Every finding on record at Delmar Nursing & Rehabilitation Center

Based on observation, interview and record review it was determined that for one (R1) out of three residents reviewed for allergies, the facility failed to ensure a resident with severe food allergy was not served food containing an allergen. The facility's failure placed the residents at risk for a serious adverse outcome including respiratory depression, anaphylaxis or even death from consuming food with a severe allergy. Due to this failure an Immediate Jeopardy (IJ) was called on 7/15/26 at 3:00 PM. The IJ was abated on 7/16/26 at 12:00 AM. Findings include: Cross refer F656;Review of R1's clinical record revealed:2/12/26 - R1 was admitted to the facility with a diagnosis of Cerebral Palsy. 2/12/26 - An allergy to peanuts was documented as severity severe on the allergy tab in the EMR.2/12/26 3:00 PM - A physician's order documented epinephrine auto-injector inject 0.3 mL intramuscularly every 24 hours as needed for an allergic reaction. 2/13/26 1:00 PM - A physician's order documented that R1 had a regular diet, pureed texture and honey thick consistency for liquids. The order also noted R1 had an allergy to peanuts and corn. 2/17/26 - An admission MDS documented that R1 required assist of one staff for ADL's including eating and a BIMs score of 15 indicating intact cognition. 3/5/26 - A review of R1's care plan lacked evidence of severe allergy to peanuts. 7/13/26 5:45 PM - A facility reported incident documented that R1 had a peanut allergy and was given peanut butter during dinner time. 7/13/26 5:56 PM - A review of the MAR documented that R1 received a dose of epinephrine. 7/13/26 7:45 PM - A review of the MAR documented that R1 received a dose of Benadryl (antihistamine). 7/13/26 8:06 PM - A provider hospital progress note documented that R1 presented to the emergency room with a history of peanut allergy and experiencing an allergic reaction. The progress note further documented that R1 received epinephrine and nebulizer treatment during transit to the hospital. Additionally, the progress note documented [R1] critical care was necessary to treat or prevent imminent or ill-threatening deterioration for the following conditions: respiratory failure and toxidrome (toxin overdose).7/13/26 8:55 PM - A nursing progress note (facility) documented that R1 had a peanut allergy and was having difficulty breathing. The note further documented that R1 received a dose of epinephrine and provider was notified. Provider ordered Benadryl 50 mg by mouth and nebulizer treatment. The progress note documented that R1's vital signs were re-assessed, oxygen provided 2L/min via nasal cannula, but oxygen saturation remained low. Provider recommendation to send R1 to emergency room for evaluation. 7/13/26 9:10 PM - A nursing progress note (facility) documented that [R1] had received peanut butter on his dinner tray and E6 (CNA) fed R1 the peanut butter. After [R1] consumed the peanut butter R1 became short of breath and was coughing. At 5:42 PM, [R1] was given epinephrine and Benadryl and [E5 (RN)] advised to monitor [R1] closely for any respiratory changes. At approximately 6:40 PM, [E4 (LPN)] informed [E5] that [R1] had a pulse oxygen reading of 84% on room air and called the on-call provider. On-call provider recommended [R1] be sent to the emergency department for evaluation.7/13/26 10:22 PM - A hospital progress note documented R1 was attempted to weaned off oxygen use and pulse oximetry level would decrease. The progress note further documented that there was concern for possible aspiration due to R1 having multiple episodes of emesis post consumption of peanut butter and an antibiotic was ordered. 7/15/26 11:55 AM - A direct observation of kitchen staff serving and plating lunch meals for dining and units. During observation, E13 (Dietary Aide) was adding drinks and desserts for residents to trays. When completed, E12 (Dietary Aide) would read the ticket and tell E7 (Cook) what entree and side was needed for the plate. Once food was plated, E12 would cover the plate and place tray on food cart to send to dining room or unit. 7/15/26 12:10 PM - A direct observation of staff serving trays to residents in dining room. Staff would look at the name on meal ticket and distribute to the residents in the dining room. 7/15/26 12:25 PM - During an interview, E14 (CNA) stated that the expectation is for staff to review dietary ticket when providing tray to resident. The ticket will have preferences, allergies, and any dietary accommodations (utensils, plates, etc.) listed on the ticket and staff is to ensure those are being followed. E14 stated that if a resident received something that they were allergic to or disliked they would notify the supervisor, would remove that item from the tray, and serve the rest of the food to the resident. 7/15/26 12:35 PM - During an interview, E7 stated the expectation is for the dietary aide who is plating the food should verify that all the items on the tray match the dietary ticket. E7 also stated that allergies are noted on tickets and will be highlighter for staff to see. 7/15/26 12:45 PM - During an interview, E9 (Dietary Manager) stated that the menu on 7/13/26 called for snickerdoodle cookie and confirmed that snickerdoodle cookie was pureed that day for the dinner meal. E9 stated the expectation is for staff to ensure all food on the tray matches the ticket before leaving the kitchen. E9 stated the facility does not place peanut butter in cups for any reason and confirmed the menu does not have peanut butter mentioned for any meal on the four-week rotation. 7/15/26 2:24 PM - During an interview, E8 stated that a nurse came down to the kitchen to notify them that R1 had received peanut butter on his tray at dinner. E8 stated he was unsure how peanut butter had made it on R1's tray as the kitchen staff does not place peanut butter in cups for the residents. 7/15/26 2:36 PM - During an interview, E10 (Dietary Aide) stated he was working on 7/13/26 and was responsible for placing dessert and drinks on R1's tray that evening. E10 stated that the ticket stated R1 was to receive a magic cup and recalls providing the magic cup to the tray. E10 stated that peanut butter was not placed on R1's tray and did not see a cup of peanut butter during prepping. 7/15/26 2:44 PM - During an interview, E11 (Dietary Aide) stated that R1 received pureed fruit on 7/13/26 and did not recall seeing a container of peanut butter in the kitchen during the shift. E11 stated that the kitchen does not serve peanut butter in cups to the resident's and has never seen peanut butter in a cup while working. E11 stated that when the staff serves peanut butter it comes right from the jar and used to make sandwiches. 7/15/26 3:20 PM - During an interview, E6 (CNA) stated that R1 had received a brown colored substance in a cup on the tray and stated the ticket documented dessert was pureed snickerdoodle cookie. E6 stated she did not realize the cup had peanut butter in it and fed it to R1. E6 stated that R1 started coughing after eating the peanut butter and E6 notified the nurse. 7/15/26 3:00 PM - Am Immediate Jeopardy was called and reviewed with the facility leadership E1 (NHA). 7/16/26 12:01 AM - The facility determined Immediate Jeopardy was abated at this time. The abatement plan included providing in person and electronic education of all staff, facility management present and completing audits in real-time during meals. updating of facility procedures with plating and traying in the kitchen, and a facility wide audit and update of allergies in EMR. 7/17/26 2:00 PM - The facility's abatement was reviewed with E1 (NHA). It was determined through observation, interview and record review that the facility completed the abatement plan on 7/16/26 12:00 AM. 7/17/26 3:00 PM - Findings reviewed with E1 (NHA) and E2 (DON) during the exit conference.

Based on interview and record review, it was determined that for one (R1) out of three residents in the investigative sample, the facility failed to develop a comprehensive resident centered care plan for an identified care area. Findings include:Cross refer F806Review of R1's clinical record revealed:2/12/26 - R1 was admitted to the facility with a diagnosis of Cerebral Palsy. 2/12/26 - An allergy to peanuts was documented as severity severe on the allergy tab in the EMR (electronic medical record).2/13/26 1:00 PM - A physician's order documented that R1 had a regular diet, pureed texture and honey thick consistency. The order also noted R1 had an allergy to peanuts and corn. 3/5/26 - A review of R1's care plan lacked evidence of severe allergy to peanuts. 7/13/26 - A facility reported investigative packet documented that R1's care plan will be updated to reflect the severe peanut allergy.7/14/26 - A review of R1's care plan documented that R1 had allergies to peanuts, corn and peanut butter with the following interventions: allergies listed on dietary ticket and in EMR (electronic medical record) and follow physician's orders as indicated. 7/15/26 3:15 - During an interview, E1 (NHA) confirmed that the care plan was updated for R1 related to aforementioned incident. 7/17/26 3:00 PM - Findings reviewed with E1 (NHA) during the exit conference.

Surveyor: Latoya GordonBased on interview, record review, document review, and facility policy review, the facility failed to ensure staff reported allegations of abuse immediately to the Administrator/designee and the administrative staff timely reported allegations of abuse to the state survey agency for 4 (Residents #19, #42, #88, and #93) of 8 sampled residents reviewed for abuse. Findings include: An undated facility policy titled, Abuse, Neglect, Mistreatment, and Misappropriation of Resident Property, revealed, It is the policy of [facility name] that abuse allegations (abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property) are reported per Federal and State Law. The facility will ensure that all alleged abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, are reported immediately, but not later than 2 hours after the allegation is made, or not later than 24 hours if the events that caused the allegations do not involve abuse and do not result in seriously bodily injury, to the administrator of the facility and to other officials (including to the State Survey Agency and adult protective services where state law provides for jurisdiction in long term care facilities) in accordance with State law through established procedures. 1. An admission Record indicated the facility admitted Resident #42 on 03/28/2025. According to the admission Record, the resident had a medical history that included a diagnosis of major depressive disorder and anxiety disorder.The admission Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 04/04/2025, revealed Resident #42 had a Brief Interview for Mental Status (BIMS) score of 15, which indicated the resident had intact cognition. The MDS indicated the resident did not have any behaviors.Contained within the facility investigation file was a handwritten statement from Occupational Therapist (OT) #31 dated 06/12/2025, which indicated On Wednesday, 6/11 [2025] prior to [Resident #52] doctor appointment, the nsg [nursing] aides were attempting to place L [left] shoulder brace. Pt [Patient (Resident #42)] accused the aide of trying to break my arm, I was in a room close by & assisted with placing brace. The brace was already halfway secured & I finished & tightened the straps. The Incident Tracking indicated on 06/11/2025 at 9:00 AM, Resident #42 reported that a certified nurse aide (CNA) intentionally pulled their arm. Per the Incident Tracking, the facility notified the state survey agency of the resident's allegation of physical abuse on 06/12/2025 at 4:14 PM. During an interview on 12/04/2025 at 1:30 PM, OT #31 stated she did not report the allegation because the aides and the nurse were in the resident's room. OT #31 stated she would consider what the resident alleged as an allegation of abuse because the resident stated staff hurt their arm. During an interview on 12/04/2025 at 12:55 PM, the Director of Nursing (DON) confirmed the incident reported by Resident #42 occurred on 06/11/2025.The DON stated staff were supposed to report allegations of abuse immediately. The DON stated the allegation should have been reported on 06/11/2025. During an interview on 12/04/2025 at 2:00 PM, the Administrator stated Resident #42 reported CNA #1 accidently hurt their arm, but it pissed them off. The Administrator stated she expected the incident to be reported as an allegation of abuse on the day that the incident happened.2. An admission Record revealed the facility admitted Resident #93 on 02/21/2025. According to the admission Record, the resident had a medical history that included a diagnosis of metabolic encephalopathy. Contained within the facility investigation file was a document titled Staff Coaching Form for Licensed Practical Nurse (LPN) #7 dated 03/21/2025, which indicated Description of Incident: On 3/21/25 Resident [Resident #93] made statement that CNA [certified nurse aide] had smacked hand while providing care. Residents [spouse] denied that the incident happened. Nurse did not report potential allegation of abuse. Action Steps: Nurse to report any allegation of Abuse or potential allegation of abuse to Nursing Supervisor, DON/ADON [Director of Nursing/Assistant Director of Nursing. During an interview on 12/02/2025 at 6:46 PM, LPN #7 stated she would have notified the DON of the allegation, but the DON was handling another incident at the time and was on the phone with another staff member. LPN #7 stated she was not sure if the resident's allegation was abuse; therefore, she did not report what the resident reported to her immediately. According to LPN #7, the former DON informed her that the incident should have been reported immediately. During an interview on 12/03/2025 at 2:52 PM, the DON stated if there was an allegation of abuse reported to staff, the staff should report the allegation immediately to the manager on duty. The DON stated the allegation involving Resident #93 was not reported to the manager on duty immediately and the staff was educated related to the reporting requirements. During an interview on 12/04/2025 at 10:50 AM, the Administrator stated that as soon as an allegation of abuse was made or occurred, it should be reported. The Administrator stated LPN #7 should have reported the resident's allegation of abuse immediately.3. An admission Record indicated the facility admitted Resident #63 on 05/24/2024. According to the admission Record, the resident had a medical history to include a diagnosis of hypertensive heart disease. A quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 11/30/2024, revealed Resident #63 had a Brief Interview for Mental Status (BIMS) score of 6, which indicated the resident had severe cognitive impairment. An admission Record indicated the facility admitted Resident #77 on 09/30/2023. According to the admission Record, the resident had a medical history to include a diagnosis of senile degeneration of the brain. A quarterly MDS, with an ARD of 11/23/2024, revealed Resident #77 had a BIMS score of 4, which indicated the resident had severe cognitive impairment. An admission Record indicated the facility admitted Resident #88 on 03/03/2021. According to the admission Record, the resident had a medical history to include a diagnosis of schizophrenia. A quarterly MDS, with an ARD of 12/11/2024, revealed Resident #88 had a Staff Assessment for Mental Status (SAMS) that indicated the resident was severely impaired in cognitive skills for daily decision making. Contained within the facility investigation file was a handwritten statement from the Activities Director (AD) dated 12/12/2024, which indicated I was in my office getting ready to leave and I heard residents screaming. As I walk out [Resident #77] was on the left of [Resident #88]. [Resident #63] was yelling saying [Resident #77] had hit [Resident #88] in the face. [Resident #88's] lip was busted and bleeding. Contained within the facility investigation file was email correspondence from Licensed Practical Nurse (LPN) #17 to former Director of Nursing (DON) #8 dated 12/12/2024, that indicated On December 11, 2024 I went to the kitchen to get ice cream and pudding for the nurse coming in at 7 pm. As I was coming back from the kitchen on station 2 I heard [the AD] hollering for me. When I got there [the AD] was standing beside [Resident #88]. [The AD] stated she was in her office and heard [Resident #88] and [Resident #63] yelling. [The AD] said that [Resident #63] told her that [Resident #77] had punched [Resident #88] in the face. The facility Investigation Summary indicated on 12/11/2024, Resident #63 reported that Resident #77 hit Resident #88. Per the Investigation Summary, the Administrator was notified of the incident on 12/13/2024. During an interview on 12/05/2025 at 11:32 AM, the Director of Nursing stated she did not know why the allegation was not reported in a timely manner. During an interview on 12/05/2025 at 12:39 PM the Administrator stated staff were expected to report any and all allegations of abuse and neglect to their direct supervisor immediately. The Administrator stated the allegation should have been reported immediately.4. An admission Record revealed the facility admitted Resident #19 on 08/10/2029. According to the admission Record, the resident had a medical history that included diagnoses of Alzheimer's disease and senile degeneration of the brain. A significant change in status Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 01/22/2025, revealed Resident #19 had a Staff Assessment for Mental Status (SAMS), that indicated the resident was severely impaired in cognitive skills for daily decision making. The MDS indicated the resident was dependent on staff for activities of daily living. The Incident Reporting System indicated on 03/30/2025 at 10:45 AM, Resident #19 was found to have a yellow fading bruise on their right upper arm and left thigh. Per the Incident Report System, the resident was not able to vocalize how the bruising occurred. The Incident Report System indicated the facility notified the state survey agency of the injury of unknown origin on 04/02/2025 at 11:02 AM. During an interview on 12/05/2025 at 3:15 PM, the Administrator stated she expected an injury of unknown origin to be reported to the state survey agency within two hours, and the incident with Resident #19 was not timely reported.

Based on interview, record review, document review, and facility policy review, the facility failed to protect a resident's right to be free from misappropriation of resident property for 1 (Resident #67) of 8 sampled residents reviewed for abuse. Beginning on 07/05/2025 until 08/14/2025, the facility failed to protect and prevent misappropriation of medication with past non-compliance. Findings include: An undated facility policy titled, Abuse, Neglect, Mistreatment, and Misappropriation of Resident Property, revealed, d. Misappropriation of resident property means the deliberate misplacement, exploitation, or wrongful, temporary, or permanent use of a resident's belongings or money without the resident's consent.An admission Record revealed the facility admitted Resident #67 on 05/23/2025. According to the admission Record, the resident had a medical history that included a diagnosis of chronic pain syndrome.A Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 05/29/2025, revealed Resident #67 had a Brief Interview for Mental Status (BIMS) score of 12, which indicated the resident had moderate cognitive impairment. The MDS indicated the resident received as-needed pain medication.Resident #67's Order Summary Report for active orders as of 07/05/2025, revealed an order dated 05/30/2025, for oxycodone hydrochloride oral tablet 5 milligram, give one tablet by mouth every four hours as needed for pain.Contained within the facility investigation was a handwritten statement from Licensed Practical Nurse (LPN) #17 dated 07/04/2025, which indicated On July 4, 2025 resident [Resident #67] asked for the little white pill. I checked the narcotics lock box and there was no card. I worked the night before [07/03/2025] there was a card and the narcotic sheet. When I checked the computer I was the last person that gave [Resident #67] PRN [pro re nata, as needed] oxycodone at 8:31 pm Thursday night 7/3/25. I checked [his/her] chart and no narcotic sheet was in the chart. Supervisor notified I reordered the medication.The facility five-day report dated 07/09/2025, revealed [LPN #17] noticed that the oxycodone was missing on 7/4 [2025] when she went to give it. She had given it on 7/3/25 and was the last person to give it. Unable to locate medication or narcotic sheet. Per the five-day report, an undetermined amount of Oxycodone could not be found or accounted for at this time.During an interview on 12/04/2025 at 10:47 AM, LPN #17 stated she worked on 07/04/2025 from 7:00 AM to 11:00 PM. LPN #17 stated she could not find Resident #67's oxycodone medication or the narcotic medication sheet and reported it to Registered Nurse (RN) #25. LPN #17 stated the staff searched for the medication and the medication sheet, but the medication and the medication sheet could not be found.During an interview on 12/03/2025 at 8:32 AM, RN #25 stated she was on duty as the charge nurse when it was reported by LPN #17 that Resident #67's medication card of oxycodone could not be located. RN #25 stated she reported the incident to the Administrator and the Director of Nursing (DON). During an interview on 12/04/2025 at 10:10 AM, former DON #10 stated she was not involved in the investigation of Resident #67's oxycodone medication because the Administrator conducted the investigation.As a result of Resident #67's missing oxycodone medication, the facility immediately implemented the following corrective actions:-On 07/05/2025, an audit of all narcotic medication cards was conducted to ensure no other medications were unaccounted for. No concerns were identified.-On 07/08/2025, the facility conducted an ad hoc (for this situation) quality assessment performance improvement (QAPI) meeting.-From 07/08/2025 to 07/09/2025, all nurses completed controlled substances competencies. -From 07/09/2025 to 07/18/2025, narcotic sheets were monitored daily for accuracy until narcotic count books were implemented on 07/18/2025.-On 07/14/2025, narcotic books were ordered by way of the pharmacy. -On 07/17/2025, the facility replaced the control drug count verification and narcotic sheet count with controlled substance book on Unit 1.-On 07/18/2025, the facility replaced the control drug count verification and narcotic sheet count with controlled substance book on Units 2, 3, and 4. -On 07/18/2025, the controlled substance policy was changed to include the controlled substance book being utilized for the narcotic count.-On 08/14/2025, the facility conducted an QAPI meeting.After review and verification of the facility's corrective actions, to include staff interviews, resident interviews, and observation of medication administration, the survey team determined the facility implemented the above corrective actions beginning on 07/05/2025 until 08/14/2025, the facility implemented corrective actions to correct the identified deficient practice and prevent recurrence; thus, past noncompliance was cited.

Based on interview, record review, document review, and facility policy review, the facility failed to implement their abuse policy when they failed to obtain witness statements from involved staff for 3 (Residents #19, #77, and #80) of 8 sampled residents reviewed for abuse. Findings include: An undated facility policy titled, Abuse, Neglect, Mistreatment, and Misappropriation of Resident Property, revealed E. Investigation Abuse Policy Requirements: It is the policy of [facility name] that reports of 'abuse' are promptly and thoroughly investigated. Procedure: The investigation is the process used to try to determine what happened. The designated facility personnel will begin the investigation immediately. A root cause investigation and analysis will be completed. The information gathered is given to administration. a. Investigation of abuse: When an incident or suspected incident of abuse is reported, the Administrator or designee will investigate the incident with the assistance of appropriate personnel. The investigation will include: * Who was involved * Residents' statements - For non-verbal residents, cognitively impaired residents or residents who refuse to be interviewed, attempt to interview resident first. If unable, observe resident, complete an evaluation of resident behavior, affect and response to interaction and document findings. * Resident's roommate statements (if applicable) * Involved staff and witness statements of events. 1. An admission Record revealed the facility admitted Resident #19 on 08/10/2029. According to the admission Record, the resident had a medical history that included diagnoses of Alzheimer's disease and senile degeneration of the brain. A significant change in status Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 01/22/2025, revealed Resident #19 had a Staff Assessment for Mental Status (SAMS), that indicated the resident was severely impaired in cognitive skills for daily decision making. The MDS indicated the resident was dependent on staff for activities of daily living. The facility five-day report dated 04/07/2025 indicated on 03/30/2025, Resident #19 was found to have a bruise on their right upper arm and left thigh. Per the five-day report, the resident was unable to state how the bruise occurred. The five-day report indicated the skin assessment completed revealed the resident had a purple/yellow fading bruise on the right upper bicep and skin discoloration on the left thigh. Contained within the facility investigation file was a document titled Accident/Incident Statement Form RN [registered nurse] Supervisor completed by RN #15 and dated 03/30/2025, which indicated 3. List all nursing staff caring for the resident during the time of incident and one shift prior: [Licensed Practical Nurse [LPN) #12 [Certified Nurse Aide (CNA) #11] [CNA #29] [CNA #28]. However, the facility investigation file did not contain evidence of statement from CNA #28 or CNA #29. During an interview on 12/05/2025 at 3:15 PM, the Administrator stated staff from the previous shifts since the last resident's skin check should have been interviewed. 2. An admission Record revealed the facility admitted Resident #77 on 09/30/2023. According to the admission Record, the resident had a medical history that included a diagnosis of senile degeneration of the brain. A quarterly Minimum Data Set (MDS), with an Assessment Reference Data (ARD) of 05/24/2025, revealed Resident #77 had a Brief Interview for Mental Status (BIMS) score of 3, which indicated the resident had severe cognitive impairment. An admission Record revealed the facility admitted Resident #80 on 11/14/2024. According to the admission Record, the resident had a medical history that included diagnoses of Alzheimer's disease and vascular dementia. A quarterly MDS, with an ARD of 05/20/2025, revealed Resident #80 had a BIMS score of 7, which indicated the resident had severe cognitive impairment. The facility five-day report dated 08/19/2025 indicated on 08/14/2025, Resident #77 wheeled over to Resident #80 and started to pull Resident #80's hair. Per the five-day report, Resident #80 yelled and staff separated the residents immediately. The five-day report indicated Resident #80's scalp was red but there were no break in the skin noted. During an interview on 12/05/2025 at 11:01 AM, Licensed Practical Nurse (LPN) #17 stated she witnessed the incident between Resident #77 and Resident #80. LPN #17 stated the facility usually requested witness statements from the staff, but she was unaware if facility management asked for her statement, because the incident occurred at the end of her shift and she went home. The facility investigation file did not contain a witness statement from LPN #17. During an interview on 12/05/2025 at 11:23 AM, the Director of Nursing (DON) stated LPN #17 was the nurse on the unit at the time and witnessed the incident between Resident #77 and Resident #80. The DON stated she was unaware if LPN #17 was asked for a witness statement. During an interview on 12/05/2025 at 11:29 AM, the Administrator stated there should have been witness statements from any staff that was in the area at the time of the incident.

Surveyor: Rachele KempBased on interview, record review, and facility policy review, the facility failed to ensure a pharmacy recommendation was implemented for 1 (Resident #37) of 5 sampled residents reviewed for unnecessary medications. Findings include: An undated facility policy titled, Medication Regimen Review and Reporting, indicated, Medication Regimen Review (MRR) or Drug Regimen Review is a thorough evaluation of the medication regimen of a resident, with the goal of promoting positive outcomes and minimizing adverse consequences and potential risks associated with medication. The MRR includes review of the medical record in order to prevent, identify, report, and resolve medication-related problems, medication errors, or other irregularities. The policy specified, 2. The Consultant's Pharmacist reviews the medication regimen and medical chart of each resident at least monthly to appropriately monitor the medication regimen and ensure that the medications each resident receives are clinically indicated. Per the policy, 8. The facility follows up on the recommendations to verify that appropriate action has been taken. Recommendations shall be acted upon in a timely manner. a. For those issues that require Physician intervention, the attending Physician either accepts and acts upon the report and recommends or rejects all or some of the report and should document his or her rationale of whey the recommendation is rejected in the resident's medical record. An admission Record revealed the facility admitted Resident #37 on 08/29/2025. According to the admission Record, the resident had a medical history that included diagnoses of Alzheimer's disease and cerebral atherosclerosis. A significant change in status Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 09/29/2025, revealed Resident #37 had a Brief Interview for Mental Status (BIMS) score of 3, which indicated the resident had severe cognitive impairment. Resident #37's Order Summary Report for active orders as of 12/05/2025, revealed an order dated 08/29/2025, for lactobacillus capsule, give two capsules by mouth one time a day related to cerebral atherosclerosis. Resident #37's pharmacy MRR for 09/02/2025, revealed a recommendation from the Consultant Pharmacist to Add a strength to the resident's order for lactobacillus capsule. Per the pharmacy MRR, the resident's order for lactobacillus only indicated to give two capsules by mouth one time a day. During an interview on 12/05/2025 at 8:10 PM, Licensed Practical Nurse Unit Manager #9 stated he was unable to locate Resident #37's MRR that contained the physician's signature to indicate the physician reviewed the Consultant Pharmacist's recommendation. During an interview on 12/05/2025 at 9:31 AM, the Consultant Pharmacist stated the recommendation for Resident #37's order for lactobacillus had not been corrected. The Consultant Pharmacist stated every medication needed to include a strength. During an interview on 12/05/2025 at 1:18 PM, Resident #37's primary physician stated if he would have seen the Consultant Pharmacist's recommendation for Resident #37's order for lactobacillus, he would have signed the recommendation to indicate agreement. Resident #37's primary physician stated lactobacillus was available in different strengths and he expected the order to include the dosage (strength). During an interview on 12/05/2025 at 1:45 PM, the Director of Nursing (DON) stated she expected staff to maintain a copy of the signed MRR for each resident. Per the DON, the physician should respond to the pharmacist's recommendations within a day or two. The DON stated the pharmacist's recommendation for Resident #37's lactobacillus should have been follow-up on. During an interview on 12/05/2025 at 2:16 PM, the Administrator stated MRRs should be completed in a timely fashion and followed up on by the physician.

Based on personnel file review and interview, the facility failed to ensure a qualified Dietary Manager (DM) was in place with appropriate competencies and skills to carryout the functions of the food and nutrition service with the potential to affect all 82 census residents. Findings include: Review of the personnel file on 09/23/24 at 1:00 PM revealed the DM hired in the past five weeks lacked management training for the food service director position. He had [AGE] years of management experience in food service. The DM had a Serve Safe certificate but lacked management training. During an interview on 09/25/24 at 12:45 PM, the DM revealed he had an associate degree in design and technology with no reference to food service management. During an interview on 09/25/24 at 3:30 PM, the Regional Corporate Consultant (RCC) verified the lack of management training and indicated that the DM would take the test as soon as possible to satisfy the management training requirements.

Based on observation, interviews, and policy review, the facility failed to ensure the three-pan sink had adequate plumbing, the insulated plate dome covers were in good condition, the kitchen was maintained in a clean manner, and the sanitizer bucket and three-pan sink had adequate sanitizer levels in accordance with professional standards for food safety. The failure has the potential to contribute to food-borne illness and cross contamination for 82 census residents. Findings include: Review of the facility's undated policy titled, Dietary Department Sanitizer Guidelines revealed the three-compartment sink, and other solutions shall be sanitized at 200-400 PPM (parts per million). 1. During observations and interview on 09/24/24 at 9:50 AM, Dietary Aide (DA) 4 was washing dishes in the three-compartment sink. Water was pouring out the plumbing beneath the sink. The plastic water line running below each sink drain ran to a pipe protruding from the floor. Water was pouring out of the pipe onto the kitchen floor near the clean dishes and food. DA4 had to mop the floor to continue working in the area. DA4 was also observed removing rags used as drain stops inside each compartment of the sink, wringing them out and re-inserting them in the drain for the next dishwashing. The facility dishwasher was broken or inoperable. The rinse water was noted to be lacking sanitizer in the third compartment sink. When questioned, the sanitizer was added to the water appropriately. Interview with the Dietary Manager (DM) at the time of the observation indicated the dishwasher was broken causing staff to use the three-compartment sink. During an interview on 09/24/24 at 10:00 AM, the Maintenance Director (MD) revealed staff reported repairs using the Tel's system in the computer. He stated the Tel's computer software produced a work order that prompted him to complete the repairs. He stated he did not have a work order for repairs of this pipe in the kitchen under the three-compartment sink. 2. During an observation and interview on 09/24/24 at 9:55 AM, six insulated dome plate covers used in the transportation of food to the units were missing the center knobs exposing the insulation from inside the plastic lid. The knob missing was the size of a Ritz cracker. The lids were stored upside down in the food service area waiting to be used for lunch. The lids with missing knobs were leaking in the upside-down position from the insulation leaving a puddle of dirty water inside of the stored lids. If the lids were used, they would have been turned over to cover the food going to the resident bedrooms, dripping the dirty water from the insulated lids into resident food. Interview with the DM at the time of the observation verified the missing knobs and threw each of the six lids in the garbage can. 3. During observations on 09/24/24 at 10:05 AM, revealed missing, peeling paint under the window opening to the dining room. In addition, a large amount of food splash was observed on the wall near the toaster too numerous to count and red in color. In addition, five overhead pipes which extended the entire length of the kitchen and food service area ceiling, were observed with large amounts of dust and dirt. During an interview on 09/25/24 at 1:30 PM, the DM, Regional Corporate Consultant, (RCC), and Administrator verified the peeling paint and splash. They confirmed there was no cleaning schedule. 4. During observation on 09/24/24 at 10:40 AM, [NAME] (C) 2 used a washcloth that moments earlier were on the wet dirty floor to wash dishes in the two-compartment sink near the stove. She washed the blender used for pureeing meatloaf, carrots, and macaroni and cheese. When finished pureeing each of the three food items, she cleaned the container, blade, and cover without sanitizing either of the items at any time and used the dirty wash rag from the floor. During an interview on 09/24/24 at 11:00 AM, C2 shrugged her shoulders as if to say ok, stating yes, I washed them. 5. During an observation and interview on 09/24/24 at 10:45 AM, a small red bucket containing a washcloth for wiping off equipment and tables in the kitchen revealed the container lacked the correct amount of sanitizing solution. The test strip used by DA2 revealed 10 PPM. She stated she put sanitizer in the bucket earlier from the sink near the three-compartment sink. 6. During an observation and interview on 09/24/24 at 11:05 AM, DA4 revealed he was washing silverware, pots and pans, insulated dome plate covers by washing, rinsing, and submerging the dishes in the sink, then with the same gloves, removing the clean dishes from the sanitizer and stacking and sorting. Interview with the DM at the time of the observation verified the findings. 7. During observations of 09/24/24 at 11:10 AM, the entrance and exit doors to the kitchen had black stains, missing paint, and a sticky substance on the inside of each door. During an interview on 09/25/24 at 1:30 PM, the DM, RCC, and Administrator verified the condition of the two doors. They confirmed there was no cleaning schedule. 8. During an observation on 09/24/24 at 11:30 AM, a large metal mouse trap was located on the floor behind the stove. The trap was coated with food debris on the top. Food debris was also located throughout the floor behind the stove in large quantities. During an interview on 09/25/24 at 1:30 PM, the DM, RCC, and Administrator verified the condition of the mouse trap and dirt behind the stove. They confirmed there was no cleaning schedule.

Based on record review, interview, and review of the facility's policy, the facility failed to ensure residents' Minimum Data Set (MDS) assessments accurately reflected the residents' status for one (Resident (R) 24) of 23 sampled residents. R24's most recent MDS indicated the resident had the serious mental illness (SMI) of bipolar disorder; however, there was not documented evidence in the resident's medical record to confirm the diagnosis. This failure placed the resident at risk for inaccurate and unmet care needs. Findings include: Review of the facility's undated policy titled, Comprehensive Interdisciplinary Assessment revealed Guidelines: Upon admission and periodically thereafter each resident shall have a comprehensive, accurate, standardized and reproducible assessment of functional capacity and needs .Procedure: I. The comprehensive assessment for each resident will describe the resident's capability to perform daily life functions and identify significant impairments in functional capacity. The Resident Assessment Instrument process with be completed on all residents per scheduling requirements listed in the Resident Assessment Instrument (RAI) Manual .V. Each discipline shall complete and electronically sign for the 'completion and accuracy of their entries' in the designated location on the MDS . Review of R24's undated Resident Face Sheet, located in the resident's electronic medical record (EMR) under the Resident tab, revealed the resident was admitted to the facility on [DATE] and most recently readmitted on [DATE] with diagnoses which included major depressive disorder and anxiety disorder. R24's Resident Face Sheet did not include the diagnosis of bipolar disorder. Review of R24's untitled Mental Health Progress notes, dated 08/14/24 and located in the resident's hard copy medical record under the PSYCH tab, revealed the following documented mental health diagnoses: major depression, anxiety disorder, and adjustment disorder with mixed anxiety and depression. Review of R24's quarterly MDS with an Assessment Reference Date (ARD) of 09/10/24 and located in the resident's EMR under the MDS tab revealed the facility assessed the resident to have a Brief Interview for Mental Status (BIMS) score of 15 out of 15 which indicated the resident was cognitively intact. The MDS also documented the resident had the active diagnosis of Bipolar Disorder. During an interview on 09/24/24 at 3:45 PM, R24 stated she had never been diagnosed with bipolar disorder. During an interview on 09/26/24 at 8:53 AM, the MDS Coordinator (MDSC) reviewed R24's quarterly MDS with an ARD of 09/10/24 and confirmed the MDS indicated R24 had the diagnosis of bipolar disorder. The MSDC stated R24's MDS was inaccurate as she double checked the resident's medical record, and the resident had not been diagnosed with bipolar disorder. The MDSC also stated she was the one who completed the resident's MDS, and she mistakenly selected bipolar disorder as one of the resident's active diagnoses. The MDSC stated it was important the MDS be correct to ensure the truest picture of the resident's status. During an interview on 09/26/24 at 9:02 AM, the Director of Nursing (DON) stated it was her expectation R24's MDS would have accurately reflected the resident's current diagnoses to ensure the appropriate care was provided. During an interview on 09/26/24 at 9:09 AM, the Administrator stated it was his expectation residents' MDS were accurate to reflect the resident's true current status.

Based on observation, interview and record review it was determined that for two (R58 and R14) out of two residents reviewed for pressure ulcers, the facility failed to provide care and services to promote healing and prevent pressure ulcers. For R58 the facility failed to prevent an avoidable deep tissue injury from developing to the left heel and a stage 4 pressure ulcer to the right ankle causing harm. For R14 the facility failed to ensure that the resident was turned and repositioned to prevent pressure ulcers. Findings include: National Pressure Ulcer Advisory Panel (NPUAP), Prevention and Treatment of Pressure Ulcers: Quick Reference Guide, second edition, published 2014, stated Do not position an individual directly on a pressure ulcer .Continue to turn and reposition the individual regardless of the support surface in use .No support surface provides complete pressure relief. An undated facility policy titled Pressure Ulcer Prevention included: A determination that development of a pressure ulcer was unavoidable may be made only if routine preventative and daily care was provided. Routine preventive care means turning and proper positioning, application of pressure reduction devices Residents at risk should be turned and repositioned at least every two hours or more frequently depending on other risk factors 1. Review of R58's clinical record revealed: 4/20/22 - R58 was admitted to the facility with diagnoses of anoxic brain damage and generalized muscle weakness. 4/20/22 - A nursing admission Braden Scale documented R58 with a score of 14 (13 - 14 is considered moderate risk of skin breakdown). 5/2/22 - The electronic record documented R58's diagnoses of disorder to the skin and subcutaneous tissue and contracture of the right/left shoulder, right/left elbow and right/left hand. a. 9/1/22 - A physical therapy discharge summary written by E12 (Physical Therapist) documented: Splint / Orthotic Recommendations: BLE ankle boots recommended to prevent further contractures and heels/ankles floating to nearest possibility to prevent skin breakdown. The quarterly MDS for 10/28/22 and 1/28/23 documented that R58 was totally dependent on one staff person to turn and reposition with no pressure ulcers and was at risk of developing pressure ulcers. R58 had one lesion on the foot (trauma to the left, second toe) and one open lesion other than ulcers, rashes, cuts (abscess to the sacrum). The MDS also documented R58 had a pressure reducing device for the chair and bed; was on a turning and repositioning program; applications of nonsurgical dressings, ointments/medications, other than to the feet and application of dressings to the feet. The 1/28/23 quarterly MDS was updated to include an additional intervention to receive nutrition or hydration interventions to manage skin problems. A review of R58's care plan last revised 1/25/23 included to turn and reposition every two hours with skin checks and an air loss mattress, effective 4/25/22. The care plan did not include interventions for R58 to wear heel boots to both feet or offload the heels. 3/6/23 - A nursing Braden Scale documented R58 with a score of 14 (13 - 14 is considered moderate risk). 3/13/23 - A nursing progress note documented that R58 had two new wound areas. The first area was a wound to the left heel that is discolored and measures 1.5 cm x 3 cm. The second area was a wound located on the right outer ankle that was not there yesterday .has open area with denuded skin that measures 3 cm x 2 cm x [undetermined depth] has red/yellow slough. The progress notes also stated that a therapy referral for positioning would be made. 3/13/23 - A wound evaluation form documented a pressure wound to the right outer ankle with an undetermined depth stage and measurements of 3 cm x 2 cm x undetermined depth. A deep tissue injury wound to the left heel with measurements of 1.5 cm x 3 cm x 0 cm. The document listed multiple treatments including turn resident to back and left side only. 3/15/23 - A review of R58's care plan included to always wear boots to feet except during care, effective 3/8/23. 3/15/23 - A physical therapy evaluation was completed for R58 in order to improve ability to exhibit preserved skin integrity and relieve pressure for decreased risk of skin breakdown The facility lacked evidence that the heel boots were applied to R58 from the time it was recommended by therapy on 9/1/22 until the boots were added to the care plan updated on 3/15/23. 3/24/23 - A wound evaluation form documented the wound to the right lateral ankle as a stage 4 pressure wound. The left heel wound was documented as a deep tissue injury. 10/6/23 9:33 AM - During an interview, E12 confirmed the heel boots were recommended for continued use after therapy discharge. E12 stated we used the heel boot to prevent pressure to the heel, we wanted to offload his heels. 10/6/23 at 9:40 AM - During an interview E6 (Unit manager), confirmed the therapy discharge summary recommendations were reviewed on 9/1/22. E6 stated that the rehabilitation department gives nursing a copy of the summary and the unit manager or the nurse signs them and puts the orders or the recommendations in the treatment interventions in the electronic chart. E6 stated, we would follow the recommendations from therapy as they provide it. R58 developed two avoidable pressure ulcers to both feet. The facility lacked evidence of using the heel boots that were recommended by the therapy department on 9/1/22. Additionally the facility failed to provide any other interventions to offload pressure to the feet. The facility failed to include the heel boots as a prevention of skin breakdown until 3/15/23, over six months later resulting in harm to the resident when R58 developed two pressure ulcers to both feet. b. 3/15/23 - A review of R58's care plan included to always wear boots to feet except during care, effective 3/8/23. On the following dates and times, R58 was observed lying in bed with left foot resting directly on the mattress without the left heel boot: 10/3/23 at 9:14 AM, 10/3/23 at 10:34 AM, 10/3/23 at 12:37 PM, 10/3/23 at 1:14 PM and 10/3/23 at 2:22 PM. 10/4/23 11:00 AM - During an interview with E14 (CNA) revealed that the heel boot to right foot started one or two weeks ago. It was further revealed E14 was not aware of where boot came from for R58. There was no further information offered about the left heel boot. 10/4/23 at 12:02 PM - An interview with E6 (Unit Manager) confirmed R58 should have boots on both feet at all times. 10/5/23 1:07 PM - An interview with E15 (Nurse Practitioner) confirmed that R58's heels were to be offloaded at all times. 10/6/23 9:33 AM - During an interview with E12 (therapist) confirmed the heel boots were recommended for R58' s continued use after R58' s therapy discharge on 9/1/22. E12 stated we used the heel boot to prevent pressure to the heel, we wanted to offload R58's heels. The facility failed to ensure R58 with a history of pressure ulcers had a left heel boot to his feet to prevent skin breakdown. 2. Review of R14's clinical record revealed: 6/23/21 - R14 was admitted to facility. 6/24/21 - A nursing admission Braden Scale documented R14 with a score of 15 (15 - 18 is considered mild risk of skin breakdown). 12/23/22 - The electronic record documented R14's diagnoses of stroke, generalized muscle weakness, contractures of left hip, left knee, left and right hand. A review of R14's care plan last revised 6/21/23 included to turn and reposition every two hours with skin checks, effective 3/20/23. 9/23/23 - R14's quarterly MDS documented that R14 was an extensive assist of two or more staff for turning and repositioning. The MDS also documented R14 had a pressure reducing device for the chair and bed and was on a turning and repositioning program. 10/4/23 9:10 AM - During an interview with R14, when asked if she gets turned on her side, she replied no. On the following dates and times, R14 was observed in bed laying on her back on 10/4/23: 9:10 AM, 10:30 AM, 11:20 AM, 12:36 PM and 1:11 PM. R14 was observed lying in bed on her back for four hours without any turning. 10/5/23 10:48 AM - During an interview E6 (UM) confirmed R14's was to be turned and repositioned every two hours. The facility failed to ensure that R14 was turned and repositioned every two hours. Findings were reviewed with E19 (NHA), E1 (NHA in training), E2 (DON) and E3 (Unit Manager) at the exit conference on 10/6/23, at 1:55 PM.

Based on observation and interview, it was determined that the facility failed to maintain the correct concentration of sanitizing solution required to ensure proper sanitization of food preparation surfaces. Findings include: 9/29/23 10:47 AM- During a tour of the kitchen, E18 (Director of Food Services) tested the sanitizer level of the solution in a red sanitizing bucket. When E18 tested the sanitizing solution, the test strip indicated that the level of chemical concentration in the bucket was not sufficient to provide proper sanitization. Findings were reviewed with E19 (NHA), E1 (NHA in training), E2 (DON) and E3 (Unit Manager) at the exit conference on 10/6/23 at 1:55 PM.

Based on observation, interview, and record review, it was determined that for three (R53, R58 and R67) out of eighteen (18) residents reviewed for care plans, the facility failed to accurately assess and document R53's dental status. For R67 and R58 the facility failed to include the use of heel boots and pxygen use. Findings include: 1. Review of R67's clinical record revealed: 8/17/23 - R67 was admitted to the facility. 8/18/23 - An initial comprehensive careplan was completed for R67. 8/29/23 - A physician's order for O2 at 2L/min via nc (nasal cannula) as needed for SOB (shortness of breath) and to maintain O2 sats above 88% was entered. 10/4/23 - A review of R67's care plan dated 8/18/23 for respiratory function failed to include evidence of oxygen use. 10/5/23 approximately 10:25 AM - E2 (DON) confirmed that R67's oxygen use was not included on the care plan. 44706 2. Review of R53's clinical record revealed: 10/3/21 - R53 was admitted to the facility. 10/16/21 through 10/5/23 - Care plans for dental status documented R53 had no natural teeth or tooth fragment(s) edentulous (lacking teeth, toothless). 10/3/23 approximately 11:00 AM - During an interview, R53 stated that he had some natural teeth on the bottom, pointed to a tooth and stated that one was cracked when he came in, but since then it had been fixed. R53 proceeded to say that he wears full upper dentures and sees the dentist on a regular basis. 10/5/23 3:35 PM - During an interview, E2 (DON) and E6 (Unit Manager) confirmed R53's care plan lacked evidence that a person-centered care plan with interventions was developed to accurately reflect R53's dental status. E2 and E3 (ADON) both confirmed that R53 had natural bottom teeth and full upper dentures. 47142 3. Review of R58's clinical record revealed: 4/20/22 - R58 was admitted to the facility with diagnoses of anoxic brain damage and generalized muscle weakness. 9/1/22 - A physical therapy discharge summary written by E12 (Physical Therapist) documented: Splint / Orthotic Recommendations: BLE ankle boots recommended to prevent further contractures and heels/ankles floating to nearest possibility to prevent skin breakdown. 3/15/23 - A review of R58's care plan included to have boots to both feet to be worn at all times except during care, effective 3/8/23. 10/4/23 11:00 AM - An interview with E14 (CNA) confirmed R58 was wearing just one heel boot and they were unaware of any interventions to offload R58's heels. When asked when the intervention to use a right heel boot began for R58, E14 stated, I think it was about one or two weeks ago, I don't know where it came from. An interview on 10/4/23 at 12:02 PM with E6 (Unit Manager) confirmed for R58 to have boots to feet at all times. The facility failed to include inteventions for bilateral heel boots to prevent further contraction and skin breakdown for R58. Findings were reviewed with E19 (NHA), E1 (NHA in training), E2 (DON) and E3 (Unit Manager) at the exit conference on 10/6/23 at 1:55 PM.

Based on interview and record review, it was determined that for three (R10, R12 and R16) out of three residents reviewed for PASARR, for R10, R12, and R126 the facility failed to ensure that a referral for a PASARR screening was completed following a new diagnosis of psychotic disorder which was not listed on the previous PASARR. Findings include: 1. Review of R10's clinical record revealed: 3/24/14 - R10 was admitted to the facility. 3/25/14 - A review of R10's medical record revealed a PASARR level I was completed prior to admission. 7/17/18 - A review of R10's medical record revealed that R10 had a PASARR level I that indicated R10 had a documented serious mental illness (depression and anxiety) and demonstrated a full level II was not indicated at that time. 8/29/19 - A review of R10's medical record revealed that R10 had the following new diagnoses: bipolar disorder, major depressive disorder, anxiety disorder, and delusional disorder. 9/20/19 - A review of the MDS revealed diagnosis of bipolar, major depressive disorder, anxiety disorder, and delusional disorder were documented. 10/4/23 2:45 PM - An interview with E4 (social worker) confirmed that a PASARR level II was never requested for R10. 2. Review of R16's clinical record revealed: 2/27/13 - R16 was admitted to the facility. 2/25/13 - An admission PASARR level I was completed for R16. 7/30/18 - A repeat PASARR level I was completed that indicated R16 had a documented serious mental illness (Schizophrenia) and demonstrated a full level II was not indicated at that time. 2/22/19 - A review of R16's medical record revealed that persistent mood disorder was added to R10's diagnoses. 7/12/19 - A review of R16's medical record revealed that delusional disorder was added to R10's diagnoses. 8/23/19 - A review of R16's medical record revealed that bipolar disorder and mood disorder was added to R10's diagnoses. 11/13/19 - An MDS (Minimum Data Set) was completed for R16 and indicated that R16 had delusional disorder, persistent mood disorder, bipolar disorder and mood disorder. 10/4/23 2:45 PM - An interview with E4 confirmed that a PASARR level II was never requested for R16. 44706 3. Review of R12's clinical record revealed: 3/2/12 - R12 was admitted to the facility. 3/2/12 - Review of R12's clinical record revealed that R12 had a PASARR Level 1 completed. 9/3/19 - Review of R12's medical record revealed that upecified psychosis, dementia without behavioral disturbances, delusional disorder, and anxiety disorder was added to R12's diagnoses. 9/30/23 - An annual MDS assessment was completed for R12 and indicated that R12 had anxiety disorder, depression, psychotic disorder, and delustional disorder. 10/4/23 9:39 AM - During an interview E4 (Social worker) confirmed R12 had a PASARR Level I on admission and that a PASSR Level II was not requested for R12. 10/5/23 1:35 PM - In an email correspondence, S1 (PASARR State Authority) revealed that, .The facility should have submitted a status change or another resident review PASARR at that time of or timely discovery that the Level 1 (Notice Date 7/30/18) was not an accurate reflection of (R 10 and 16's) mental health status and new diagnoses. Findings were reviewed with E19 (NHA), E1 (NHA in training), E2 (DON) and E3 (Unit Manager) at the exit conference on 10/6/23 at 1:55 PM.

Based on interview and record review, it was determined that for two (R15 and R46) out of eighteen residents reviewed for care plans, the facility failed to update these residents' care plans to reflect the use of insulin. 1. Review of R46's clinical record revealed: 2/17/20 - Resident was admitted to the facility. 3/9/21 - R46's care plan for diabetes was completed. 12/1/22 - A medication order was entered, as follows: Levemir FlexTouch U-100 Insulin 100 unit/mL (3 mL) subcutaneous pen .: inject 4 units by subcutaneous route once daily. 8/29/23 - R46's most recent care plan meeting was convened. 10/4/23 untimed - Review of R46's care plan revealed there was no reference to insulin usage. 10/5/23 at approximately 10:25 AM - During an interview with E2 (DON), she confirmed there was no care plan for R46's use of insulin. 46988 2. Review of R15's clinical record revealed: 7/18/19 - R15 was admitted to facility. 2/16/23 - A care plan for diabetes was initiated and revealed R15 was a controlled diabetic taking oral hypoglycemics (medication to control blood sugar) and diet controlled. 7/26/23 12:52 PM - A physician's order was written for Lispro insulin three times a day with meals. Also, for Lispro sliding scale three times a day with finger sticks and written for Lantus insulin at bedtime. 7/26/23 3:52 PM - A care plan was updated but did not include insulin. 10/04/23 1:50 PM - An interview with E3 (UM) confirmed that R15's care plan did not include use of insulin to reflect R15's current needs. The facility failed to update R15's and R46's care plan to reflect the current need of insulin. Findings were reviewed with E19 (NHA), E1 (NHA in training), E2 (DON) and E3 (Unit Manager) at the exit conference on 10/6/23 at 1:55 PM.

Based on observation, interview and record review, it was determined that for two (R14 and R58) of four residents reviewed for ROM/mobility, the facility failed to provide care to maintain or prevent further decline in function/mobility. Findings include: An undated facility policy titled Pressure Ulcer Prevention included: Routine preventive care means turning and proper positioning, application of pressure reduction devices Residents at risk should be turned and repositioned at least every two hours or more frequently depending on other risk factors The use of soft foam devices (i.e. carrots, palm protectors, etc.) should be considered to alleviate pressure if the resident has a contracted hand after appropriate evaluation by OT for device orders and application instructions. 1. Review of R14's clinical record revealed: 6/23/21 - Admission of R14 to facility. 12/23/22 - The electronic record documented R14's diagnoses of stroke, generalized muscle weakness, contractures of left hip, left knee, left hand and right hand. A review of R14's care plan last revised 6/21/23 included to always wear palm guard to right hand except during hygiene and meals, effective 8/10/21. 9/23/23 - R14's quarterly MDS documented that R14 had an impairment on both sides for the upper extremities and the lower extremities for functional range of motion. 9/29/23 10:50 AM - During an interview with E16 (CNA), when asked if R14 wears or uses any kind of devices on her hands E16 stated, she does not have any. 10/3/23 10:22 AM and 11:36 AM - R14 was observed without a palm guard on the right hand. 10/4/23 10:30 AM - R14 was observed without a palm guard on the right hand. 10/4/23 11:00 AM - During an interview, E14 (CNA) stated there was no place in the electronic record or any other place to document applying devices including splints or guards for the residents. 10/4/23 11:20 AM, 12:36 PM and 2:20 PM - R14 was observed without a palm guard on the right hand. 10/5/23 10:14 AM - During an interview, E17 (Rehab Director) confirmed R14 has an active treatment to use a right palm protector. E17 stated, we have her documented that she refuses .she is on my splint list as not compliant with it .it [right palm protector] started 8/9/21 .they [CNA's] are still supposed to attempt to try to have her wear it every day. 10/5/23 10:43 AM - E17 was observed placing a palm protector device on R14's right hand. E17 confirmed the device not being present and stated she [R14] put it on very well and we are considering bringing her back in therapy. E17 confirmed that R14 did not refuse the palm protector. 10/5/23 10:48 AM - During an interview E6 (UM) confirmed R14 is supposed to wear a palm protector and if not to document a refusal in the progress notes . if refused, it will be documented in the care plan as a refusal. The facility lacked evidence in the clinical record or the care plan that R14 refused wearing the palm guard. The facility failed to apply R14's palm guard to maintain ROM and prevent further contracture. 2. Review of R58's clinical record revealed: 4/20/22 - R58 was admitted to the facility with a diagnoses of anoxic brain damage and generalized muscle weakness. 5/2/22 - The electronic record documented R58's diagnoses of disorder to the skin and subcutaneous tissue and contracture of the right/left shoulder, right/left elbow and right/left hand. A review of R58's care plan last revised 7/19/23 included interventions for the resident to be out of bed to geri-chair for positioning and comfort, effective 4/26/22. The care plan also included an intervention for wedges to be used for positioning, which was effective 8/17/22. The care plan also included to turn and position R58 to back and left side only, every two hours and as needed with skin checks. 7/29/23 - R58's quarterly MDS documented R58 had an impairment on both sides for the upper extremities and the lower extremities for his functional range of motion. The MDS also documented R58 was totally dependent of one staff for turn and reposition and was totally dependent of two or more staff for transferring from bed to chair. 9/4/23 - An occupational therapy progress report documented R58 uses a small wedge for his right lower extremity to maintain good positioning in bed and reduce risk of skin breakdown, beginning on 5/24/23. On the following dates and times, R58 was observed in bed laying on his back without any wedges in place: 10/3/23 at 9:14 AM, 10/3/23 at 10:34 AM and 10/3/23 at 12:37 PM. 10/3/23 2:22 PM - R58 was observed in bed laying on his back without any wedges in place. 10/3/23 - R58 remained on his back from 9:14 AM to 2:22 PM without ever being repositioned with the wedges. 10/4/23 9:10 AM - R58 was observed in bed laying on his back without any wedges in place. The facility failed to reposition R58, a totally dependent resident, with a history of contracture, from back to left side every two hours using wedges to prevent further contracture. Findings were reviewed with E19 (NHA), E1 (NHA in training), E2 (DON) and E3 (Unit Manager) at the exit conference on 10/6/23 at 1:55 PM.

Based on observation, interview and record review, it was determined that for one (R67) out of three residents reviewed for respiratory care, the facility failed to ensure that R67 oxygen tubing was changed. Findings include: An undated facility policy for oxygen use stated Tubing change - Oxygen cannula tubing is charted weekly and prn (as needed). Review of R67's clinical record revealed: 8/17/23 - R67 was admitted to the facility. 8/29/23 - A physician's order for O2 at 2L/min via nc (nasal cannula) as needed for SOB (shortness of breath) and to maintain O2 sats above 88%. 9/29/23 11:49 AM - An observation revaled that R67's oxygen tubing was not labeled on the following dates and time: 9/29/23 11:49 AM; 10/4/23 at 9:27 AM; and 10/5/23 at 9:30 AM. 10/5/23 approximately10:25 AM - E2 (DON) confirmed there was no order for oxygen tubing to be changed and that R67's oxygen use was not referenced on care plan. Findings were reviewed with E19 (NHA), E1 (NHA in training), E2 (DON) and E3 (Unit Manager) at the exit conference on 10/6/23 at 1:55 PM.

Based on observation and interview, it was determined that one medication room out of one medication reviewed the facility failed to maintain medications narcotics under a double locks for one out of one medication rooms. In addition, the facility failed to monitor refrigerator temperatures. Findings include: 10/5/23 10:05 AM - The following was reviewed in the med room: - The refrigerator narcotic box containing six vials of lorazepam (medication to treat seizures and anxiety) was not secured to the fridge and was unlocked. - Review of the September 2023 temperature log for the medication refrigerator revealed that four out of thirty days: 9/1/23, 9/9/23, 9/14/23 and 9/15/23 morning shifts were missing temperature and staff initials. 10/5/23 10:53 AM - During an interview, E2 (DON) and E6 (UM) confirmed that the specified dates, times and initials were not documented on the temperature log and the narcotic box was unsecured. Findings were reviewed with E19 (NHA), E1 (NHA in training), E2 (DON) and E3 (Unit Manager) at the exit conference on 10/6/23 at 1:55 PM.

Based on observation and interview it was determined that the facility failed to ensure sanitary disposal of garbage. Findings include: 9/29/23 10:48 AM - During a tour of the kitchen, two large trash cans containg food waste and other kitchen debris were left uncovered with no lids available in the area. Findings were reviewed with E1 (NHA in training), E19 (NHA) on October 3, 2023 at 10:17 AM. Findings were reviewed with E19 (NHA), E1 (NHA in training), E2 (DON) and E3 (Unit Manager) at the exit conference on 10/6/23 at 1:55 PM.

Based on interview and record review, it was determined that the facility failed to develop policies and procedures for the monthly MRR (Medication Regimen Reviews) that included time frames for different steps in the MRR process. Findings include: 10/4/23 - A review of the undated facility's policy titled Medication regimen review and reporting lacked information of the facility's time frame to respond to the pharmacy recommendations based on identified irregularities. 10/5/23 10:01 AM - An interview with E2 (DON), who stated that the facility completes a Monthly Medication Review (MRR) for each resident. The pharmacy will submit the recommendations and the MD will review it. E2 reviewed the policy and confirmed that the policy lacked information on timeframes for the steps of the MRR process. 10/6/23 - Findings were reviewed with E19 (NHA), E1 (NHA in training), E2 (DON), E3 (Unit Manager) on 10/6/23 at 1:55 PM.

Based on observation, and interview it was determined that the facility failed to ensure that food was stored, prepared, and served in a sanitary manner. Finding include: Facility Policy: Dietary Department Infection Control Guidelines (no date) states that staff in the kitchen are to wear hair nets or caps to ensure a healthy environment and minimize the risk of food born infections. Facility Policy : Dietary Department Sanitizer Guidelines (no date) states sanitizer solution is checked when the sanitizing bucket is refreshed and then every four hours during the shift. Audits are completed by the kitchen manager twice a week and through a sanitation audit completed by the supervisor once a week. 1. 3/9/22 8:10 AM - During the intial tour of the kitchen, the following observations were made: - Two packages of open grated cheese were noted in the walk in refridgerator were unlabeled. - Three large open bottles of ranch dressing were not labeled and one of these was not properly closed and had dressing on the lid. These observations were confirmed with E11 (cook). 2. 3/9/22 8:10 AM - E13 (Dietary Aide) was observed in the kitchen without a hairnet on. 3/9/22 1:00 PM - A random observation revealed that E13 (Dietary Aide) was not wearing a hairnet in the kitchen. 3/9/22 2:15 PM - During an interview with E12 (Dietary Manager) confirmed that E13 (Dietary Aide) was not wearing a hairnet when observed after lunch. 3/9/22 3:42 PM - During an interview E12 confirmed that he would re-educate kitchen staff on the wearing of hair restraints in the kitchen. 3. 3/9/22 8:40 AM - During the kitchen tour, E13 (Dietary Aide) performed a test on the sanitizer bucket to determine strength of the sanitizer solution, she and the surveyor both saw the test strip read zero ppm (meaning the bucket did not have any sanitizer). A retest was performed with the same result. E13 then dumped the bucket and refilled it and retested the solution, which again read zero ppm. The surveyor observed that the tubing coming from the sanitizer liquid was not filled with sanitizer liquid. E13 stated she usually tests the solution when she starts work and then at least one more time during the shift. 3/9/22 9:00 AM - In an interview E12 (Dietary Manager) confirmed that the sanitizer was not flowing into the line. He stated that this system was working on 3/8/22. E12 then called E9 (Environmental Manager) to look at the system and repair it. 3/9/22 10:10 AM - In an interview E12 (Dietary Manager) stated the staff will use spray sanitizing solution until the sanitizer system is repaired. 3/9/22 12:45 PM - A random observation confirmed that the sanitizing solution was now flowing into the tubing and delivered into the bucket as designed. 3/9/22 3:42 PM - In an interview E12 (Dietary Manager) provided auditing process policy of sanitizing solution concentrations. E12 provided logs for the past two months (January and February) which confirmed audits were completed. E12 also confirmed that staff tested the sanitizing solution anytime the bucket is refreshed and every four hours. 3/16/22 2:50 PM - Findings were reviewed with E1 (NHA), E2 (DON), and E2 (ADON) during the exit conference.

Based on interview, record review, and review of other clinical documentation it was determined that the facility failed to ensure that six (R2, R9, R12, R15, R10, and R8) out of 17 sampled residents received the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being, in accordance with the comprehensive assessment and plan of care. R9 hit his head during a fall and had a change in status as evidenced by descending blood pressure (BP) and also developed fluid in the lungs. The facility failed to recognize the significance of R9's neurological status change(change in level of consciousness) along with the presence of fluid in the lungs. The facility failed to closely monitor R9's condition by failing to consistently complete R9's neurological assessment. These failures resulted in R9 being found unresponsive with no pulse or respiration. Cardiopulmonary resuscitation (CPR) was initiated and R9 was sent to the hospital. R2 had a debridment (removing unhealthy or dead tissue from a wound) of a right toe corn ulceration at a podiatrist's office and did not receive the recommended treatment in the facility for the wound for one month. This resulted in the wound not healing and developing an infection that moved to the bone and blood of the resident requiring hospitalization . R12 had an unwitnessed fall and neurological checks were not initiated. R15 had two unwitnessed falls and neurological checks were not thoroughly completed. The facility failed to ensure that R10 received the care necessary to attain his highest level of well-being when he had a change in his respiratory status. R10 was noted to be "breathing funny" between 11:15 PM and 11:30 PM on [DATE] but no nursing assessment and intervention were identified in the record until approximately 2 AM when R10 reported difficulty breathing and soon became unresponsive requiring cardiopulmonary resuscitation (CPR) and transfer to the hospital via 911.The facility failed to ensure that R8 received the care necessary for her highest level of well-being when the facility failed to obtain emergency care on [DATE] at the instruction of a cardiologist (E33). This resulted in a 2 day delay in R8 being treated for [REDACTED]. 1. R9 was readmitted to the facility from the hospital on [DATE]. Review of R9's Medication Administration Record [REDACTED]. (milligram) by mouth at 7:19 PM and [MEDICATION NAME] (hypnotic for [MEDICAL CONDITION]) 10 mg. by mouth at 9 PM. Review of the facility's incident report dated [DATE] documented that R9 experienced a fall on [DATE] at approximately 10:10 PM in which R9 reported that he hit his head. This report documented that the attending physician, E5 was notified of the fall on the following day, [DATE] at 8 AM. The facility's policy and procedure titled "Neurological Checks" was reviewed which indicated: - Neurological checks with complete vital signs are completed every 15 min. (minutes) for the first hour post injury, then every hour for four hours, and then every eight hours for 72 hours unless assessment reveals a more frequent assessment is indicated. Observe for changes from baseline assessment data such as refusal to eat or drink, restlessness, increased confusion, progressive drowsiness or any other progressive deterioration. - Notify physician of any negative changes in assessment status that develop or continue or as neurological status is evaluated over the 72 hours post injury. R9's "Neurological Assessment Flowsheet" dated [DATE] was reviewed. The baseline assessment was completed at 10:15 PM on [DATE] which documented that R9's level of consciousness (LOC) was alert, pupils equal and reactive to light (PERL), hand grasps equal, appropriate response to pain, blood pressure (BP) ,[DATE]; no temperature obtained; heart rate (HR) per minute 76; respiration rate (RR) per minute of 20 and was signed by E6 (Registered Nurse). For the 10:30 PM assessment, there were no assessments for LOC, pupil response, hand grasps, and pain response. BP decreased to ,[DATE]; no temperature; HR 70, RR 22 and no signature of the staff who completed the assessment. For the 10:45 PM assessment, there were no assessments for LOC, pupil response, hand grasps, and pain response. BP decreased to ,[DATE]; no temperature; HR 74, RR 20 and with no signature of the staff who completed the assessment. An interview with E6, who provided care during the 3 PM-11 PM shift on [DATE] was conducted on [DATE] at approximately 2:55 PM. E6 confirmed that complete neurological assessments were not obtained at10:30 PM and 10:45 PM. In addition, E6 verbalized that she did not recall whether the physician and/or R9's power of attorney were notified of the fall. Lastly, E6 confirmed that the physician was not consulted regarding the decreasing BP from the baseline of ,[DATE]. At 11 PM, R9's LOC documented a change to drowsy and PERL. For hand grasps and pain response, it was documented, "Unable to obtain." BP ,[DATE]; T 97 F (Fahrenheit) ; HR 60; RR 18 and R9 was observed "sleeping" and was signed by the night shift Registered Nurse, E7. At 12 midnight, R9's LOC was documented as drowsy and PERL. For hand grasps and pain response, it was documented, "Unable to obtain." BP decreased to ,[DATE]; no T; HR was 57; RR was 20, and R9 was observed "sleeping." This assessment was signed by E7. Despite the negative changes in BP from baseline of ,[DATE] to ,[DATE] at 12 midnight, record review lacked evidence that the physician was notified of the changes in assessment. An interview with E2 (Director of Nursing) on [DATE] at approximately 2 PM confirmed that the neurological assessment was not complete and that if a resident was sleeping, the expectation was that the nurse attempt to wake the resident in order to complete the neurological assessment. At the 1 AM assessment, R9 continued to be drowsy with PERL. Hand grasps and pain response were documented as "Unable to obtain." For the vital signs, the staff documented "Ref. BP" or refused BP and signed by E7. At the 2 AM assessment, R9 continued to be drowsy with PERL. Hand grasps and pain response were documented as "Unable to obtain." BP was ,[DATE]; T 98; HR 72; RR 18 and R9 observed sleeping. This assessment was signed by E7. At the 3 AM assessment, R9 continued to be drowsy with PERL. Hand grasps not assessed, however, R9 moved all his extremities and appropriately responded to pain stimuli. For the vital signs, the staff documented "Ref. BP" or refused BP and signed by E7. Nurse's Note (N.N.) dated [DATE] and timed 3:42 AM documented that R9 appeared to be sleeping as evidenced by even respirations and unlabored on oxygen at 2 liters via nasal cannula. R9 opens eyes for neuro checks and then returns to sleep easily. [MEDICATION NAME](brand name for [MEDICATION NAME]) from prior shift effective. No new neuro symptoms noted. BP ,[DATE] P (pulse) 57 and R 18. Review of written statement by E7(Registered Nurse) dated [DATE] documented that R9 responded appropriately during neuro checks by opening his eyes and lifting his hands to command. Respirations remained even and unlabored, lungs clear in upper lobes, pulse ox ,[DATE]% consistently. Fluid heard in lower lobes but R9 scheduled for [MEDICAL TREATMENT] on the morning of [DATE]. (Last respiratory assessment dated [DATE] stated clear breath sounds, diminished bases.) This assessment did not present different behavior from resident's previous assessment after taking Ambien. 4:44 AM, E9 Certified Nursing Assistant (CNA)was in room talking with R9 about getting his bath and having breakfast before [MEDICAL TREATMENT]. 4:45 AM, E7 found resident unresponsive. Although the above written statement documented that pulse oximetry was obtained, interview with E2, Director of Nursing on [DATE] at 1:45 PM revealed that the facility had no evidence of any pulse oximetry after R9's fall on [DATE]. An interview with E7 on [DATE] at approximately 10:30 AM revealed that she documented "unable to obtain" during the assessments at 11 PM, 12 MN, 1 AM and 2 AM since R9 was sleeping so well which E7 attributed to the [MEDICATION NAME] and the [MEDICATION NAME] which were administered prior to the fall at approximately 9 PM and 7 PM respectively. E7 verbalized that R9 would not grasp his hands but would lift his hands to command, however, unable to assess pain stimuli. For the lack of vital signs at 1 AM and 3 PM, E7 verbalized that she recalled the certified nursing assistant, E9 informing her that E9 was not able to obtain vital signs due to R9's refusal and E7 proceeded to obtain vital signs. E7 further verbalized that she did not recall the vital signs and/or whether E7 documented this in the clinical record. Lastly, E7 verbalized that she did not consult the attending physician when R9's BP decreased to ,[DATE] at 12 midnight assessment and/or the inability to complete neurological assessment including refusal by R9. An interview with E9 on [DATE] at 9:30 AM revealed that she did not complete any vital signs after R9's fall on [DATE]. An interview with E3 (current Assistant Director of Nursing and unit manager for unit 1) on [DATE] at approximately 1 PM confirmed that the neurological assessments were not consistently completed after R9's fall on [DATE]. N.N. dated [DATE] and timed 5:32 AM documented that at 4:45 AM, R9 was found with his feet on the floor lying in his bed with no respiration or pulse and CPR was initiated. An interview with R9's attending physician, E5 on [DATE] at approximately 2 PM confirmed that it was his expectation that a complete neurological assessment be conducted per the facility's policy. This included, awakening a resident, such as R9, who was sleeping to complete the assessment. E5 verbalized the lack of critical thinking by the staff which resulted in the physician not being notified of the descending BP as well as the inability to consistently complete the neurological assessment. The facility failed to recognize the significance of completing a neurological assessment after R9's fall. In addition, the facility failed to identify R9's decreasing BPs and refusal for an assessment as a negative change, thus, failed to consult E5. These failures resulted in R9 being found unresponsive with no pulse or respiration. Cardiopulmonary resuscitation (CPR) was initiated and R9 was sent to the hospital. Review of emergency room records from the hospital dated [DATE] and timed 5:58 AM documented that R9 had no spontaneous respiration and no audible heart sounds. Computed tomography (CT is a diagnostic procedure that uses special X-ray equipment to create cross-sectional pictures of the body) of R9's head was normal. R9 remained in comatose state and on a ventilator. R9 expired in the hospital on [DATE]. Findings reviewed with E1, Administrator and E2, Director of Nursing on [DATE] at 2 PM. 2. R2's annual minimum data set assessment ((MDS) dated [DATE] documented the resident was severely cognitively impaired for decision making, was dependent on staff for all activities of daily living and had no foot problems. According to clinical record documentation R2 had an appointment with E21, Podiatrist on [DATE]. According to a report from E21, the physical examination revealed; there was an ulceration of the right second toe over the proximal interphalangeal joint (hinge joint between toe bones). There was a portion of the base of the middle phalanx (toe bone) present in the wound. E21 further described; debrided the ulcer on the left (sic written as left but annotation note says right second toe not left ) second toe. A portion of the cartilage and bone were removed as well. The area was bleeding well. It appears this wound should heal. The patient is to avoid shoe pressure to the area. The wound should be dressed daily with [MEDICATION NAME] cream. We will see the patient again in one month. The patient is to avoid all shoe pressure to the dorsal aspect (top surface) of the right foot. It was documented that education materials "wound care" were provided. A Division of Long Term Care Residents Protection investigative witness statement [DATE] from E19, CNA documented that she accompanied R2 to the podiatrist appointment. She stated that when she returned back to the nursing home she gave the paperwork to E22 licensed practical nurse (LPN) with the appointment card for the next visit. This statement was confirmed again with E19 on [DATE]. The Physician order [REDACTED]. Review of the [DATE] and [DATE] Treatment Orders revealed that there was no treatment ordered to the right foot or toe. Review of Nurses' Notes from [DATE] until [DATE] lacked any documentation about the ulceration to the right toe. Review of the electronic Grid Treatment / Assessment Report Skin Weekly Audit documentation for [DATE], [DATE], [DATE] and [DATE] documented there was "no new skin issues noted". A written statement from E17, LPN documented that on [DATE] when doing the skin check she got called away and never got back to check her feet. On [DATE] at 10 AM this statement was confirmed with E17. There were no physician visits documented during this period of time. This was confirmed in writing on [DATE] with E1, Administrator. The facility failed to have a system in place for the incorporation of recommendations and or orders from outside providers onto the physician order [REDACTED]. A nurse's note dated [DATE] and timed 12:13 AM documented that "(name of E23 aide) reported that R2 has a dressing on her right toes with thick dried blood around it. I went in room to assess the area. I took the dressing off and saw a wound on the top of her right second toe that measures 1.3 cm x 1.5 cm. The toe looks black and look like it going to fall apart. Resident was pulling her foot away from me when I was cleaning the area. I administered prn (as needed) Tylenol 650 mg for s/s (signs and symptoms) of pain. Which is effective as resident stayed quietly until the ambulance came get her ". A nurse's note dated [DATE] and timed 10:37 AM documented that E2 had returned from the hospital and was to follow-up with the wound center on Monday. A nurse's note dated [DATE] and timed 10:27 AM documented that the hospital had called with positive blood cultures (infection in blood) and wanted the resident sent back to the emergency room for possible admission. Hospital records dated [DATE] documented final [DIAGNOSES REDACTED]. "The toe will fall off by itself and she was just treated for [REDACTED]. A nurse's noted dated [DATE] and timed 5:43 PM documented that the resident was readmitted to the facility on comfort care. The resident expired on [DATE] at 6:30 AM. R2's death certificate documented the immediate cause of death to be [MEDICAL CONDITION] with [MEDICAL CONDITION] and coronary disease as secondary. On [DATE] at 1:30 PM the above facts were reviewed with E2, Director of Nursing (DON) and E11, Clinical Services Coordinator. On [DATE] E2 provided some corrective action documents that the facility initiated including staff discipline forms, chart audits, new skin audit forms and an aide to nurse communication book. 3. Cross-refer F157, example 5 and F250, example 1. R10 had multiple [DIAGNOSES REDACTED]. R10 had low oxygen levels documented in a nursing note dated [DATE] timed 4:30 PM (88% - 91%) and a chest x-ray was ordered by the physician on [DATE]. On [DATE] the order for the chest x-ray was discontinued due to R10 refusing. R10's involved family member (F4) was not notified of these events. On [DATE] beginning at about 11:15 PM - 11:30 PM, R10 experienced a change in his breathing according to an undated written statement obtained by facility staff from CNA E26 and given to the surveyor upon request on [DATE]. E26 wrote that R10 "was breathing funny and had blood on his shirt (a little spot but noticeable on his left arm)". E26 wrote that nurse E27 checked on R10 who said he was fine and the blood was probably from a nose bleed (R10 had one a few days prior). The clinical record contained no documentation of how R10 was "breathing funny" at the start of the shift or what assessment and intervention, if any, the nurse (E27) had performed. CNA E26 wrote that later in the shift, R10 came to the nursing station and was hard to understand because his words weren't coming together and it looked like he was struggling to breathe. CNA E26 wrote that she ran and got nurse E27 to come check R10. E27 wrote a nursing note dated [DATE] timed 3:01 AM that around 2 AM, R10 was short of breath with an oxygen saturation level of 91% and a pulse of 102 beats / minute. E27 wrote that R10 refused oxygen and became unresponsive shortly after this requiring cardiopulmonary resuscitation (CPR) and transfer to the hospital via 911. Interview with the RN supervisor (E28) on [DATE] at 11:06 AM revealed that she had been called by nurse E27 to evaluate R10 for chest pain and found R10 to be lethargic with an extremely low oxygen level below 70%. There was no documentation of R10 reporting chest pain or of any assessment of R10's chest pain by E27. E28 stated that R10 quickly became unresponsive after she arrived to the unit and she then assisted with CPR. E27 stated to the surveyor on [DATE] at 10:35 AM that before E28 arrived, he (E27) was looking in R10's chart to "see what medications" he could give R10 but E27 never stated to the surveyor that R10 was having chest pain. R10 was "breathing funny" between 11:15 PM and 11:30 PM on [DATE] but no nursing assessment or intervention was identified until about 2 AM when the resident was having difficulty breathing and then became unresponsive. Chest pain was reported by R10 according to nurse E28 who was called to evaluate the resident but no chest pain was documented by any nurse and there was no evidence of assessment or intervention in response to the chest pain. A chest x-ray ordered on [DATE] was never performed due to refusal although R10 had cognitive impairment and mental illness requiring family assistance with decision making. R10's family was never notified of his respiratory issues and need for a chest x-ray. A few weeks later, R10 became unresponsive and required CPR in the facility. 4. R8 had [DIAGNOSES REDACTED]. Nursing note documentation beginning on [DATE] indicated that R8 had a decreased appetite and intermittent nausea, vomiting, and stomach upset. Facility staff reported these issues to the physician (E5) and the nurse practitioner (E13) and monitoring of R8's condition was provided along with medication changes. A nursing note dated [DATE] timed 6:30 PM documented that R8 vomited and on [DATE] R8 complained of stomach upset and was not eating much. On [DATE] at 2:35 PM, a nurse documented that a "moderate sized area of partially dried substance" with a foul odor was found on the floor of R8's room and that R8 was unable to say if she had vomited or been incontinent of stool. According to the note, R8 was cleaned up and after consuming milk and a can of Glucerna (a nutritional supplement drink) she (R8) was transported to a scheduled office appointment with E33, a cardiologist (physician heart specialist). According to a [DATE] 8:29 AM interview with E19, she was the transport CNA who drove the facility vehicle to take R8 to the cardiologist (E33) about a 10 or 15 minutes drive from the facility. E19 told the surveyor that while in the examination room prior to the cardiologist (E33) seeing her, R8 vomited dark brown greenish colored liquid that smelled like feces. E19 explained that she recognized this as the same substance she had seen that morning on the floor and on the wheels of R8's bed in the facility. E19 recalled that when E33 (cardiologist) came to the door of the examination room, he told her to take R8 over to the emergency room (which was across the street from his office). E19 stated that she drove R8 to the hospital as she was told, pulled up to the emergency room (ER) door, and opened the door of the vehicle. E19 stated that before getting R8 out of the vehicle, she remembered she had other transports that morning so she called the Director of Nursing (E2) so other arrangements could be made. E19 stated that E2 told her to bring R8 back to the facility because the facility's physician wasn't aware of R8 going to the hospital. R8 stated that she drove R8 back to the facility as instructed by E2. Documentation (office visit note dated [DATE]) from E33, the cardiologist, confirmed that R8 vomited "a large volume of bilious emesis" (contained bile) and that E33 had "explained (to E19) that she (R8) needed care beyond what we could provide in the office setting, and instructed the aide (E19) to take her (R8) directly to the emergency room . I (E33) called the emergency room physician on duty and presented the case to him and told him to expect (R8)". E33 listed this instruction as an order in his note: "Consult with Emergency Medicine on [DATE]". Nurse E34 was interviewed by the surveyor on [DATE] at 9:50 AM and stated that she received a call from E19 on [DATE] and E19 said she had been told by E33 to take R8 to the hospital. E34 stated that she (E34) then called R8's responsible party and told them R8 was being taken to the hospital. E34 stated that she then walked to E2's office to tell her and found that E2 was on the phone with E19. In a written statement dated [DATE] provided to a State survey agency investigator, E2 wrote that she was notified by E19 that R8 had vomited in E33's office and that E33 had recommended R8 be sent to the ER. E2 wrote that E12 (nurse practitioner) was in the facility that day, evaluated R8, and did not want her sent to the ER. Surveyor interview on [DATE] at 12:15 PM with E12, however, revealed that she was not aware of the appearance and odor of R8's emesis (vomit) at E33's office and that the decision to have R8 return to the facility was E2's. The facility's other nurse practitioner, E13 was interviewed on [DATE] at 11:45 AM and she stated that she told the staff not to send R8 to the hospital for vomiting, however, she stated that she was not aware of the appearance or odor of the emesis. E13 stated that if she knew that, she would have sent R8 to the ER and that she has sent other residents to the ER for the same thing. E12 examined R8 upon R8's return to the facility on [DATE]. R8 remained in the facility until [DATE] when she was admitted to the hospital after an x-ray performed in the facility on that date revealed a partial bowel obstruction. There was a two day delay in [DIAGNOSES REDACTED]. to take R8 to the ER. The facility also failed to ensure that the nurse practitioners (E12 and E13) had complete information about R8's condition. 5. R12 was admitted to the facility [DATE] for a 5-day hospice respite. A nurse's note dated [DATE] and timed 9:57 PM documented "This nurse had just left resident to go to nurse's station to get CNA to clean resident up. CNA went to clean resident up.CNA went to resident's room and found resident on floor, supine, on floor mat. Resident had period of apnea [MEDICATION NAME] 30 secs. After shaking resident's shoulder, resident took a big breath and answered staff. Resident is awake, alert and oriented to self and place. Resident stated he was going to get up and sit in chair so staff could change his bed. Resident offers no complaints at this time of pain or discomfort. No injuries noted at this time. CNA states she had checked personal bed alarm every time she was in room the change resident and it was turned on. Bed alarm was checked during post fall and it was turned off. Resident states he does not like the sound when it alarms. (Dr. name) notified and Girlfriend notified. CNAs back at nurses' station stating they just watched the resident turn off the bed alarm". An interview on [DATE] at 10:35 AM with E30, LPN, revealed that if a fall is unwitnessed then neurological checks should be done. He stated that he remembered this resident and he was not totally alert and oriented. Review of the clinical record lacked evidence that the facility initiated neurological checks for this unwitnessed fall. This was confirmed by interview with E1, Administrator and E2, Director of Nursing on [DATE] at 2 PM. 6. R15 had two falls on [DATE] one at 6:10 PM and another at 8 PM. The facility incident reports documented that R15 was found on the floor in her room from an unwitnessed falls and neurological checks were initiated. Review of the Neurological Assessment Flow sheet revealed that R15 was assessed 17 times between 6:19 PM on [DATE] and 11 PM on [DATE]. The following assessments were absent; -The right eye was not checked for pupil response 17 of the 17 opportunities with staff documenting four times "right cataract". -The left eye was not checked for pupil response 13 out of 17 opportunities. -Hand grasp was not checked 5 out of 17 opportunities. -Vital signs were not checked for 9 out of 17 opportunities. R15 was seen by the eye doctor on [DATE] at which time the doctor was able to assess both eyes for pupil response in spite of the [MEDICAL CONDITION]. The facility failed to do complete neurological assessments after R15 had two unwitnessed falls. These findings were reviewed with E1, Administrator and E2, Director of Nursing on [DATE] at 2 PM.