Every finding on record at Doctors Community Rehabilitation and Patient Care

Based on record review and staff interview, it was determined the facility failed to report an allegation of injury of unknown origin immediately or no later than 2 hours after the allegation was made aware to the facility's administration team. This was evident for 1 out of 2 residents reviewed for allegations of an injury of unknown during the complaint survey.The findings included: Intake #3029671 was reviewed on 7/7/2026 at approximately 11:30 AM for an injury of unknown origin allegation involving Resident #10.Review of the investigation records on 7/7/2026 at 12:17 PM revealed that the facility was made aware of an allegation of an injury of unknown origin involving Resident #10 on 5/29/2026 at 10:30 AM. Further review of records revealed that the facility did not report the allegation to the Office of Health Care Quality and other appropriate agencies until 6/1/2026. During an interview on 07/9/2026 at 2:37 PM with the Director of Nursing she stated, On 5/29/2026 there was an allegation of injury of unknown origin involving Resident #10, the facility investigated and the allegation was not substantiated. The allegation was not reported until 6/1/2026 because they were treating it as a medical issue instead of an injury of unknown origin. All concerns were discussed with the Administration team at the exit conference on 7/10/2026.

Based on medical record review and staff interview, it was determined the facility staff failed to ensure Minimum Data Set (MDS) assessments were accurately coded. This was evident for 1 (Resident #18) of 5 residents reviewed for a fall during a complaint survey.The findings include: The MDS is part of the Resident Assessment Instrument that was Federally mandated in legislation passed in 1986. The MDS is a set of assessment screening items employed as part of a standardized, reproducible, and comprehensive assessment process that ensures each resident's individual needs are identified, that care is planned based on those individualized needs, and that the care is provided as planned to meet the needs of each resident. On 4/15/26 at 7:10 AM a review of Resident #18's medical record was conducted and revealed Resident #18 had a fall on 1/18/26 at 13:45 (1:45 PM). Resident #18 sustained a hematoma and was sent to the emergency room for evaluation.Review of Resident #18's quarterly MDS with an assessment reference date (ARD) of 4/2/26, Section J, falls, failed to capture the fall of 1/18/26. On 4/15/26 at 11:00 AM an interview was conducted with the MDS Coordinator who stated that the person that did the MDS was not working today. The MDS Coordinator confirmed the error and stated she would do a correction.

Based on medical record review and interview, the facility failed to follow standard of practice during the care of the resident. This was evident for 1 (Resident #31) out of 3 residents reviewed for activation of emergency services during a complaint survey.The findings include: MOLST (Medical Orders for Life-Sustaining Treatment) is a portable and enduring medical order form covering options for cardiopulmonary resuscitation (CPR) and other life-sustaining treatments. The medical orders are based on a resident and/or health care agent's directions about medical treatments. Review of Resident #31's medical record on [DATE] revealed the Resident was admitted to the facility in 2023. Further review of Resident #31's medical record revealed a MOLST dated [DATE] that stated the Resident was an Attempt CPR. Review of Nursing Supervisor #10's nurse's note for Resident #31 on [DATE] at 6:37 AM stated: 1 AM- The nurse on duty notified the nursing supervisor of the resident has become unresponsive and has no palpable pulse via telephone. 1 AM- CPR (Cardiopulmonary Resuscitation) and ventilations initiated. 1:05 AM- Resident's responsible party called and made aware of ongoing CPR efforts. Responsible party verbalized wishes to continue current advanced directives of full code. 1:05 AM On call provider notified of resident's change in condition. Verbalized to continue CPR and notify 911. 1:10 AM- 911 called to facility. 1:15 AM- 911 on site at facility, CPR maintained. 1:23 AM CPR efforts terminated and resident pronounced deceased by EMT/Paramedic on site. During interview with Nursing Supervisor (NS) #10 on [DATE] at 6:35 AM, NS #10 stated he received a call from LPN (Licensed Practical Nurse) #9 on [DATE] that Resident #31 was unresponsive. NS #10 stated he went to the Resident's room and staff were performing CPR. NS #10 was asked why he called the family first. NS #10 stated he left the room to call the family to update them and make sure that is what they wanted because the Resident looked pretty bad. NS #10 stated they did and then he called the on-call provider who told him to continue CPR and call 911. NS #10 stated he then called 911 and they were here quickly because they are right down the road. NS #10 stated EMS (Emergency Medical Services) took over CPR and pronounced the Resident deceased . NS #10 stated CPR did not stop until EMS pronounced the Resident. NS #10 was asked if an AED (Automated External Defibrillator) was placed by the facility staff and NS #10 stated yes but it said, shock not advised. Review of the EMS report for Resident #31 on [DATE] revealed it stated 911 was called on [DATE] at 1:16 AM, EMS arrived on the scene at 1:21 AM and the Resident was pronounced at 1:23 AM. The Report states the patient is in bed in cardiac arrest, skin is cold and rigor mortis has begun to set in. The Report also states staff of the nursing home have been providing CPR with an AED, but it did not advise a shock. Review of the facility's CPR policy dated [DATE] revealed it states: If a patient does not have a DNR (Do not resuscitate) order, CPR certified staff will initiate CPR and emergency medical services (EMS) will be activated. Review of the AHA (American Heart Association)'s 2025 guidelines for CPR revealed the following steps: check for responsiveness, shout for nearby help, activate emergency response system, send someone to get AED/defibrillator, for no breathing or no pulse start CPR. Interview with the Director of Nursing, Market Lead Clinical Specialist and Administrator on [DATE] at 1:10 PM confirmed the facility staff failed to call 911 prior to calling the Resident's representative and on call provider on [DATE] for Resident #31 per standards of practice.

Based on medical record review and interview, the facility staff failed to administer and hold medications as ordered by the physician . This was evident for 3 (Resident #31, #24 and #20) of 36 residents reviewed during a complaint survey.The findings Include: 1.The facility staff failed to administer a medication as ordered by the physician to Resident #31. Review of Resident #31's medical record on 4/9/26 revealed the Resident was admitted to the facility in 2023 with a diagnosis to include heart failure. Further review of the Resident's medical record revealed the was sent to the emergency room on 2/27/26 for abnormal labs. On 2/28/26 the Resident was followed up by Nurse Practitioner (NP) #24 who ordered to increase the Resident's Lasix from 20 mg to 40 mg daily for 7 days. Lasix is a medication used to treat fluid retention that can be caused by heart failure. Review of Resident #31's February and March 2026 Medication Administration Records revealed the Resident was administered Lasix 40 mg for 7 days through 3/6/26 but the facility staff failed to resume Resident's Lasix 20 mg on 3/7/26. The facility staff resumed administering Lasix 20 mg on 3/8/26, therefore the Resident missed one dose of Lasix 20 mg on 3/7/26. Interview with the Administrator on 4/16/26 at 12:05 PM confirmed the facility staff failed to administer Lasix 20 mg to Resident #31 on 3/7/26. 2) On 4/14/26 at 7:36 AM a review of Resident #24's medical record was conducted and revealed Resident #24 was admitted to the facility in June 2022 with diagnoses that included cerebral infarction (stroke) and hypertension. Review of Resident #24's physician's orders revealed Resident #24 was prescribed the medication Amlodipine Besylate 10 milligrams (mg) every day since 4/26/23 for hypertension (high blood pressure). The physician order stated to hold the medication if the SBP (systolic blood pressure), which was the top number on the blood pressure reading, was less that 110 and/or if the heart rate was less than 60 beats per minute. Review of Resident #24's April 2026 Medication Administration Record (MAR) documented on 4/4/26 Resident #24's heart rate was 52 and on 4/5/26 the heart rate was 54. The medication was administered by Licensed Practical Nurse (LPN) #26. The medication was administered outside of physician ordered parameters. Review of Resident #24's February 2026 MAR documented on 2/13/26 the heart rate was 51 and was administered by LPN #27. On 2/21/26 the heart rate was 59 and on 2/22/26 the heart rate was 55. The medication was administered by LPN #26. The medication was administered outside of physician ordered parameters. Review of Resident #24's January 2026 MAR documented on 1/13/26 the heart rate was 50 and on 1/14/26 the heart rate was 56. The heart rate was administered by LPN #27. The medication was administered outside of physician ordered parameters. Review of Resident #24's December 2025 MAR documented on 12/18/25 the heart rate was 56 and was administered by LPN #28. On 12/29/25 the heart rate was 55 and the medication was administered by LPN #27. The medication was administered outside of physician ordered parameters. Review of Resident #24's care plan, exhibits or is at risk for cardiovascular symptoms or complications related to TIA (Transient Ischemic Attack), CVA (stroke), uncontrolled HTN (hypertension), that was initiated on 6/24/22, documented the interventions, assess and monitor vital signs as ordered and report abnormalities to physicians; monitor apical heart rate. Review of nursing notes failed to produce documentation that the medication was held and the physician was notified. On 4/16/26 at 10:35 AM an interview was conducted with the Director of Nursing (DON). The concern related to the administered medication outside of physician ordered parameters was discussed. The DON agreed that it was a concern, and she stated that she would, look into it. On 4/16/26 at 11:43 AM LPN #23 was interviewed and stated he would look into the issue and agreed that the medication should have been held, and the physician should have been notified. On 4/16/26 at 1:09 PM the DON confirmed the surveyor's concerns related to the physician ordered parameters not being followed. The DON stated that they needed to start immediate education. 3) On 4/14/26 at 11:24 AM a review of Resident #20's medical record was conducted and revealed Resident #20 was admitted to the facility in January 2026 with diagnoses that included diastolic (congestive) heart failure and supraventricular tachycardia. Review of Resident #20's physician's orders revealed the medication Metoprolol Tartrate 25 mg., give 1 tablet 2 times per day for hypertension. The physician's order stated to hold for SBP below 110 or heart rate below 60 beats per minute. Review of Resident #20's February 2026 MAR documented on 2/1/26 at 9:00 AM the blood pressure was 106/66. The systolic number was below 110, however the medication was administered by LPN #7. On 2/4/26 at 9:00 AM the blood pressure was 99/57. The systolic number was below 110, however the medication was administered by Registered Nurse (RN) #30 (Agency nurse). The medication was administered when it was outside of physician ordered parameters. Review of Resident #20's January 2026 MAR documented on 1/9/26 at 9:00 PM the blood pressure was 109/68. The systolic number was below 110, however the medication was administered by LPN #29. The medication was administered when it was outside of physician ordered parameters. Review of Resident #20's care plan, at risk for cardiovascular symptoms or complications related to diagnosis of hypertension had the intervention, administer meds as ordered and assess for effectiveness and side effects and report abnormalities to physician. Review of nursing notes failed to produce documentation that the medication was held and the physician was notified. On 4/16/26 at 7:55 AM an interview was conducted with LPN #7. LPN #7 was asked if there were parameters for a SBP below 110 and the blood pressure was 106/66 would she give the medication or hold it. LPN #7 stated said she would hold it. LPN #7 was shown the February MAR for 2/1/26 with her initials that the medication was given. LPN #7 stated, how could I do that. I will tell you that if the blood pressure is recorded you can't change it, but I do take the blood pressure before giving the med. But it is documented that way so I can't say. On 4/16/26 at 10:35 AM the issue with the medication given outside of the parameters was discussed with the DON and she agreed that it was a concern. On 4/16/26 at 1:09 PM the DON confirmed the surveyor's concerns related to the physician ordered parameters not being followed. The DON stated that they needed to start immediate education.

Based on observations, interviews, and record review, it was determined that the facility failed to maintain an effective pest control program so that the facility is free of pests. This was evident in the kitchen during the initial kitchen tour. The findings include: On 12/03/2025 at 8:43 AM, an observation was made during the initial kitchen tour. A small brown insect was observed crawling on kitchen wall by hand wash sink near the walk-in Refrigerators. On 12/03/2025 at 9:11 AM, a surveyor conducted an interview with Resident #6's representative. They reported that they had observed roaches in the resident's room. On 12/04/2025 at 12:05 PM, an interview was conducted with the Maintenance director (Staff #1). When asked if the facility had any issues with pest control, Staff #1 stated that any issues will be reported directly to the pest control company and the facility keeps copies of their reports. This surveyor made Staff #1 aware of the surveyor's insect sighting in the kitchen.

Based on interviews and medical record review, it was determined the facility failed to follow up with neurologist consultation recommendations which resulted in a delay of care for the resident. This was evident for 1 (Resident #109) of 1 resident reviewed for use of outside sources during the survey. The findings include: On 12/03/2025 at 10:14 AM, during an interview with Resident #109, they stated that they were having a concern with a vibration feeling in their left ear. They stated that they were seeing a neurologist, but had not been seen for about eight months. On 12/08/2025 at 10:33 AM, a review of a neurologist consult from 5/13/25 revealed recommendations for the resident to obtain an electroencephalogram (EEG), the EEG results report to be faxed when it is completed, and that there would be a follow up appointment after reviewing the results. An EEG (electroencephalogram) is a painless, non-invasive test that records your brain's electrical activity using sensors (electrodes) placed on your scalp, showing brain waves as wavy lines to help diagnose conditions like epilepsy, sleep disorders, brain tumors, or confusion from head injuries, providing crucial info on brain function that structural scans miss. On 12/08/2025 at 10:34 AM, a review of resident medical records for orders, revealed that an EEG had been ordered and marked completed on 6/8/2025. On 12/08/2025 at 10:35 AM, a review of progress notes revealed a nursing note from 6/16/2025 at 3:02 PM that stated, Resident went to the EEG appointment with his/her sister at 9 am and came back at 2:30 PM. On 12/09/2025 at 12:36 PM, during an interview with the Director Of Nursing (DON), she stated that they were able to locate the results of the EEG but were not able to find if the results had been sent to the neurologist following the results. At this time the concern for the delay in care was brought to the DON's attention. The Neurologist office was waiting for the EEG results in order to make a follow up appointment for the resident. The resident had not been seen since prior to the EEG being completed. On 12/10/2025 at 9:37 AM, during an interview with the administrator, she stated that she was not sure what happened but the results of the EEG were never sent to the neurologist. She stated that her expectation is that when diagnostic tests are completed, they will send the results immediately to where they need to go.

Based on record review, observations, and staff interviews, it was determined that the facility failed to follow appropriate infection control practices. This was evident for 2 (Resident #4 and #6) out of 33 residents reviewed during the recertification survey.The findings include:Enhanced Barrier Precautions (EBP), are infection control guidelines for nursing homes, recommended by the Centers for Disease Control and Prevention, to stop the spread of dangerous antibiotic-resistant germs by requiring gowns and gloves only for high-contact care (bathing, dressing, wound care, device care) for residents with wounds, devices, or known multi-drug-resistant organisms. 1) On 12/09/2025 at 11:21 AM A review of Resident #6's medical records was conducted. The review revealed that the resident had a pressure ulcer on the sacrum that required daily dressing change. There was an order that indicated EBP should be followed during wound care. On 12/09/2025 at 11:33 AM An observation of Resident #6's wound care was conducted. Assisting with the wound care procedure was Staff #7 (Wound Team Lead) and Staff #6. Staff #6 was observed wearing gloves only, no gown. On 12/09/2025 at 11:40 AM Staff #7 was observed removing the dirty dressing. She then cleaned the wound, removed the gloves and wore clean gloves to apply a clean dressing to the wound. No hand hygiene was performed. On 12/09/2025 at 12:00 PM An interview with Staff #7 was conducted. When asked why she did not perform hand hygiene before wearing clean gloves and applying a clean dressing, she replied that she was taught that unless the gloves were visibly soiled, one does not have to clean her hands before wearing clean gloves. On 12/09/2025 at 12:23 PM An interview with Staff #6 was conducted. She acknowledged that she forgot to wear a gown as indicated on the EBP order because she was in a rush. On 12/09/2025 at 12:33 PM Further review of the facility's dressing change procedure instructions revealed that the staff should perform hand hygiene after removal of dirty dressing and before wearing clean gloves to apply clean dressing. On 12/09/2025 at 1:57 PM The Director of Nursing (DON) and administrator were made aware of the infection control concerns identified. 2) On 12/11/2025 at 10:05 AM, a review of Resident #4 records and the facility's Infection Surveillance Monthly report for November 2025 was conducted. Resident #4 had a red stop sign in their Electronic Health Record (HER) profile. The Infection Surveillance report shows that the resident had Clostridium difficile and a Wound infection, both of which had been resolved. Resident #4 had active/open wounds with wound care orders according to their medical record. On 12/11/2025 at 10:09 AM, an observation of the 100 unit and Resident #4's room was made. No signage on door or inside room stating the resident was on EBP was seen. A Personal Protective Equipment (PPE) cart was seen across hallway. On 12/11/2025 at 10:19 AM, an interview with the Infection Preventionist (IP) was conducted. When asked about if Resident #4 had any active infections, the IP stated that they do not have any current infections. When asked why the resident has a Red Stop sign in their EHR profile, the IP stated that this was a precaution that the resident was still susceptible to infection because of the history of infection and active wounds. When asked if there should be something on the Resident's door or entrance to notify staff and visitors of EBP for the resident, the IP stated yes but staff also is aware of the precaution because of the sign in the EHR. On 12/11/2025 at 10:42 AM, an interview with the DON was conducted. When asked what is used to make staff and visitors aware that a resident is on EBP, The DON stated that there should be signage on the door that states EBP, a red stop sign in the resident's electronic health record, and a PPE cart adjacent to the room. When asked if there would be a case that the sign is not on the door and the red sign in the EHR, the DON stated no they should both be there. When asked who is in charge of placing signs on the door, the DON stated that the unit manager oversees it for their unit and the IP provides oversight ensuring the appropriate residents have the correct signage.

Based on record review and interviews, it was determined that the facility failed to ensure Resident #45 was free from a significant medication error. This was evident for 1 (Resident #45) of 1 resident reviewed during the annual survey. The findings include: On 12/10/2025 at 9:41 AM, Complaint #2604899 was reviewed which revealed a concern that Resident #45 was receiving double doses of their thyroid medication, Synthroid, which had resulted in an abnormal lab value. Synthroid, also known as levothyroxine, is a prescription, man-made thyroid hormone medication used to treat an underactive thyroid gland condition called hypothyroidism. On 12/10/2025 at 9:58 AM, a review of the resident's medical records revealed a change in condition progress note that read, On 8/18/ 2025 resident endocrinologist communicate via fax to start resident on Synthroid 150 mcg to be given in the am, assigned nurse verified the new order with NP (Nurse Practitioner) in house verbally NP approved Synthroid 150 assigned nurse on duty transcribe synthroid 150 mcg to the Mar but did not discontinue the previous order for synthroid 137 mcg. As a result the resident received this medication x 4 dose. On 12/10/2025 at 10:04 AM, a review of Resident #45's medication administration report for August of 2025, revealed that on 8/18/25 ,8/19/25 ,8/20/25 ,and 8/21/25 the resident was receiving both orders of the synthroid medication. On 12/11/2025 at 11:05 AM, The Director of Nursing (DON) was interviewed. During the interview with the DON, she confirmed that she was aware of the medication error and Resident #45 receiving double the medication. She stated that her expectation of the staff was to double check medication orders and to call the doctor if two orders for the same medication appear. She stated that the old order for Synthroid should have been discontinued at the same time the new order was placed. She stated that her expectation for her staff was, when we got a new order and noted the old order it should have been reviewed, questioned and the older order should have been discontinued.

Based on record reviews and interviews, it was determined that the facility failed to code the resident's status accurately on the Minimum Data Set assessment (MDS). This was evident for 1 (Resident #8) out of 2 residents reviewed for accuracy of assessments during the annual survey. The findings include: The MDS is a federally mandated assessment tool that helps nursing home staff members gather information on each resident's strengths and needs. Information collected drives resident care planning decisions. MDS assessments need to be accurate to ensure each resident receives the care they need. On 12/04/2025 at 8:16 AM A review of Resident #8's medical records was conducted. The review revealed that Resident #8 was admitted into the facility on 4/13/2009, however, a medical diagnosis of Schizophrenia was created on 9/6/2023. On 12/05/2025 at 10:09 AM Further review of the resident's MDS was conducted. MDS assessment completed on 5/29/25, under section I, Active Diagnosis, the resident was not coded for schizophrenia, however, the MDS completed on 8/28/25 revealed that the resident was coded for schizophrenia. On 12/05/2025 at 11:46 AM The facility was asked to provide supporting documentation for coding schizophrenia on 8/28/25. On 12/05/2025 at 12:23 PM An interview with MDS coordinator, Staff #3, was conducted. She also brought documentation that stated Resident #8 was evaluated on 8/18/25 for antibiotic management consult. The provider documented past medical history that included schizoaffective disorder. Staff #3 acknowledged that there were no psychiatric notes or other documentation that indicated the resident had schizophrenia. She reported that another MDS coordinator, Staff #4, inaccurately coded for schizophrenia and that the schizophrenia diagnosis should not have been coded. Staff #3 stated that she would amend the MDS. On 12/08/2025 at 9:59 AM Further review of Resident #8's medical records revealed that the schizophrenia diagnosis was removed from the resident's medical history. Additionally, the MDS was modified to remove Schizophrenia on 12/5/2025. On 12/08/2025 at 12:21 PM The facility administrator and Director of Nursing (DON) were made aware of the concerns.

Based on interviews and record reviews, it was determined that the facility failed to update a resident's care plan to reflect individualized preferences. This was evident for 1 (Resident #6) out of 7 residents reviewed for care plan development during the annual survey.The findings include:On 12/03/2025 at 9:38 AM An interview with Resident #6's Representative was conducted. They reported that they have communicated to the facility that they preferred only female providers to care for Resident #6. However, there was a day in which the Resident Representative found a male staff caring for the resident. On 12/10/2025 at 10:10 AM A review of Resident #6's medical record was conducted. The review failed to show any documentation of the resident's female preference for provision of care. On 12/10/2025 at 10:14 AM An interview with Staff #6 was conducted. When asked if she was aware of Resident #6's preference, she said yes, that the resident preferred only female Geriatric Nursing Assistants (GNAs) to care for them. She also added that the preferences are documented on the care plan. On 12/10/2025 at 10:46 AM An interview with the unit manager, Staff #10, was conducted. When asked where a resident's preference for female GNAs would be documented, he reported that the preferences should be in the resident's care plan. A review of Resident #6's care plan was done with the surveyor and the staff. The care plan did not have the preferences documented. On 12/10/2025 at 10:55 AM An interview with the facility's administrator was conducted. She stated that if a resident prefers female staff, it's the facility's policy to document the preference in the care plan. On 12/10/2025 at 12:08 PM A brief interview with the Director of Nursing (DON) was conducted. She confirmed that it is the facility's process to update the care plan if a resident prefers only female GNAs, and that the care plan and tasks were not updated to reflect the gender preference for Resident #6.On 12/10/2025 at 12:18 PM The facility administrator and DON were notified of the failure to update the care plan concerns.

Based on record reviews and interviews, it was determined that the facility failed to administer medications in a timely manner. This was evident for 1 (Resident #128) out of 1 residents reviewed for medication administration during the complaint survey. The findings include: On 12/10/2025 at 1:00 PM A review of the complaint # 2624858 submitted to the Office of Health Care Quality (OHCQ) was conducted. The review alleged that Resident #128 was not given their morning medications on 6/13/2025. On 12/10/2025 at 1:25 PM An interview with the complainant was conducted. The complainant stated that Resident #128 reported that they were not given medications and vital signs were never obtained on 6/13/2025. On 12/11/2025 at 9:14 AM A review of Resident #128's medical record was conducted. The review revealed a Situation, Background, Assessment Recommendation (SBAR) note dated 6/13/2025, that reported the resident was never given morning medications. A review of June 2025 Medication Administration Record (MAR) failed to show that medications were administered the morning of June 13th, 2025. The following medications were not administered as ordered: Furosemide Oral Tablet 40 MG (Furosemide) Give 1 tablet by mouth one time a day for Edema Folic Acid Oral Tablet 1 MG (Folic Acid) Give 1 tablet by mouth one time a day for Supplement Ferrous Sulfate Oral Tablet 325 (65 Fe) MG (Ferrous Sulfate) Give 1 tablet by mouth one time a day for Supplement Docusate Sodium Oral Tablet 100 MG (Docusate Sodium) Give 1 tablet by mouth two times a day for Constipation Amlodipine Besylate Oral Tablet 5 MG (Amlodipine Besylate) Give 1 tablet by mouth one time a day for High blood pressure (HTN) Amiodarone HCl Oral Tablet 200 MG (Amiodarone HCl) Give 1 tablet by mouth one time a day for Arrhythmia Losartan Potassium 100 MG TAB Give 1 tablet by mouth one time a day for HTN Metformin HCl Oral Tablet 1000 MG (Metformin HCl) Give 1 tablet by mouth one time a day for Diabetes Before breakfast Metoprolol Succinate ER Oral Tablet Extended Release 24 Hour 25 MG (Metoprolol Succinate) Give 1 tablet by mouth one time a day for HTN Gabapentin Oral Tablet 600 MG (Gabapentin) Give 1 tablet by mouth every 8 hours for Neuropathy. Tylenol Extra Strength Oral Tablet 500 MG (Acetaminophen) Give 2 tablet by mouth every 8 hours for Pain On 12/11/2025 at 10:56 AM An interview with Staff #14 was conducted. When asked what the facility's expectation was for medication administration and documentation, she stated that nurses are required to sign off medications immediately after the medication is given to a resident. The facility staff is expected to document why a medication is not given to a resident, such as refusals or if a resident is out of the facility. On 12/11/2025 at 11:22 AM An interview with the Director of Nursing (DON) was conducted. Per DON, the medication error incident was submitted to OHCQ on 6/13/25. She further stated that the facility was able to substantiate that Resident #128 was not given their medications as ordered on 6/13/2025. On 12/11/2025 at 12:02 PM Further review of the facility's incident report revealed a note that stated on 6/13/2025, the nurse assigned to Resident #128 had a rough day, the medication cart was not organized, and the nurse spent a lot of time looking for medications. On 12/11/2025 at 1:32 PM A follow-up interview with the DON was conducted. She stated that the nurse who was assigned to care for Resident #128 on 6/13/2025, refused to provide a statement of what happened that day that led to some residents not receiving medications. On 12/11/2025 at 1:38 PM The Administrator and DON were notified of the medication error concern.

Based on record review and staff interviews, it was determined that the facility failed to provide rehabilitative services as ordered. This was evident for 1 (Resident #129) out of 1 resident reviewed for therapy services. The findings include: On 12/09/2025 at 10:00 AM, a review of Complaint #2604787 was completed. The complainant alleged that Resident #129 was not receiving his therapy as ordered. On 12/09/2025 at 10:28 AM, the rehab documentation for the months of July and June of 2025 for Resident #129 was reviewed. Physical Therapy (PT) saw the resident, 7 times in the month of July (7/24, 7/20, 7/16, 7/14, 7/10, 7/9, 7/3) and 8 times in the month of June (6/30, 6/28, 6/24, 6/22, 6/16, 6/15, 6/14). Resident #129 had a total of 15 sessions. Resident #129's order resident should have had PT sessions 5 times per week for 4 weeks this would be a total of 20 sessions for all 4 weeks. On 12/10/2025 at 9:13 AM, an interview with the Director of Rehab (Staff #9) was conducted. When asked why Resident #129 missed 5 sessions of PT, Staff #9 stated that she believed the resident's order was 3-5 times rather than 5 times a week. This surveyor verified with Staff #9 that Resident #129's order from 6/13/25 to 7/21/25 was to receive PT 5 times a week for 4 weeks. When asked why the resident missed 5 sessions of PT Staff #9 stated that there was scheduling conflicts. On 12/15/2025 at 10:00 AM, an interview with the Director of Nursing (DON) was conducted. The DON acknowledged that rehab has had an issue with residents missing therapy sessions.

Based on observations, interviews and record reviews, it was determined that the facility failed to provide dental health evaluation and services to the residents. This was evident for 2 (Resident #15 and #10) out of 4 residents evaluated for dental health. The findings include: 1.) On 12/03/2025 at 8:28 AM An observation and interview were conducted. Resident #15 was observed with missing teeth on the bottom of the mouth. When asked if they had dentures, Resident #15 stated that they had the top plate, but the bottom plate was lost. On 12/08/2025 at 12:33 PM A review of Resident #15's medical record was conducted. The review revealed that the resident had an oral health evaluation completed on 6/9/23 that indicated the resident had lower dentures. On 12/08/2025 at 12:40 PM An interview with Staff #13 was conducted. She reported that she had never seen Resident #15 with dentures. On 12/08/2025 at 1:56 PM An interview with the Director of Nursing (DON) was conducted. She reported that Resident #15 had upper dentures only and that the facility's dentures documentation was inaccurate, that is, the resident did not have lower dentures. The DON was asked what the facility's policy was on conducting routine dental services for residents, the DON replied that she would verify and provide the oral health policy. On 12/09/2025 at 9:20 AM The facility provided the oral health policy. Review of this policy revealed that residents' oral health was to be evaluated routinely, annually and as needed. On 12/09/2025 at 11:16 AM Staff #2 provided documentation of oral health assessment completed after surveyor's intervention that noted Resident #15 had several missing teeth and decayed teeth were noted on the lower jaw. On 12/09/2025 at 1:50 PM An interview with the DON was conducted. She confirmed that Resident #15's last oral health assessment was completed on 6/9/2023. DON reported that the facility was in the process of scheduling a dental visit for Resident #15. 2.) On 12/03/2025 at 10:18 AM An observation and interview were conducted. Resident #10 was observed with missing teeth, and they also reported that they've had occasional tooth pain. On 12/08/2025 at 9:24 AM A review of Resident #10's medical record was conducted. The review revealed a note entered on 8/21/2025 at 9:39 AM by Nutrition Staff that stated the resident complained of tooth pain and sore gums. According to the note, the nursing staff was aware, and a dental appointment was pending. Moreover, there was another progress note dated 8/16/25 that indicated the resident was evaluated because they complained that their mouth was sore. The note stated, dental consult for oral abscess, appointment scheduled for Monday 8/25/25. A review of the resident's records revealed an order that stated to consult with dental for treatment as needed for patient health and comfort. On 12/08/2025 at 10:10 AM Further Review of Resident #10's medical chart failed to show that the resident was evaluated by a dentist. The facility was asked to provide evidence for dental services provided for the resident in 2025. On 12/08/2025 at 11:17 AM An interview with the administrator and Staff #2 was conducted. They both confirmed that there was no evidence that the resident left the facility for the 8/25/25 dental appointment. On 12/08/2025 at 11:29 AM Another follow up interview with Staff #2 was conducted. She reported that she had added an order for dental consultation for the resident to be seen on 12/9/2025. On 12/09/2025 at 9:42 AM The facility provided Resident #10's oral health evaluation that was completed on 1/16/2024. Staff #2 confirmed that there was no evidence that the resident had an oral health assessment completed in 2025. On 12/09/2025 at 1:52 PM The facility administrator and DON were notified of the oral health concerns identified.

Based on record review, interviews, and observations, the facility failed to maintain an environment free from staff-to-resident verbal and non-verbal abuse for 2 (Resident #28, #3) of 19 residents. Specifically, 1) Housekeeper 1 (HK1) used curse words toward and made a threatening gesture toward Resident (R) 28 by raising his/her middle finger one time within R28's bedroom and when 2) General Nursing Assistant (GNA) verbally abused R3 and used derogatory comments while providing care. The facility census was 126. The facility implemented effective and thorough corrective measures following these incidents and prior to the start of this survey. The facilities plan and action were verified during this survey, therefore this deficiency was found to be past noncompliance with a compliance date of 1) 8/1/24 and 2) 5/10/25.The findings include: 1) A review of the facility's Center Operations Policies and Procedures Manual including a policy titled, “OPS300 Abuse Prohibition,” dated 7/1/13 with a revision dated 10/24/22, Revision 6.0 revealed, “Policy: Centers prohibit abuse, mistreatment, neglect, misappropriation of resident/patient (hereinafter “patient”) property, and exploitation for all patients…Federal Definitions: Abuse is defined as the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, injury, or mental anguish… It includes verbal abuse, sexual abuse, physical abuse, and mental abuse…Verbal Abuse is any use of oral, written, or gestured language that willfully includes disparaging and derogatory terms to patients or their families, or within their hearing distance… Mental Abuse includes, but is not limited to humiliation, harassment, and threats of punishment or deprivation. Mental abuse may occur through either verbal or nonverbal conduct which causes or has the potential to cause the patient to experience humiliation, intimidation, fear, shame, agitation, or degradation…PURPOSE: To ensure that Center staff are doing all that is within their control to prevent occurrences of abuse, mistreatment…for all patients.” Record review of R28’s electronic medical records revealed he/she was admitted on [DATE] with diagnoses including Congestive Heart Failure, Pulmonary Hypertension, Atrial Fibrillation, Morbid Obesity, Hypertensive Heart Disease with Heart Failure, Difficulty Walking, Muscle Weakness, and Adjustment Disorder with Anxiety. Review of R28’s Minimum Data Set (MDS) assessments dated 3/15/24 and 3/17/25, revealed Brief Interview for Mental Status (BIMS) scores of 15 on both assessments, an indication of intact cognition. Further review of progress notes dated 7/29/24 through 8/1/24 revealed R28 was assessed by nursing and social services following the incident without ill effects noted. Record review of the facility’s investigation initiated on 7/29/25 revealed the alleged perpetrator was identified and placed on administrative leave. Further review of the 5-day follow submitted on 8/1/24, revealed the allegation was verified, and the perpetrator was terminated from the facility. In an interview on 8/28/25 at 1:30 p.m., R28 said he/she has enjoyed his/her care at the facility, sharing that he/she felt it was now time for him/her to move to an assisted living facility, adding that the facility has been helpful in initiating and facilitating this request. When asked about any problems or issues, he/ she stated, “they have been nice to me.” When inquiry was made specifically about the facility-reported incident, R28 recalled the incident and stated he/she has not seen that person since the incident and he/she was happy that he/she no longer had to worry about that housekeeper being disrespectful and rude to him/her. During an observation on 8/28/25 at 1:30 p.m., R28 appeared well-groomed and cognitively intact. He/She engaged this surveyor in pleasant conversation. He/She said he/she has enjoyed his/her care at the facility, sharing that he/she felt it was now time for him/her to move to an assisted living facility, adding that the facility has been helpful in initiating and facilitating this request. When asked about any problems or issues, he/she stated, “they have been nice to me.” When inquiry was made specifically about the facility-reported incident, R28 recalled the incident and stated he/she has not seen that person since the incident and he/she was happy that he/she no longer had to worry about that housekeeper being disrespectful and rude to him/her. In an interview on 8/28/25 at 11:50 a.m., the Director of Environmental Services (DES) stated that both R28 and an unidentified Geriatric Nurse Aide (GNA) reported the incident to him/her and to the former Director of Nursing (DON) immediately following the incident. DES stated HK1 was immediately placed on administrative leave, pending an investigation. Once the investigation was completed and verified, HK1 was terminated from the facility. The DES stated his/her expectation was that no one should ever curse at or “flip off” a resident and that suspected abuse of a resident “should be reported immediately.” DES said education on abuse and neglect is mandatory for environmental services staff annually, and as needed, adding that re-education was provided to the entire department following the incident. 2) Record review of the facility's abuse, neglect and exploitation policy dated 07/01/13, and last revised on 10/24/22 documented the following: The facility prohibits abuse, mistreatment, neglect, misappropriation of resident/patient property, and exploitation for all Residents. This includes, but is not limited to, freedom from corporal punishment, involuntary seclusion, and any physical or chemical restraint not required to treat the patient’s medical symptoms. Facility also strives to comply with the Elder Justice Act (EJA). Under the EJA, employees are designated as mandated reporters and are obligated to immediately report any reasonable suspicion of a crime against a patient/Resident. Reporting a reasonable suspicion of a crime only to an immediate supervisor does not meet the obligation to report. Retaliation in any form against an employee who reports a reasonable suspicion is strictly prohibited. The Facility will implement an abuse prohibition program through the following: Screening of potential hires; Training of employees (both new employees and ongoing training for all employees); Prevention of occurrences; Identification of possible incidents or allegations which need investigation; Investigation of incidents and allegations; Protection of patients during investigations; and Reporting of incidents, investigations, and facility response to the results of their investigations. Record review of R3s face sheet showed his admission date was dated 04/24/24, his diagnoses included, Cognitive Communication Deficient, Congestive Heart Failure and Chronic Kidney Disease. Record review of R3s federally mandated quarterly Minimum Data Set (MDS) dated [DATE] documented a Brief Interview of Mental Status (BIMS) score of 6/15 indicating R3 was cognitively impaired. Record review of R3s Care Plan initiated on 8/28/25 documented. R3 was dependent on staff to meet emotional, intellectual, physical, and social needs due to physical limitations. Record review of R3s progress notes dated 5/10/25 showed Licensed Practical Nurse (LPN) 5 documented, she was told GNA -9 used the “F” word to Resident R3 while providing care and documented GNA-9 was assigned to provide, R3 with Resident care. GNA-9 stated, she will not be fucking stressed out. R3 stated, he asked GNA-9 for oatmeal and GNA-9 said kiss my” ASS”, LPN 5, notified the supervisor and the Director of Nursing (DON). Record review of a written statement dated 5/10/25, GNA-9 documented, she was in the room with two residents when R3 asked for a boiled egg, and his/her roommate asked for oatmeal. According to GNA-9, R3 kept saying things to her and she began to argue with R3 and told R3, “Fuck You”, and the argument continued and documented she spoke out of anger. Record of a written statement dated 5/10/25, GNA 4 documented on 5/10/25 she was getting ready for Resident care, when breakfast trays were brought to the floor. DD then asked GNA-9 to help with passing out trays. GNA-9 refused to help her and went to R3s room and stayed there. GNA 4 later overheard GNA-9 shouting “Fuck Yourself” when R3 asked for cereal. GNA 4 wrote, GNA -9 always used curse words and did not always listen to instructions. Record review of a written statement dated 5/10/25, LPN 5 documented she instructed GNA-9 for help with breakfast trays. LPN -5 wrote GNA-9 did not do what she told her to do; GNA- 9 continued with patient care. Later, R3 asked GNA-9 for oatmeal and she stated she did not give R3 breakfast and whomever gave R3 breakfast should give him oatmeal. During an interview on 8/22/24 at 10:05 AM, LPN 5 revealed she was the charge nurse on 5/10/25 and she supervised GNA-9. LPN 5 stated R3 asked GNA-9 for cereal. According to LPN 5, GNA-9 then said, “kiss my ass”, “fuck you”. LPN 5 explained R3 had cognitive impairment, and she concluded, GNA-9 verbally abused R3 and should have never used derogatory comments. During an interview on 8/22/24 at 10:15 AM, GNA-4 stated on 5/10/25 she was the head GNA on duty and was working with GNA-9 she explained at approximately 7:00 AM GNA-9 refused her orders and went into R3s room and stayed there. Later on, she heard GNA-9 shouting at R3 and his/her roommate. According to GNA-4, GNA-9 told R3 “Fuck yourself” and used the F-word multiple times. GNA-4 stated she reported the abuse to LPN-5. During an interview on 8/25/25 at 8:30 AM GNA –9 revealed she was on duty on 5/10/25 and she explained at approximately 7:30 AM her supervisor instructed her to assist too many Residents at the same time. She stated it was a bad day for her and added she was overly stressed. She explained R3 started demanding too many breakfast choices and she got upset with R3 when R3 continued to talk back to her. She stated she told R3, “Fuck You”. According to GNA-9, she did not understand that was not the correct way to respond at the time and concluded she should have walked out of R3s room. During an interview on 8/22/25 Administrator (A)1 revealed verbal abuse was not permitted and explained GNA 9's choice of words were verbal abuse and were not acceptable. During an interview on 8/22/25 at 2:15 PM the Regional Director of Nursing (RDON) 8 revealed GNA 9s conduct while she provided care was not in accordance with facility policy and was considered verbal abuse. She stated the facility in serviced all staff and the GNA-9 was terminated immediately. During an interview on 8/22/25 at 4:15 PM the Regional Nursing Consultant (RNC) 2 revealed abuse of any kind was not tolerated and she explained GNA-9 verbally abused R3 and her behavior was not acceptable.

Based on record review and interviews, it was determined that the facility failed to clarify a medication discrepancy on the hospital discharge summary, monitor appropriate dosing of a medication by ordering the correct laboratory testing, and take action on abnormal laboratory results required for accurate medication dosing. This was found to be evident for 1 (#43) out of 6 residents reviewed for Vancomycin administration. This deficient practice resulted in harm to the resident. The findings include: Bacteremia is the presence of bacteria in the blood. Vancomycin is an antibiotic used to treat serious bacterial infections. Proper administration requires blood levels be monitored for accurate dosing. According to the National Institute of Health (NIH), the Vancomycin serum trough levels (the low point) are recommended for monitoring and concentrations are recommended in the range of 15 to 20 micrograms in one milliliter (mcg/mL). The reference level for Vancomycin peak levels (the high point) is 20 to 40 mcg/mL. There is no reference level for random (a level not timed with dosing) Vancomycin levels. A record review on 04/18/24 at 07:29 AM, revealed that Resident #43 had been transferred to the hospital with a diagnosis of Vancomycin Toxicity on 4/6/24. Review of the Medication Administration Record found orders for Vancomycin one gram intravenously one time a day for bacteremia for 22 days ordered and discontinued on 3/23/24. Additionally, on 3/23/24 a second order was found for Vancomycin one gram intravenously two times a day for bacteremia. Review of Resident #43's Hospital Discharge Medications section dated 3/22/24 listed both Vancomycin one gram every day and Vancomycin one gram twice a day, however in the plan of care it was stated that it should be given once a day. The Hospital Course/Discharge Diagnosis stated that the Infectious Disease (ID) recommendations were for Vancomycin one gram to be given every day. No notes were found in the medical records regarding an order clarification, therefore the surveyor requested documentation from the Director of Nursing (DON) of how the physicians determined that the dosage would be Vancomycin one gram twice a day. The DON spoke with Registered Nurse (RN) #40, regarding why Vancomycin twice a day was ordered. RN #40 stated to the DON that when she came in, she did not have the Vancomycin to administer. She called the Pharmacy and they stated they did not have the order. She then checked the discharge summary but stated she did not see two orders for Vancomycin. During an interview with Nurse Practitioner #23 on 04/22/24 at 01:10 PM, the surveyor asked how the Vancomycin order was determined to be once or twice a day. She stated, I don't know why the Vancomycin was changed from once a day to twice a day. Usually, the provider reviews the orders unless she isn't here, then it is reviewed by the after hours providers. We document that in the progress notes. I discovered after the fact that the resident was discharged back to the hospital for Vancomycin toxicity. A telephone interview was conducted with RN #40 on 04/23/24 at 09:08 AM. The surveyor asked about clarifying the Vancomycin orders when Resident #43 was admitted . RN #40 stated when she could not find the Vancomycin to administer, she called the pharmacy who informed her that they did not have the Vancomycin order. RN #40 then reviewed the after visit summary and only saw the order for Vancomycin one gram twice a day, looked for a provider signature on the medication summary but did not find one, and she clarified with the on call providers. RN #40 further stated she was unable to remember who she spoke with or the conversation. Review of the closed record and laboratory values on 4/18/24 at 8:48 AM, revealed that Resident #43 had multiple Vancomycin levels drawn during his/her Admission. On 3/29/24, a random Vancomycin level was obtained with a result of 50 mcg/mL. The result was signed by Nurse Practitioner (NP) #36, no action was taken. On 4/2/24, a random Vancomycin level of 82 mcg/mL was obtained, signed off by NP #23 and no action was taken. On 4/5/24 a random Vancomycin level was obtained that was greater than 100 mcg/mL. This was reviewed by the Medical Director and two Vancomycin doses were held. On 4/6/24, the Vancomycin level was greater than 100 mcg/mL. This was reviewed by the Medical Director and Resident #43 was transported to the hospital. A review of the 4/19/22 Hospital Transfer Summary on 4/22/24 at 07:13 AM revealed that Resident #43 was admitted to the hospital with a Vancomyicin level greater than 200 mcg/mL on 4/6/24. During the hospital course Resident #43 was diagnosed with Acute Renal Failure with Tubular Necrosis - resolved as of 4/19/24. During an interview conducted on 04/19/24 at 1:00 PM, the Medical Director was asked how the providers assess residents who were administered Vancomycin for renal failure. The Medical Director responded that lab orders are normally ordered every week to check the Vancomycin levels. Based on the Vancomycin levels the pharmacy monitors redosing of Vancomycin and the facility monitors for side effects when we visit residents and monitor laboratory values. She further stated Resident #43 did not have any side effects and his/her vital signs were normal. We did not suspect any problems. When residents are admitted , we do baseline laboratory testing as soon as possible. Laboratory results are monitored every day. Orders are normally written when a resident is admitted and the on call physician reviews the orders. They must have realized there were two orders written and changed it from one to the other. The on call provider would have done that. She further stated that the DON is looking for documentation about how the dosing was determined. The surveyor reviewed all the laboratory results with the Medical Director. The surveyor pointed out that although the laboratory value was random, the timing of the collection was 10 hours after the last dose. When asked if that could be considered a trough level and interpreted as one, the medical director stated, That is a good point. On 04/22/2024 at 11:26 AM, during an interview with Nurse Practitioner (NP) #23, the surveyor asked what the expectation was when she reviewed and signed off on laboratory results. NP #23 stated that the unit secretary prints the laboratory results and flags them in the patient charts for the providers to review and sign off. When asked what she used as a reference for abnormal levels when the labs stated there was no normal value for a random Vancomycin level, NP #23 replied she would review it based on her knowledge, but generally laboratory results have reference values unless there is a comment that explains it. When we order Vancomycin levels, we always order a trough, but the nurses don't always put a Vancomycin trough level on the requisition request. During the continued interview the surveyor and NP #23 reviewed the NP's note that revealed she signed off on Resident #42's Vancomycin level of 82 on 04/02/24. The note did not indicate an order had been placed to address the high Vancomycin level. The NP stated I signed off on the Vancomycin Level of 82 dated 04/02/24, I don't remember seeing it. That was an error, I should have stopped the Vancomycin and had a trough level drawn the next day. During an interview with the Medical Director on 04/22/24 at 12:01 PM, the surveyor asked what her expectations are when the Nurse Practitioners review laboratory results and find abnormal values. She stated they are expected to address any concerns. Normally they make their own decisions, but I am available if they need to consult with me. When asked why the laboratory orders placed were Vancomycin levels instead of Trough levels, she stated that when we write the Vancomycin level order, we always mean Vancomycin trough level when we order it. Trough levels should always be drawn before the next dose is given. When asked how the pharmacy gets the laboratory results so they can monitor the results she stated that the facility faxed the laboratory results to the pharmacy daily. The way the Vancomycin levels came up as random is not the normal way we order Vancomycin levels. My providers were caught off guard when they reviewed the results because there were no reference levels with the laboratory results. Resident #43 was asymptomatic, so no red flags were raised by their clinical presentation. On 04/22/24 at 12:36 PM, the DON stated she was not able to confirm the Vancomycin level results were faxed to the pharmacy. When asked about ordering random Vancomycin levels vs the Vancomycin trough levels, she stated the physicians needed to order the Vancomycin trough level precisely. We are supposed to write exactly what is in the order on the laboratory sheet. The surveyor interviewed the DON on 04/23/24 at 11:41 AM and asked about the process for ordering laboratory testing. She replied when the laboratory tests are ordered they go on the order sheet. When the laboratory results come back in, the unit secretary places the results on the chart and flags it for the provider to review. If the laboratory result doesn't come in, the unit secretary is responsible to notify the nurse that it was not done. On 04/23/24 at 01:14 PM, the survey team advised the DON, Administrator and Regional Clinical Lead, that the deficient level of practice had been identified as causing actual harm to Resident #43.

Based on surveyor observation, medical record review and staff interview, it was determined that the facility failed to maintain confidentiality of resident medical records as evidenced by accessibility of a laboratory log. This was found to be evident for 7 (Residents #3, 16, 42, 51, 55, 71 and 77) out 7 Residents reviewed for confidentiality of medical records. The findings include: On the initial tour of the nursing unit 400 conducted on 4/15/24 at 8:38 AM the surveyors observed a black binder that sat on the countertop at the nursing station. The review of the black binder revealed a laboratory log that included Residents #3, #16, #42, #51, #55, #71, and #77 names and laboratory information. The laboratory log included the following documents for April 1, 2024 through April 15, 2024: resident lab test log divided by dates, list of residents who were scheduled for a specific lab by dates, Clinical Laboratory Outpatient Requisition forms that were attached for each resident that had a lab scheduled, and the lab and diagnostic record from Point Click Care (PCC) (a computer software for nursing home medical record documentation) that listed the resident names and laboratory tests that were due for each day. During an interview conducted on 04/15/2024 at 8:40 AM the Registered Nurse (RN) staff #2 confirmed that the black binder was the resident's laboratory log. The RN further stated that the binder should have been stored behind the nursing station away from public access. The surveyors observed RN staff #2 remove the binder from the countertop and place it behind the nursing station.

Based on record review, and interviews, it was determined the facility failed to notify the Ombudsman of residents that transferred or discharged . This was found evident of 3 (Resident #17, #90 & 73) of 5 residents reviewed for hospitalization during the survey. The finding include: 1a) On 4/15/24 at 11:56 AM, the surveyor interviewed Resident #17. During this interview Resident #17 stated he/she had recently been hospitalized . On 4/19/24 at 7:47 AM, the surveyor reviewed Resident #17's medical record. The review revealed that Resident # 17 was transferred to the hospital on 3/15/24. On 4/19/24 at 11:33 AM, the surveyor requested documentation that the Ombudsman was notified of Resident #17's March hospitalization . The Director of Nursing (DON) stated she would look for the documentation. On 4/19/24 at 2:13 PM, the DON stated she was not able to find any documentation that the Ombudsman was notified, and she believed the communication was not done after speaking with the Social Worker and business office. 1b) On 4/15/24 at 3:26 PM, the surveyor conducted a phone interview with Resident #90's son and daughter. During the interview the family reported Resident #90 had been recently transferred to the hospital. On 4/26/24 07:11 AM, the surveyor reviewed Resident #90's hospital discharge summary dated 3/25/24. Resident #90 was treated for sepsis and readmitted back to the facility. On 4/26/24 at 10:36 AM, the surveyor requested documentation demonstrating that the Ombudsman was notified of Resident #90's transfers in March. On 4/26/24 at 12:08 PM, the surveyor conducted an interview with the Director of Nursing (DON). During the interview the DON stated she was unable to provide any documentation the ombudsman was notified of Resident #90's hospital transfer from March. 49815 1c) During an interview on 4/16/24 at 10:39 AM Resident #73 stated to the surveyors that he/she was hospitalized for 5 days. On 4/24/24 at 7:30 AM the surveyor reviewed Resident #73 ' s medical record. The review of the medical record revealed that Resident #73 was transferred to the hospital in October of 2023. Further review of Resident #73's medical record revealed an eINTERACT Transfer Form that was completed by Registered Nurse (RN) #2 for the hospital transfer dated 10/18/23. The eINTERACT Transfer Form stated that Resident #73 ' s Representative/Emergency Contact was notified of the transfer and aware of the clinical situation, but there is no documentation that the facility Ombudsman was notified of Resident #73 ' s transfer to the hospital on 10/18/23. The surveyors interviewed the Director of Nursing (DON) at 12:10 PM on 4/26/24 and the DON stated that the expectation was that the Social Services staff or the Business Office staff was to notify the Ombudsman of the Resident transfers and discharges. In addition, the Director of Nursing also stated that there was not a system in place for this process, and that going forward the responsibility for the notification of Resident transfers and discharges to the Ombudsman would be completed by the Guest Services Director.

Based on observation, interview and medical record review it was determined that the facility failed to: 1) revise residents care plans and 2) to hold care plan meetings with an interdisciplinary team for residents at the time of the Minimum Data Set (MDS) assessment. This was found evident for in 3 (Resident # 42, #75 and #80) and 1 (Resident #322) of 10 residents reviewed for care planning. The findings include: Care plans are developed for residents to guide the care that residents receive in the facility. They are required to be developed within 7 days of completion of a resident's admission comprehensive Minimum Data Set (MDS) assessment and revised at least every quarter (or more often as needed). The facility is required to have care plans developed and revised by an interdisciplinary team. A wound vac is a negative pressure wound therapy device that decreases air pressure on the wound and helps wounds heal more quickly. The Minimum Data Set is part of the federally mandated process for clinical assessment of all residents in Medicare and Medicaid certified nursing homes. This process provides a comprehensive assessment of each resident's functional capabilities and helps nursing home staff identify health problems of residents. Foley catheter is a device inserted into the bladder that drains the urine from the bladder into a collection device. 1a) On 4/18/24 at 9:30 AM the surveyor conducted a medical record review of Resident #42's chart. The medical record review revealed that Resident #42 had a physician order for a wound vac to the sacrum ordered 3/15/24 and there was a physician order to hold wound vac due to active bleeding on 4/15/24. Further review of the medical record on 4/19/24 revealed that there was no revision or update to the care plan that the wound vac was on hold. The wound vac remained on the care plan as an intervention. 1b) On 4/23/24 at 8:30 AM the surveyor conducted a medical record review of Resident #80's chart. The medical record review revealed that Resident #80 had a physician order for Clopidogrel 75 milligrams (mg) daily dated 8/18/23. Clopidogrel is an antiplatelet medication which prevents clots from forming by working to stop your platelets from sticking together. Further review of the medical record revealed that section N - Medications of the quarterly Minimum Data Set (MDS) completed on 3/4/24 indicated that Resident #80 took an antiplatelet medication but not an anticoagulant medication. The resident's plan of care had a focus, goal and interventions for an anticoagulant medication, but there was not a care plan for an antiplatelet medication. The focus of the care plan was: Resident is at risk for injury or complications related to the use of anticoagulation therapy medication - clopidogrel. In addition, the surveyor reviewed Resident #80's physician orders and the review revealed that Resident #80 had a physician order for clopidogrel and Aspirin, but did not have any order for an anticoagulant medication. 1c) On 4/16/24 at 9:24 AM the surveyor interviewed Resident #75 and did not observe a foley catheter drainage bag. On 4/22/24 at 1:25 PM the surveyor conducted a medical record review of Resident #75's chart. The medical record review revealed that Resident #75 had a current care plan that addressed indwelling foley catheter care dated 11/27/23 with no revisions or updates to the care plan. On 4/23/24 the surveyor interviewed the Director of Nursing (DON) and the DON confirmed that Resident #75 does not have a Foley catheter. On 4/17/24 at 9:24 AM the surveyor conducted a review of Resident #75's medical record. The medical record review revealed that Resident #75 had a resolved pressure ulcer of the right heel as documented on the Skin/Wound evaluation assessment dated [DATE]. Further review of the medical record revealed that there was no documentation of a right heel pressure ulcer addressed on the care plan since 11/16/23 for Resident #75. 44440 2) On 4/16/24 at 9:38 AM, the surveyor conducted an interview with Resident #322. During the interview Resident #322 stated he/she had never had a care plan meeting. On 4/18/24 at 12:51 PM, the surveyor reviewed Resident #322's medical record. A post admission patient family conference note was written on 3/27/24. The note entailed baseline care planning information and anticipated needs for discharge. On further review no note or documentation that a comprehensive care plan was completed following the baseline care plan. On 4/19/24 at 11:28 AM, the surveyor conducted an interview with the Director of Nursing (DON). During the interview the DON stated within 7 days after completing the comprehensive assessment it is expected to have a care plan meeting. She stated she would look for documentation of the care plan meeting for Resident #322. On 4/19/24 at 12:25 PM, the surveyor reviewed Resident #322's progress notes. A note was written that same day at 12:08 PM, by Social Service Designee, Staff #51. The note stated Staff #51 met with Resident #322 to schedule a care plan meeting for 4/22/24 at 11AM. On 4/23/24 at 11:59 AM, the surveyor interviewed the Social Services Director, Staff #48. During the interview Staff #48 stated she was unfamiliar if Resident #322. She further stated a care plan meeting is usually set up 7-10 days after admission. She stated she would have to follow up to find out why there was a delay in the care plan meeting for Resident #322. On 4/23/24 at 12:53 PM, the surveyor interviewed Staff #51. During the interview Staff #51 stated she met with Resident #322 a few days earlier for a care plan meeting. The surveyor asked if the care plan meeting was completed within 7 days after Resident 322's Minimum Data Set assessment. Staff #51 agreed the meeting was delayed.

Based on observations, review of resident's medical records, and interviews, it was determined that the facility staff failed to provide activities of daily living care in accordance with the Resident's care plan for dependent Residents. This was found to be evident for 5 (Resident #322, #97, #321, #41 and #80) out of 7 reviewed during the survey for activities of daily living. The findings include: Activities of Daily Living (ADLs) is a term used collectively to describe fundamental skills required to independently care for oneself, such as eating, bathing, and mobility. A care plan is a federally mandated tool that is based on a resident's assessment and describes the services that the facility will provide to the resident to attain or maintain the resident's physical, mental, and psychosocial health. The care plan must be developed and revised after each assessment. The Minimum Data Set (MDS) is part of the federally mandated process for clinical assessment of all residents in Medicare and Medicaid certified nursing homes. This process provides a comprehensive assessment of each resident's functional capabilities and helps nursing home staff identify health problems. 1a) On 4/16/24 at 9:28 AM, the surveyor conducted an interview with Resident #322. During the interview Resident #322 stated that he/she had never been offered a shower. On 4/18/24 at 12:42 PM, the surveyor reviewed Resident #322's care plan. A care plan was created on 3/27/24 stating Resident #322 is at risk for decreased ability to perform (ADLs) related to generalized weakness. An additional care plan created on 4/5/24 stating, Resident #322 states it is important to engage in daily routines that are meaningful and are preferred. One of the interventions listed was, it is important for me to choose between a tub bath, shower, bed bath or sponge bath. On 4/24/24 at 10:30 AM, the surveyor interviewed Registered Nurse Staff #45 on the 100 Unit hallway. During the interview Staff #45 explained the process for identifying which residents would be offered a shower for the day. She pulled out a book and the surveyor was shown a shower schedule. Staff #45 stated the showers that were scheduled for that day are also communicated by having those residents room numbers added to the staffing sheet posted at the nurses station. She further stated that after a shower was completed a shower sheet would be filled out by both the Geriatric Nursing Assistant (GNA) and nurse. The sheets are then filed in the shower book. She further stated if a resident refuses, that is documented as well. On 4/24/24 at 10:33 AM, the surveyor reviewed the shower log book. Two shower sheets were in the book for the entire month of April and both were dated 4/20/24. The next shower sheet was dated 3/18/24. On 4/24/24 at 10:41 AM, the surveyor interviewed Licensed Practical Nurse (LPN) Staff #46 on the 200 Unit hallway. Staff #46 confirmed the same process for shower schedules and documentation. The surveyor asked the LPN where the shower logbook was located for the 200 hallway. Staff #46 flipped the pages in a binder and asked her Unit Supervisor, Staff #42, where the shower sheets were being stored. No sheets were noted in the book. At this time Staff #42 also looked in the book and stated he was unable to find them but he would look and follow up. On 4/24/24 at 10:49 AM, the surveyor conducted an interview with the Director of Nursing (DON). During the interview the surveyor reported the observations of the missing shower documentation and the report from Resident #322 that a shower was never given. The surveyor asked for documentation that indicated if a shower was given/offered on the shower days scheduled for Resident #322. On 4/25/24 at 10:00 AM, the surveyor conducted a follow up interview with the DON. During this interview the DON stated she was not able to provide any documentation that a shower was offered or competed for Resident #322 and that only bed baths had been recorded. 1b) On 4/16/24 at 10:46 AM, the surveyor conducted and interview with Resident #97. During the interview Resident #97 stated he/she had never been in the shower since admitted . The resident further stated he/she was only offered a pan of water to bathe with. On 4/24/24 at 10:30 AM, the surveyor interviewed Registered Nurse Staff #45 who was in the 100 Unit hallway. During the interview Staff #45 explained the process for identifying which residents would be offered a shower for the day. She pulled out a book and the surveyor was shown a shower schedule. Staff #45 stated the showers that were scheduled for the day are also communicated by having those residents room numbers added to the staffing sheet posted at the nurses station. She further stated that after a shower was completed a shower sheet would be filled out by both the Geriatric Nursing Assistant (GNA) and nurse. The sheets are then filed in the shower book. She further stated if a rsident refuses, that is documented as well. On 4/24/24 at 10:33 AM, the surveyor reviewed the shower log book. Two shower sheets were in the book for the entire month of April and both were dated 4/20/24. The next shower sheet was dated 3/18/24. On 4/24/24 at 10:41 AM, the surveyor interviewed Licensed Practical Nurse (LPN) Staff #46 on the 200 Unit hallway. Staff #46 confirmed the same process for shower schedules and documentation. The surveyor asked the LPN where the shower logbook was located for the 200 hallway. Staff #46 flipped the pages in a binder and asked her Unit Supervisor, Staff #42, where the shower sheets were being stored. No sheets were noted in the book. At this time Staff #42 also looked in the book and stated he was unable to find them but he would look and follow up. On 4/24/24 at 10:49 AM, the surveyor conducted an interview with the Director of Nursing (DON). During the interview the surveyor reported the observations of the missing shower documentation and the reports from the resident that a shower was never given. The surveyor asked for documentation of when a shower was given/offered on the shower days scheduled for Resident #97. On 4/24/24 at 1:38 PM, the surveyor reviewed Resident # 97's care plan. On 3/14/24 a care plan was created for Resident #97 which stated, Resident #97 requires assistance and is dependent for ADL care in bathing, rooming, personal hygiene, dressing, bed mobility, transfer, locomotion, toileting related to limited mobility. On 4/25/24 at 10:00 AM, the surveyor conducted a follow up interview with the DON. During this interview the DON stated she was not able to provide any documentation that a shower was offered or competed for Resident #97 and that only bed baths had been recorded. 1c) On 4/15/24 at 2:24 PM, the surveyor observed Resident #321 resting in bed with a film noted on his/her teeth. On 4/24/24 at 10:30 AM, the surveyor interviewed Registered Nurse Staff #45 who was in the 100 Unit hallway. During the interview Staff #45 explained the process for identifying which residents would be offered a shower for the day. She pulled out a book and the surveyor was shown a shower schedule. Staff #45 stated the showers that were scheduled for the day are also communicated by having those Residents room numbers added to the staffing sheet posted at the nurses station. She further stated that after a shower was completed a shower sheet would be filled out by both the Geriatric Nursing Assistant (GNA) and nurse. The sheets are then filed in the shower book. She further stated if a resident refuses, that is documented as well. On 4/24/24 at 10:33 AM, the surveyor reviewed the shower log book. Two shower sheets were in the book for the entire month of April and both were dated 4/20/24. The next shower sheet was dated 3/18/24. On 4/24/24 at 10:41 AM, the surveyor interviewed Licensed Practical Nurse (LPN) Staff #46 on the 200 Uunit hallway. Staff #46 confirmed the same process for shower schedules and documentation. The surveyor asked the LPN where the shower logbook was located for the 200 hallway. Staff #46 flipped the pages in a binder and asked her Unit Supervisor, Staff #42 where the shower sheets were being stored. No sheets were noted in the book. At this time Staff #42 also looked in the book and stated he was unable to find them but he would look and follow up. On 4/24/24 at 10:49 AM, the surveyor conducted an interview with the Director of Nursing (DON). During the interview the surveyor reported the observations of the missing shower documentation and the reports from the resident that a shower was never given. The surveyor asked for documentation of when a shower was given/offered on the shower days scheduled for Resident #321 On 4/24/24 at 11:55 AM, the surveyor reviewed Resident #321's care plan. A care plan was initiated on 3/29/24 and stated, Resident # 321 requires assistance and is dependent for ADL care in relation to recent illness, fall, hospitalization resulting in fatigue, activity intolerance, confusion and limited mobility. On 4/25/24 at 10:00 AM, the surveyor conducted a follow up interview with the DON. During this interview the DON stated she was not able to provide any documentation that a shower was offered or competed for Resident #321 that only bed baths had been recorded. 45733 1d) During an initial screening, on 4/17/24 at 09:10 AM, Resident #41 was observed wearing a food-stained gown, the face was greasy, food was left on the lips and the eyes were crusty. The bed linen had a few stains on the cover sheet. Furthermore, the resident stated that he/she did not have someone to help with the morning grooming. Record review, on 4/18/24 at 01:02 PM, revealed that Resident #41 was admitted to the facility on [DATE] with diagnoses of a left side stroke and depression. He/she was able to answer questions appropriately and made his/her needs known. Further record review of the quarterly Minimum Data Set assessment section GG of the functional ability and goals, dated 3/1/24, revealed that this resident needed the level of maximum to dependent assistance care in all Activities of Daily Living (ADLs). Observation and interview, on 4/29/24 at 10:16 AM, found that Resident #41's face again was not cleaned. He/she had breakfast leftover on his/her left cheek and crusty eyes were present. The resident stated that no morning grooming assistance had been provided and he/she did not know what day the shower was scheduled. During interview, at Resident #41's bedside, on 4/29/24 at 10:40 AM, the Unit Manager Staff #9 agreed that this resident had not yet been provided with a morning grooming assistant, which was a failure by the nursing aide. Advised Staff #9 that this was a concern. Additionally, Staff #9 was asked for the resident's shower schedule and agreed to provide it for a review. However, Staff #9 never provided Resident #41's shower schedule. During the exit meeting, on 4/30/24 at 1:20 PM, the Director of Nursing and the Administrator were made aware of the concern that no proper grooming assistant was provided to Resident #41 to maintain this resident's good grooming and hygiene. 49815 1e) During an interview conducted on 4/16/24 at 10:52 AM the surveyors observed a black substance underneath Resident #80's fingernails. At 11:15 AM on 4/24/24 the surveyor visited Resident #80 and observed a few fingernails on both Resident's hands with a black substance underneath them. The resident stated to the surveyor that my nails were cut 3 weeks ago or so. The surveyor visited Resident #80 on 4/25/24 at 10:45 AM and again observed the black substance underneath the resident's fingernails. At 11:25 AM on 4/25/24 the surveyor interviewed the Director of Nursing (DON) about the expectation for fingernail care. The Director of Nursing stated that nail care should be performed during showers, bed baths and whenever needed for the rsident, and if the resident refuses, then there should be documentation about the refusal. The surveyor shared with the DON that Resident #80 was observed with a black substance underneath her fingernails for multiple days. The surveyor reviewed Resident #80's medical record on 4/25/24 and it was documented in the care plan that the resident is dependent for ADL care, and there was not a care plan that indicated that the resident refused ADL care or fingernail care. Further review of the medical record revealed that on the Geriatric Nursing Assistant (GNA) Task Flow sheet for Activities of Daily Living (ADL), the resident required extensive assistance and was dependent on staff for personal hygiene and bathing.

Based on observation, interview and record review it was determined that the facility failed to maintain proper sanitation for storage of food in the kitchen and on the nursing units. This was evident in the kitchen, on 2 out of 4 nursing units, and on 1 random observation of a beverage cart found during an annual survey. The findings include: 1a) During the initial tour of the kitchen on [DATE] at 8:15 AM the surveyors observed the following: dish machine log missing evening temperature on [DATE], walk-in freezer stocked too full of food items and disorganized with food items on floor, gnats flying around the freezer and around bread cart, freezer fan on ceiling with ice and sediment, ice on food in freezer, open loaf of bread dated ,d+[DATE], kitchen floor with crumbs and dried stains, aluminum pan on the floor underneath the food preparation table, pair of shoes on kitchen floor, trash piled up at the entrance to kitchen door, and wet-nesting on serving pans on the drying rack in the dishwashing area. Wet-nesting occurs when wet dishes or pots and pans are stacked, preventing them from drying and creating conditions that are ripe for microorganisms to grow. Food Drug Administration (FDA) guidelines mandate that all wares should be air dried. Using towels to dry dishes is never permitted. At 8:38 AM on [DATE] on the initial tour of the 400 nursing unit the surveyors observed the residents nourishment refrigerator log incomplete with only 3 dates for the month of April recorded and the refrigerator was dirty with spilled red substance and unlabeled food items that had missing dates and resident names. The surveyors interviewed the Director of Nursing (DON) at 9:00 AM on [DATE] regarding the nourishment refrigerator on the 400 nursing unit. The surveyors conveyed to the DON that the residents nourishment refrigerator had missing temperatures, spilled liquid and unlabeled food items. The DON stated that the expectation is for the temperature to be taken daily, the refrigerator to be kept clean, and the food items to be labeled. At 9:45 AM on [DATE] the surveyors and the Nursing Home Administrator conducted a brief tour of the kitchen. The following was observed: gnats flying around as the kitchen was entered, food items on the freezer floor, ice on the ceiling freezer and on the food items, freezer too full and food items on the floor, broken hand sink and crumbs and dried stains on the kitchen floor. In addition, the surveyor shared with the Nursing Home Administrator (NHA) of the observations that were identified on the initial tour of the kitchen at 8:15 SAM on [DATE]. On [DATE] at 8:12 AM the surveyors observed in the kitchen with the Assistant Food Services Director (AFSD) #6 at the walk-in freezer. Packages of meat on the floor and ice/frost on the ceiling of the freezer and on the food items. The Nursing Home Administrator on [DATE] provided the surveyor an inventory of food items from the walk-in freezer that were discarded on [DATE] due to the accumulation of ice/frost on those food items. The food items included: 3 roast beef, 4 packs of chicken, 3 hams, 1 corn beef, 2 turkeys, 2 boxes of pizza dough, 2 boxes of cookies, and 1 pumpkin pie. In addition, the NHA provided the surveyor a copy of an in-service sign in sheet that listed the Topic: Freezer, the Presenter: AFSD #6, and the Date: [DATE]. On [DATE] at 12:30 AM the surveyors received from the Nursing Home Administrator an invoice dated [DATE] and a work order dated [DATE] from Aireco Supply, Inc.1 which is the company that the facility uses for repair of the kitchen walk-in freezer. At 8:47 AM on [DATE] the surveyors toured the kitchen with the Food Services Director (FSD) #5 and with the AFSD (#6) for the later part of the tour. The following was observed during the tour: ice/frost on the ceiling of the freezer and on the food items, freezer thermometer covered in ice, italian sausage links and chicken patties covered in ice and packaging not properly closed, one italian sausage link lying on shelf not in covered package, cinnamon rolls in cardboard box full of ice, ice cream in cardboard boxes sitting on kitchen floor from delivery, thermometer on floor of walk in refrigerator, temperature log for refrigerator and freezer not checked for this date of [DATE], kitchen staff checked temperatures of freezer and refrigerator from the outside thermometer instead of the internal thermometer of the freezer and refrigerator, unlabeled and expired food items in the dry storage area (biscuit mix [DATE], noodles no date and opened, [NAME] noodles [DATE], lasagna noodles [DATE], torn bag of tricolor pasta noodles with several noodles lying in cardboard box, egg noodles no date, opened, cheerios and rice Krispies no date on plastic container, package of [NAME] ' s salad dressing expired [DATE], cake mix expired date [DATE], craisins in a plastic bag in cardboard box opened not sealed no date; 2 containers of salad dressing in the reach in refrigerator without a date, wet-nesting on food preparation pans that were stacked together on the drying shelf, and dark substance on the wall behind the sink near the dishwasher. On [DATE] at 10:05 AM the kitchen observations on [DATE] were reviewed with the Director of Nursing. 1b) Between 10:30 AM and 10:45 AM on [DATE] the surveyor and the Director of Nursing conducted observations of the nourishment refrigerators on all 4 nursing units. The following was observed: 400-nursing unit at 9:00 AM nourishment refrigerator missing temperature recordings for ,d+[DATE] - ,d+[DATE], soda bottle, 3 water bottles, 2 health shake cartons, and jar of applesauce not labeled or dated. 300-nursing unit at 9:07 AM 3 containers of Resident food with a date of [DATE]; 200 unit at 9:15 am nourishment refrigerator missing temperature recordings for ,d+[DATE], ,d+[DATE], ,d+[DATE], ,d+[DATE] - ,d+[DATE], ,d+[DATE] - ,d+[DATE], and ,d+[DATE], items not labeled and dated - yogurt, 2 ice cream cups, 3 bottles of water, bottle of milk, and large bottle of creamer. 100-nursing unit at 9:21 am items not labeled and dated - large bottle of creamer, pudding cup, ,d+[DATE] Hershey chocolate bar, 2 health shake cartons with label pulled off. On [DATE] at 11: 00 AM the surveyor reviewed the Policy Titled: FNS 413 - Food Brought in for Patients/Residents from the Food and Nutrition Policies and Procedures effective date [DATE] and review date [DATE]. The facility policy indicated that food items in the nourishment refrigerators were to be labeled with Resident name and date and that the items are good for 3 days. This was confirmed with the Director of Nursing. During observation of the meal delivery on nursing unit 400 on [DATE] at 8:30 AM with the Food Services Director the surveyors observed wet-nesting on the plate lids that were used to cover the plates of the Residents ' food during services delivery from the meal cart to the Resident rooms. 45733 1c) Observation in the hallway, on [DATE] at 09:01 AM, the kitchen staff pushed a beverage kart from room to room to give each resident their choice of beverage. Observation, on [DATE] at 09:20 AM, found that the same beverage kart was left outside of room [ROOM NUMBER] in the hallway. The surveyor examined 4 out of 6 beverage containers with the used end date of [DATE] (orange juice, prune juice, nectar & honey consistency). At this time, the kitchen staff had already finished serving breakfast to all the residents about 10 minutes and went back to the kitchen. In addition to the expired 4 beverages, the kart was left unattended in the hallway so that anyone could have access to the beverage and the kart did not have a proper temperature control method to keep them below 41 degrees Fahrenheit. During interview, on [DATE] at 9:30 AM, the Unit Manager Staff #9 viewed the 4 expired beverage containers and agreed that the 4 beverages were expired and should not have been served to the residents and the kart should not be left in the hallway. During interview, on [DATE] at 09:29 AM, the Kitchen Serving Staff #26 stated that he was not working on [DATE], but per kitchen serve beverage procedure that residents should not have received expired- beverages and the beverage's kart should not left in the hallway unattended. During interview, on [DATE] at 10:15 AM, the Director of Nursing (DoN) reviewed the above findings and agreed that if the Kitchen staff had followed the correct procedure, then the expired beverages would not have been served to the residents. The DoN also agreed that the kart should not have been stored in the hallway, which was unsafe and the temperature could not be controlled.

Based on review of facility investigative materials, resident medical records, and interview with facility staff, it was determined that the facility failed to ensure that a resident's wishes to refuse Cardio-Pulmonary Resuscitation (CPR), as expressed in his or her Medical Orders for Life-Sustaining Treatment (MOLST), were followed when the resident was found to be pulseless and unresponsive. This was evident for 1 (Resident #3) of 4 residents reviewed for death during the complaint survey. This failure resulted in actual harm to Resident #3. The facility implemented effective and thorough corrective measures following this incident and prior to the start of this survey. The facilities plan and action was verified during this survey, therefore this deficiency was found to be past noncompliance with a compliance date of [DATE]. The findings include: Facility Reported Incident #MD 236 was reviewed on [DATE] at 12:26 PM. Review of the facility's investigation demonstrated that Resident #3's Medical Orders for Life-Sustaining Treatment (MOLST) form dated [DATE] contained a Do Not Resuscitate (DNR) order, Option A-2, Do Not Intubate. During the review, it was found that Resident #3 became unresponsive, was found to be pulseless, and was declared deceased on [DATE]. The investigation demonstrated that, at the time the resident was found to be pulseless, Registered Nurse (RN) #4 provided chest compressions as part of Cardio-Pulmonary Resuscitation (CPR) for between two and five minutes. This MOLST form dated [DATE] was the only MOLST form in Resident #3's medical record, had not been voided, and was active at the time that CPR chest compressions were being provided to the pulseless resident. The MOLST form is completed by a physician in consultation with a resident or their representative or is based on a resident's advanced directives. It is designed to create durable orders for care to be provided to a resident who experiences cardiac or respiratory arrest. Primarily, it specifies whether cardio- [MEDICAL CONDITION] resuscitation (CPR) and other life sustaining measures should be used if a resident was found unconscious and pulseless. A review of Resident #3's medical record and ongoing review of the facility's investigation was conducted on [DATE] at 12:40 PM. Based on review of an RMS Event Summary Report dated [DATE], it was revealed that Resident #3 began experiencing distress on [DATE] at 1:50 AM. Based on the statement made during the facility's investigation by Geriatric Nursing Assistant #5, the resident expressed that his/her blood sugar was low to Geriatric Nursing Assistant (GNA) #5 and GNA #5 contacted the resident's assigned nurse, RN #4. Based on RN #4's progress note from [DATE] at 2:35 AM, RN #4 assessed and treated the resident's low blood sugar. RN #4 also attempted to reach the resident's on-call physician, leaving a message. But, then Resident #3 experienced shortness of breath and had an oxygen saturation rate of 78%, indicating that the oxygen content of the resident's blood was getting critically low. RN #4 supplemented the resident's oxygen using a non-rebreather mask and called 911. Despite that, RN #4 heard the resident collapse to the floor around 2:30 AM and the resident was found to be pulseless and unresponsive. RN #4's statement that he made for the facility's investigation demonstrated at that point, that RN #4 began CPR without checking Resident #3's MOLST form to determine if the resident had a Full Code order (perform CPR) or a do not resuscitate (DNR) order. In the statement that licensed practical nurse (LPN) #7 made during the facility's investigation, LPN #7 indicated that Supervisor #6, a Registered Nurse, came to the resident's room after checking the resident's MOLST form and informed RN #4 that the resident had a DNR order. RN #4 then stopped performing chest compressions. In his statement, RN #4 indicated that he provided chest compressions from between two to five minutes before stopping. The resident was not revived by RN #4's actions and the resident was declared deceased on [DATE] at 2:15 AM. This was witnessed by both Licensed Practical Nurse (LPN) #7 and Supervisor #6 who had been called to the floor to assist with Resident #3's deteriorating condition. On [DATE], the Administrator and the Director of Nursing (DON) began investigating Resident #3's death after receiving an anonymous call. The anonymous caller was concerned about hearing screaming in the middle of the night of [DATE]. They discovered on [DATE] by interview that CPR had been performed by RN #4 against the resident's wishes as expressed through the resident's MOLST form. In response, RN #4 was suspended immediately, and no nursing employee could begin their shift until they had received education that the MOLST must be checked prior to initiating CPR. The education included what is the MOLST, where to find the MOLST, and what to do in a code. The training continued until [DATE] at which point every nursing staff member had received the education. On [DATE], interviews were conducted by the survey team with RN #8, RN #9, RN #10, LPN #11, RN #12, and LPN #13 who were all on duty. These six staff were asked about what actions they would take when finding a resident unresponsive and all six staff stated that they would check the resident's MOLST prior to initiating CPR. When asked where the MOLST form could be found, all six staff indicated that it was maintained as the first sheet in the physician's orders [REDACTED]. Also, on [DATE], a total of 24 resident medical records were audited by the survey team at random among all the units. In these audits, the MOLST form was located where the above six staff indicated it could be found , and all of the MOLST forms clearly indicated whether or not CPR should be performed if the resident was found pulseless and unresponsive. The Director of Nursing (DON) was interviewed on [DATE] at 8:40 AM. During the interview, the DON demonstrated Quality Assurance (QA) material that he maintained in which every death (17 in total) in the facility since [DATE] was audited to determine if a resident's wishes according to the MOLST form were followed. The QA material showed that 12 residents' MOLST forms identified residents as DNR. Of these 12, all 12 residents had CPR withheld when they were found pulseless and unresponsive. A record review of three of these deaths (Residents #6, #7, and #8) was performed by the survey team on [DATE] at 9:22 AM. The review revealed that the resident's MOLST form had been followed based on the progress notes written at the time of the resident's passing. Based on the above actions taken by the facility and verified by surveyors on site, it was determined that the facility's deficient practice was past-noncompliance with a compliance date of [DATE].

Based on review of medical records, facility policy and staff interview it was determined that facility staff failed to have a system in place to allow all staff, including supplemental staff, to accurately authenticate and follow a resident's (Resident #245) Advanced Directive. This was evident for 1 of 31 residents reviewed during stage 2 of the survey. The findings include: During a review of the medical record for Resident #245 on [DATE] the surveyor noted two physician's certificates related to medical condition, decision making and treatment limitations, dated [DATE] and [DATE]. Part B of the certificates, regarding medical ineffectiveness, indicate Cardiopulmonary Resuscitation (CPR) and mechanical ventilation would not prevent or reduce the deterioration of the resident's health or prevent his/her impending death. Part C of the certificates regarding decision making indicate the resident lacks adequate decision making , including decisions about life-sustaining treatments due to Dementia. Cardiopulmonary Resuscitation (CPR) consists of the use of chest compressions and artificial ventilation to maintain circulatory flow and oxygenation during [MEDICAL CONDITION]. <http://emedicine.medscape.com/article/ 81-overview> The resident's MOLST (Medical Order for Life Sustaining Treatment) form, dated [DATE] indicated the resident was not to receive CPR. Further review of the medical record revealed a nursing progress note dated [DATE] (late entry for [DATE]) reporting that the resident was noted to be unresponsive, a code (emergency alert to all facility staff) was called, and CPR was initiated. The progress note also reports paramedics assumed CPR procedures upon arrival to the facility. On [DATE] at 2:35PM the findings were discussed with the Director of Nursing. He/she stated permanent employees are aware that the MOLST form is placed in the chart before the physician's orders [REDACTED].#5) who was unfamiliar with the process for finding the resident's code status. Staff # 5 was assisted by another nurse, Staff #4, a facility employee, who the Director of Nursing stated was not aware of the location of the MOLST form in the medical record. Failure to follow a resident's Advanced Directives and ensure its validity has the potential to fail to meet the resident's wants and needs while in the facility.

Based on medical record review and interview of facility staff it was determined that the facility staff failed to honor the resident's right to refuse life-sustaining treatment. This was evident for 1 of 5 sampled residents selected for review. The findings include: Resident #5 was a [AGE] year with multiple [DIAGNOSES REDACTED]. Review of the resident's medical record and interview of the nursing home administrator, Staff #1, on [DATE] revealed that prior to [DATE], the resident wanted cardiopulmonary resuscitation (CPR) if her heart stopped beating and/or if she stopped breathing. On [DATE] through [DATE] the resident was hospitalized and treated for [REDACTED]. The resident was readmitted to the facility on [DATE]. Review of the resident's medical record and interview of the nursing home administrator on [DATE] revealed that on [DATE] the resident met with the social worker, Staff #2, and made the decision that she did not want cardiopulmonary resuscitation if her heart stopped beating and/or if she stopped breathing. On [DATE] the certified registered nurse practitioner, Staff #3, signed the physician's orders [REDACTED]. review of the resident's medical record revealed [REDACTED].#4, documented in the resident's progress notes that at 12:10 p.m. the resident was in the dining room eating her lunch. At 12:15 p.m. the geriatric nursing assistant, Staff #5, called for help because the resident was unresponsive. The resident was transferred from the dining room to her room. The facility staff was unable to obtain a blood pressure or a pulse. CPR was initiated by facility staff and 911 was activated. The resident was subsequently transferred to the hospital via 911 where she later expired. The initiation of CPR was in violation of the resident's right to refuse cardiopulmonary resuscitation. As a result of the incident, the facility conducted a facility-wide audit to ensure that the physician orders [REDACTED]. Facility staff have been educated regarding physician orders for life sustaining treatments.