Every finding on record at Dexter Health Care

Based on record review and interviews, the facility failed to follow a physician's order to perform wound vac dressing changes every 48 hours for 1 of 2 residents reviewed for wound vac care (Resident #1 [R1]).Finding: On 5/27/25 at 9:20 a.m., in an interview with a hospital Social Worker (LMSW), she stated the facility called on 5/4/26 asking for wound vac supplies because they had none and that the wound vac dressing changes had not been done as of 5/4/26. The LMSW stated on 4/22/26, she discussed the resident retuning to the facility with a wound vac on 4/30/26. The LMSW indicated the last wound vac dressing change was completed on 4/29/26.On 4/27/26, a review of R1's clinical record was completed. R1 was admitted to the facility on [DATE]. Documentation on R1's hospital Discharge summary, dated [DATE], indicated the resident had a physician's order for wound vac dressing changes every 48 hours.A review of R1's Treatment Administration Record (TAR), indicated that R1 had the first dressing change done on 5/5/26. What would have been scheduled wound vac dressing changes on 5/1/26 and 5/3/26 were not coded as being done.On 5/27/26 at 12:35 p.m., in an interview with the surveyor, the Administrator confirmed that the physician order to change the wound vac dressing every 48 hours did not occur on what would have been the change dates of 5/1/26 and 5/3/26.

Based on record review, observation, and interview, the facility failed to ensure infection control practices were implemented to prevent the spread of infections, including Enhanced Barrier Precautions (EBP) for open wounds. For 1 of 1 resident reviewed with open wounds. (Resident 1 [R1])Finding:A review of the sign posted on a resident's room indicated the following:Before entering the resident's room, a sign posted outside R1's room indicated that the Resident was on EBP. The sign indicated that staff were required to wear a gown, gloves protection when providing care.Review of facility policy on Enhanced Barrier Precautions, dated 11/2017 with a revised date of 3/2025, indicates that EBP are required for any residents with a history of Multidrug Resistant Organism (MDRO) infections, with an indwelling catheter, or a chronic wound infection. For these residents, Personal Protective Equipment (PPE) is required for high-contact resident care activities, including dressing, bathing/showering, transferring, providing hygiene or grooming, device care, and with bed mobility, changing linens, wound care, or prolonged high contact with items in the resident's room.On 12/30/25 at 12:45 p.m., the surveyor observed a Certified Nursing Assistant (CNA-1) enter R1's room to empty his/her catheter bag. A sign was posted outside of R1's room, indicating that R1 was on EBP and that staff providing direct care to the resident should be wearing a gown and gloves. Review of R1's clinical record revealed that he/she had been on EBP due to ileostomy, open surgical wound and open pressure ulcers. During this observation on 12/30/25 at 12:45 p.m., CNA1 stated she forgot R1 was on EBP and she needed to Donn a gown to empty his/her catheter bag. The surveyor confirmed this finding at the time of the observation.

Based on a clinical record review and interviews, the facility failed to ensure that clinical records were complete and contained accurate information for 1 of 1 sampled resident with a surgical wound. (Resident #1 [R1]).Finding:On 12/30/25 at 2:45 p.m., during a clinical record review for R1 there was an order dated 12/23/25 which instructed nursing to follow these instructions regarding wound dressing management. R1 should have daily dressing changes on surgical wound by his care team at the facility. He/she should also have his drain output recorded every 12 hours. The drain should stay in place until the first follow-up in the clinic in approximately 1 week. R1 had an amputation and returned to the facility with a surgical drain (supposed to stay in place 1 week until seen at the clinic), the nurse documented she found the drain almost out and that she called the surgical center and was told by the nurse to go and pull the drain. On 12/30/25 at 2:45 p.m. during interviews with the charge nurses and a review of the Treatment Administration Record (TAR) for December 2025 and the nursing notes for R1, documentation shows the drain was removed at this facility on 12/24/25 1 day after his/her return to facility. The clinical record lacked evidence of a written or verbal order from the Medical Provider/surgical team to remove the surgical drain.On 12/30/25 at 3:12 p.m. during an interview with the Director of Nursing the surveyor confirmed that R1's clinical record did not have a written or verbal order to remove the surgical drain.

Based on observations, Medication Administration Record (MAR) review, and interviews, the facility failed to ensure a Physician ordered medication was available for use for 1 of 14 residents observed during medication administration (Resident #12 [R12]).Findings:R12's clinical record contained a Physician order Lidocan External Patch 5 % (Lidocaine) [a patch that adheres to skin to decrease pain]. Apply to two patches lower back topically in the morning for pain. Apply one left side and one to right side remove after 12 hours - Start Date- 08/20/2025 0800. On 9/10/25 at 9:54 a.m. during a medication administration observation with a surveyor, the Certified Nursing Assistant - Medications (CNA-M) reviewed the order for R12's Lidocaine patches and stated to the surveyor that the medication was not available and that the nurse was aware. The CNA-M made an entry on the electronic health record, Effective Date: 09/10/2025 09:54 Type: Orders - Administration Note Lidocan External Patch 5 % Apply to two patches lower back topically in the morning for pain Apply one left side and one to right side remove after 12 hours Medication not available. Nurse aware. On 9/10/25 at 10:07 a.m. the CNA-M stated to R12 that there weren't any pain patches yet. In an interview with a surveyor at this time, R12 stated that he/she hasn't had pain patches in more than a week and doesn't know why. R12 stated that he/she uses two patches, one on his/her right lower hip for pain and one on his/her back near the left kidney for pain.R12's MAR was reviewed and revealed that the Lidocaine pain patch medication wasn't administered on 8/29/25 through 8/31/25, 9/1/25, 9/2/25, and 9/5/25 through 9/10/25. On 9/11/25 at 2:22 p.m., in an interview with the surveyor, the Director of Nursing (DON) reviewed the MAR and stated that the facility has the Lidocaine 4% patches and would obtain a physician order to change the order from Lidocaine 5% patches to 4% patches. At this time, the surveyor confirmed with the DON that R12 has not received his/her Lidocaine 5% pain patches as ordered from 8/29/25 through 8/31/25, 9/1/25, 9/2/25, and 9/5/25 through 9/10/25, for a total of 11 days.

Based on interviews and record reviews, the facility failed to protect a resident's right to a dignified existence for 1 of 1 resident reviewed for abuse (Resident #44 [R44]).Findings: On 9/8/25 at 12:35 p.m., during an interview with a surveyor, R44 stated a nurse refused to administer scheduled pain medication when requested and had shouted, in a public setting, that R44 didn't need pain medicine because R44 is paraplegic and can't feel pain anyway. R44 stated everyone could hear.On 9/9/25 at 3:25 p.m., a surveyor reviewed written statements from witnesses that corroborated R44's statement. Clinical record review indicates active diagnoses including paraplegia and chronic pain.On 9/10/25 at 11:00 a.m., during an interview with a surveyor, the Director of Nursing (DON) stated R44 and the Licensed Practical Nurse did not get along, the Licensed Practical Nurse was usually assigned to another unit but was terminated following this incident. At this time the surveyor confirmed with the DON that R44's dignity was not protected when the License Practical Nurse publicly mocked R44's medical condition.

Based on record review and interview, the facility failed to revise a care plan for a resident requiring Enhanced Barrier Precautions for 1 of 1 resident reviewed for Tube Feeding (Resident #6 [R6]). Finding: The facility's policy, Enhanced Barrier Precautions, revised 3/2025, indicated that an example of when staff are to utilize these precautions are when providing device care or use such as a feeding tube. On 9/8/25, R6's clinical record was reviewed and indicated that R6 received Tube Feedings. On 9/9/25 at 2:01 p.m., a surveyor observed an Enhanced Barrier Precaution sign on the wall outside R6's door. On 9/9/25 at 2:19 p.m., during an interview with the Director of Nursing, a surveyor confirmed that R6's care plan was not updated for Enhanced Barrier Precautions.

Based on clinical record review, observation, and interview, the facility failed to ensure a resident was free from a significant medication error when a medication to control blood pressure was prepared and ready to be administered to a resident that was in excess of the prescribed dose as ordered by a physician for 1 of 14 residents reviewed during a medication administration observation (Resident #23 [R23]).Findings:On 9/10/25 at 8:41 a.m., during a medication administration observation a surveyor reviewed the electronic health record (EHR) for R23 with the Certified Medication Assistant - Medications (CNA-M) for Metoprolol Succinate ER Oral Tablet Extended Release 24 Hour 50 MG [milligram] (Metoprolol Succinate) Give 2 tablet by mouth one time a day. Pharmacy Active 8/12/2025 08:008/11/2025. On 9/10/25 at 8:42 a.m.,the CNA-M reviewed the order on the EHR, pulled a medication card from the medication cart for R23 that had a prescription written from PharMerica (the facility's pharmacy) on the card, METOPROLOL SUCC ER 100 MG TAB 1 TABLET BY MOUTH DAILY, and pop 2 tablets out of the medication card into a medication cup. On 9/10/25 at 8:44 a.m., the surveyor stopped CNA-M before she administered the medication and asked if she was going to administer the medication in the medication cup to R23. The CNA-M stated yes, the medication pass was stopped, and the surveyor confirmed a significant medication error that CNA-M was going to administer Metoprolol Succinate ER oral tablet 2 tablets of 100 mg that equaled 200 mg, double the dose ordered by the physician instead of the physician ordered Metoprolol Succinate ER oral tablet 2 tablets of 50 mg that equaled 100 mg.

Based on record review and interviews, the facility failed to ensure a contract was signed between the facility and Hospice Agency for 1 of 1 resident (Resident #4 [R4]) reviewed with services from St [NAME] Hospice. Finding: On 9/8/25 at 11:05 a.m., during entrance conference with the Administrator, a surveyor requested to review the Hospice contracts. On 9/9/25, a surveyor reviewed R4's clinical record who was admitted to the facility in April 2025. The resident was transferred to St. [NAME] Hospital where a contract was signed between the resident and St. [NAME] Hospice on 4/29/25 to provide Hospice services to the resident while at the facility. As of 9/9/25, R4 was still receiving Hospice services at the facility from St. [NAME] Hospice. On 9/9/25 at 2:45 p.m., the during an interview with a surveyor, the Administrator stated that she does not have a copy of the contract between the facility and St. [NAME] Hospice and that she has contacted the Hospice agency for a copy. On 9/10/25 at 10:33 a.m., during an interview with a surveyor, the Administrator stated that she had contacted the Hospice agency, and no contract has been provided by the agency. The surveyor confirmed this finding at this time.

Based on observations, facility policy review, and interviews, the facility failed to ensure that Enhanced Barrier Precautions (EBP) were followed for 1 of 3 residents who were on EBP (Resident #6 [R6]). Finding: The facility's policy, Enhanced Barrier Precautions, revised 3/2025, indicated that an example of when staff are to utilize these precautions are when providing device care or use such as a feeding tube. The precautions included wearing a gown and gloves. On 9/8/25, R6's clinical record was reviewed and indicated that R6 received Tube Feedings. On 9/9/25 at 2:01 p.m., a surveyor observed an Enhanced Barrier Precaution sign on the wall outside R6's door. The surveyor observed disposable gowns and gloves in the room by the entrance. The surveyor observed Licensed Practical Nurse #1 (LPN1) wash her hands and put on gloves but did not put on a gown. LPN1 checked placement of R6's feeding tube, flush the feeding tube and then attach the feeding setup tube to R6's feeding tube. On 9/9/25 at 2:12 p.m., while outside R6's room, standing next to the EBP sign, the surveyor asked LPN1 if she was supposed to wear a gown to which LPN1 stated yes. The surveyor confirmed this finding at this time. On 9/9/25 at 2:13 p.m., during an interview with a surveyor, the Director of Nursing stated that gowns and gloves were to be worn when doing care to R6's feeding tube.

Based on review of the facility's policy's, review of the Nursing Facility Reportable Incident Form, review of the facility investigative report, review of the clinical record, and staff interviews, the facility failed to ensure a resident's right to be free from mental abuse, physical restraint, and involuntary seclusion. Specifically, Registered Nurse #1 (RN1) engaged in multiple abusive behaviors, including yelling at the resident repeatedly in response to the resident banging on the door and requesting to go outside, resulting in the resident being transferred to an acute care hospital. For 1of 2 residents sampled (Resident #1[R1]) for abuse. Findings:A facility document titled Identifying types of Abuse, revised 3/2025, indicated the following: Mental abuse is the use of verbal or non-verbal conduct which causes (or has the potential to cause) the resident to experience humiliation, intimidation, fear, shame, agitation, or degradation. Verbal abuse may be a type of mental abuse. Verbal abuse includes the use of verbal, written or gestured communication, or sounds, to residents within hearing distance, regardless of age, ability to comprehend, or disability.The facility's policy, Use of Restraints, revised 3/2025, indicated that seclusion, which is defined as the placement of the resident alone in a room, shall not be employed and defines Physical Restraints as any manual method or physical or mechanical device, material or equipment attached or adjacent to the resident's body that the individual cannot remove easily, which restricts freedom of movement or restricts normal access to one's body. On 8/18/25, the Division of Licensing and Certification received a Nursing Facility Reportable Incident Form for an incident that occurred on 8/16/25. The report indicated that on 8/16/25, staff reported to the Director of Nursing (DON) that Resident #1 (R1) was agitated and Registered Nurse #1 (RN1) escalated resident's behavior to the point that R1 bit RN1's hand. Per documentation on this incident form, on 8/18/25, staff came to further report additional information to the events that occurred on 8/16/25 between RN1 and R1 that occurred when R1's behaviors were escalating and R1 was exit seeking, which included RN1 put R1 in his/her room and closed and held the door for several seconds up to one minute. On 8/26/25 a review of facility's investigation into the 8/16/25 incident was conducted and indicated the following: On 8/16/25 at 8:41 a.m., Licensed Practical Nurse #1 (LPN1) sent the DON a text message that indicated that RN1 was bitten by a resident which broke the skin on RN1's right hand. On 8/16/25 at 8:41 a.m., the DON responded to this message from LPN1, asking RN1 to complete an incident report and follow up with Work Health on Monday. At 11:04 a.m., Certified Nursing Assistant #1 (CNA1) reported to the DON via text messages that R1 was swinging at RN1 and RN1 was flapping her arms right back at the resident and telling the resident to go ahead and hit her; the DON responded back to CNA1 at 11:11 a.m. At 11:09 a.m., CNA3 texted the DON that she had concerns regarding RN1's behavior towards R1; at 11:12 a.m., the DON spoke with CNA3 via telephone and asked if she [the DON] needed to come in, to which CNA3 responded that R1 was being sent to the hospital.On August 16, 2025, multiple Certified Nursing Assistants (CNAs) observed RN1 forcibly placing R1 in his/her room and holding the door shut, preventing R1 from exiting. CNA1 and CNA3 confirmed witnessing RN1 physically restrain R1 and restrict movement.CNA2 and CNA4 reported that RN1 engaged in repeated verbal altercations with R1, including statements such as you're not going out and you need to stop, delivered in a frustrated and escalating tone.CNA2 described RN1 physically holding R1's arms down and dragging the wheelchair, resulting in R1 biting RN1 during the struggle.CNA4 stated that RN1's actions-including repeated physical redirection and verbal commands-escalated R1's behavior and contributed to emotional distress.RN1 acknowledged during interviews that she fought with [R1] a little bit to remove his/her hands from the wheelchair wheels and admitted to placing R1 in his/her room multiple times.Staff statements consistently indicated that RN1's conduct was not aligned with trauma-informed care or de-escalation practices and contributed to R1's agitation.R1's clinical record indicated R1 was sent to the hospital at 11:30 a.m. on 8/16/25 for an evaluation. On 8/19/25, the Medical Doctor (MD) documented that R1 was evaluated in the emergency room on 8/16/25 for physically assaulting a staff member. Urinalysis was negative and R1 was pleasantly confused, but not combative while there. R1 returned to the facility with improved mood but continued exit-seeking, responsive to re-direction. R1's care plan was reviewed and included a FOCUS, dated 12/8/24, of Resident has a behavior problem, confrontational related to (r/t) dementia with interventions, initiated on 12/8/24, that included: approach/speak in a calm manner, divert attention, and minimize potential for the resident's disruptive behaviors by offering tasks which divert attention. The care plan also included another FOCUS, dated 12/8/24, of Resident has impaired/cognitive function/dementia or impaired thought process r/t dementia with interventions, initiated on 12/8/24, that included: the resident understands simple consistent, simple, directive sentences. Provide the resident with necessary cues - stop and return if agitated. On 8/26/25, at 12:15 p.m., during an interview with a surveyor, CNA1 stated that R1 had been acting out after breakfast, around 8:30 a.m. on 8/16. CNA1 was passing medications in another hallway and looked up and saw RN1 put R1 in his/her room and closed the door and held it, but she wasn't sure how long. CNA1 stated, later in the day around 1030 a.m., I was B wing on my way up the hall, I saw RN1 and R1 together. I heard R1 say that if you don't stop that, I am doing to deck you. RN1 was moving her hands up and down while standing in front of R1. (CNA1 demonstrated to the surveyor the motion as she had her arms in front of her, moving them up and down in front of her the chest area). CNA1 stated, I did not see any contact by RN1, but RN1 did say go ahead and hit me. I stepped in between (RN1 and R1) and brought R1 back to his/her room. R1 gets in his/her moods but he/she can be easy to calm down but not like Saturday, I think it was provoked or RN1 added to his/her being aggressive.On 8/26/25 at 1:35 p.m., during an interview with the Administrator and DON, the surveyor confirmed that the interactions between RN1 and R1 were allegations of abuseOn 8/26/25 at 2:04 p.m., during an interview with a surveyor, CNA2 stated that R1 was out front at the door kicking it and yelling. We all tried to redirect R1, but he/she wouldn't stop yelling and kicking and trying to get out the door. CNA2 stated she was able to help RN1 remove R1 from the front entrance area and to the hallway. CNA2 stated that as she was walking away, she saw RN1 hold R1's door closed, and R1 was inside, kicking the door and once RN1 let go, R1 opened the door and came out. CNA2 stated she didn't know how long she held the door shut. CNA2 stated at one-point, RN1 held R1's arms down, RN1 was standing from behind the chair because R1 was kicking the door and RN1 didn't want to get hit. RN1 tried to wheel him/her around, RN1 was behind R1, RN1 tried to hold his/her arms down while standing behind, and R1 bit her. On 8/28/25 at 9:41 a.m., during an interview with a surveyor, RN1 stated, after the third time she took R1 back to their room that she took R1 outside and there was a housekeeper out there watering the plants. RN1 stated that she asked the Housekeeper if they could watch R1 for a little bit and R1 calmed down after being outside for a bit. RN1 stated that after the Housekeeper brought R1 back inside and took him/her to their room to be washed up that R1 wanted to go back out but RN1 didn't have anybody that could go out with R1 at that moment. RN1 stated, I mean I don't know if you ever worked with demented people, you can't really reason with them so it was like we were trying to explain to him/her, alright give us a few minutes we'll find somebody to go out with you and you can go back out but R1 didn't want to hear that. The surveyor asked RN1 if she ever held R1's hands down and RN1 stated, I didn't hold his/her hands down, I tried to pick them up so that I could wheel the chair but that was it, I didn't try to hold them, I just tried to get them out of the way of the wheels. On 8/29/25 at 12:47 p.m., the surveyor asked CNA2 to explain the observation on 8/16/25 in more detail on how RN1 held R1's arms down. CNA2 stated that R1 was flailing his/her arms up trying to hit RN1 and then RN1 reached over his/her shoulders, to hold them down and then CNA2 heard RN1 say OW but CNA2 did not see the action of biting. CNA2 stated, It was dragged out and that after RN1 was bitten by R1, RN1 took him/her outside and when R1 came back inside, he/she was better for a bit. On 8/29/25 at 1:50 p.m., during an interview with a surveyor, CNA4 stated RN1 just kept saying to R1, you need to stop, you need to stop, you can't go outside. CNA4 further stated that RN1 was speaking in a frustrating manner and R1's hands were kind of moving. CNA4 stated, I am not sure that R1 could have moved his/her arms because of the way that RN1 had her arms positioned because she had her arms crossed around R1's upper shoulder. I'm not sure R1 would have been able to lift his/her arms up. CNA4 continued to say that she did try to redirect R1 and the behaviors that R1 was showing were normal behaviors for the weekends which she sees this regularly and is good at deescalating R1. CNA4 stated that she was trying not to let the situation progress but was told by RN1, no you are not helping the situation. CNA4 stated that she was personally yelled at and told to remove herself from the situation by RN1. CNA4 stated that RN1's actions towards R1, repeatedly stating to R1, you can't go outside, you can't go outside and just kept taking R1 back to his/her room made R1 worse and that the situation was escalated by RN1.

Based on review of the facility's Nursing Facility Reportable Incident Form and investigation, facility policy review, employee file review, and interviews, the facility failed to ensure a resident was free from involuntary seclusion for 1 of 1 facility reported incidents reviewed (8/16/25).Finding:The facility's policy, Use of Restraints, revised 3/2025, indicated that seclusion, which is defined as the placement of the resident alone in a room, shall not be employed. On 8/18/25, the Division of Licensing and Certification received a Nursing Facility Reportable Incident Form for an incident that occurred on 8/16/25. The report indicated that staff reported that Resident #1 (R1) was exit seeking and escalating and saw Registered Nurse #1 (RN1) bring R1 back to his/her room and closed and held the door for a few seconds, up to a maybe a minute.On 8/26/25, RN1's employee file was reviewed and included a Performance Correction Notice, dated 8/18/25 that indicated RN1 was on leave, pending investigation, because of an incident with an allegation of abuse that included details that RN1 was outside R1's door, holding the door shut for an amount of time while R1 was in his/her room, attempting to get out. On 8/26/25, the surveyor reviewed the written statements gathered by the facility as part of their investigation for the 8/16/25 incident. On 8/16/25, Certified Nursing Assistant #2 (CNA2)'s written statement indicated that on around 8:15 a.m., R1 was at the front door angry, yelling and screaming, kicking the door, and was trying to get out. Multiple staff tried to redirect R1 from this behavior but R1 kept getting louder. RN1 told R1 to stop it, that he/she was not going out and to stop kicking the door. RN1 then grabbed R1's wheelchair to move it away from the door when R1 grabbed the wheels to stop it. R1 yelled I'm not moving you son of a . RN1's response was oh yes you are! CNA2 assisted RN1 to help move R1 from in front of the door and to the hallway. R1 was taken to his/her room by RN1. CNA2 heard loud banging, turned around, and saw RN1 holding R1's door closed. R1 was kicking the door from the inside. RN1 eventually let the door go and went into the nurse's station. On 8/18/25, CNA1's written statement indicated that around 8:30 a.m. that morning (8/16/25), she saw RN1 put R1 in their room, shut the door and held it shut but was not sure how long it was shut because she was in the middle of passing medications. On 8/18/25, CNA3 wrote that on 8/16/25, she had observed RN1 push R1 in his/her wheelchair and then proceeded to hold the door shut not letting R1 out. On 8/26/25 at 12:15 p.m., during an interview with a surveyor, CNA1 stated that R1 had been acting out after breakfast, around 8:30 a.m. on 8/16. CNA1 was passing medications and looked up and saw RN1 put R1 in his/her room and closed the door and held it, but she wasn't sure how long.On 8/26/25 at 1:05 p.m., during an interview with the Administrator and Director of Nursing, the surveyor confirmed that written statements/interviews indicated that RN1 was observed holding R1's door, with R1 kicking the door wanting to get out. On 8/26/25 at 2:04 p.m., during an interview with a surveyor, CNA2 stated that R1 was out front at the door kicking it and yelling. We all tried to redirect R1 but he/she wouldn't stop yelling and kicking and trying to get out the door. CNA2 was able to help RN1 remove R1 from the front entrance area and to the hallway. CNA2 stated that as she was walking away, she saw RN1 hold R1's door closed, and R1 was inside, kicking the door. Once RN1 let go, R1 opened the door and came out. CNA2 stated she didn't know how long she held the door shut.

Based on review of the facility's investigation/written statements and interviews, the facility failed ensure that a resident was free from restraint when a Registered Nurse used body contact as a method of physical restraint to limit a resident's voluntary movement for 1 of 1 facility reported incidents reviewed (8/16/25). Finding:The facility's policy, Use of Restraints, revised 3/2025, indicated Physical Restraints are defined as any manual method or physical or mechanical device, material or equipment attached or adjacent to the resident's body that the individual cannot remove easily, which restricts freedom of movement or restricts normal access to one's body. On 8/26/25, RN1's employee file was reviewed and included a Performance Correction Notice, dated 8/18/25 that indicated RN1 was on leave, pending investigation, because of an incident with an allegation of abuse that was considered restraining a resident that included details that RN1 held a resident's arms/hands down while resident was trying to hit staff. On 8/26/25, the surveyor reviewed the written statements and interviews provided as part of the facility's investigation for the 8/16/25 incident. On 8/16/25, Certified Nursing Assistant #2 (CNA2)'s written statement indicated that she heard super loud banging on the door because Resident #1 (R1) was trying to get out and that she ran to the area. Registered Nurse #1 (RN1) came around and yelled at R1, saying I told you to stop it, you're not going out! RN1 proceeded to drag R1's (wheel)chair when R1 threw a cup of coffee at RN1. RN1 was trying to hold R1's hands down because after he/she threw the coffee, R1 tried to hit her (RN1), so she (RN1) kept trying to hold R1's hands down. RN1 stated to R1 that you're not going to hit me. RN1 and R1 argued back and forth and the next thing RN1 screamed, OW, R1 friggen bit me! On 8/18/25, CNA4's written statement for the 8/16/25 incident indicated, RN1 removed R1 away from the front door repeatedly as the situation escalated, CNA4 saw RN1 put her arms around R1's upper chest as she wheeled him away from the door, both of them yelling at each other. On 8/26/25 at 2:04 p.m., during an interview with a surveyor, CNA2 stated at one-point, RN1 held R1's arms down, RN1 was standing from behind the chair because R1 was kicking the door and RN1 didn't want to get hit. She tried to wheel R1 around, she was behind R1, she tried to hold his/her arms down while standing behind, and R1 bit her. On 8/29/25 at 12:47 p.m., during an interview with a surveyor, CNA2 stated that R1 was flailing his/her arms up trying to hit her and then RN1 reached over his/her shoulders, to hold them down and then she heard RN1 say OW but she did not see the action of R1 biting RN1.On 8/29/25 at 1:50 p.m., during an interview with a surveyor, CNA4 stated RN1 just kept saying to R1, you need to stop, you need to stop you can't go outside as RN1 was speaking in a frustrated manner. R1's hands were kind of moving but CNA4 stated that she didn't think R1 could have moved his/her arms because of the way that RN1 had her arms crossed around R1's upper shoulder.

Based on facility policy review, the Nursing Facility Reportable Incident Form and investigation review, timecard review, and interviews, the facility failed to protect residents after staff notification of concern of behavior by a Registered Nurse towards a Resident for 1 of 1 facility reported incident reviewed (8/16/25).Finding:The facility's Identifying types of Abuse, revised 3/2025, indicated the following: Mental abuse is the use of verbal or non-verbal conduct which causes (or has the potential to cause) the resident to experience humiliation, intimidation, fear, shame, agitation, or degradation. Verbal abuse may be considered to be a type of mental abuse. Verbal abuse includes the use of verbal, written or gestured communication, or sounds, to residents within hearing distance, regardless of age, ability to comprehend, or disability.On 8/18/25, the Division of Licensing and Certification received a Nursing Facility Reportable Incident Form for an incident that occurred on 8/16/25. The report indicated that on 8/16/25, staff reported to the Director of Nursing (DON) that Resident #1 (R1) was agitated and Registered Nurse #1 (RN1) escalated resident's behavior to the point that R1 bit RN1's hand. Review of the facility's investigation with written statements and facility interviews that were provided to the surveyor on 8/26/25 indicated the following:On 8/16/25 at 8:41 a.m., Licensed Practical Nurse #1 (LPN1) sent the DON a text message that indicated that RN1 was bit by a resident which broke the skin on RN1's right hand. On 8/16/25 at 8:41 a.m., the DON responded to this message from LPN1, asking RN1 to complete an incident report and follow up with Work Health on Monday. At 11:04 a.m., Certified Nursing Assistant #1 (CNA1) reported to the DON via text messages that R1 was swinging at RN1 and RN1 was flapping her arms right back at the resident and telling the resident to go ahead and hit her; the DON responded back to CNA1 at 11:11 a.m. At 11:09 a.m., CNA3 texted the DON that she had concerns regarding RN1's behavior towards R1; at 11:12 a.m., the DON spoke with CNA3 via telephone and asked if she needed to come in, to which CNA3 responded that R1 was being sent to the hospital. The CNAs were asked to complete written statements regarding what they had seen.On 8/18/25, the DON again asked for written statements from CNA1 and CNA3, which started the facility's investigation. The statements obtained included additional information that RN1 and put her hands on R1 and that RN1 had put R1 in his/her room and closed the door and held it shut.On 8/26/25, a review of RN1's timecard indicated that she worked on 8/16/25 from 6:27 a.m. thru 6:57 p.m., and on 8/17/25 from 6:28 a.m. thru 6:57 p.m.On 8/26/25 at 1:35 p.m., during an interview with the Administrator and DON, the DON stated that we called the staff on 8/16/25 but no one mentioned anything physical. The DON stated that she spoke with Licensed Practical Nurse #1 (LPN1) and asked her to assume care of R1 when he/she returned from the hospital. The surveyor confirmed that RN1's interaction with R1 that was texted on 8/16/25 by staff at 11:04 a.m. was an allegation of a form of abuse but RN1 was allowed to remain at the facility providing patient care throughout the weekend.On 8/27/25 at 2:10 p.m., during an interview with a surveyor, LPN1 stated that the DON asked her to assume care of R1 but RN1 told her no, because R1 was RN1's patient. LPN1 stated that when R1 returned from the hospital, there were no further behaviors. On 8/28/25 at 9:41 a.m., during an interview with a surveyor, RN1 stated that she took care of R1 both Saturday and Sunday because R1 was her patient.

Based on Nursing Facility Reportable Incident Form review and interview, the facility failed to notify the State Agency (Division of Licensing and Certification [DLC]) timely for an allegation of abuse for 1 of 1 facility reported incidents reviewed (8/16/25).Finding:On 8/18/25, the Division of Licensing and Certification received a Nursing Facility Reportable Incident Form for an incident that occurred on 8/16/25. The report indicated that on 8/16/25, staff reported to the Director of Nursing (DON) that Resident #1 (R1) was agitated and Registered Nurse #1 (RN1) escalated resident's behavior to the point that R1 bit RN1's hand. Per documentation on this incident form, on 8/18/25, staff came to further report additional information to the events that occurred on 8/16/25 between RN1 and R1 that occurred when R1's behaviors were escalating and R1 was exit seeking, which included RN1 putting R1 in his/her room, closed the door and held the door for several seconds up to one minute. In addition, on 8/16/25 at 11:04 a.m., Certified Nursing Assistant #1 (CNA1) reported to the DON via text message that R1 was swinging at RN1 and RN1 was flapping her arms right back at the resident and telling the resident to go ahead and hit her. On 8/16/25 at 11:09 a.m., CNA3 texted the DON that she had concerns regarding RN1's behavior towards R1. The facility started an investigation on 8/18/25 for the employee to resident interactions that occurred on 8/16/25. On 8/26/25 at 1:35 p.m., during an interview with the Administrator and DON, the surveyor confirmed that the interactions between RN1 and R1 were allegations of abuse, and the State Agency was not notified timely.

Based on record review, facility investigation with written statements, and interviews, the facility failed to fully develop and implement a care plan for a resident who was agitated and trying to leave the facility for 1 of 1 facility reported incidents reviewed (8/16/25) when staff observed a Registered Nurse yelling at the resident instead of approaching/speaking in a calm manner and for the intervention to distract the resident from eloping, the resident preferences was BLANK. Finding:On 8/18/25, the Division of Licensing and Certification received a Nursing Facility Reportable Incident Form for an incident that occurred on 8/16/25. The report indicated that staff reported that Resident #1 (R1) was exit seeking and escalating.On 8/26/25, R1's care plan was reviewed and included the following:Focus: The resident is an elopement risk/wanderer related to (r/t) safety awareness, dementia with interventions that included distract resident from wandering by offering pleasant diversions, structure activities, food, conversation, television, book. Resident prefers: IS BLANK. This care area was initiated on 12/8/24 and revised on 6/13/25. Focus: The resident has a behavior problem .r/t dementia with interventions that included minimize potential for the resident's disruptive behaviors by offering tasks which divert attention and to intervene as necessary approach/speak in a calm manner. This care area was initiated and revised on 12/8/24. On 8/26/25, a surveyor reviewed the facility's investigation with written statements from staff regarding the incident that occurred 8/16/25Certified Nursing Assistant #4 (CNA4) wrote that she observed Registered Nurse #1 (RN1) remove R1 from the front door numerous times and take him/her back to their room. At one point, RN1 and R1 were yelling at each other. On 8/26/25 at 12:22 p.m., during an interview with a surveyor, CNA1 stated R1 gets in his/her moods but can be easy to calm down but not like that Saturday, CNA1 stated that she thought R1 was provoked with RN1 adding to his/her being aggressive. This all started around 8:30 a.m., when R1 returned from breakfast. CNA1 stated that around 10:30 a.m., she intervened between R1 and RN1 and took R1 back to his/her room after she observed RN1 mimicking R1's flapping arms and telling R1 to go ahead and hit her. On 2:04 p.m., during an interview with a surveyor, CNA2 stated that R1 has dementia, and he/she was triggered on that day (8/16/25) . R1 gets triggered easily and you have to let him/her be. If someone is wound up, you got to leave them alone for a bit. R1 wanted to go outside. and kept yelling and saying this is a prison and he/she has the right to go out.yelling it loudly, disruptive to the other residents. At one point, RN1 was mimicking R1 with the arms and both were yelling. With all of us wanting to defuse it, all you had to do was take him outside, but it was a busy time for us. As a result of this incident and facility investigation, the following corrective actions were initiated:-On 8/17/25, R1's care plan had a new care area developed the resident is/has potential to be physically aggressive strike out related to dementia with an intervention that included staff take turns taking resident outside one on one. -RN1's last day worked was 8/17/25 and was terminated for 8/28/25.-Education to staff on challenging behaviors in dementia care and aggressive or violent behavior was started on 8/19/25 with completion due by 8/29/25.

Based on record review and interviews, the facility failed to ensure that clinical records were complete and contained accurate information which included documentation of Resident Representative notification of hospital transfer, charge nurse documentation of resident behaviors as directed per Treatment Administration Record (TAR), and documentation to indicate that a resident returned from the hospital for 1 of 1 facility reported incidents reviewed (8/16/25). On 8/26/25, the surveyor reviewed Resident #1's (R1) clinical record after an incident that occurred on 8/16/25 which resulted in R1 being transferred to the hospital for evaluation of increased behaviors. The clinical record lacked evidence of documentation on 8/16/25 of Resident Representative notification or an attempt to notify, notes from Registered Nurse #1 (RN1) who had signed of the treatment sheet that behaviors were monitored, or information regarding when R1 returned to the facility after being transferred from the hospital. On 8/26/25 at 1:35 p.m., during an interview with the Administrator and the Director of Nursing, the surveyor confirmed RN1 did not document behaviors in the clinical record as directed by a treatment on the TAR, dated 4/5/25, which directed licensed staff to monitor for the following behaviors and to document behaviors in the nurses/progress notes. On 8/16/25, RN1 documented on R1's TAR that behaviors were monitored but lacked evidence of RN1 documenting the behaviors in the nurses/progress notes. In addition, the clinical record lacked evidence of R1 returning to the facility after a hospital transfer. On 8/27/25 at 2:10 p.m., during an interview with a surveyor, Licensed Practical Nurse #1 (LPN1) stated that she did call R1's Resident Representative and left a message; she thought she documented the information in R1's clinical record. The surveyor confirmed with LPN1 that she had not documented this information in the clinical record. On 8/28/25 at 9:41 a.m., during an interview with a surveyor, RN1 stated that (on 8/16/25) she documented on the TAR earlier in the shift on the behavior monitoring treatment but forgot to go back and update the clinical record when R1 started behaviors around 8:30 a.m. In addition, RN1 stated that she was supposed to document information on R1's return from the hospital forgot to document R1's return to the facility from the hospital in the clinical record but forgot to.

Based on a complaint report, clinical record reviews, and interviews, the facility neglected to protect a resident from receiving another residents medications resulting in the resident being transported to an Acute Care Emergency Department and later admitted to the hospital for evaluation, monitoring and treatment of low blood pressure and syncope episodes. (Resident #31 [R31]). Finding: During a recertification survey surveyors were made aware that R31 received another residents medications the morning of 10/28/24 which resulted in R31 having to be transported to the Emergency department for evaluation and treatment. A review of R31's clinical record, in the nurse's notes, a nurse's note dated 10/28/24 at 6:30 a.m., documents that a medication was held due to an error in medication given, the night nurse was made aware and was told to wait for the day nurse of the incident. Nursing note dated 10/28/24 at 7:51 a.m., documents that R31 was given the wrong medication (another residents). he/she was given Gabapentin (anticonvulsant medication) 400 milligram (mg) Hydroxyzine (antihistamine) 25 mg, Metoprolol succinate (beta blocker, heart medication) 100 mg, Protonix 40 mg, Spironolactone (diuretic) 25 mg, and that R31 reported nausea. On call provider was notified and received new orders to hold Lasix, Bupropion, Finasteride, Tamsulosin for 24 hours, and to hold morning Oxycodone. Vital signs at that time were listed as Blood pressure (BP) was 138/70, pulse was 71, temperature was 97.2, and oxygen saturation was 94% on room air (RA). On 10/28/24, a third eye provider note was entered at 8:49 a.m., addressing the incident with wrong medications being received by R31. The note documents the most concerning medications given in error are Gabapentin in combination with Hydroxyzine which can be sedating. The provider notes the Metoprolol will drop his/her BP and pulse significantly in the next 24 hours. On 10/28/24 at 9:09 a.m., a nursing note was entered that at 8:35 a.m. R31 was assisted to the bathroom and reported more nausea, he/she then slumped down. Staff called for assistance the nurse found resident to have had a syncope episode, he/she was lowered to the floor, and when R31 was arousable he/she yelled what is going on vital signs were taken with BP at 120/70, pulse at 70. resident was upset, 911 was called, MD was made aware, BP retaken and dropped to 90/70 with pulse between 70-72. BP then returned to 120's over 70's per the nursing note. R31 was then sent to the emergency room . On 10/31/24 during an interview with the facility staff (CNA-M), who was working on the day of the medication error and who's log on was used for the medication pass. She stated that all of the other residents morning medications were given to R31. The list of medications received by R31 is Lisinopril 20 mg, Metoprolol 100 mg, Clopidogrel 75 mg, Jardiance 25 mg, Sertraline 100 mg, Omeprazole 20 mg, Glipizide 10 mg, Eliquis 5 mg, Bumetanide 2 mg, Preservision 1 capsule, Gabapentin 400 mg, Hydroxyzine 25 mg and Trelegy inhaler 2000-62-5.25 1 inhale. Two of the medications were for high blood pressure (Lisinopril and Metoprolol), one was an anticoagulant (Eliquis), one antiplatelet (Clopidogrel) two were antidiabetic (Jardiance and Glipizide), one was a Diuretic (Bumetanide) one is an anticonvulsant (Gabapentin), and one was an antihistamine (Hydroxyzine), and the other medications had less serious potential for side effects. R31 was not allergic to any of the incorrect medications received. Documentation in the facility's Administering oral medications policy, dated 2/2022: on page 2 of 2, under steps in the procedure #10 stated, confirm the identity of the resident. On 10/30/24 at 1:36 p.m., in an interview with the surveyor, Certified Nursing Assistant-Medication Aide (C.N.A.-M) stated she was passing medications on B. The Adult Education CNA-M instructor, and her student came down to B wing, they let her know they would be passing medications on the A wing. They went to the A wing and the CNA-M logged into the computer for them for the medication pass and the Adult Education CNA-M instructor and the student took over passing the medications. They came out to confirm the resident they had the medications for was on the outside of the room (near the door) and the CNA-M said no he/she was on the inside (by the window). And they said that they just gave medication to the wrong resident. The CNA-M then proceeded to notify the nurses on duty. On 10/30/24 at 2:00 p.m. in an interview with the surveyor, the Adult Education CNA-M instructor stated that on 10/28/24 they arrived at 6:00 a.m. The Adult Education CNA-M instructor stated she did not have her own log in for the computer system Point Click Care (PCC). The CNA-M logged onto the computer, we looked up the medications and diagnosis and prepared the residents medications this was around 6:30 a.m. The student said good morning (using the other residents name) and R31 said what can I do for you, the student then stated she had (the other residents name) medications and R31 stated right here when we gave R31 his/her medication cup he/she did say that was quiet a few meds this morning the Adult Education CNA-M instructor and her student then went to the CNA-M and told her that R31 said he/she was the other resident name and that was when we knew we gave the wrong medications to the wrong resident. The CNA-M told the charge nurse, and we took R31's vital signs (blood pressure, pulse, respirations) R31 came out to the cart and asked why everyone was after him/her. We told him/her they received the wrong medications, and he/she then stated his/her stomach was hurting (nausea). It was explained that we would be checking him/her every hour. We went back to do vital signs, and he/she became very lethargic and faint and was in bed. The ambulance was called, and he/she was taken to the hospital within an hour or two of receiving the wrong medications. On 10/30/24 at 2:00 p.m., in an interview with the surveyor, the Adult Education CNA-M instructor it was confirmed that on the morning of 10/28/24, the wrong medications were given to R31, and that they did not confirm the residents identity before giving the medications. On 10/31/24 R31 remained at the hospital being treated for receiving the wrong medications.

Based on the Center for Disease Control and Prevention, Enhanced Barrier Precaution policy, Wound Care policy, record reviews, observations, and interviews the facility failed to maintain an infection prevention and control program designed to help prevent the development and transmission of communicable diseases and infections during pressure ulcer dressing changes for 2 of 2 residents requiring pressure ulcer dressing changes (Resident #17 [R17], and Resident #11 [R11]). In addition, the facility failed to follow Enhanced Barrier Precautions (EBPs) pertaining to a Resident with an indwelling urinary catheter for 1 of 1 resident observed for urinary catheter care (R17). Findings: The Centers for Disease Control and prevention Definition and Scope of Enhanced Barrier Precautions: dated 6/23/24 states, Enhanced Barrier Precautions (EBP) involve gown and glove use during high-contact resident care activities for residents known to be colonized or infected with a multi-drug resistant organisms (MDRO) as well as those at increased risk of MDRO acquisition (e.g., residents with wounds or indwelling medical devices). A review of the facility's Enhanced Barrier Precautions (EBPs) policy and procedure, revised 2/2024, page 1, #5 EBPs are indicated (when contact precautions do not otherwise apply) for residents with wounds and/or indwelling medical devices regardless of multi-drug resistant organisms. A review of the facility's wound care policy and procedure (revised 2/2022) indicated on page 1, under Equipment and Supplies (necessary when performing wound care), #4 Personal Protective Equipment (gowns, gloves, mask, etc. as needed). On 10/29/24, a review of R17's clinical record was completed. R17 is diagnosed with multiple sclerosis, relative immobility, peripheral neuropathy, a chronic Stage IV pressure ulcer on the right ischial area (lower part of hip bone) and an indwelling urinary catheter due to neuromuscular dysfunction of the bladder. A physician order indicated R17's pressure ulcer wound is to be changed every other day on the day shift. On 10/30/24 at 6:35 a.m., a surveyor went to observe the morning pressure ulcer wound dressing change. Upon entering R17's room, attending to R17 was Licensed Practical Nurse #2 (LPN2), Certified Nurse Assistant #1 (C.N.A.1) and Certified Nurse Assistant #2 (C.N.A.2). LPN2 stated she just finished the dressing change. LPN2 was wearing protective gloves and a protective mask, but was not wearing a protective gown. C.N.A.1 and C.N.A.2 were finishing R17's morning bathing and urinary catheter care. C.N.A.1 and C.N.A.2 were both wearing protective gloves and mask, but were not wearing a protective gown. On 10/30/24 at 7:00 a.m., in an interview with the surveyor, LPN2 stated she did not have a gown on and stated she was unaware of the Enhanced Barrier Precautions and stated she should have worn a gown for the dressing change. On 10/30/24 at 7:45 a.m., in an interview with the surveyor, C.N.A.1 and C.N.A.2 stated they were not wearing a protective gown and knew that they should have been. They stated they were aware of the EBP sign on R17's room entrance door. 33242 2. On 10/29/24, a surveyor reviewed R11's current physician orders and noticed the R11 had an order for a daily pressure ulcer dressing change to the right foot, third toe. The surveyor had observed Enhanced Barrier Precaution signs outside of other resident rooms by the door entrance but did not notice one for R11. On 10/29/24 at 2:25 p.m., a surveyor observed Licensed Practical Nurse #1 (LPN1) complete a pressure ulcer dressing change for R11. LPN1 only donned gloves and did not don a gown as directed by the facility Enhanced Barrier Precautions and Wound Care policies. During this dressing change, a second surveyor walked by the room and noted that LPN1 was not wearing a gown during this procedure.

Based on record reviews and interviews, the facility failed to ensure that physician orders for medications and treatments were followed for 6 of 25 sampled residents medications reviewed (Resident #11 [R11]), R14, R15, R27, R30, R144, ). Findings: 1. On 10/30/24, a review of R15's clinical record was completed. Documentation in R15's nurse's notes indicated that on 10/9/24, R15 was sent to the Emergency Department due to respiratory concerns. On 10/11/24, R15 returned from the hospital with an order for Levaquin (an antibiotic) 750 milligrams (mgs) by mouth everyday for 7 days to treat pneumonia. On 10/13/24, a nurse's note indicated R15 returned from the hospital with an order for Levaquin and this facility was notified by pharmacy that they sent a note to R15's physician regarding prior authorization for it's use and that the medication may be contraindicated with R15's other medicines. There has been no update from the physician. The nurse note indicated that R15 had not received the antibiotic. On 10/17/24, a nurse's note indicated that on 10/16/24, R15 was started on Levaquin. On 10/30/24 at 2:00 p.m., in an interview with the Director of Nursing, the surveyor discussed and confirmed that R15 did not receive the antibiotic Levaquin until 5 days after the physician ordered the Levaquin. 32540 2. On 10/29/24 at 10:51 a.m., during a record review for R144, a written order was noted to change Macrobid (an antibiotic) to be given for 5 days not 14 days. On 10/15/24 the order was changed to 5 days, the Medication Administration Record (MAR) indicates he/she received a morning dose on 10/15/24. The order was changed and reentered at 8:00 p.m. and the evening dose was not signed off as given. On 10/16/24, the morning dose and the evening dose were not signed off as being given resulting in R144 missing 3 doses of his/her antibiotic treatment. 3. On 10/28/24 1:35 p.m., during an interview with the surveyor, R14 stated that he/she has a rash on his/her stomach that staff are supposed to clean and put a cream on every day and they are not doing it. On 10/28/24, R14's clinical record and orders were reviewed. R14 had a written order dated 10/15/24, regarding moderate to severe yeast under pannus (excess skin hangs over genitals and or thighs) area: Not healing well cleanse under pannus fold twice a day (BID) dry. Apply nystatin powder well, keep folded towel under pannus to air. And to assess for possible ringworm to bilateral lower extremities. On 10/15/24, another written order was for ketoconazole (antifungal) 2% cream, apply daily for 4 weeks to both legs and feet in morning. During the record review the Treatment Administration Record (TAR) shows that the order was put in the system as an as needed treatment and had not been done daily as ordered by the Provider since ordered on 10/15/24 (15 days of treatments missed). The TAR shows that the ketoconazole cream order was not followed on 4 days since the order was written on 10/15/24 (4 days of treatments missed) On 10/29/24 at 2:30 p.m., during an interview with the Nurse Manager, the orders for R144 and R14 were reviewed and the surveyor confirmed R144's and R14's orders were not followed as outlined above. 33242 4. On 10/30/24, R11's clinical record was reviewed and included an order, dated 3/3/24, for Protonix (reduces acid in the stomach), 40 mgs twice a day. The clinical record lacked evidence of a change of this order until the Physician signed a new set of block orders on 10/22/24, decreasing this order to once a day beginning 10/1/24. A review of the Medication Administration Record (MAR) for October indicated that R11 received Protonix only once a day. On 10/30/24 at 3:30 p.m., the Director of Nursing and surveyor reviewed R11's clinical record. It was noted that during transfer of the orders from the previous electronic charting system to the current electronic system, the frequency was incorrectly entered, which reduced the administration from twice a day to once a day without a physician order until 10/22/24, the Physician signed the physician orders which were entered into the new system which included the reduced frequency. The DON notified the Physician after this interview to notify of the error on the transfer of the orders. The surveyor confirmed that from 10/1/24 - 10/21/24, R11's physician order was not followed which was to receive the medication twice a day. 5. On 10/30/24, R27's clinical record was reviewed and included the following: R27 had an unwitnessed fall in their room on 8/19/24 at 4:30 pm. The documentation indicated that neuros were initiated. The surveyor reviewed the Neurological Flow Sheet and noted there there was 7 assessments missing from 8/19/24 9:15 a.m. to 8/20/24 1:15 p.m., were there was nothing documented. On 10/30/24 at 10:07 a.m., during an interview with a surveyor, the Nurse Manager and Licensed Practical Nurse (LPN) #1 both stated that neuros are to be completed for unwitnessed falls. During this interview, the surveyor confirmed that neuros were not completed as indicated. R27's physician orders included a medication order, dated 12/6/22, for Trazodone (anti-depressant) 50 mgs to be administered once a day; the clinical record lacked evidence of an order to discontinue this medication. A review of the Medication Administration Record (MAR) for October 2024 did not include this medication. On 10/30/24 at 2:14 p.m., during an interview with a surveyor, the Director of Nursing was unable to find an order to discontinue this medication and confirmed that R27 had not received this medication from 10/1/24 - 10/29/24. 6. On 10/29/24, R30's clinical record was reviewed and indicated that R30 had an ileostomy as of March 2024 but the surveyor could not find any active orders for the care of it. On 10/29/24 at 9:35 a.m., during an interview with a surveyor, R30 stated that he/she does have an ileostomy. On 10/29/24 at 1:53 p.m., during an interview with a surveyor, the Resident Assessment Instrument (RAI) Coordinator stated she was unable to unable to find orders for the care of the ileostomy in the current electronic orders.

Based on record review and interviews, the facility failed to ensure that a resident's choice in the area of bathing was being followed for 1 of 1 sampled resident (Resident #3 [R3]). Finding: On 10/28/24 at 12:30 p.m., during an interview with a surveyor and a resident representative, he/she stated that one of their concerns is that R3 does not always get his/her scheduled showers, and that staff tell them that because R3 was already washed he/she did not need a shower. The resident representative stated that R3 likes his/her showers and only gets one once a week. On 10/30/24, R3's electronic clinical record was reviewed which indicated that R3 was to receive a shower on Saturdays day shift. Review of the electronic clinical records electronic charting System (ECS) (facility was transitioning from one electronic system to another and went live with the new system on October 1, 2024) ECS shows documentation that for the Months of August and September R3 missed 5 showers. For the month of October, the new electronic charting Point Click Care system (PCC) lacks evidence that R3 received any showers in the month of October. On 10/30/24 at 10:08 a.m., a surveyor and the Director of Nursing (DON) reviewed R3's bathing documentation for the months of August through October 2024, which noted missing/incomplete documentation in regard to showers. The surveyor confirmed there is no evidence that R3's choices were being honored for bathing.

Based on clinical record review and interviews the facility failed to follow physician orders [REDACTED]. In addition, the facility discontinued a sling scale order without an order resulting in resident not receiving insulin from ,[DATE] through [DATE] and resident being hospitalized (Resident #1). Findings: Resident #1's Medication Administration Record (MAR) contained a standing order, dated [DATE] to Notify the physician of any routine or PRN (as needed) blood glucose of 60 or below, or 400 or above. A physicians order dated [DATE] indicates, Blood glucose monitoring twice a day (BID) for 10 days. On [DATE] the MAR reflects a p.m. bs of 406. The electronic and paper clinical record lacks evidence of documentation that the physician was notified for a blood sugar >400. On [DATE] and [DATE], the MAR lacks evidence that p.m. bs were obtained. On [DATE] at 6:28 a.m., the MAR reflects a bs of 435. The electronic and paper clinical record lacks evidence of documentation that the MD was notified for a blood sugar >400. Physician Telephone Orders dated [DATE] indicated [MEDICATION NAME] R Normal Resistance sliding scale BID. The orders lacked clarification of sliding scale. On [DATE] at 6:18 a.m. the MAR dated reflects a bs of 401. The electronic and paper clinical record lacks evidence of documentation that insulin was administered and that physician was notified for a BS >400. Physician Telephone Orders dated [DATE] to discharge (d/c) [MEDICATION NAME] R and start [MEDICATION NAME] R sliding scale subcutaneous (SQ) BID. ,[DATE] = 2 units, ,[DATE] =4 units, ,[DATE] = 6 units ,[DATE] = 8 units. ,[DATE] = 10 units >400 = 12 units call MD. On [DATE] at 4:33 p.m the MAR reflects a bs 444, treated with 12 units of insulin. as ordered. The electronic and paper clinical record lacks evidence of documentation that the physician was notified for bs of 444. On [DATE] at 5:36 a.m., the MAR reflects a bs of 347, treated with 10 units of insulin. The physician sliding scale order reads for BS ,[DATE] give 8 units. The RN did not administer appropriate dose as ordered. On [DATE] when orders to check blood [MEDICATION NAME] twice daily for 10 days stopped, The MAR indicated the resident received [MEDICATION NAME] R on [DATE] and then stopped on [DATE] and discontinued on [DATE]. The medical record revealed blood glucose monitoring was not completed and insulin was not administered to Resident #1 on [DATE], [DATE] and [DATE]. The medical record lacked evidence of an order to discontinue the [MEDICATION NAME] R. On [DATE] at 3:35 p.m, in an interview with the Director of Nurses (DON) and RN , the RN assumed that when the BID monitoring for blood glucose monitoring expired that the insulin sliding scale order also was discontinued as well. On [DATE] at 3:45 p.m. the DON confirmed that Resident #1 sliding scaled was discontinued without a physicians order. On [DATE] at 8:31 a.m., nurses notes indicate Resident #1 was incoherent, lethargic, easily arousable, unable to hold straw, holding juice in mouth then let it drooled out, denied pain. Lungs clear, O2 (oxygen) saturation 95% RA (room air). The electronic and paper clinical record lacks evidence of the physician being notified of a significant change in condition. On [DATE] at 6:12 p.m., nurse's notes indicate UA (urinalysis) in house dip stick checked: protein: + (positive), [MEDICATION NAME]: +, glucose: +, others unremarkable. The electronic and paper clinical record lacks evidence of the physician being notified of abnormal lab results. On [DATE] at 1:44 p.m., nurse's notes indicate resident noted this morning to have a decreased responsiveness, po oral intake, unable to take pills this morning, VS WNL (vital signs within normal limits), blood sugar noted to be 535, 12 units insulin given per sliding scale. Patient moaning RN spoke with son who wished to have resident transferred to hospital. RN also spoke with POA (power of attorney) daughter and she agreed. On [DATE] at 12:51 p.m. nurse's notes indicated biopsy result: Scabies. New order Eurax 10% cream TID (three times a day) for 30 days. Ivermectin 3 milligram (mg) tablets give 5 tablets on day 1, 2, 8, 9, 15, 27 and 29th day. The electronic and paper clinical record lacks evidence of an signed physician order [REDACTED]. On [DATE] the Eurax cream was entered and the MAR dated and 5 doses documented as given. The medical record lacked evidence of Ivermectin being added as an order signed by a physician or to the MAR and if resident received any doses of Ivermectin. The Nurse's Notes dated [DATE] at 12:50 p.m. (Late Entry for [DATE] time 12:30 pm). Spoke with a physician that was covering for the resident's physician, about resident's decline in condition. Resident started on Ivermectin and questioned physician about side effects, if it could cause an increase in lethargy that we are seeing that is new today. The physician related that if it was caused by Ivermectin then we should monitor for rebound in mentation and then lethargic are next dose. Will pass onto primary nurse. The electronic and paper clinical record lacks evidence of an order for [REDACTED]. The electronic and paper clinical record lacks evidence of Ivermectime being added to the MAR and the resident receiving any doses. On [DATE] at 9:12 p.m. and [DATE] at 10:06 p.m. nurse's notes indicate held - Ivermectin 3 mg tablets (5 tablets) held waiting delivery, c/n (charge nurse) aware. The physician's orders [REDACTED].

Based on record review and interviews the facility failed to notify physician of change in a residents condition, failed to notify physician of abnormal lab results, failed to follow physician orders [REDACTED]. Findings: Resident #1's Medication Administration Record [REDACTED]. A physicians order dated 12/15/16 indicates, Blood glucose monitoring twice a day (BID) for 10 days. On 12/16/16 at 2:23 p.m., Nurse's Notes indicate resident suddenly dropped head down and not responding. She squeezed fingers tight, closed lips tight, resistant to move arms. The electronic and paper clinical record lacks evidence that the physician was notified of a significant change in condition. On 12/19/16 the MAR indicated [REDACTED]. The electronic and paper clinical record lacks evidence of documentation that the physician was notified for a blood sugar >400. On 12/20/16 and 12/21/16, the MAR indicated [REDACTED]. On 12/22/16 at 6:28 a.m., the MAR indicated [REDACTED]. Physician Telephone Orders dated 12/22/16 indicated [MEDICATION NAME] R Normal Resistance sliding scale BID. The orders lacked clarification of sliding scale. The nursing notes lacked evidence that the physician was notified of the a.m. blood glucose until physician was in for routine rounds and had written orders for sliding scale. On 12/23/16 at 6:18 a.m. the MAR indicated [REDACTED]>400. On 12/24/16 at 4:33 p.m the MAR indicated [REDACTED]. The electronic and paper clinical record lacks evidence of documentation that the physician was notified for a bs >400. On 12/25/16 at 5:36 a.m., the MAR indicated [REDACTED]. The physician sliding scale order reads for bs 301-350 give 8 units. The RN did not administer appropriate dose as ordered. On 12/25/16 the Physician order [REDACTED]. On 1/11/17 at 3:45 p.m. the DON confirmed that Resident #1 sliding scaled was discontinued without a physicians order. On 12/28/16 at 8:31 a.m., nurses notes indicate Resident #1 was incoherent, lethargic, easily arousable, unable to hold straw, holding juice in mouth then let it drooled out, denied pain. Lungs clear, O2 (oxygen) saturation 95% RA (room air). The electronic and paper clinical record lacks evidence of the physician being notified of a significant change in condition. On 12/28/16 at 6:12 p.m., nurse's notes indicate UA (urinalysis) in house dip stick checked: protein: + (positive), [MEDICATION NAME]: +, glucose: +, others unremarkable. The electronic and paper clinical record lacks evidence of the physician being notified of abnormal lab results. On 12/29/16 at 1:44 p.m., nurse's notes indicate resident noted this morning to have a decreased responsiveness, po oral intake, unable to take pills this morning, VS WNL (vital signs within normal limits), blood sugar noted to be 535, 12 units insulin given per sliding scale. Patient moaning RN spoke with son who wished to have resident transferred to hospital. RN also spoke with POA (power of attorney) daughter and she agreed.

Based on interviews and medical record review the facility failed to notify the physician of blood glucose monitoring results, decline in a resident condition, incorrect insulin dose given and lab results for 1 of 7 resident reviewed. (Resident #1) Findings: On 12/14/16, Resident #1 had a standing order on the Medication Administration Record [REDACTED]. Physician order [REDACTED]. On 12/19/16 the MAR indicated [REDACTED]> (greater than) 400. On 12/22/16 at 6:28 a.m., the MAR indicated [REDACTED]>400. Physician Telephone Orders dated 12/22/16 indicated [MEDICATION NAME] R Normal Resistance sliding scale BID. The orders lacked clarification of sliding scale. The nursing notes lacked evidence that the physician was notified of the a.m. blood glucose of 435 until physician was in for routine rounds and had written orders for sliding scale. On 12/23/16 at 6:18 a m., the MAR indicated [REDACTED]>400. On 12/25/16 at 5:36 a.m. the MAR indicated [REDACTED]. The sliding scale order reads for bs 301-350 give 8 units. The electronic and paper clinical record lacks evidence the physician was notified of the incorrect dose of insulin was administered. On 12/28/16 at 8:31 a.m., Nurse's Notes indicate resident incoherent, lethargic, easily arousable, unable to hold straw, holding juice in mouth then let it drooled out, denied pain. Lungs clear, O2 (oxygen) saturation 95% RA (room air). The electronic and paper clinical record lacks evidence of the physician being notified of a significant change in condition. On 12/28/16 at 6;12 p.m., Nurse's Notes indicate UA (urinalysis) in house dip stick checked: protein: + (positive), [MEDICATION NAME]: +, glucose: +, others unremarkable. The electronic and paper clinical record lacks evidence of the physician being notified of lab results. On 12/29/16 at 1:44 p.m., Nurse's Notes indicate resident noted this morning to have a decreased responsiveness, po oral intake, unable to take pills this morning, VS WNL (vital signs within normal limits), blood sugar noted to be 535, 12 units insulin given per sliding scale. Patient moaning RN spoke with son who wished to have resident transferred to hospital. RN also spoke with POA (power of attorney) daughter and she agreed. The electronic and paper clinical record lacks evidence that the physician was notified of a blood sugar of 535, resident change in medical condition, resulting in a transfer and admission to the hospital. A facility incident report dated 12/29/16 indicated a medication error for discontinuation of sliding scale. The incident report lacks evidence of the physician having been notified. On 1/11/17 at 3:45 p.m. the above finding was confirmed with the Director of Nursing (DON) and RN.

Based on review of residents' medical records, review of staffing patterns, review of facility policy, review of employee training records and interviews, a Registered Nurse, Charge Nurse neglected to immediately initiate cardiopulmonary resuscitation for Resident #11, who was found to be without evidence of vital signs and who was a "Full Code" (CPR is to be administered in the event of cardiac or respiratory arrest), which resulted in the identification of immediate jeopardy. From [DATE] through [DATE], six of thirty seven residents were identified with a "Full Code" status and at risk for not receiving CPR in the event of a cardiac or respiratory arrest, when on 1 of 25 night shifts reviewed, there were no staff members that were certified in CPR. The facility was unable to demonstrate a system was in place to ensure that staff certified in CPR were on duty 7 days a week, 24-hours a day to meet the needs of residents who desired CPR. The facility also failed to demonstrate a system was in place to ensure staff were knowledgeable about when to initiate CPR on residents, who were found unresponsive and without evidence of vital signs (pulse, respiration and blood pressure). These systemic failures constituted immediate jeopardy, for those residents identified at risk for not receiving CPR. Findings: 1. Resident #11's "Face Sheet," dated [DATE], under the section titled "Advanced Directives" indicated the resident was a "full code status (desired CPR in the event of cardiac or respiratory arrest), no ventilator, wants hospitalization and antibiotics". The resident's physician's orders [REDACTED]. Resident #11's "late entry" electronic nursing note, dated [DATE], indicated a Certified Nursing Assistant (C.N.A.) reported to the Registered Nurse (RN)/Charge Nurse that the resident's right arm was making a strange motion. The note indicated the writer completed his/her task then went to check on the resident. Upon entering the room the resident was found to be unresponsive. The time of death was noted to be 2:23 a.m. The late entry note did not indicate Cardiopulmonary Resuscitation (CPR) was initiated in accordance with full code procedures. On [DATE] at 12:15 p.m., in an interview with a surveyor, the Registered Nurse, Charge Nurse stated that at 2:11 a.m. on [DATE], a CNA reported to her that the resident was making an odd movement with his/her right arm that the CNA had not seen before. The RN Charge Nurse entered the resident's room at 2:23 a.m. and found the resident to be without vital signs. The RN Charge Nurse stated she did not begin CPR and was not aware of the resident's code status when she entered the room to assess the resident. On [DATE] at 7:10 p.m., in an interview with a surveyor, a CNA stated that she had noticed the resident's right arm stayed on the bed when they rolled the resident. When the CNA asked the resident if he/she was okay the resident responded "yes". The CNA stated she reported her concern about the resident's right arm to the RN, Charge Nurse and less than 15 minutes later they entered the resident's room and the resident did not have a pulse. The CNA stated CPR was not initiated. The facility provided the survey team with a list of staff currently certified in CPR, The RN, Charge Nurse, who worked on [DATE] at the time of the incident was certified to complete CPR. On [DATE] at 2:45 p.m., in an interview with a surveyor, the RN, Director of Nursing stated that CPR certification for employees is not required. She stated the facility offers CPR classes for those who wish to be certified. She stated that all charge nurses are expected to know residents code status and the information is noted on the MAR for quick reference. 2. Resident #15's physician orders, dated [DATE], indicated the resident was a "Full Code" (desired CPR in the event of a cardiac or respiratory arrest). Resident #30's physician orders, dated [DATE] and [DATE] indicated the resident was to have CPR, wanted hospitalization and antibiotics and was not to have a ventilator in the event of a life threatening incident. Resident #47's physician orders, dated [DATE], indicated the resident was a "Full Code". Resident #48's physician orders, dated [DATE], indicated the resident was a "Full Code". Resident #66's "Discharge Transfer Summary" form, dated [DATE], indicated the resident was a "Full Code". Resident #61's physician orders, dated [DATE], indicated the resident was a "Full Code". Resident #66's physician orders, dated [DATE], indicated the resident was a "Full Code". Review of nurse staffing schedules, payroll sheets and the list of staff who were CPR certified, indicated that for 1 of 25 night shifts reviewed ([DATE]) there were no staff on duty who were certified in CPR. On [DATE] at 10:45 a.m., in an interview with a surveyor, the RN, Director of Nursing stated that that it was in the facility procedure that if a code was not witnessed then CPR would not be started. The facility policy and procedure for "CPR/DNR" step #6 indicated that in the event that the resident, family/ responsible party and physician still do not wish to have any written advanced directives that CPR will be instituted if a cardiac or respiratory arrest is witnessed." The policy did not address what staff were to do in the event they discovered a unwitnessed cardiac or respiratory arrest on a resident with advanced directives indicating "Full Code" (the desire to have CPR). On [DATE] at 10:10 a.m., in an interview with a surveyor, a RN, Assistant Executive Director of the Maine State Board of Nursing stated the if a patient is identified as a "Full Code" and needs CPR, then the Professional Nurse will interceded and provide that care in the event of respiratory or [MEDICAL CONDITION]. The facility was unable to provide evidence of a system to ensure CPR trained staff were available twenty four hours a day, seven days a week for those residents identified as "Full Codes" (desiring CPR in the event of a respirator and/or [MEDICAL CONDITION]. The failure of the facility to have staff who were certified in CPR placed the residents with full code status at risk of potential harm or death. On [DATE] a "Notice of Determination of Immediate Jeopardy" was faxed and sent to the facility. On [DATE] a corrective action plan to the immediate jeopardy was received from the facility indicating that licensed nursing staff would initiate CPR with residents who have an established and recorded code-status of "Full Code" in the event they are discovered non-responsive, not breathing and without a heart rate and that the facility would ensure that personnel will be scheduled continuously who have CPR certification. The corrective action plan indicated that the facility policy has been updated to reflect that residents, who have a code status of "Full Code will have CPR initiated if they (the residents) are discovered non-responsive, not breathing and without a pulse, whether the event is witnessed or unwitnessed. The corrective action plan also indicated that nursing personnel will review the amended policy prior to working further shifts. The facility indicated that this plan was put in place on [DATE], at the time the immediate jeopardy was identified to the facility, but the survey team. The survey team accepted the corrective action plan to ensure the health and safety of residents was maintained; however the facility will submit a plan of correction to address the systemic changes and identify measures to ensure continued compliance.

Based on record review and interviews, the facility failed to follow a physician's order for cardiopulmonary resuscitation (CPR) for 1 of 7 sampled residents (#11) who were identified as a "Full Code" (desiring CPR). On [DATE] at 2:23 a.m., Resident #11 was found unresponsive without vital signs and CPR was not initiated in accordance with physician orders and in accordance with the resident's advanced directives. The resident is deceased . This failure to perform CPR in accordance with physician orders resulted in an immediate jeopardy. Finding: Resident #11's "Face Sheet," dated [DATE], under the section titled "Advanced Directives" indicated the resident was a "full code status (desired CPR in the event of cardiac or respiratory arrest), no ventilator, wants hospitalization and antibiotics". The resident's Physician's Orders, dated [DATE] through [DATE], directed staff to ensure the resident was a full code, that the resident was hospitalized , received antibiotics and was not ventilated in the event of an acute illness or life threatening event. Resident #11's "late entry" electronic nursing note, dated [DATE], indicated a Certified Nursing Assistant (C.N.A.) reported to the Registered Nurse (RN)/Charge Nurse that the resident's right arm was making a strange motion. The note indicated the writer completed his/her task then went to check on the resident. Upon entering the room the resident was found to be unresponsive. The time of death was noted to be 2:23 a.m. The late entry note did not indicate Cardiopulmonary Resuscitation (CPR) was initiated in accordance with full code procedures. On [DATE] at 12:15 p.m., in an interview with a surveyor, the Registered Nurse, Charge Nurse stated that at 2:11 a.m. on [DATE], a CNA reported to her that the resident was making an odd movement with his/her right arm that the CNA had not seen before. The RN Charge Nurse entered the resident's room at 2:23 a.m. and found the resident to be without vital signs. The RN Charge Nurse stated she did not begin CPR and was not aware of the resident's code status when she entered the room to assess the resident. On [DATE] at 7:10 p.m., in an interview with a surveyor, a CNA stated that she had noticed the resident's right arm stayed on the bed when they rolled the resident. When the CNA asked the resident if he/she was okay the resident responded "yes". The CNA stated she reported her concern about the resident's right arm to the RN, Charge Nurse and less than 15 minutes later they entered the resident's room and the resident did not have a pulse. The CNA stated CPR was not initiated in accordance with the resident's advanced directives and in accordance with physician orders, constituting an immediate jeopardy. On [DATE], surveyors discussed this finding with the RN, Director of Nursing and the Administrator. On [DATE] a "Notice of Determination of Immediate Jeopardy" was faxed and sent to the facility. On [DATE] a corrective action plan to the immediate jeopardy was received from the facility indicating that licensed nursing staff would initiate CPR with residents who have an established and recorded code-status of "Full Code" in the event they are discovered non-responsive, not breathing and without a heart rate and that the facility would ensure that personnel will be scheduled continuously who have CPR certification. The corrective action plan indicated that the facility policy has been updated to reflect that residents, who have a code status of "Full Code will have CPR initiated if they (the residents) are discovered non-responsive, not breathing and without a pulse, whether the event is witnessed or unwitnessed. The corrective action plan also indicated that nursing personnel will review the amended policy prior to working further shifts. The facility indicated that this plan was put in place on [DATE], at the time the immediate jeopardy was identified to the facility, by the survey team. The survey team accepted the corrective action plan to ensure the health and safety of residents was maintained; however the facility will submit a plan of correction to address measures to ensure continued compliance.