:00 p.m., a closed record review was conducted. Documentation included a physician's order for R177, dated 7/28/24, for treatment which read, Clean skin tear to left elbow and left hand with normal saline pat dry apply border gauze until healed. Also dated 7/28/24, a skilled nursing note was documented, but there was no mention of an incident or the skin tears that R177 had suffered. Documented on 7/30/24, a weekly skin note was completed by RN1 and read in part, .skin tear to left hand steri strips applied and foam dressing applied. Dated 7/30/24, a doctor's progress note read in part, the skin tear on the left elbow happened by rubbing on the arm of the wheelchair. The note did not mention the skin tear to the left hand. On 10/31/24, an employee (AS1) that wanted to remain anonymous showed the surveyor a text message that was sent to the administrator on 7/28/24, which read, I really need to talk to you. AS1 stated, I reported the incident of [R177's name redacted] skin tears and of her complaining that CNA1 was rough with her. AS1 stated that the administrator's response was to be careful of what you are saying and accusing people of. AS1 then stated, I never heard anything else about the incident and assumed nothing was done. On 10/31/24, a request was made for the facility to provide evidence of an investigation for the skin tears that R177 had suffered, or how the facility determined it had been caused. On 10/31/24, a review of facility documentation was conducted. The facility document titled, Abuse, Neglect and Exploitation - Prevention, Reporting and Investigation, read in part, .Protecting the resident. In addition, to initial Mandatory reporting, to ensure the safety and protection of residents, any team member who know of or suspect abuse, neglect or exploitation of a resident must also immediately notify the ED/SNA/designee. The SNA/designee: a) upon receiving notification of any known or suspected abuse, neglect, or exploitation of a resident contacts the licensed nurse who evaluates the resident and provides the necessary intervention, for example, calls 911 if emergent. b) Removes the individual alleged to be involved in the abuse, neglect or exploitation from the area. i. ensure that any team member alleged to be involved in the abuse, neglect or exploitation is placed on administrative leave, pending the results of the investigation. ii. Ensures that non-team members alleged to be involved in the abuse, neglect or exploitation will be asked to leave the resident area and await further instructions. c) ensures that the resident's (i) physician, (ii) legal representative and (iii) family member or other individual regularly involved in the residents day to day care are notified as soon as practicable within timeframes established within laws/regulations .Investigation: The SNA/designee: Validates that the mandatory report of known or suspected abuse, neglect or exploitation has been made to the applicable authorities in accordance with state/federal requirements. The SNA/designee manage and directs the investigation of all abuse, neglect and/or exploitation. The SNA/designee implements corrective actions as indicated by the results of the investigation. If a written report of the investigation findings is required by applicable law or regulation, the SNA completes such report and ensures that it is submitted timely. On the morning of 11/1/24, the evidence was again requested from the administrator to indicate that that an abuse investigation had been conducted or that the cause of R177's multiple injuries had been determined, but no documentation of either was provided. On 11/01/24 at approximately 1:45 p.m., an end of day meeting was conducted with the administrator, the acting director of nursing, the general manager, and the social worker, during which the above concerns were discussed. No additional information was provided prior to survey exit.

Based on observation, staff interview, clinical record review, and facility documentation review, the facility staff failed to adequately develop a comprehensive care plan to address the behavioral health care needs for one resident (Resident #7 - R7), in a survey sample of 20 residents. The findings included: For R7, who had a diagnosis of dementia, had documented behaviors, and was given psychotropic medications on a scheduled/routine basis, the facility staff failed to develop a comprehensive care plan to include the routine use of psychotropic medication with the targeted behaviors being treated, as well as how facility staff were to provide routine care in the presence of behaviors. On 10/29/24 at 10:47 a.m., R7 was visited and interviewed in her room. R7 was noted to be very hard of hearing but was able to engage in conversation and interview appropriately. R7 displayed no behaviors during the interview. On 10/29/24-10/30/24, a clinical record review was conducted. This review revealed that R7 had a diagnosis of dementia and an active order, that read, Haloperidol Lactate Oral Concentrate, give 0.5 mg by mouth two times a day for restlessness. Prior to that order, documentation indicated that R7 had the Haloperidol ordered to be given every 4 hours as needed for anxiety. According to R7's comprehensive care plan, there was a focused care area that was developed 8/2/24 and last revised on 9/3/24, which indicated R7 was on a psychotropic medication, but there was no indication for the reason the psychotropic medication was being used, nor for what behaviors or side effects that staff should be monitoring. Neither did the care plan include measurable goals or projected reduction/endpoint for the psychotropic medication. The only care area of R7's care plan noting behaviors was labeled as an elopement risk/wanderer that read, The resident is/has potential to be verbally aggressive, verbally refusing care, calling staff names stupid r/t [related to] dementia. The two interventions listed for this focus areas read as Wonder guard to left ankle and Offer resident choice during care and activities. (SIC) This comprehensive care plan did not include any clear documentation of R7's behaviors that required management by psychotropic medication, nor were any non-pharmocological interventions listed on how staff were to approach and provide daily care in the presence of behaviors. On 10/31/24 at 6:13 p.m., an interview was conducted with the acting director of nursing (DON). When asked about the targeted behaviors for R7, the acting DON stated that staff should be monitoring for behaviors and documenting as such. On 10/31/24 at 7:31 p.m., another interview was conducted with the acting DON. When again asked about R7's behaviors, the acting DON stated that R7 had agitation and aggression. She stated that R7's behaviors included, Hallucinations, delusions, and she is always bending down in the wheelchair. She [R7] is almost blind and doesn't see very well. She will say where did my husband go, he was right here. She is normally very calm, but she was pushing away the aide trying to deliver care; very unusual behavior. According to the facility policy titled, Individualized Care Plan which read in part, . 4. The IDT [interdisciplinary team] develops comprehensive care plan addressing the resident's most acute problems. The comprehensive care plan will include a. services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial wellbeing . d. Support the behavioral health care needs, identified in the comprehensive assessment . On 11/1/24, during an end of day meeting, the facility administrator and other management staff in attendance, were made aware of the above findings. No additional information was provided prior to the conclusion of the survey.

Based on resident interview, staff interview, and clinical record review, the facility staff failed to follow professional standards of nursing practice for one resident (Resident #102-R102) in a survey sample of nine residents. The findings included: For R102 the facility nursing staff failed to clarify a physician order for insulin, where the number of units to be administered had two different values within the administration directions. On 1/7/25, during a clinical record review, it was noted that R102 was admitted to the facility on [DATE], following an acute care hospitalization . Discharge orders from the hospital indicated that R102 was to receive Tresiba FlexTouch U-100, 100 unit/mL (3 mL) Insulin Pen. This medication order read, Inject 86 units beneath the skin every night at bedtime. R102's admission orders which were signed by the attending physician and medical director of this facility on 1/3/25, indicated that the 86 units of Tresiba were to be given nightly at bedtime. According to R102's medication administration record (MAR), Lantus Solostar was being administered at 88 units nightly at bedtime, since 1/3/25. Review of R102's paper clinical record revealed a faxed paper from the pharmacy, received on 1/3/25 at 11:23 a.m., that indicated a therapeutic interchange was being recommended and had a note that read, Please adjust your MAR for an approved therapeutic interchange to Lantus Solostar 86 units at bedtime. On the afternoon of 1/7/25, an interview was conducted with the Assistant Director of Nursing Services (ADNS). The above findings were brought to her attention. The ADNS stated that the therapeutic interchange orders switching medicaions are entered into the electronic health record of residents by the pharmacy. No explanation was provided as to why this discrepancy was not questioned. On 1/7/25 at approximately 3 p.m., during a meeting with the facility's interim administrator, interim director of nursing, and general manager were made aware of the above concerns regarding the discrepancy of R102's insulin orders. On 1/8/25 at 8:15 a.m., an interview was conducted with the attending physician/medical director (MD). The doctor was shown the above information regarding R102's discharge orders from the hospital, signed admission orders to this facility, and faxed paper in the clinical record for the therapeutic interchange from Tresiba to Lantus. The MD confirmed that the dosage should have been 86 units and not 88 units. The doctor went on to state that when given at such large doses the difference of a few units doesn't pose a significant risk to the resident and noted that R102's blood sugars have not been adversely affected as a result. On 1/8/25, in the afternoon, a telephone interview was conducted with a pharmacist and pharmacy manager with the facility's contracted pharmacy. The pharmacist confirmed that the interchange for this medication would not have changed the dosage and that 88 units was a typographical error on the pharmacy's part. On 1/8/25 at approximately 2:40 p.m., R102 was visited in his room. When asked about the insulin, R102 was able to indicate he receives insulin but was unsure of the exact dosing and stated that his wife manages his medications. On 1/9/25, at approximately 9:30 a.m., licensed practical nurse #2 (LPN #2) was asked to show the surveyor the medication administration record information on the computer that the nurse would see when the medication is being administered. According to the medication administration record information available to the nurse, it read, Lantus Solostar 100 unit/ml. Inject 88 unit subcutaneously at bedtime for dm2 [type 2 diabetes]. Dispensed supply: Lantus Solostar 100 unit/ml. Inject 86 units sub-q at bedtime for diabetes mellites. LPN #2 read the order and was asked what she would give if this medication was due on her shift. LPN #2 stated, The order has two different things. I would have to call the doctor to get clarification before I administer anything. On 1/9/25, in the afternoon, during a meeting with the facility administrator and director of nursing the above was again discussed and both confirmed that the nurses should have followed professional nursing standards and clarified the insulin order prior to administering the injections. According to the Lippincott Manual of Nursing Practice, Eighth Edition, on page18, it noted Common Legal Claims for Departure from Standards of Care. This section read in part, .Following medical orders which should not have been followed such as medication dosage errors. Failure to act as a patient advocate, such as not questioning illegible or incomplete medical orders . No additional information was provided.

Based on observation, staff interview, clinical record review, and facility document review, the facility staff failed to follow physician orders for two of twenty residents in the survey sample (Residents #14 and #26). The findings include: 1. License practical nurse (LPN #2) pulled one vitamin D3 25 mcg (micrograms) for Resident #14 (R14) when the physician's order required two tablets of vitamin D3 mcg. A medication pass observations was conducted on 10/30/24 at 8:20 a.m. with LPN #2 administering medications to R14. Among the medications administered was one tablet of vitamin D3 25 mcg. The label of the medication was reviewed and indicated R14 was to receive two vitamin D3 25 mcg tablets. LPN #2 continued to pull medications for R14 and place them into a medication cup. LPN #2 then put all medications cards back into the cart, closed and locked the cart and started to step away from the cart to distribute the medications in the cup. LPN #2 was questioned regarding the vitamin D3. LPN #2 observed one vitamin D3 in the cup then reviewed the physicians order and verbalized not realizing R14 was ordered two vitamin D3 tablets. R14's clinical record documented a physician's order dated 9/17/24 for vitamin D3 25 mcg with instructions to give two tablets daily. This finding was reviewed with the administrator, director of nursing and regional nurse consultants during a meeting on 10/30/24 at 5:01 p.m. with no further information presented prior to the end of the survey. 41449 For Resident #26 (R26), the facility staff failed to carry out physician orders and administer medications in accordance with physician orders. On 10/29/24, a closed record review was conducted of R26's clinical record. The record included a physician progress note dated 11/20/23, that read, Brief Update: Met with patient's daughter who requested home medications be restarted: Tramadol 50mg q6h prn [every 6 hours as needed], KDUR 20meq BID [twice a day], Fibercon BID, and nighttime O2 [oxygen]. Plan to start as requested. On 10/30/24 at 8:18 a.m., an interview was conducted with the physician and medical director, who was the author of the note dated 11/20/23, referenced above. When asked about the process that he gives/writes orders, the physician explained that he doesn't have the ability to enter orders into the electronic health record at this facility like he does at other facilities, so he writes the orders on an order sheet, puts it in the chart, and flags it for the nurses. The doctor was shown the progress note in R26's chart that was written on 11/20/23 and asked what his intention was. The physician said, When I put in a brief update note, that is my reminder to do the orders. Usually I do orders the same day, but at times I will wait on labs or cultures before giving orders. On 10/30/24, a review of R26's closed paper chart was conducted. Included was a physician order dated 11/20/23, that read, Tramadol 50 mg q 6 prn, KDur 20 meq q d [every day], Fibercon 2-tab BID [twice a day], no orange juice per daughter. According to the medication administration record and physician orders for R26, the Tramadol order was never carried out, therefore was not available for administration if needed. The order for KDur was replaced with Klor-Con, which was not started until 12/13/23. The order for Fibercon was replaced with Metamucil and that did not start until 11/30/23. On 10/30/24 at 5:01 p.m., during an end of day meeting held with the facility administrator and director of nursing, the above concerns were shared. They were given copies of the physician order dated 11/20/23, as noted above and asked to see if they could determine why the orders were not implemented and initiated timely. On 10/31/24 at 7:24 p.m., a meeting was held with the director of nursing (DON). When asked if she had found out any information with regards to the R26's delayed medication orders, the DON stated that she had been the nurse that signed the order and said, He [the doctor] may have told me to wait and hold off for him to review lab work because labs indicated she didn't need it. When asked if there was any indication of this conversation or if labs were drawn, the DON said that she had nothing to provide. When asked to provide the facility policy regarding physician orders, the facility administrator reported to the survey team that they had no such policy. No further information was provided prior to conclusion of the survey.

Based on staff interview, clinical record review, and facility document review, the facility staff failed to implement non-pharmacological interventions for pain for one of twenty residents in the survey sample (Residents #14, R14). The findings include: Diagnoses for R14 included; post surgical hip repair, chronic kidney disease, major depression, and chronic pain. The most current MDS (minimum data set) was a five day assessment with an ARD (assessment reference date) of 9/22/24. R14 was assessed with a cognitive score of 12 out of 15, indicating cognitively intact. Review of Physician orders indicated an order dated 9/16/24 for Oxycodone 10 mg [milligrams] give 2 tablets by mouth every 6 hours for severe pain. Review of R14's medication administration record (MAR) for September and October 2024 indicated R14 received Oxycodone on 9/19/24, 9/28/24, and 10/10/24. Review of R14's progress notes surrounding the dates Oxycodone was given were reviewed and did not indicate non-pharmacological interventions were performed. On 10/31/24 at 6:12 PM the director of nursing (DON) was interviewed regarding using non-pharmacological interventions prior to administering pain medication. The DON verbalized that staff should be using and documenting non-pharmacological interventions prior to giving pain medication. The DON verbalized review of progress notes did not show evidence of using other interventions prior to giving pain medication. The facilities Pain Management Program was reviewed and read in part D. Non-Pharmacological Interventions [ .] Consider using multiple nondrug therapies to better meet resident's individual needs. All interventions are evaluated and documented in the same way as medication therapy [ .]. The above finding was presented to the administrator and general manager on 11/1/24 at 1:30 p.m. no other information was presented prior to exit conference on 11/1/24.

Based on resident interview, staff interview, and clinical record review, the facility staff failed to follow professional standards of nursing practice for one resident (Resident #102-R102) in a survey sample of nine residents. The findings included: For R102 the facility nursing staff failed to clarify a physician order for insulin, where the number of units to be administered had two different values within the administration directions. On 1/7/25, during a clinical record review, it was noted that R102 was admitted to the facility on [DATE], following an acute care hospitalization. Discharge orders from the hospital indicated that R102 was to receive Tresiba FlexTouch U-100, 100 unit/mL (3 mL) Insulin Pen. This medication order read, Inject 86 units beneath the skin every night at bedtime. R102's admission orders which were signed by the attending physician and medical director of this facility on 1/3/25, indicated that the 86 units of Tresiba were to be given nightly at bedtime. According to R102's medication administration record (MAR), Lantus Solostar was being administered at 88 units nightly at bedtime, since 1/3/25. Review of R102's paper clinical record revealed a faxed paper from the pharmacy, received on 1/3/25 at 11:23 a.m., that indicated a therapeutic interchange was being recommended and had a note that read, Please adjust your MAR for an approved therapeutic interchange to Lantus Solostar 86 units at bedtime. On the afternoon of 1/7/25, an interview was conducted with the Assistant Director of Nursing Services (ADNS). The above findings were brought to her attention. The ADNS stated that the therapeutic interchange orders switching medicaions are entered into the electronic health record of residents by the pharmacy. No explanation was provided as to why this discrepancy was not questioned. On 1/7/25 at approximately 3 p.m., during a meeting with the facility's interim administrator, interim director of nursing, and general manager were made aware of the above concerns regarding the discrepancy of R102's insulin orders. On 1/8/25 at 8:15 a.m., an interview was conducted with the attending physician/medical director (MD). The doctor was shown the above information regarding R102's discharge orders from the hospital, signed admission orders to this facility, and faxed paper in the clinical record for the therapeutic interchange from Tresiba to Lantus. The MD confirmed that the dosage should have been 86 units and not 88 units. The doctor went on to state that when given at such large doses the difference of a few units doesn't pose a significant risk to the resident and noted that R102's blood sugars have not been adversely affected as a result. On 1/8/25, in the afternoon, a telephone interview was conducted with a pharmacist and pharmacy manager with the facility's contracted pharmacy. The pharmacist confirmed that the interchange for this medication would not have changed the dosage and that 88 units was a typographical error on the pharmacy's part. On 1/8/25 at approximately 2:40 p.m., R102 was visited in his room. When asked about the insulin, R102 was able to indicate he receives insulin but was unsure of the exact dosing and stated that his wife manages his medications. On 1/9/25, at approximately 9:30 a.m., licensed practical nurse #2 (LPN #2) was asked to show the surveyor the medication administration record information on the computer that the nurse would see when the medication is being administered. According to the medication administration record information available to the nurse, it read, Lantus Solostar 100 unit/ml. Inject 88 unit subcutaneously at bedtime for dm2 [type 2 diabetes]. Dispensed supply: Lantus Solostar 100 unit/ml. Inject 86 units sub-q at bedtime for diabetes mellites. LPN #2 read the order and was asked what she would give if this medication was due on her shift. LPN #2 stated, The order has two different things. I would have to call the doctor to get clarification before I administer anything. On 1/9/25, in the afternoon, during a meeting with the facility administrator and director of nursing the above was again discussed and both confirmed that the nurses should have followed professional nursing standards and clarified the insulin order prior to administering the injections. According to the Lippincott Manual of Nursing Practice, Eighth Edition, on page18, it noted Common Legal Claims for Departure from Standards of Care. This section read in part, .Following medical orders which should not have been followed such as medication dosage errors. Failure to act as a patient advocate, such as not questioning illegible or incomplete medical orders . No additional information was provided.

Based on, staff interview and clinical record review, and facility document review, the facility staff failed to provide supervision to prevent a fall with injury resulting in harm for one of 19 residents, Resident #276 (R 276). This was a closed record review and a facility reported incident. R 276 left the facility without staff knowing, fell on the sidewalk and fractured the maxillary sinus and right occipital bone (facial, and head bones) Findings include: R 276 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The most recent MDS (minimum data set) was an initial with an ARD (assessment reference date) of 11/26/17. R 276 was assessed with [REDACTED]. R 276's electronic record was reviewed on 1/18/18 and evidenced, via progress notes dated 11/26/17 (time stamped 11:00 a.m.) that R 276 became agitated, aggressive and uncooperative with staff prior to breakfast, R 276 refused to use the wheelchair and insisted to ambulate with a cane to the dining room for breakfast. Another progress noted dated 11/26/17 (time stamped 12:00), documented that R 276 was observed lying face down on the in the parking lot and complaining of facial and knee pain and that the facilities staff had been notified by assisted living staff personal who had been notified by a vendor. At this time emergency services were called and R 276 was sent to the hospital. A late entry progress note dated 11/26/17 (time stamped 4:30 p.m.) summarized the event that took place earlier with R 276. The progress note evidenced that R 276 was observed standing in the hallway with a cane and was unsteady, with anxious body language, verbalizing that medications were not given the day prior to the incident and documents that R 276 has confusion. Documentation also indicates (the evening prior to the incident) that R 276 refused to sit in wheelchair, saying that she (R 276) has been using a cane for years, the staff were unable to redirect R 276 and the staff observed R 276 ambulating unassisted with repeated attempts to redirect. Review of R 276's admission evaluation (titled Service Evaluation and Health Assessment) dated 11/22/17 indicated (under section Fall Care Plan) that R 276 had confusion and used an assistive device. The evaluation documented (under the section for walking) that ambulation was not evaluated at the time of the evaluation. The evaluation also indicated that R 276 was not an elopement risk. Review of R 276's comprehensive MDS dated [DATE], section C (cognitive patterns) that R 276 was coded as having short-term memory loss and was moderately impaired in daily decision making skills that required supervision. Under section G (functional status), R 276 was coded as needing physical assistance with locomotion on and off the unit. Review of R 276's progress notes documented that R 276 was confused at times. A progress note dated 11/23/17 indicated that R 276 was newly diagnosed with [REDACTED]. There was no other documentation to confirm this [DIAGNOSES REDACTED]. Review of physical therapy notes indicated that therapy was working with R 276 on strength training that included walking with a walker with supervision. Review of R 276's care plan did not evidence a care plan related to cognition or interventions for ambulation or devices used for ambulation/locomotion. Review of the facilities investigation surrounding the incident documented that R 276 refused to use a wheel chair, insisted on using a cane, was agitated and aggressive towards staff and was not easily redirected. The investigation indicated that R 276 was observed sitting in a common area at 11:00 a.m. on 11/26/17 and was found outside by a vendor driving a truck and had been sitting in the truck for 10 minutes (R 276 was found when the driver got out of his truck at 11:35 a.m.). The investigation did not evidence that any staff person observed R 276 leave the facility. On 1/18/18 at 9:00 a.m. rehab tech (other staff, OS #11) was interviewed. OS #11 was asked how therapy communicates information to nursing staff regarding how a resident uses a device for locomotion/ambulation while at the facility. OS #11 verbalized that after an evaluation is completed an order is written and/or a verbal conversation between therapy and nursing staff communicates how or what device is used when ambulating or transferring a resident. Documentation of R 276's communication between therapy and nursing staff was not seen by this surveyor. On 1/18/18 at 9:30 a.m. the MDS coordinator (registered nurse, RN #3) was interviewed concerning R 276's care plan. After reviewing the information presented to RN #3, RN #3 verbalized that a care plan for cognition and how R 276 will ambulate should have been care planned. On 1/18/18 at 10:15 a.m. The director of nursing (DON) was informed of the above finding. The DON verbalized that she did not realize that R 276 was confused at times, she (DON) verbalized that it was not reported to her regarding R 276 being disoriented. The DON verbalized that the care plan was an oversight and should have been updated and feels that R 276 was unsupervised at the time of the fall and she should have been supervised. No further information was presented prior to exit conference on 1/18/18.

Based on observation, staff interview, and clinical record review, the facility staff failed to ensure nutritional parameters for the prevention of weight loss for two of 16 residents in the survey sample, Resident # 6, resulting in harm, and Resident # 1. 1.) The facility staff failed to adequately assess and ensure nutritional interventions were implemented and evaluated for the prevention of weight loss and failed to reassess, implement new and/or add additional interventions after a significant weight loss was identified for Resident # 6, as a result Resident # 6 lost a total of 19.8 lbs in 5 weeks, which was identified as harm. Resident # 6 weighed 102. 6 on admission (09/10/15) and weighed 82.8 on 10/14/15 just prior to being discharged on [DATE]. 2.) The facility staff failed to ensure interventions for weight loss were consistently implemented for Resident # 1 for the prevention of weight loss and failed to monitor the resident for additional weight loss, as a result Resident # 1 lost 13.8 lbs from March 5th through June 25th for a total of 7.5 % in 3 months and lost an additional 4.4 lbs from June 25th through September 16th for a total of 18.2 lbs (greater than 10% in 6 months). Findings include: 1.) Resident # 6 was admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. A 5 day, full admission MDS assessment with CAAS (care area assessment summary) dated 09/17/15, was reviewed. This MDS assessed the resident with a cognitive score of 9, indicating the resident had moderate impairment in daily decision making skills. This MDS assessed the resident as requiring limited assistance with one person physical assistance for eating and assessed the resident as 5'7 (ft/in.) tall and weighing 100 lbs. The resident triggered in the CAAS section for cognition and nutrition. The most current MDS (minimum data set) was a significant change assessment dated [DATE]. This MDS assessed the resident again, with a cognitive score of 9 indicating the resident had moderate impairment in daily decision making skills. The resident was assessed as being independent with eating with setup help only. This MDS also assessed the resident as being 67 inches tall (5'7) and weighing 83 lbs (pounds). Resident # 6's clinical record was reviewed during the survey process from October 19th through October 22nd. During clinical record review, Resident # 6's weight records were reviewed from admission to present. The weight record revealed the following: 09/11/15 = 102.6 lbs (admission weight) 09/16/15 = 99.8 lbs 09/23/15 = 96.0 lbs 10/01/15 = 89.4 lbs 10/07/15 = 86.2 lbs 10/14/15 = 82.8 lbs A nutrition assessment could not be located in the clinical record for Resident # 6. A skilled nursing service evaluation and health assessment (nursing admission assessment) dated 09/10/15 was reviewed and documented: .Dining/Nutritional/Oral Dietary: .natural teeth .Nutritional Risk Factors: Weight loss .NAS (no added salt) .3 meals/day .> 3 meals/day .usually does not snack between meals .has snacks once a day .mid-morning .Preferred snacks: choc. ice cream .signature CDM (certified dietary manager) 09/11/5 . Nutrition/dietary notes were reviewed and documented the following: 09/11/15 (7:29 p.m.)-Admission note .skilled services after hospital stay .current diet is CCHO- (consistent carbohydrate) diet she reports no chewing or swallowing problems .weighs -102.6 .BMI (body mass index) < (less than) 19.0 will add fortified foods and glucerna .120 ml (milliliters) TID (three times daily) Will follow .signature CDM. The resident's MARS/TARS (medication administration records/treatment administration records) for September and October (2015) were reviewed. According to the September 2015 MARS/TARS the Glucerna 120 ml tid for Resident # 6 did not start until 09/14/14 at 1400 (2:00 p.m.), three days after it was recommended by the CDM. Resident # 6 did not receive Glucerna 120 ml tid from 09/11/5 though 09/14/14 (10:00 a.m.). The Glucerna was documented with initials, no amount or volume of Resident's #6 intake was recorded. A physician's progress note dated 09/15/15 for Resident # 6 was reviewed and documented: .seen today for complaints of weeping from her right leg .the [MEDICAL CONDITION] is not tense .[MEDICATION NAME] (range 3.2-5.2) 3.2 ([MEDICATION NAME] result from 09/07/15) .[MEDICAL CONDITION] is likely dependent .increase in [MEDICAL CONDITION] over past couple days .elevate RLE (right lower extremity) as much as possible [MEDICAL CONDITION] present on admission, worse postop .signature of attending physician. 09/16/15 (4:29 p.m.)-14 day note: .slowly progress her current diet remains ccho-diet with thin liquids .continues to feed herself with set up only with all meals .consumes > (greater than) 50% of most meals .glucerna supplementation 120 ml tid due to low BMI and po intake .currently weighs 99.8 lbs weight down slightly will continue fortified foods as nutritional support .will follow .signature of CDM. Resident # 6 lost 2.8 lbs in 5 days (from 09/11/15 through 09/16/15). 09/17/15 (1:39 p.m.)-New Admit .female with right [MEDICAL CONDITION] with surgical repair, [MEDICAL CONDITIONS] embolism .CCHO (Not DM{diabetes mellitus}) fortified foods and intake 51-75% resident has refused meals 3 times in past 7 days weight 99.8 lbs .Change glucerna to ensure + (plus) 120 ml tid .estimated needs 1589 kcal .54.5 gm (grams) .and 1589 cc .following .signature of RD (Registered Dietitian). On 09/18/15, Ensure vanilla can .120 ml by mouth three times daily was ordered, not Ensure + (plus) as recommended by the RD (Registered Dietitian). Ensure was documented by initials as administered, no amount or volume consumed was recorded. 09/24/15 (5:18 p.m.)- .WEIGHT WARNING: 96.0 vital date 2015-09-23 .with noted weight loss X (times) 14 days .resident po intake is poor as well as she is refusing to eat meals at lunch times some days .states she does not want anything she is not hungry, but if we insist will drink a glass of choc. milk .continue ensure med pass fortified food and a milkshake with her lunch and dinner meals .signature of CDM. Resident # 6 lost and additional 3.8 lbs from 09/16/15 to 09/23/15 for a total of 6.6 lbs. 09/24/15 (5:31 p.m.)- .prefers choc. milk not milkshake with her lunch and dinner meals .signature CDM. According the resident's MARS/TARS for September 2015, Resident # 6 did not receive any milkshakes. Chocolate milk was not added until 09/28/15, four days after the recommendation by the CDM. The chocolate milk was documented by initials, not by volume consumed by resident. 10/01/15 (7:13 p.m.)-WEIGHT WARNING: 89.4 .with noted weight changes related to fluid loss and poor po intake. Will request a re-weight and follow up with resident on meal preferences .signature of CDM. Resident # 6 lost an additional 6.6 lbs from 09/23/15 to 10/01/15 for a total of 13.2 lbs. No re-weight could be located in the clinical record. 10/04/15 (5:15 p.m.)- .visited .today to follow up on her meal preferences and weight changes. She states her weight is fine because her clothes still fit her well. She feels she eats plenty .does not want any snacks between meals or milkshakes but she will sip on a glass of choc. milk .will continue to encourage po intake, encourage resident to eat meals in dining room instead of her room .continue ensure 120 ml tid .fortified foods .current weight 89.4 lbs will request a re-weight. Will follow .signature of CDM. No re-weight could be located in the clinical record. 10/08/15 (12:52 p.m.)-At risk note: .is refusing to eat her lunch meal. We offer meal alternative she is refusing all offers so we tried a glass of choc. milk. Resident states she does not want anything she is not losing weight because her clothes fit fine .continue current diet and encourage po intake .signature of CDM. Ensure vanilla 120 ml TID was documented on the October MAR from Oct. 1st through Oct. 15th. Documentation included initials, but did not include amount/volume consumed by the resident. 10/08/15 (3:42 p.m.)-WEIGHT WARNING: 86.2 .not eating very well at meals .refusing meals .encouraging po intake but she insisting she (sic) not hungry and her weight is fine because her clothes fits (sic) fine .Will continue her current diet and encourage po .signature CDM. Resident # 6 lost an additional 3.2 lbs from 10/01/15 to 10/07/15 for a total of 16.4 lbs. Resident # 6's October 2015 MARS were reviewed. A hand written entry was added to the MAR, which documented: 09/28/15 Choc. milk with lunch and dinner FYI (for your information). Chocolate milk was not documented as administered for the entire month of October. Resident # 6's CCP (comprehensive care plan) documented: .09/11/15 the resident has impaired cognitive function .Observe/document/report PRN (as needed) any changes in cognitive function, specifically changes in: decision making ability, memory, recall and general awareness, difficulty expressing self, difficulty understanding others, level of consciousness, mental status . 10/15/15 (2:14 p.m.)-WEIGHT WARNING: 82.8 .continues to have weight loss related to poor po intake and refusing to eat .will request care plan conference with RP (responsible party) .have orders for psych eval for not eating .try increasing ensure to 1 can BID (twice daily) and continue fortified foods, snacks between meals .signature of CDM. Resident # 6 lost an additional 3.4 lbs between 10/08/15 and 10/15/15 for a total weight loss of 19.8 lbs, in just 5 weeks. Ensure one can BID (twice daily) was added to the MAR indicated [REDACTED]. The amount/volume of ensure consumed by the resident was not documented. A physician's orders [REDACTED].? (questionable) depression Not Eating .signature of attending physician (signed 10/13/15). 10/19/15 (8:35 p.m.)- .Res has had a significant weight loss X 30 days related to fluid loss and poor po intake .advised all staff to encourage .up for meals and out to dining room .if she refuses to leave her room, to ensure she is set up with a meal tray .able to feed herself but needs much encouragement to eat or drink at meals .weighs 82.8 lbs with 17 % weight change X 30 days .is not drinking her supplement or eating her snack between meals .We are trying choc. milk with meals as she stated and her family has stated she enjoys drinking .tried to update meal preferences and she insists her weight is fine because her clothes fit her. We are starting and appetite stimulant at this time, and psych to follow .continue to follow .signature of CDM. No information or documentation was found to evidence Resident # 6 was drinking her supplement, no information or documentation was found to evidence Resident # 6 was receiving snacks between meals. No information or documentation was found to evidence for the month of October 2015 that the resident received any chocolate milk with meals. [MEDICATION NAME] 7.5 mg (milligrams) by mouth every night at bedtime, was ordered and started on 10/19/15 by the physician on call. Resident # 6's CCP (comprehensive care plan) was reviewed and documented the following: * (Date initiated: 09/11/15 The resident has potential nutritional problem related to [MEDICAL CONDITION], poor po (by mouth) intake .Monitor meal percentage of intake and record every meal .multivitamin with minerals daily as supplement .Obtain weekly weight weekly for four weeks, then every month and per MD order .lunch meals-choc. milk .Choc. milk with lunch and dinner meals . * (Date initiated: 09/24/15 .offer snacks between meals, and Choc. milk with lunch and dinner meals, and Choc. milk with lunch and dinner meals . * (Date initiated: 10/02/15 .will gain one to two pounds by next review) . * (Date initiated: 10/16/15 Ensure 1 can twice daily as supplement . On 10/21/15 at approximately 1:30 p.m., the (director of nursing) and the administrator were made aware of the serious concerns related to Resident # 6's significant weight loss in a meeting with the survey team. The DON voiced that interventions had been put in place, such as weighing the resident, supplements and different meal choices. The DON was asked how weight loss is identified. The DON voiced that we track in PCC (point click care) and it monitors and if there is a weight warning or concern it triggers and the CDM is made aware. An interview was requested with the CDM at this time. At approximately 2:00 p.m., on 10/21/5 the CDM, DON and administrator were interviewed with the survey team. The CDM voiced that weights are done weekly on Tuesdays and Wednesdays and are addressed on Thursday at the 'At risk weekly meetings.' The DON voiced that nursing, social services, the administrator, ADON (assistant director of nursing), DON, MDS (minimum data set-nurse), and activities attend the meetings and that residents are identified as 'at risk.' Once identified staff go to the resident up date food preferences, come up with an intervention, such as supplements, fortified foods then the CDM makes a recommendation, nursing contacts the physician for an order (if the physician is in agreement), then the CDM tracks the weights. The DON was asked if Resident # 6 had been identified as at risk, the DON voiced, yes. The CDM was asked how interventions are tracked. The CDM voiced that she will ask the nurse if the resident took ensure and ask CNAs (certified nursing assistants) and the nurses if she (Resident # 6) is accepting snacks. The CDM was asked if this was tracked, the CDM voiced that she did not think that there was a flow sheet for tracking percentages of snacks. The CDM was asked if she contacted the physician or the RD regarding Resident # 6's significant and continued weight loss. The CDM stated, Yes, maybe on October 15th .was getting nowhere with supplements and I requested an appetite stimulant, I got no response from the doctor. The CDM was asked if that information was documented, the CDM voiced, no. The CDM voiced that the resident was seen by the RD on September 17th, but had not been seen since. On 10/21/15 at approximately 5:50 p.m., the administrator and DON (director of nursing) were again made aware of the above information and the serious concerns related to Resident # 6 in a meeting with the survey team. The DON and administrator were informed that the resident did not consistently receive interventions (supplements) recommended as evidenced above and no evidence could be located to determine the amount that the resident received and that the interventions in place were not what was originally recommended by the RD. The RD had recommended Ensure + (plus) on 09/17/15 and Ensure (regular) is what was implemented by facility staff and documented as administered, the resident never received Ensure + (plus). The DON was asked how supplement intake is monitored. The DON voiced that 'we don't have documentation for the glucerna, chocolate milk or ensure.' The DON was then asked if they don't have documentation as to what the resident actually consumed, how would you know if the interventions are effective. The DON stated, I don't have a good answer for you .I would write down how much they took. The DON was also made aware that according to the CCP the resident's meal percentages were suppose to be recorded beginning on 09/11/15, but had not actually started until 9/22/15 according to the documentation. The DON was asked how it could be determined how much the resident was actually eating without documentation. The DON voiced that she would pull the intake records. The DON was asked if Resident # 6 had the psych evaluation that was ordered on [DATE]. The DON voiced, no that they (psych) comes in every other week and was due to be seen next week. The DON voiced that the RD comes in twice a month and was scheduled to be in this week. A policy was requested on weights at this time. On 10/22/15 at approximately 7:40 a.m., the DON presented a policy on weights. The policy titled, Weight Management Guidelines documented: .nursing department should provide the Dietary Department with . weights of each resident. Residents with significant weight variance should be identified and appropriate interventions implemented .Be sure to re-weigh when there is a weight variance of plus or minus 5 pounds. Significant weight variance should usually be calculated by the Dietary Manager or Diet Technician/Clinical Manager .Where computerized weight variance programs are used the community should assign responsible parties to input the weights .Each nursing station should provide a completed copy of its monthly weight record to the Dietary Manager .Weights should be reviewed and recorded .Suggested parameters for evaluating significance of unplanned and undesired weight loss .1 week (Significant loss/gain) 2% (Severe loss/gain) greater than 2% .1 month (Significant loss/gain) 5 % (Severe loss/gain) greater than 5 % .3 months (Significant loss/gain) 7.5 % (Severe loss/gain) greater than 7.5% . Resident # 6's meal percentage records were reviewed. Percentages presented were documented from 09/22/15 through 10/22/15. The documentation did not specify an actual percentage, but a range from 0-25%, 26-50%, 51-75%, 76-100% of a meal consumed. Actual percentages were not documented. This form documented that Resident # 6 refused on 14 separate occasions. On 10/22/15 at 9:35 a.m., the RD was interviewed in a meeting with the survey team. The RD voiced that she is in the facility 2 visits per month (16 hours). The RD further voiced that she is given a list of at risk residents from the CDM and will see those residents on her next scheduled visit and then follow up accordingly. The RD was asked when she saw Resident # 6 and she voiced, September 17th. The RD was asked what was the next visit to the facility after September 17th; the RD voiced October 6th and provided documentation of the visits for 09/17/15 and 10/06/15. The 09/17/15 visit log included Resident # 6 and documented: .D/C (discontinue) Glucerna Add Ensure + (plus) 120 ml TID Add NAS (no added salt) to diet . The RD was unaware that Resident # 6 was receiving Ensure (regular) instead of Ensure + (plus). The 10/06/15 RD visit log did not include Resident # 6. The RD was asked if Resident # 6 was seen on 10/06/15, the RD voiced, no. The RD was asked why the resident was not seen. The RD voiced that the CDM is suppose to 'leave me a list, not sure if she was on the list.' The RD further voiced that the CDM can call her if there needs to be a menu change, or if there is a weight loss, or to change a supplement. The RD was asked is she was aware that Resident # 6 lost 16 lbs from when she was seen by the RD on 09/17/15 through October 6 (the next scheduled RD visit), the RD voiced that she was unaware that Resident # 6 lost 16 lbs during that time frame. The RD was asked how she evaluated the supplements that Resident # 6 was getting or if it was what was recommended. The RD voiced that she asks staff if the resident is drinking their supplement and then voiced that she looks at the MARS/TARS to verify. The RD was asked if she verified through the MARS/TARS that the resident had not consistently received supplements and that on several occasions there had been a delay in starting the supplements. The RD voiced being unaware. The RD was then asked if she was aware that recommended Ensure + (plus) by her (the RD) on 09/17/15 was not actually administered to the resident. The RD was made aware that according to the physician's orders [REDACTED]. The RD voiced being unaware. The RD then voiced that she (RD) felt comfortable with the interventions in place and voiced that you can't force someone to eat. The RD voiced that the Ensure was changed from 120 ml tid to one can bid, which gave the resident more. The RD was asked if she looks at labs to help with assessment information. The RD voiced, yes and verbalized that we look at [MEDICATION NAME], but it isn't a good indicator and went on to say that the resident has [MEDICAL CONDITION]. The RD was then asked if she had actually seen, interviewed and/or visited with Resident # 6. The RD stated, No, I haven't interviewed her, normally I do. The RD was asked where she got the information regarding Resident # 6's admission nutrition note, the RD voiced that the information came from the resident's chart. The RD voiced that she did not meet with or see the resident on 09/17/15 and has not seen the resident to date. The RD was asked if she had communicated with the physician regarding Resident # 6's weight loss or nutritional concerns; the RD voiced, no I don't normally communicate with the doctor. On 10/22/15 at approximately 10:00 a.m., the on call physician was interviewed with the survey team. The on call physician voiced that from her perspective it looked like Resident # 6 had the proper nutritional support. The on call physician voiced that the resident's attending physician had documented on the resident back in April of 2015 and documented that the resident was socially isolated, that the resident did not have a [DIAGNOSES REDACTED]. The on call physician voiced that she was notified on October 19th, that the resident may be depressed and that she (MD) seen the resident and voiced that the resident was 'flat' and had poor appetite. The on call physician went on to say, 'felt at least worth a try' and further voiced good success with [MEDICATION NAME] and she was prescribed an appropriate dose for a geriatric patient. On 10/22/15 at 12:15 p.m., the attending physician was interviewed via telephone with the survey team. The physician voiced that the resident has a prior history of weight loss and dementia. The physician was asked if other possibilities were ruled out for the weight loss. The physician voiced that the resident denied other symptoms. The physician was asked what types of lab tests or other studies are looked at to determine nutritional status. The physician voiced, [MEDICATION NAME]. The physician was made aware of the resident's last [MEDICATION NAME] of 3.2 on 09/07/15 and was asked if that had been assessed or if another [MEDICATION NAME] level had been ordered. The physician stated, .did not get that, I probably should have done that, I should have been looking at that, it's my fault. The attending physician then voiced that she (physician) was happy with the interventions in place. The physician was informed about the interventions in place had been delayed on several occasions and that Ensure (regular) was implemented instead of Ensure + (plus) as recommended by the RD and that intake records did not actually identify how much the resident was consuming. The physician stated, I see your point, I don't have an answer .sorry I didn't get another [MEDICATION NAME] to see where we were (with her), told me she was eating just fine. The physician voiced that she could look on her computer to see if she may have more notes that she could sent to the facility regarding Resident # 6. No additional notes or information was presented to the survey team during the survey process. On 10/22/15 at approximately 3:10 p.m., the administrator, DON, ADON and SW (social worker) met with the survey team. The administrator presented a documented time line for Resident # 6 regarding the weight loss. The administrator read the time line to the survey team, repeatedly verbalizing that Resident # 6 had a good appetite on dates from 09/18/15 through 10/21/15 with only one occasion of refusing to eat and one occasion of not eating well, also voicing that on 10/13/15 that the resident was referred to geri psych for not eating and depression. No further information or documentation was presented prior to the exit conference on 10/22/15 at 7:15 p.m., to evidence that Resident # 6 was adequately assessed on admission for a known history of weight loss, that appropriate and consistent interventions were put in place or that adequate monitoring and evaluation was completed to prevent a significant weight loss for Resident # 6. 2.) The facility staff failed to ensure interventions for weight loss were implemented for the prevention of weight loss and failed to evaluate the resident for additional weight loss. Findings include: Resident # 1 was admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. The most current MDS was a quarterly assessment dated [DATE]. This MDS assessed the resident with a cognitive score of 11, indicating the resident had moderate impairment in daily decision making skills. The resident was also assessed as limited assistance with one person physical assistance for eating. The resident was also assessed as being 60 inches tall and weighing 145 lbs. The resident's 5 day admission assessment with CAAS (care area assessment summary) dated 12/23/14 was reviewed for comparison. This MDS assessed the resident as having a cognitive score of 9, indicating moderate impairment in daily decision making skill and assessed the resident as requiring limited assistance with one person physical assist for eating. The resident was also assessed as being 60 inches tall (5'0) and weighing 163 lbs. The resident triggered in the CAAS section for cognition and nutrition. During the survey process on 10/19/15 through 10/22/15, Resident # 1's clinical record was reviewed. Resident # 1's weight records were reviewed from admission and revealed the following: 12/17/14-162.8 01/01/15-156.2 01/08/15-152.2 01/22/15-155 02/11/15-154.2 03/05/15-160.6 04/23/15-154.4 05/21/15-150.4 06/18/15-149.6 06/25/15-146.8 07/02/15-146 07/22/15-145.2 07/30/15-142.6 08/19/15-143.6 09/16/15-142.4 10/01/15-142.2 10/14/15-143 Resident # 1's current POS dated 10/01/15 through 10/31/15 was reviewed and documented: .Ensure med pass 240 ml (milliliters) by mouth three times daily for supplement .Milkshake with lunch and dinner meals daily for supplement Regular, No Added Salt diet-add fortified foods . No start dates were listed for these physician's orders [REDACTED]. Resident # 1's dietary notes were reviewed and documented: 12/22/14-12:15 p.m.New admit .Diet NAS with poor intake 25-50%. Wt: 162.8 .No nutritional labs due. Rec: Snacks between meals. Following .signature of RD. 01/02/15-1:42 p.m.WEIGHT WARNING: 156.2 .noted weight loss related to fluid loss and poor po intake. Will add a milkshake with lunch and dinner meals and refer to RD for weight loss .signature of CDM. 01/13/15-9:12 p.m.continues to require meal supervision .currently weighs 152.2 lbs her weight is down 10.2 lbs .requires much encouragement to eat at meals .will add ensure med pass 120 ml tid for supplement .signature of CDM. 02/06/15-2:07 p.m.WEIGHT WARNING: 155 .significant weight changes .po intake > (greater than) 50% of most meals .po intake has improved .signature of CDM. 03/09/15-10:01 a.m.continues to require meal supervision with assistance with meals .much improvement with her po intake .currently weighs 160.6 (up 5.6 lbs) .will consider D/C (discontinue) ensure med pass RD to review .signature of CDM. 03/12/15 10:28 a.m.Agree that fortified foods, milkshakes L & D (lunch and dinner) and Ensure is too much for BMI=31.4. Rec. D/C Ensure at med pass and milkshakes at L & D .signature of RD. The CDM documented on April 27th, that the resident's weight was down to 154.4 with .noted weight changes . The CDM documented on May 28th that the resident's weight was down to 152.0 and will continue milkshake with her lunch and dinner meals. Resident # 1's MARS/TARS were reviewed from March, 2015 through present (October 2015). According to the MARS/TARS the resident's ensure and milkshakes were discontinued on March 16, 2015 as recommended by the CDM and the RD. Resident # 1 lost 13.8 lbs from March 5th through June 25th for a total of 7.5 % in 3 months. No supplementation was restarted until August 3rd, when Ensure 240 ml was started three times daily. The resident's milkshake with lunch and dinner was documented on the August MAR/TAR as an FYI (for your information) there was no evidence that this supplement had been administered. The resident's September MARS/TARS were reviewed and documented that snacks between meals were initiated on 09/18/15. The resident's CCP was reviewed and documented: .09/17/15 .The resident has nutritional problem related to poor food intake .08/20/15 Ensure three times daily as supplement with med pass .12/30/14 Fortified foods .08/28/15 Eating: .needs assistance with eating her meals. She has her food on a colored plate due to decreased vision to help to increase her independence with feeding herself. Explain position of food on her plate .12/16/14 identify the position on her plate using numbers on clock system 07/28/15 Monitor and evaluate any weight loss. Determine percentage lost and discuss with resident, notify MD and RD .monitor and record food intake each meal .12/16/14 .All meals on a colored plate due to poor vision . Resident # 1 lost an additional 4.4 lbs from June 25th through September 16th for a total of 18.2 lbs (greater than 10% in 6 months). Resident # 1 was observed on the evening of 10/19/15 for a dinner observation. Resident # 1 was observed from 5:20 p.m. to 6:00 p.m. The resident did not have a colored plate as described in the resident's CCP and did not receive any assistance from staff for meal consumption. Resident # 1 was observed on 10/22/15 from 7:35 a.m. to approximately 8:00 a.m., the resident did not have a colored plate as described in the resident's CCP and minimal cueing was observed from staff. On 10/11/15 at 9:30 a.m., the RD was interviewed regarding Resident # 1, in a meeting with the survey team. The RD voiced that she had not seen this resident, as she was not on the high risk roster. The RD was made aware of the above concerns related to Resident # 1. The RD stated, She was obese and that is why she discontinued the milkshake and ensure. The RD was made aware that no interventions had been put in place to maintain the residents nutritional parameters after the supplements were discontinued. The RD ask the survey team, Was she care planned for weight reduction? Resident # 1 weights were discussed with the RD and the RD voiced, both of those would have been significant weight loss (referring to weight lost for 3 month and 6 months). The RD was asked if something should have been done to help Resident # 1 maintain the weight that facility staff helped her gain. The RD responded, could have been, should have been .I will look at her today. The RD was asked what her responsibility is to ensure residents maintain nutritional parameters. The RD voiced, making sure I'm informed of weight loss and in these two cases (Resident # 1 and Resident # 6) it did not happen. No further information or documentation was presented prior to the exit conference on 10/22/15 at 7:15 p.m. to evidence that facility staff implemented interventions for the prevention of weight loss for Resident # 1.

Based on observation, staff interview, facility document review, and clinical record review the facility failed to ensure the accuracy of glucose monitoring equipment for diabetic management for two of 11 residents, Resident #11 and #2. This resulted in Immediate Jeopardy (IJ) (Level 4, Isolated) on 9/4/13 at 2:35 p.m. and Substandard Quality of Care (SQC). Resident #11 and #2 were receiving blood sugar tests from glucometers that were functioning out of manufacturers reference ranges. Resident #11 was receiving sliding scale insulin based on an inaccurate glucometer reading. The findings include: On 9/4/13 at 11:30 a.m. during general observation rounds a glucometer test was performed with LPN #3. Testing solution was added to the test strip and 409 was the result. The reference range for the test being performed was 230-287. This indicated that the glucometer was out of range indicating false readings. The test was again performed and the result was 422. At this time new batteries were obtained and the result again was 422. License practical nurse (LPN #3) verbalized that the night shift usually did the testing of the glucometers each night and went onto say that the glucometers were recently purchased a few months ago and was going to get a new glucometer out of storage. At approximately 11:45 a.m. this time the surveyor went to the second medication cart and requested that LPN #2 run a test on her glucometer located in the medication cart. The test was completed and read 387, indicating the glucometer was out of range. Both containers of test strips were reviewed for expiration date and revealed expiration dates of November 2014 and March 2015. The testing solutions showed expiration date of October 2014 and December 2014, with an opened date of 4/8/13. The insert from the solution was then reviewed and revealed that the solution should be discarded after 90 days from opening. At this time new solution was requested and both glucometers were checked again. The results from the glucometers were 103 and 100 (reference range 230-287), indicating the machine was now reading low. The new glucometer was then checked and read 123 (also low). On 9/4/13 at 12:15 p.m. the director of nursing (DON) was interviewed concerning the above finding. The DON verbalized that the glucometers had been purchased a few months ago. The DON was then asked for documentation regarding glucometer testing. The DON then went to the nurses station and pulled out a log book and verbalized (after reviewing the book) that the tests had not been done. The log book was also reviewed by the surveyor and revealed the last documented glucometer accuracy test was 5/10/13. On 9/4/13 at 1:45 p.m. during a meeting with the DON and nurse consultant the DON was asked if an inservice was performed when new glucometers were put in place. The DON verbalized that no inservice was done because the glucometers were similar to the ones the facility had been using. The DON was asked what her expectation would be for the frequency of testing the glucometers. The DON verbalized that she felt that testing should be done nightly and when batteries were changed or the machine was dropped. According to the manufacturer instructions, the glucometer should be tested for accuracy: Before testing with the system for the first time. When you open a new bottle of test strips. Whenever you suspect the meter or test strips may not be functioning properly. If test results appear to be abnormally high or low or are not consistent with clinical symptoms. The test strip bottle has been left open or has been exposed to light, temperatures below 39 F or above 86F, or humidity levels above 80%. To check your technique. When the meter has been dropped or stored below 32F or above 122F. Each time the batteries are changed. On 9/4/13 at 2:35 p.m. the administrator and DON were advised of the concern for resident safety due to glucometers being out of manufactures specifications and at this time the facility was placed in immediate jeopardy and substandard quality of care. The survey team explained expectations to the facility for plan of removal and asked for a list of all residents receiving glucometer (accu checks) checks. The DON presented a list of resident's receiving accu checks (Residents #2 and #11) and the survey team added Resident #11 to the survey sample. Resident #2 was already in the sample. The survey team then reviewed Resident #11 and Resident #2 clinical records. A. Resident #11 was admitted to the facility on [DATE] with a readmission on 6/24/13 with [DIAGNOSES REDACTED]. Resident #11's most recent MDS (minimum data set) was a 60 day with an assessment reference date of 8/19/13, Resident #11 was assessed as being cognitively intact with a score of 14. Review of Resident #11's clinical record revealed a physician's orders [REDACTED].= 4 units, 301-350 = 6 units, 351-400 = 8 units, 401-450 = 10 units, >451=12 units, before each meal and at night. The order gave parameters of how much insulin would be given depending on the reading of the accu check. Resident #11's Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. Documentation through nursing notes and physician progress notes [REDACTED].#11. On 9/4/13 at 4:15 p.m. Resident #11's physician was interviewed concerning Resident #11's blood sugar readings. The physician verbalized knowledge of Resident #11's blood sugars (in terms of the wide range) and also said she would expect to see such a wide range based on Resident #11's noncompliance of diet (eating snacks, etc.) but felt that blood sugars were being controlled appropriately. B. Resident #2 was admitted to the facility on [DATE] with a re-admission on 5/20/13. [DIAGNOSES REDACTED]. The minimum data set ((MDS) dated [DATE] assessed Resident #2 with severely impaired cognitive skills for decision-making. Resident #2's clinical record was reviewed on 9/3/13. Resident #2 had a physician's orders [REDACTED]. The order stated, "Accucheck daily at 1600 (4:00 p.m.) prior to T.F. (tube feeding) - Notify MD/NP (physician/nurse practitioner) if blood glucose > (greater than) 200." The clinical record documented the resident had a physician's orders [REDACTED]. In addition Resident #2 had a physician's orders [REDACTED]. Resident #2's medication administration records (MAR's) documented the resident had blood sugar checks each day using the facility's glucometer at 4:00 p.m. with 5 units [MEDICATION NAME]administered as ordered. The Drug Handbook for Nursing 13th edition on pages 656 through 658 describes [MEDICATION NAME] N insulin as an antidiabetic agent used for the treatment of [REDACTED]. This reference lists [DIAGNOSES REDACTED] as the most common adverse effect of insulin. Page 656 of this reference lists [MEDICATION NAME] N insulin as a high alert medication stating, "The Institute for Safe Medication Practices (ISMP) includes this medication among its list of drugs which have a heightened risk of causing significant patient harm when used in error." (1) On 9/4/13 at 3:00 p.m. the DON and administrator presented a plan of IJ removal to the survey team and as follows: 1. All diabetics with orders for glucometer testing have potential to be effected by this deficient practice. 2. A new glucometer was obtained and tested for accuracy. Nurses educated on procedure for testing glucometer according to manufacturers recommendation. Director of nursing or designee to ensure no nurses work until educated on this process. 3. All diabetic residents with orders for glucometer testing for accurate blood glucose levels with new glucometer. 4. Procedure put in place to check glucometer every night on 11-7 and per manufactures recommendations. Director of nursing or designee to review results of quality control testing daily. 5. 9/04/13. The DON verbalized that a new glucometer had been obtained and was going to be tested . The survey team asked to observe the glucometer being tested . On 9/4/13 at 3:15 p.m. the DON presented a new glucometer and run a glucometer test which showed to be in compliance according to manufacturers recommendations. The survey team then asked for documentation that Resident's #2 and #11 had been tested and documentation indicating education was being carried out for glucometer testing. On 9/4/13 at 4:10 p.m. the DON presented evidence that Resident's #2 and #11 had been tested with the new glucometer. The readings were reviewed by the survey team and compared to previous readings and indicated no concern. On 9/4/13 at 4:25 p.m. the DON presented documentation with nurses signatures evidencing that education had been given involving glucometer use, quality control checks, caring for the glucometer and error codes. The DON also presented a monitoring form for nightly glucose monitoring and education evidencing nightly checks. The survey team reviewed the plan of removal and accepted the plan with removal of the immediate jeopardy status on 9/4/13 at 4:35 p.m., reducing the scope and severity level of the remaining deficient practice to isolated, level 2*. On 9/5/13 at 7:45 a.m. this surveyor reviewed the glucometer test log and evidenced that glucometer test had been completed on the 11-7 shift. No other information was presented concerning the above finding prior to exit conference on 9/5/13. (1) Turkoski, Beatrice B., Brenda R. Lance and Elizabeth A. Tomsik. Drug Information Handbook for Nursing. Hudson, Ohio: Lexi-Comp, 2011. *State Operation Manual Appendix P - Survey Protocol for Long Term Care revised 4/24/09 defines Level 4 as "immediate jeopardy, a situation in which immediate corrective action is necessary because the facility's noncompliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment, or death to a resident receiving care in a facility." Level 2 is defined as, "noncompliance that results in no more than minimal physical, mental and/or psychosocial discomfort to the resident and/or has the potential (not yet realized) to compromise the resident's ability to maintain and/or reach his/her highest practicable physical, mental and/or psychosocial well-being as defined by an accurate and comprehensive resident assessment, plan of care, and provision of services."

Based on staff interview, clinical record review, and in the course of a complaint investigation the facility staff failed to ensure one of 3 residents was free from an unnecessary medication. Resident # 1 was administered [MEDICATION NAME], an oral hypoglycemic medication used to control blood sugar levels, without a [DIAGNOSES REDACTED]. Findings include: Resident # 1 was admitted to the facility 2/7/12 with a readmitted 0f 3/21/12. [DIAGNOSES REDACTED]. The most recent MDS (minimum data set) was an admission assessment dated [DATE]. Resident # 1 was coded as being cognitively intact with a total summary score of 14 out of 15. The closed clinical record was reviewed at approximately 3:00 p.m.on 4/11/12. Resident # 1 had been discharged from the facility 3/14/12 having met all care plan goals. The discharge summary was reviewed. The medications Resident # 1 was discharged with included: Vitamin B12 1000 mcg once/day, Vitamin D 50,000 units every Friday, and Folic Acid 1 mg once/day. Resident # 1 was admitted back to the facility on [DATE] from the hospital after suffering "weakness and falls at home." The hospital discharge summary included a list of medications the resident had taken while in the hospital. Included in the list of medications was "Glycotrol (sic) capsule one tablet p.o. once daily." GlycoTrol is a dietary supplement containing Vitamin B12, B 6, and amino acids. On 4/11/12 at approximately 5:00 p.m. Licensed Practical Nurse # 1 (LPN # 1) was interviewed about the admission process of Resident # 1. LPN # 1 stated "Resident # 1 was already in the process of admission when I came on; she was admitted during shift change so another nurse had already actually started the admission. I reviewed the medication list, wrote out the POS and got the physician to sign it." LPN # 1 went on to say "it was my understanding the pharmacy didn't have the Glycotrol and that was changed to [MEDICATION NAME] by the doctor." LPN # 1 was then asked if she knew why the pharmacy didn't have the Glycotrol. LPN # 1 stated she did not know as the nurse who started the admission passed that information on to her before leaving. Review of the admission orders [MEDICATION NAME] 5 mg p.o qd." The medication was written on the MAR indicated [REDACTED] Resident # 1 was administered [MEDICATION NAME] 5 mg at 5:00 p.m. on 3/22/12 per the physician's orders [REDACTED]. Was transported via stretcher @ 0815. Dr's office and family notified." On 4/12/12 at approximately 8:30 a.m. the electronic hospital records were reviewed. The ER report revealed the resident was admitted with a blood sugar of 13. It was first thought the resident had a stroke, but the physical exam did not support that. Resident # 1 received IV (intravenous) [MEDICATION NAME] in the ER and was admitted to ICU where she received hourly blood sugar testing and IV [MEDICATION NAME]. Hospital records made note of the resident having received an oral hypoglycemic medication at the facility, and noted the resident did not have a [DIAGNOSES REDACTED]. The discharge report documented "It was found the patient had been discharged from the (name of hospital) hospital on GlycoTrol but inadvertently received an oral hypoglycemic one time dose." It was also noted the resident had mental status changes while in the hospital which delayed her discharge by one day due to her refusing medications and becoming more confused and agitated. Documentation revealed the resident was given a dose of [MEDICATION NAME] (no amount was documented) 4/4/12 and on the morning of 4/5/12 was "awake, alert, mental status back to baseline." On 4/12/12 at approximately 9:30 a.m. the attending physician for Resident # 1 was interviewed. The physician stated "(name of resident #1) was admitted [DATE]. I saw her that same day. Per protocol nursing goes ahead and takes the orders from the discharge summary and I signed off on everything. One of the nurses pointed out the Glycotrol and wasn't sure about the dose. I thought it was a typo and thought it was supposed to be [MEDICATION NAME]'s only one letter's difference in the two and I hadn't heard of Glycotrol. I don't typically even use [MEDICATION NAME], so when the pharmacy said they didn't have Glycotrol I told the nurse to use [MEDICATION NAME] 5 mg once a day. I didn't go back and review the chart, but my notes say she wasn't a diabetic." On 4/12/12 at approximately 9:55 a.m. Licensed Practical Nurse (LPN) # 2 was interviewed via telephone about the admission of Resident # 1. LPN # 2 stated "Resident # 1 was admitted right at change of shift. I tried to clarify the orders; there were 2 meds (medications) not available when I spoke with the pharmacy. One of the meds was the Glycotrol. I called the doctor who said he was coming in and I told him about the unavailable Glycotrol. He said OK- give 5 mg of [MEDICATION NAME] in place of the Glycotrol. The pharmacy did not say why the Glycotrol wasn't available; just that it was unavailable and what did the physician want to use. When they said that I circled the medication and showed it to the Dr. who said just use the [MEDICATION NAME]." No further information was presented prior to the exit conference 4/12/12. This is a complaint deficiency.

Based on observation, staff interview, and clinical record review, the facility staff failed to provide supervision, assistance and safety devices to prevent an accident which resulted in a fracture for 1 of 13 residents. (Resident #2) The findings include: The facility staff failed to supervise Resident #2 to prevent an accident, which resulted in the resident falling and receiving a Left hip fracture and also failed to ensure the fall precaution intervention of a chair safety alarm was utilized after the fall. Resident #2 was readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The current minimum data set (MDS) with an assessment reference date (ARD) of 8/31/11 assessed the resident as having both short and long term memory loss and requiring moderate assistance with decision making. The clinical record was reviewed. The "Interdisciplinary Progress Notes" documented the following: ? "8/13/11 at 1635 (4:35 p.m.) - Guest found sitting on floor in room by maintenance staff member. Nurse writer and PT (physical therapist named) went to room to assist guest. She was found sitting upright on floor on her buttocks. No s/s (signs or symptoms) initially of distress, ROM (range of motion) WNL (within normal limits). Guest able to stand upright with minimal assistance from staff...Left hip X-Ray ordered fall occurred approx 0815 (8:15 a.m.), 0915 (9:15 a.m.) guest with Left hip pain. Guest medicated with (name of prescription pain medication written here) x (times) 1 then no further c/o (complaint of) Left hip pain." ? "8/14/11 at 1645 (4:45 p.m.) - Guest with Left hip pain at 0900 (9:00 a.m.). Hip x-ray ordered on [DATE] had not been obtained to come today. Did not come on 8/13/11 due to inclement weather. Dtr (daughter) called to notify and to ask her permission to send guest to (name of hospital written here) ER (emergency room ) for eval (evaluation) of Left hip pain. Dtr said to 'please send her'...Resident sent out at 1010 (10:10 a.m.)...Called to check on guest at 1545 (3:45 p.m.) notified that she has a fracture." ? "8/14/11 at 1650 (4:50 p.m.) - Dtr stated that in addition to Dx (diagnosis) guest also has a UTI (urinary tract infection)." ? "8/14/11 at 1700 (5:00 p.m.) - Dtr also stated that guest was not ale to tell hospital staff how her fall occurred. She was not able to tell how it occurred @ (at) the time of incident as well." Physician's telephone orders showed the following documentation: ? "8/13/11 at 0952 (9:52 a.m.) - XRAY Left hip due to c/o pain s/p (status [REDACTED]. ? "8/14/11 (no time written in) - Send to (name of hospital) ER to eval for Left hip pain (s/p fall)." An MDS assessment with an ARD of 7/26/11 included the the following in Section G, Functional Status: ? "G0110 - C. Walk in room - Extensive assistance-resident involved in activity, staff provide weight-bearing support with one person physical assist." ? "G0300 - Balance During Transitions and Walking - A. Moving from seated to standing position; B. Walking (with assistive device if used); C. Turning around and facing the opposite direction while walking; D. Moving on and off toilet; E. Surface-to-surface transfer (transfer between bed and chair or wheelchair)." All were coded as a "2" which indicates the resident was "not steady, only able to stabilize with human assistance." ? "G0600 - Mobility Devices - B. Walker; C. Wheelchair (manual or electric) were checked." The Care Area Assessment (these are areas that the resident is considered to have a problem and would benefit from a care plan and interventions) triggered for Falls as a problem and was checked off by the facility as being care planned for the problem of falls. The care plan that was in effect included the following interventions: ? "Memory/Mood/Cognition/Delirium - Her memory is impaired; Help (name of resident written here) to the bathroom frequently; 8/9/11 She is taking a med for dementia." ? "Bed Mobility/Transferring/Ambulation/ Locomotion & Balance - (Name of resident) transfers with the assist of one person for safety. She needs cues for foot and hand placement; She walks with therapy using a rolling walker." ? "Falls/Safety - Help with all transfers; Working with therapy; (Name of resident) takes Aspirin daily. Use caution with ADL's (activities of daily living) and transfers because it can cause excessive bruising and bleeding; Help (name of resident) to the bathroom frequently. Change pull up as needed; 8/2/11 Help with bathroom needs; 8/13/11 Help to bathroom when she awakens; 8/14/11 To ER for eval due to c/o pain." ? "Pain - 8/9/11 On tapering Prednisone for gout." ? "Cardiac & Respiratory - (Name of resident written here) takes a fluid pill." ? "Rehabilitation Services/Restorative Nursing - Working with PT (physical therapy) and OT (occupational therapy) for strengthening; She needs to walk using rolling walker and assist of one person." The current care plan included and undated additional intervention of "Pressure alarm on bed and chair. Check every shift for placement and function." Also noted on the current physician order [REDACTED]. A physical therapy progress note dated 8/12/11 document "Objective Measurements - Pt (patient) required (S) (supervision) for ambulation due to her poor safety awareness associated with her dementia; pt displayed LOB (loss of balance) due to occasional foot drag when amb w/walker (ambulating with walker) and would require cueing to slow cadence speed and correct gait deficit." On 9/13/11 at 3:25 p.m., the resident was observed in bed with a bed alarm attached to her. On 9/14/11 at 12:45 p.m., Resident #2 was observed in the dining room eating lunch. The resident's chair alarm was attached to her. On 9/14/11 at 2:15 p.m., the administrator and director of nurses were made aware of the findings during a meeting with the survey team. The administration was asked for the thinned record regarding Resident #2 and the 8/13/11 unwitnessed fall. On 9/15/11 at 11:00 a.m., the administrator and DON were asked about an investigation regarding Resident #2's 8/13/11 unwitnessed fall with fracture. On 9/15/11 at 11:35 a.m., the physical therapist that takes care of Resident #2 was interviewed regarding the resident's ambulation ability prior to her 8/13/11 fall. The physical therapist stated that Resident #2 "could get up by herself strength wise; safety awareness is poor. Tried to educate but she needed someone with her due to cognition." The therapist went on to state that this was "still resident's biggest drawback. Recently in therapy, the resident stated 'I got to go to the bathroom', with the leg rests on her wheelchair and no rolling walker nearby the resident attempted to get up." The therapist stated that this occurred "one to two weeks after she came back to the facility from the hospital after the fall with Left hip fracture." The thinned record then was brought to this surveyor. This surveyor was unable to locate the initial admission assessment for Resident #2's 7/19/11. The facility staff were asked for assistance locating the resident's initial admission assessment. On 9/15/11 at 12:50 p.m., Resident #2 was observed in the dining room eating lunch. The chair alarm was noted on the chair but not attached to the resident. A staff member was at the next table feeding another resident, not watching Resident #2. At 12:55 p.m., the administrator was brought to the dining room and observed the resident without the alarm attached to her. The administrator attached the alarm to the resident. On 9/15/11 at 1:00 p.m., the administrator and director of nurses were again asked for the thinned record and the resident's admission assessment. This surveyor also asked for the resident's fall risk assessment. The director of nurses stated that the "fall risk assessment was on the admission assessment." When asked about Resident #2's fall risk assessment and fall precautions, the director of nurses stated that the resident "should have been on fall precautions." On 9/15/11 at 1:00 p.m., the administrator and director of nurses were asked about the facility's investigation policy and the "Accident Investigation Report Form." The administrator stated that "the form was not done, it is to be initiated by the nurse" that first came in contact with the resident after the incident occurred. On 9/15/11 at 4:05 p.m., licensed practical nurse (LPN) #3 was interviewed regarding Resident #2's 8/13/11 fall. LPN #3 stated that she (the nurse) "was at the nurse's station and the maintenance man was walking up the hallway when he saw Resident #2 sitting on the floor. One of our physical therapists and I went to the room to assist the resident. She was sitting where you could see her from the hallway, she was sitting with her legs ajar, but stated that she was not in pain and had no problems with range of motion. About an hour or so later, she complained of pain in her Left hip. I gave her some medication and set up the mobile x-ray to come to x-ray her hip. I worked 7-3 on the 13th and the 14th. When I came in on the 14th I saw that the x-ray was not done because the person who does this was unable to come because of the storm we had. I do not know if anyone tried to follow up, so I got the resident set up to go to the ER to be checked out." LPN #3 was then asked about the resident's safety awareness prior to the fall. LPN #3 stated that "she tried to get up a lot; she used to try to get up from the wheelchair." A copy of Resident #2's admission assessment was never provided to this surveyor during the survey process.