Every finding on record at Dunbar Center

Based on record review, staff interview, and Adult Protective Services (APS) interviews, the facility failed to protect a vulnerable resident from neglect when a facility staff member witnessed Resident #117 being removed from the premises by an unknown individual. The resident appeared to be exhibiting signs of distress but the staff member failed to take action or report the incident. The facility was unaware of the resident's whereabouts and well-being for approximately three hours, exposing the resident to an unsupervised, unsafe environment. Resident identifier: #117. Facility census: 116.The State Agency (SA) determined that harm was caused to Resident #117 when the witnessed removal from the premises, was not immediately reported. Additionally, the resident's removal from the premises resulted in a hospitalization where the resident was seen by a Sexual Assault Nurse Examiner (SANE). A SANE is a registered nurse who has received special training to care for patients who have experienced sexual assault or abuse. The SANE report demonstrated findings objectively concerning for sexual assault. Resident #117 was ordered Flagyl, Rocephin IV for potential UTI as well as potential Gonorrhea, doxycycline, and creatinine clearance was pending for initiation of Biktarvy (a prescription medication used to treat HIV). Additionally hepatitis panel, HIV, and syphilis testing were ordered. The plan was to discuss with the patient's surrogate regarding giving Biktarvy X1 given unknown assailments.Findings include:a) Review of the Facility's Reportable IncidentA review of the facility's state reportable log, completed on 08/25/26 at 10:30 AM, revealed a reportable for Resident #117 alleging sexual assault on 07/01/26. The five day follow-up for the above reportable was dated 07/09/26. The follow-up report summarized incident as follows:-On Wednesday July 1 at approximately 8:00 PM, [NAME] Center staff began making evening rounds and were unable to locate [Resident #117's name]. Her assigned CNA, was following up to complete resident care and had attempted to locate throughout the facility. Without success, a 'Code Adam' was initiated: this is the possible elopement signal that all staff members are aware of. All facility staff began looking for [Resident #117's name], called local emergency services to the facility, made the Medical Director aware, and notified the resident's health care surrogate. A staff member called the local hospitals to see if the resident had presented to the local emergency room: she was identified to be at [name of local hospital] emergency room (ER) with her granddaughter.-Through witness statements and documentation, it was identified that the resident's granddaughter, who is not her medical decision maker, came to visit the facility earlier in the evening. Resident #117 accompanied her granddaughter to the front porch in order to visit outside at approximately 6:00 PM. It was further identified that the resident's granddaughter removed [Resident #117's name] from the facility's property at approximately 6:30 PM without notifying any facility staff. -It was noted that the granddaughter presented the resident to the emergency department of the local hospital at approximately 9:30 PM, three (3) hours later. The facility was informed by hospital staff that the granddaughter had voiced allegations of possible sexual abuse by facility staff to the emergency department employees. Facility administration immediately reported the allegation of sexual abuse to the appropriate state agencies - OHFLAC, regional ombudsman, and Adult Protective Services (APS). An investigation was immediately initiated.-It was noted that Resident #117 was a [AGE] year-old, long-term care, female resident who had been admitted to the facility on [DATE]. She was noted to be alert, with consistent confusion, and had a current Brief Interview for Mental Status (BIMS) score of 14, which had been completed in May 2026. The resident did not have decision making capacity, but had good support from her APS health care surrogate. Resident #117 was diagnosed with mild cognitive impairment, generalized anxiety disorder, major depression, COPD, and generalized weakness.-The facility's interim Director of Nursing (DON) contacted the hospital to obtain their documentation regarding the resident's medical assessment and any required treatment in the emergency department. Per the emergency department's history & physical final report, Resident #117 arrived at the ER at approximately 9:30 PM and reported that she was being abused in the facility daily by a male staff member she referred to as [NAME], who routinely provided care to her, and normally wore a Florida hat. The resident stated that the abuse had included vaginal and anal penetration, and she had been found previously in a pool of blood. Residents also stated that she did not recall the last time that this abuse occurred; suggesting possibly the previous Wednesday or Friday. It was also noted in the documentation from the hospital that the resident was asked further questions regarding her home environment and her sexual health. At this time, the resident reported no injuries, abuse, or neglect at home, as well as no history of sexual abuse.-The facility did recognize that a staff member [Name of CNA] did fit the description that was provided by the resident to ER staff members. The CNA routinely wears head gear. He was suspended pending investigation and a statement was obtained from the CNA. He denied any inappropriate actions/behaviors towards Resident #117, or any other resident in the facility.-Resident #117's roommate, who was alert and oriented, had capacity to make her own medical decisions was interviewed and asked if she had ever witnessed any inappropriate care provided to [Resident #117's name]. The roommate stated that she had witnessed no staff members or visitors act inappropriately towards her, or her roommate, in any way. She stated that she has been in the facility for eight (8) years and had never seen anyone act sexually inappropriate towards a resident. The roommate did disclose that [Resident #117's name] had masterbated in the room, on occasion, with the curtain closed.-[Resident #117's name] was last seen by her registered nurse (RN), in the dining room at approximately 5:45 PM. The resident was happy, eating, and cooperative with staff. The RN accompanied the resident back to the Dogwood nurses station. Shortly after at approximately 6:00 PM, [Resident #117's name] accompanied her granddaughter to the front patio to visit. A staff member's written statement documented witnessing the resident's granddaughter leading her into her vehicle and leaving the facility at approximately 6:30 PM. Hospital documentation noted the arrival of Resident #117 at the local emergency department to be at 9:30 PM. -The facility noted that per staff statements, [Resident #117's name] showed no signs/symptoms of any distress upon leaving the facility. She was clean, walking with minimal assistance, and showed no emotional anguish. The staff member who witnessed [Resident #117's name] being taken to the car by her granddaughter was not familiar with the resident, nor that the facility was unaware of her departure.-All residents in the facility with a BIMS Score of 8 or higher were interviewed regarding their care in the facility; questions included if they felt safe in the facility, if any resident or staff member had ever touched them inappropriately, or if they have ever witnessed another resident being touched; no issues were noted.-All residents in the facility with a BIMS score of 7 or less received skin checks with no new skin issues noted.-All staff members at the center were interviewed; all denied having any knowledge of any sexual abuse or mistreatment by any employee towards any resident in the facility. Several staff members did state that they recalled [Resident #117's name] frequently following the alleged perpetrator around, only wanting him to take care of her. All staff members stated that the CNA in question was a great aide, provided great care to all residents, and had assisted him while providing care to residents on several occasions; no concerns were noted.-[Name of local hospital] documentation indicated that while in the emergency room, a Sexual Assault Nurse Examanier (SANE) nurse examination demonstrated findings objectively concerning sexual assault. She was treated for this assault preventatively.-The facility was unable to account for Resident #117's well-being, or location from 6:30 PM to 9:30 PM. -It was noted that [Resident #117's name] would not return to the facility because her health care surrogate (APS) stated that they had made the decision to move the resident to another facility where her family would not be aware of where she was residing for her safety.-The facility did not substantiate the the allegation of staff to resident sexual abuse.The State Agency (SA) Surveyor completed a detailed review of the reportable file and found a statement from the then Director of Rehab, dated 07/07/26, that read: On Wednesday, July 1 at approximately 6:30 PM, I was sitting in the car, getting ready to leave the facility, talking to my cousin on the phone about what we were going to have for dinner. I noticed a resident sitting outside on the patio, outside of the therapy department, talking with her granddaughter. I did not recognize the granddaughter at all. I then saw the granddaughter leading the resident towards the back part of the parking lot, walking. The granddaughter was leading her grandmother by the hand, almost pulling her towards the car. The resident wasn't screaming or anything, but it was evident that she was very hesitant to be going with her granddaughter. I did not see them get into a vehicle, but I then saw the car peel out and speed off towards the entrance of the facility. I did not realize that there was any problem whatsoever until the next morning during stand-up when the issue/allegation/reportable was discussed.During an interview, on 08/25/26 at 1:45 PM, the Social Worker said that the Director of Rehab gave her written statement six (6) days later and then never came back to the facility. The Social Worker also noted the Director of Rehab had only worked at the facility for a short time. The Social Worker then stated, After we found this out we did a whole house in-service.A review of the whole house in service was dated for 07/24/26. The in-service defined the different types of abuse, and further read: The center will implement an abuse prohibition program through the following:Screening of potential hiresTraining of employees (both new employees and ongoing training for all employeesPrevention of occurrencesIdentification of possible incidents or allegations which need investigationInvestigation of incidents and allegationsProtection of patients during investigations; andReporting of incidents, investigations, and center response to the results of their investigationsAnyone who witnesses an incident of suspected abuse, neglect, involuntary seclusion, injuries of unknown origin, or misappropriation of patient property is to tell the abuser to stop immediately and report the incident to his/her supervisor immediately, regardless of shift work. Report suspected abuse immediately to the supervisor.b) Adult Protective Services (APS) / Health Care Surrogate (HCSG) interviewsDuring a phone interview on 08/25/26 at 2:00 PM with the Complainant, and APS worker who came to investigate the incident, stated, I investigated the sexual abuse at the facility and it was unsubstantiated on the facilities end. I called in the complaint due to the fact, that the facility had no idea where [Resident #117's name] was for 3 hours, and according to the hospital report something obviously happened while she was with her granddaughter whose house she was removed from for neglect. I am not her Health Care Surrogate. I will give you his number.During a phone interview on 08/25/26 at 2:15 PM, Resident #117's APS/HCSG said that the resident was an APS referral while living in the community because she had a bad infection and was sick and there was no power or food at the home. He also said that they did not have the authority to say if family can visit or not, but it is a given that a resident under them should not leave the facility without them knowing it and especially this particular resident because the APS case was against the granddaughter. He also disclosed that the resident was moved to a nursing home further away for her safety from the family.c) Record ReviewA record review, completed on 08/25/26 at 2:45 PM, revealed that Resident #117 was originally admitted to the facility from the hospital on [DATE].The discharge paper work from the hospital to the nursing home included a History and Physical report, that included the following: History of present illness: 79 F w/ PMH of COPD, HTN, GAD who presents w/chest pain and anxiety. Previously lived with her daughter until she passed away suddenly. Has had intermittent panic attacks since. Was previously admitted to [Name of Hospital} and discharged to her granddaughters but there was concern for social security checks being taken, no food in the house, and unsafe living conditions. She presented for long term care but thought she had made amends with her granddaughter. However, she came back today after not being able to stay there and needing long term care. No chest pain, dysuria, anxiety, cough, shortness of breath at bedside.Assessment/planAdult neglectStatus post APS referral with APS as surrogate and social services following for placement.A general patient admission progress note at the facility, with an effective date of 5/11/26, read as follows: Resident arrived from [Name of Local Hospital] via ambulance, brought in on a stretcher via emt's and transferred to bed, resident alert and oriented x3, able to voice all needs to staff, admitting diagnosis of adult neglect, severe.A general patient note, dated 06/23/26, read as follows: Social worker (SW) called APS and inquired about the resident's granddaughter wanting to DC (discharge) resident. According to APS, they are still involved and still decision maker unless changed by the DR (doctor). APS doesn't want to pursue the resident being DC'd from the facility.Further record review of Resident #117's care plan revealed no evidence that the care plan indicated any of the following:The resident's granddaughter was removed as decision maker due to neglect The resident's granddaughter had inquired about removing the resident from the facilityThe legal health care surrogate, APS, did not want the resident discharged from the facility with the granddaughterA review of the Physician Determination of Capacity, dated 05/13/26, revealed that Resident #117 was determined by the physician to be incapacitated. A record review, completed on 08/26/26 at 10:30 AM, revealed the following nurses note, dated 07/01/26 at 11:08 PM, that read: At 9:17, staff notified the interim DON that the resident could not be located. Staff conducted a thorough search of the facility and surrounding grounds. When the resident was not found, 911 was contacted, and APS (the residents healthcare surrogate) was notified. Staff then contacted [Name of Local Hospital] where the charge nurse confirmed that the resident was a patient at their facility. The resident has been transported by granddaughter. [Name of Medical Director / Physician] was notified of the situation. An APS representative was notified and arrived at the center. The resident's face sheet and order summary faxed to [Name of Local Hospital].Further record review revealed the H&P final report from the emergency department revealed the chief complaint as PT (patient) was at a nursing facility and had blood in her diaper and states she was sexually assaulted. The H&P noted under the history of present illness: In discussion with the patient, she states she is being assaulted every day. She is sitting in a pool of blood. Appears to be vaginal and anal penetration, with a foreign object. She states this is being done by [NAME] who wears one of those Florida hats all the time. She struggles to provide further information. She does not remember the last time this occurred, she believes that is Friday or Wednesday.The H&P listed the following under Assessment/Plan:Adult sexual abuse, suspected, initial encounterSANE nurse examination demonstrated findings objectively concerning for sexual assault.Patient has been ordered Flagyl, Rocephin IV for potential UTI as well as potential Gonorrhea, doxycycline, and creatinine clearance is pending at this time for initiation of Biktarvy. Additionally hepatitis panel, HIV, and syphilis testing were ordered today.Will discuss with the patient's surrogate regarding giving Biktarvy X1 given unknown assailments.Social work consult to determine active investigations.d) NeglectNeglect is explicitly defined as the failure of the facility, its employees or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish, or emotional distress.

Based on record review, resident and family interviews, and staff interviews, the facility failed to ensure residents received timely assessment, intervention, and treatment for acute changes in condition. Specifically, the facility failed to ensure a resident exhibiting signs and symptoms consistent with sepsis, respiratory distress, hypoxia, hypotension, tachycardia, and acute clinical deterioration received timely emergency medical evaluation and transfer to the hospital; failed to follow physician orders for skin and wound care; and failed to provide pain management as ordered. This failed practice placed residents at risk for serious injury, harm, impairment, or death and had the potential to affect all residents requiring timely assessment, treatment, and intervention for changes in condition. Resident Identifiers: #123, #129, and #4. Facility census: 118.The State Agency determined this deficient practice constituted Immediate Jeopardy beginning on 06/15/2026. The facility implemented its Immediate Jeopardy removal plan, and the Immediate Jeopardy was removed on 07/01/2026, when the facility achieved substantial compliance. Findings included: a) Resident #123 Record review of the Nurse Practitioner's acute visit, dated 06/15/26 at 1:00 PM, revealed Resident #123 was more lethargic than normal. The acute visit note stated, . responsive only to verbal stimuli before drifting back to sleep, cool and clammy, tachypneic (abnormal rapid and shallow breathing), with oxygen saturation ranging from 86-89% on room air and heart rate fluctuating to 125 beats per minute. Respiratory therapy initiated oxygen at 3 liters per minute, increasing oxygen saturation to 94%. The resident remained hypotensive with a manual blood pressure of 90/72. The assessment included septicemia, tachypnea, tachycardia, and acute hypotension. Orders were given to obtain laboratory studies including CBC, CMP, lactic acid, blood cultures, urinalysis with culture and sensitivity, KUB, initiate IV fluids, administer ceftriaxone 1 gram IV every 12 hours, and closely monitor vital signs. Record review of the After-Hours Telehealth Consult, dated 06/15/26 at approximately 7:00 PM, revealed the following: WBC (white blood count) 22.1, BUN (Blood Urea Nitrogen) 60, creatinine 2.5, GFR 19, hemoglobin 9.4, hematocrit 28.9, and platelet count 105, representing a significant decline from previous laboratory values. During the telehealth evaluation, the resident appeared acutely ill with respiratory distress, increased work of breathing, respiratory rate of 24, oxygen saturation fluctuating between 80% and 92% despite oxygen at 2 liters per minute, fever, acute kidney injury, suspected infection/sepsis, and hypoxia. The assessment included acute respiratory distress with hypoxia, suspected acute infection/sepsis, leukocytosis, acute kidney injury, fever, anemia, thrombocytopenia, and significant decline from baseline laboratory values. The plan from the after hours telehealth consultant directed the resident to be transferred immediately to the emergency department for further evaluation and management. Record review revealed Resident #123 was not transferred from the facility until 06/15/26 at approximately 8:38 PM. Records dated 06/16/26 at 7:33 AM revealed Resident #123 was admitted to a local acute care facility with diagnoses of sepsis, kidney stone with obstruction, and hypoxic respiratory failure. During an interview on 06/24/26 at 1:15 PM, the facility Nurse Practitioner stated there had been been an instance in which, in her professional judgment, residents needed to be sent to the hospital and she had received pushback from the Director of Nursing (DON). The Nurse Practitioner stated during Resident #123's evaluation, she became concerned the resident was septic. The Nurse Practitioner explained that sepsis could be life-threatening and required immediate rehydration, prompt laboratory testing, initiation of broad-spectrum antibiotics, and constant monitoring. The Nurse Practitioner stated she informed the resident's family she was going to send the resident to the hospital. When exiting the resident's room, the DON (in the presence of the Administrator) stated they wanted to treat the resident in-house. The Nurse Practitioner stated the DON entered her orders into the computer. The Nurse Practitioner further stated, It was around 1:00 PM when I wanted to send her (Resident #123) out. It was sometime after I left the building at 5:00 PM when she was sent out. The Nurse Practitioner stated in her professional opinion if the resident had been sent out when she had originally asked, it had the potential to possibly change the outcome. Medical Record Review (MRR) revealed Emergency Medical Services (EMS) was contacted on 06/15/26 at 8:15 PM. When EMS arrived the resident's blood pressure was reported to be 70/40. The EMS narrative note stated that upon arrival at the facility, staff reported the patient had recently been battling a UTI (urinary tract infection) for which she was currently receiving Intravenous (IV) fluids. They stated that the patient had been having issues for a few days now, but that she got worse approximately 5 hours ago. EMS narrative note described the resident as pale, clammy, and warm to the touch. The narrative included that the resident was hypotensive (low blood pressure), tachycardic (abnormally fast resting heart rate - typically over 100 beats per minute) and her blood glucose level was 226. Resident's temperature was 101.4. She was on 4 liters of oxygen via nasal canula which the facility had placed her on due to her low oxygen levels. It was noted that the resident was not normally on oxygen. During an interview on 06/25/26 at 11:30 AM, Resident #123's sister stated the resident requested her temperature be taken on the morning of 06/15/26 and approximately one hour elapsed before nursing assessed her. The sister stated the resident's temperature initially measured 100.3 degrees F and later increased to 101.9 degrees F. The sister stated she repeatedly requested the resident be sent to the hospital. She stated nursing informed her they planned to keep the resident at the facility, start an IV, and obtain laboratory work. The sister stated the resident's breathing worsened throughout the day and she was not informed the resident would be transferred until approximately 8:00 PM, with EMS transporting the resident around 8:30 PM. The sister stated, I feel if my sister went out that morning, when she wanted to be sent out, she may not have passed away like she did. During an interview on 06/29/26 at 12:45 PM, the Administrator stated that when a resident had an order to be sent to the hospital, the nurse was to call the DON or on-call nurse, who would ask about the resident's symptoms, what interventions had been completed, and what the family had been told. During an interview on 06/29/26 at 1:16 PM, Resident #123's son stated he spoke with the Administrator and the DON around 9:00 AM on 06/15/26 requesting his mother be sent to the hospital. He stated the DON repeatedly told him the resident could be treated in house. The son stated the resident was not transferred until approximately 8:00 PM. He stated the hospital physician informed the family the resident had an obstructing kidney stone requiring emergency surgery and stated that in 30 years he had never seen an infection that severe. The son stated despite surgery, the resident's condition continued to decline, the family elected comfort measures, and the resident died. During an interview with Registered Nurse (RN) #154 the following was reported: Last Monday, I think it was the 15th, I went in to give [Resident's First Name] her morning medications. She could swallow them and was awake and alert. I do not work that side often, so I was not as familiar with her. Her family was with her and said that for the past 2 days she had been sweating so bad that they had to change her clothes several times throughout the day. I finished my morning med pass and was sitting at the nurses station charting, when I saw the CNA, Nurse Practitioner (NP) and Respiratory therapist go into her room, so I followed them. The resident was barely arousable and when the Respiratory Therapist checked her oxygen level, it was sitting in the mid-80's so we put her on 3 liters of oxygen. The NP, Respiratory Therapist, and I assessed the situation and felt that she needed to be sent out. We have instructed before anyone is sent out, we have to run it by the Director of Nursing (DON). I went to tell the DON and she said, 'We can treat that here. It is just Sepsis.' Around 6:00 PM, that evening the daughter came out and said, 'I feel like her temperature has got worse.' I went in and checked her temperature, and it was 101.8. She was taking shallow breaths and not making any sense with her speech. Her oxygen level, on 3 litters at this time, was in the 80's so we bumped it up to 4 liters. I reached out to the DON again, to tell her what was going on. The DON's response was, 'We still are not sending her out it is just Sepsis.' I told the family member that the DON was still not recommending sending her out. The family said we want her sent out immediately, I went to the DON again, and said, 'The family wants her sent out immediately.' The DON said, 'I need you to go back in there and tell the family we can treat her here, and you need to quit freaking out.' I told the DON that I was going to call the on-call physician. She said, 'Go ahead, I still do not think he will send her out.' I called the on-call Physician and went over her lab readings. The on-call physician said, Send her out immediately. I called the DON and told her what the blood work was and that the on-call physician said to send her out immediately. The DON still did not want to send her out. In the meantime, the night shift nurse came in and she has worked here longer than me. I caught her up to speed on what was going on with the resident and the night shift LPN said she did not care what the DON had said. She called EMS. When EMS arrived her blood pressure was 70/40 even after we had bolused all that fluid. During an interview with RN #11 the following was reported: There has been a time when I have seen a resident getting worse, and they wouldn't send them out. The management staff (Director of Nursing and Administrator) make it hard. If you have a resident that is in their right mind and has capacity and they say, I don't feel good, send me out, they don't do it. I just don't agree with that at all. During an interview with LPN #115 the following was reported, As a nurse, I feel that the facility frowns upon sending people out to the hospital. We (nurses) have been told in monthly nursing meetings not to think about sending anyone out until we talk to [The Director of Nursing's First Name] first. I had a male patient who had capacity. He was coughing up a lot of productive cough and I had to put him on 02. The next morning his O2 kept dropping. The resident wanted to go to hospital. I called Dr. (name). My unit manager said, 'Let's go get (name of DON)'. Dr. (name) said to send him. (DON name) did not want him to go. She said we can treat him here and what exactly did you tell Dr. (name)? I was questioned why I wanted to send him out even when the doctor gave the order to send. It took about 45 minutes. He passed away at the hospital. During an interview with LPN #109 the following was reported, The DON has told us that we have to go through her before we send anyone to the hospital. During an interview on 06/25/26 at 2:05 PM, the Market President of the facility stated, If a Provider gives an order for someone to go out, they are going to go out. He also reported that the DON would defer to speaking to the Corporate Clinical Lead if she had any clinical questions or needed guidance. During an interview on 06/25/26 at 2:40 PM, the Corporate Clinical Lead stated the DON had never called her regarding the facility's ability to treat suspected sepsis in-house. She also stated that the DON rarely called her regarding anything. During a telephone interview, conducted on 06/29/26 at 4:09 PM, the Director of Nursing (DON) stated the facility attempts to treat residents in-house whenever possible because hospitalization can be a traumatic experience for residents. The DON stated she encouraged the Nurse Practitioner to provide treatment in the facility because the NP was new to the building and unfamiliar with what conditions could be managed in-house. The DON stated orders were obtained for laboratory work, blood cultures, intravenous fluids, and antibiotics. The DON stated antibiotics were not administered because the order directed staff to administer them after obtaining blood cultures; however, blood cultures could not be obtained because the facility did not have the appropriate culture bottles. The DON stated intravenous fluids were administered. After the laboratory results returned and showed abnormal findings, the DON stated staff contacted the telehealth physician, at which time the decision was made to transfer the resident to the hospital. Review of hospital medical records was completed on 06/29/26 and revealed the following findings (pasted as written): Emergency Department ED Primary Note History of Present Illness (name of Resident #123) is a 76 y.o. female who had concerns including Weakness. Arrival via EMS. Patient presenting to emergency department for complaint of generalized weakness. Patient presenting here from (name of facility). Patient reporting that she's had 3 days of generalized malaise and weakness not feeling well feels like her heart is been racing. Patient with a previous history of CVA and left-sided deficits. Patient denies any known fever or chills. (Name of facility) reported to EMS that she had a low-grade fever at home.Physical Exam ED Triage Vitals [06/15/26 2103] BP (Non-Invasive) (!) 84/44 Heart Rate (!) 135 Respiratory Rate (!) 24 Temperature 37.1 degrees C (98.8 degrees F) SpO2 95 % CT CHEST ABDOMEN PELVIS WO IV CONTRAST Final Result by Edi, Radresults In (06/15 2354) 1. Moderate right hydroureteronephrosis with obstructive calculus in the distal right ureter measuring 6 mm. Additional nonobstructive right renal calculi. 2. Small right and trace left pleural effusions. 3. Large hiatal hernia with partially intrathoracic stomach. 4. Avascular necrosis of the right femoral head and moderate degenerative joint disease of the right Medical Decision Making [AGE] year-old female patient presenting to emergency department complaint of weakness. Patient presenting here from local nursing facility (name of facility) patient reporting 3 days of generalized weakness malaise not feeling well fast heart rate. Patient reporting that she has had some abdominal pain reports she has colitis but it has not been confirmed. Patient also reporting that she thinks she's still has a urinary tract infection that she had been treated for. EMS reporting that the patient had low-grade fever at the facility. Patient's physical exam reveals a ill-appearing pale appearing elderly female patient that has generalized weakness appearance with irregular rate and rhythm, abdomen exam is benign, left-sided deficits present Please see ED course below for details the patient's laboratory and image findings. Patient taken to exam room [ROOM NUMBER] rather quickly after triage secondary to tachycardia and hypotension. Patient ordered 30 per kg IV fluid resuscitation that is adjusted full were concerns for potential heart failure. As can be seen below patient's laboratory workup reveals multiple abnormalities most significant in his leukocytosis 17.2 patient's creatinine at 1.99 patient's urinalysis shows abnormalities as below. Patient's initial lactate is 4.0. Patient has never been to this facility before unable to compare labs to what baseline is for this patient. I did scan the patient chest abdomen pelvis given the patient was now requiring oxygen does not typically require oxygen but her renal function does not support IV contrast for CT angiogram therefore without contrast as chest abdomen pelvis was performed reveals abnormalities as seen below. Patient covered with sepsis protocol treatments if foods and antibiotics. Sepsis protocol was satisfied. Patient's case was discussed with Urology which has recommended NPO status may require stent placement tomorrow. Patient's case then discussed with the hospitalist which did agree with admission of the patient. Critical Care Attestation: As the ED physician, I have provided critical care for this patient. This patient has high probability of imminent life or limb threatening deterioration due to acute renal failure, acute respiratory failure, and sepsis d) Center for Disease Control According to the Center for Disease Control, If an individual is suspected of having sepsis, the healthcare provider overseeing care of the resident/patient should immediately be alerted. Antibiotics should be started as soon as possible. Resident/patient progress should be checked frequently. Treatment requires urgent medical care, usually in an intensive care unit in a hospital, and includes careful monitoring of vital signs and often antibiotics (https://www.cdc.gov/sepsis/hcp/clinicalcare/index.html#cdc_clinical_care_treatment_care_specific-treatment-if-you-suspect-sepsis). A resident with sepsis might have one or more of the following signs or symptoms: -Clammy or sweating skin, -Extreme pain or discomfort, -Fever, -High heart rate, -Low blood pressure, -New onset or increased confusion or disorientation, -Shortness of breath. Immediately alert the doctor, physician assistant, or nurse practitioner overseeing the resident's care. In most cases, a resident who is suspected of having sepsis, or who may be developing sepsis, will need to be transferred quickly to a hospital to receive intensive evaluation and treatment. (https://www.cdc.gov/sepsis/media/pdfs/Factsheet-Longterm-care-sepsis-nurses 508.pdf) The facility administration was informed of the immediate jeopardy on 06/30/26 at 5:09 PM. A plan of correction was accepted on 06/30/26 at 5:09 PM. The immediate jeopardy began on 06/15/26 when the Nurse Practitioner's request to send the resident out for acute care treatment was not followed up on by the Director of Nursing (DON). The immediate jeopardy was abated on 07/01/26 at 8:40 AM. The abatement plan of correction is listed below: All residents of the facility have the potential to be affected. NHA and IDON were Re-educated by the market team on the escalation process on 6/30/26 with a post test. Nurse Practitioner Re-educated on 6/30/26 concerning orders to send residents to the hospital with a post test. The Director of Nursing/designee completed an audit on 6/30/26- to ensure residents are not showing signs and symptoms of sepsis with immediate correction upon discovery. Reeducation will be provided by the Director of Nurses (DON)/designee to all licensed nurses beginning on 6/30/26 to ensure residents are provided timely follow up of care and escalation process. Post test completed to validate understanding. Any facility staff not available during this time frame will be provided reeducation, including posttest by the DON/designee upon the beginning of next shift to work. New facility staff will be provided education, including posttest during orientation by the DON/designee. The Director of Nursing (DON)/designee will monitor starting on 7/1/26 to ensure all residents are not showing signs and symptoms of sepsis by reviewing progress notes, vital signs, ACS reports, missed antibiotics and IVF and lab results daily for 2 weeks including weekends and holidays, then 3 times a week for 2 weeks then randomly thereafter. Results of monitors will be reported by the DON/designee monthly to the Quality Improvement Committee (QIC) for any additional follow-up and or in-servicing until the issue is resolved, then randomly thereafter as determined by the QIC committee. Physician Orders: Must be carried out timely, including oxygen, IVF, labs, hospital transfers, medications and documented in the medical record Family/POA Requests: Resident and/or POA request for resident to be sent to the hospital. staff must carry out the order timely with physician notification Escalation and Notification Protocol: If the nurse providing care does not agree with the physician/DON/Administrator, the escalation process will be activated. The employee should notify the Market Clinical/Regulatory team. e) Resident #129 Record review completed on 07/01/26 of the Treatment Administration Record (TAR) revealed the following dates were not signed of as being completed or refused: Skin tear treatment: 03/07/26, 03/15/26, 03/29/26, 04/11/26 Stage two (2) pressure ulcer treatment: 03/07/26, 03/15/26, 03/29/26, 04/11/26 Wound care to Left Lower Limb: 04/11/26 During an interview on 07/01/26 with the Interim Director of Nursing (IDON), the IDON confirmed the TAR was not signed off as being completed or being refused by Resident #129 for the above-mentioned days. f) Resident #4 An electronic medical record review, completed on 07/02/2026 at 9:33 AM, revealed the following physician order: 06/12/26 Physician Order: HYDROcodone-Acetaminophen Oral Tablet 5-325 MG (Hydrocodone-Acetaminophen) Controlled Drug. Give 2 tablets by mouth every 4 hours as needed for pain level 4-6. The physician order was dated 06/12/26. Review of June 2026 and July 2026 Medication Administration Records revealed the medication had been administered without a documented pain level of 4-6 on the following dates:-06/12/26-06/13/26-06/14/26-06/15/26-06/16/26-06/17/26-06/18/26-06/19/26-06/20/26-06/21/26-06/22/26-06/23/26-06/24/26-06/25/26-06/26/26-06/27/26-06/28/26-06/29/26-06/30/26-07/01/26-07/02/26 During an interview, on 07/02/26 at 10:44 AM, the Corporate Clinical Lead/RN reported the facility had failed to capture Resident #4's pain levels prior to administering the medication (as per physician orders) and that it would be addressed immediately.

Based on record review and staff interviews, the facility failed to designate one or more qualified Infection Preventionists responsible for the facility's Infection Prevention and Control Program in accordance with regulatory requirements. Specifically, the facility failed to ensure the individual(s) responsible for infection prevention had completed specialized infection prevention training while overseeing the Infection Prevention and Control Program. This failed practice had the potential to affect all residents residing in the long-term care facility. Facility census: 118.Findings Included:During the facility entrance conference the Administrator reported the facility did not have an official Infection Preventionist at this time. The Administrator indicated that the Clinical reimbursement Coordinator held an Infection Preventionist certification.Further record review revealed Registered Nurse (RN) #139, Clinical Reimbursement Coordinator, had completed Infection Preventionist (IP) certification; however, she was not functioning as the facility's designated Infection Preventionist.During an interview on 07/01/26 at approximately 11:00 AM, RN #139 stated her only infection prevention responsibility was completing the weekly National Healthcare Safety Network (NHSN) reporting.During an interview on 07/01/26 at approximately 12:00 PM, the Administrator stated the Director of Nursing (DON) and other clinical managers performed the facility's infection prevention and infection control responsibilities. The Administrator further stated those staff members had not completed the specialized Infection Preventionist training, confirming the facility had not designated a qualified Infection Preventionist to oversee the Infection Prevention and Control Program as required.

Based on direct observation and interview with the Facility Maintenance Director (#119), the facility failed to consistently maintain ambient temperatures within the required range in the 100/200 Nurses' Station and the 300/400 Nurses' Station. This was a random opportunity for discovery and had the potential to affect more than a limited amount of residents. Facility census: 118.Findings included:a) On 06/30/2026, at approximately 4:08 PM, the State Surveyor observed and documented the wall-mounted thermostat located at the 100/200 Nurses' Station, which displayed a temperature reading of 83 F.The temperature reading was obtained through direct visual observation of the facility's wall-mounted thermostats in the respective locations at the time of survey observation.On 06/30/2026, at approximately 4:25 PM, the State Surveyor conducted an environmental observation of the facility's ambient temperatures in resident care areas in the presence of the Facility Maintenance Director (#119). During the observation, the surveyor requested that the Facility Maintenance Director obtain ambient temperature readings utilizing the facility's temperature monitoring device to verify the temperatures within the observed areas. The surveyor observed and verified the Maintenance Director performing the temperature checks and confirmed the readings displayed.At that time, the Facility Maintenance Director obtained a temperature reading at the 100/200 Nurses' Station, which measured 82.2 F, and a temperature reading at the 300/400 Nurses' Station, which measured 83.0 F. The surveyor observed and verified both readings as they were obtained.During the same observation, the State Surveyor observed facility residents seated in common areas in close proximity to the 100/200 Nurses' Station and the 300/400 Nurses' Station. Residents were observed remaining in these areas during the period in which ambient temperatures were noted to be above the recommended comfort range.

Based on record review, resident interviews and staff interviews, the facility failed to ensure all food was temped before leaving the kitchen, to ensure safe and appetizing temperatures of the food and to prevent foodborne illness. The facility failed to ensure all foods were palatable, hot foods were served hot, and cold foods were served cold. This failed practice was also true for one (1) of one (1) meal tray's tested throughout the survey process. This failed practice had the potential to affect more than a limited number of residents. Facility census: 118. Findings Included: a) Healthcare Services Group (HCSG) Policy #6 titled, Food Quality and Palatability states: -Food will be prepared by methods that conserve nutritive value, flavor and appearance. Food will be palatable, attractive, and served in a manner, form, and texture to meet resident's needs.-Proper safe and appetizing temperature: Food should be at the appropriate temperature as determined by the type of food to ensure resident's satisfaction and minimize the risk for scalding and burns. b) HCSG Policy #16 titled, Food Preparation states: -All foods are prepared in accordance with the FDA Food Code. c) Food Temperature Logs On 06/29/26 at 11:01 AM this surveyor asked the Healthcare Services Group (HCSG) Dietary Account Manager (DAM) for a copy of the food temperature logs for the month of June 2026. She stated I cannot find it. The State Agency Surveyor then asked for any food temperature logs for this year (2026). The DAM stated I have checked the trash and everywhere, and I cannot find the temperature logs. On 06/29/26 at 12:12 PM, before starting the tray line, the dietary staff only took and wrote down four (4) regular consistency food item temperatures. Temperatures were taken for the BBQ Chicken, Coleslaw, [NAME] Beans, and the Ham & Cheese Sandwich. d) Test Tray. On 06/29/26 at 12:50 PM, a regular consistency test tray was made and sent to Dogwood Hall at 12:51 PM. The HCSG Director of Operations (DO) took the temperature of the following foods at 1:02 PM. The temperatures were: -Ham & Cheese Sandwich - 67.5 degrees Fahrenheit (F)-Coleslaw - 68 degrees F-Lettuce and Tomato - 79.3 degrees F-Mixed Fruit - 55.2 degrees F At the time of receipt by the resident, foods should be at a temperature of no less than 120 F for hot foods and no more than 50 F for cold foods, per the food code. e) Resident Council Resident Council was held on 07/01/26 at 10:30 AM. The residents in attendance stated, If we eat in our rooms, the cold food is hot and the hot food is cold. If we want it to be the correct temperature, we have to eat in the dining room.

Based on observation and staff interviews, the facility failed to store, prepare, distribute and serve food in accordance with professional food safety standards. Additionally, the facility failed to follow proper sanitation practices for the kitchen. This practice had the potential to affect more than a limited number of residents. Facility census: 118. Findings Included: a) Department Staffing Policy Healthcare Services Group (HCSG) Policy #2 titled, Department Staffing states: -The Dining Services will employ sufficient staff, with appropriate competencies and skill sets to carry out the functions of food and nutrition services in a manner that is safe and effective. -Adequate staffing will be provided to prepare and serve palatable, attractive, nutritionally adequate meals, at proper temperatures, at appropriate times and to support proper sanitary techniques being utilized. -All employees will be provided with job descriptions and appropriate education and tools for executing their duties. b) Food Preparation Policy HCSG Policy #16 titled, Food Preparation states: -All foods are prepared in accordance with the FDA Food Code. -Dining Services staff will be responsible for food preparation procedures that avoid contamination by potentially harmful physical, biological, and chemical contamination. -All utensils, food contact equipment, and food contact surfaces will be cleaned and sanitized after every use. -Separate cutting boards for meat, poultry, and produce will be maintained. c) Food Storage: Dry Goods Policy HCSG Policy #18 titled, Food Storage: Dry Goods states: -All dry goods will be appropriately stored in accordance with the FDA Food Code.-The Dining Services Director or designee regularly inspects the dry storage area to ensure it is well lit, well-ventilated and not subject to sewage or wastewater backflow or contamination by condensation, leakage, rodents or vermin. -All packaged and canned food items will be kept clean, dry, and properly sealed. -Toxic materials will not be stored with food. d) Food Storage: Cold Foods Policy HCSG Policy #19 titled, Food Storage: Cold Foods states: -All Time / Temperature Control for Safety (TCS) foods, frozen and refrigerated, will be appropriately stored in accordance with guidelines of the FDA Food Code.-All foods will be stored wrapped or in covered containers, labeled and dated, and arranged in a manner to prevent cross contamination. e) Storage: Chemicals Policy HCSG Policy #20 titled, Storage: Chemicals states: -All chemicals will be properly stored.-All chemicals will be in separate / secured area.-All chemicals will be retained in their original containers. If chemicals are not in original container, the holding container will be clearly labeled with the name corresponding with the Safety Data Sheet (SDS). f) Ice Policy HCSG Policy #21 titled, Ice states: -Ice will be prepared and distributed in a safe and sanitary manner.-The Dining Services Director will coordinate with the Maintenance Director to ensure that the ice machine will be disconnected, cleaned and sanitized quarterly and as needed, or according to manufacturer guidelines. g) Equipment Policy HCSG Policy #27 titled, Equipment states: -All food service equipment will be clean, sanitary, and in proper working order.-All equipment will be routinely cleaned and maintained in accordance with manufacturer's directions and training materials.-All staff members will be properly trained in the cleaning and maintenance of all equipment.-All food contact equipment will be cleaned and sanitized after every use.-All non-food contact equipment will be clean and free of debris. h) Environment Policy HCSG Policy #28 titled, Environment states: -All food preparation areas, food service areas, and dining areas will be maintained in a clean and sanitary condition.-The Dining Services Director will ensure that the kitchen is maintained in a clean and sanitary manner, including floors, walls, ceilings, lighting, and ventilation.-The Dining Services Director will ensure that all employees are knowledgeable in the proper procedures for cleaning and sanitizing of all food service equipment and surfaces.-All food contact surfaces will be cleaned and sanitized after each use.-The Dining Services Director will ensure that a routine cleaning schedule is in place for all cooking equipment, food storage areas, and surfaces.-All trash will be contained in covered, leak proof containers that prevent cross contamination.i) Ware Washing Policy HCSG Policy #22 titled, Ware Washing states: -All dishware, service ware, and utensils will be cleaned and sanitized after each use.-All dishware will be air dried and properly stored. j) Kitchen Observations The following concerns were observed during the inital walkthrough of the kitchen on 06/29/2026 at 10:00 AM:1.One (1) soiled cleaning cloth located in the handwashing sink, near the toaster.2.Debris on the knife rack.3.There was one (1) cutting board that had green bell peppers, onions and strawberries that were all being cut on the same board.4.The drip pan under the stove was soiled.5.The stove top was soiled with built up food debris.6.The inside of the convection oven was soiled.7.There was no use by date on one (1) opened container of quick oats.8.There was one (1) employee 20 oz Pepsi soda pop located on the table beside the vinegar and spices in the kitchen.9.The meat slicer had some older food debris located on it.10.The top of the inside of the microwave was soiled with food debris.11.The bottom of the reach-in refrigerator had water pooling with one (1) case of opened Mighty Shakes sitting in the water.12.There was no use by date on one (1) case of Mighty Shakes that were sitting in the pooling water.13.There were six (6) outdated vanilla yogurts located in the reach-in refrigerator with a use by date of 06/28/26.14.There were five (5) sandwiches not labeled and did not have a use by date in the reach-in refrigerator.15.No use by date on one (1) case of opened bacon located in the walk-in refrigerator.16.No open or use by date on one (1) case of blueberries located in the walk-in refrigerator.17.One (1) bag of opened sliced potatoes located in the walk-in refrigerator without a label.18.One (1) cut onion outdated in the walk-in refrigerator with a use by date of 06/26/26.19.One cut tomato outdated in the walk-in refrigerator with a use by date of 06/25/26.20.There was ice buildup in the walk-in freezer.21.Six (6) cases of ice cream cups located in the walk-in freezer that had been thawed and refrozen.22.The ice machine located in the service hall has a black substance on the inside near the top of the machine.23.There was a brown liquid in the floor located in the dry food storage room.24.There was one (1) case of bleach on the same shelf beside one (1) case of food thickener.25.There were four (4) packages of hotdog buns with a green substance on the buns in the dry food storage room.26.Two (2) packages of outdated flour tortillas located in the dry food storage room with a use by date of 06/23/26.27.The handwashing sink located in the dish room was soiled and needs repairs completed to the hot faucet.28.No paper towels at the handwashing sink located in the dish room.29.One package of outdated hotdog buns located in the kitchen with a use by date of 06/26/26.30.No open or use by dates on four (4) loaves of bread located in the kitchen.31.There was one (1) gallon of 2% milk located in the Maple pantry that was outdated with a use by date of 06/26/26.32.The microwave located in the Dogwood pantry was soiled with food debris.33.The facility staff are not taking PM shift temperatures of the refrigerators and freezers located in both pantries.On 06/29/26 at 11:35 AM, during a follow-up visit to the kitchen additional observations included:1.One (1) soiled cloth sitting on the countertop near the meat slicer.2.Dishware on the clean side of the dish room are not being stored properly. They were not stored upside down and had lint and particles located on the interior well.3.There was one (1) soiled tray located on a clean cup / tumbler rack.4.There was a soiled black cart sitting beside the griddle.5.The grease trap for the exhaust vent is soiled with grease and cobwebs.6.There was one (1) spray bottle without a label located at the three-compartment sink.7.The kitchen ceiling is dirty with lint and pest particles and needs to be cleaned and painted.8.There is a hole located in the ceiling near an electrical pole above the steam table with a cleaning cloth sticking out of it.9.There was one (1) steam table pan sitting on the floor underneath the steam table.10.The trays used for the residents' lunch meals were wet.11.One (1) set of soiled gloves laying on the countertop beside the toaster.12.The toaster had crumbs in the tray.13.There is wall damage above the electrical box measuring about fourteen inches long.14.There was debris on the floor behind the stove, steamer and oven.15.There was one (1) bottle of unlabeled chemical in a spray bottle sitting on the floor behind the steamer.16.There was a soiled cloth laying on the countertop beside the three-compartment sink.17.One drawer beside the coffee maker had dried coffee grounds spilled in it.18.One drawer with clean serving utensils had the handles going in all different directions near the toaster.These observations were verified by the Healthcare Services Group (HCSG) Regional Chef (RC) and/or the HCSG Dining Account Manager (DAM).

Based on observation and staff interviews, the facility failed to store and dispose of garbage and refuse properly. This was a random opportunity for discovery. The failed practice had the potential to affect more than a limited number of residents at the facility. Facility census: 118. Findings Included: a) Environment Policy The Healthcare Services Group (HCSG) Policy #28 titled Environment states: -All food preparation areas, food service areas, and dining areas will be maintained in a clean and sanitary condition.-All trash will be contained in covered, leak-proof containers that prevent cross-contamination. b) Garbage and Refuse Policy The HCSG Policy #30 titled Dispose of Garbage and Refuse states: -All garbage and refuse will be collected and disposed of in a safe and efficient manner.-The Dining Services Director will ensure that: Appropriately lined containers are available within the food services area for disposal of garbage or other refuse. Garbage and refuse is removed from the kitchen area routinely during the day and at the end of the workday.c) Observations On 06/29/26 at 10:05 AM, the State Agency Surveyor found a box full of garbage sitting on the wet floor under the three-compartment sink. On 06/29/26 at 10:30 AM, the trash receptacle located beside the handwashing sink in the dish room did not have a liner but contained trash. On 06/29/26 at 11:45 AM the trash receptacle located in the dish room that had a blue lid was soiled and needed to be cleaned on the outside. During an interview at 11:46 AM the Healthcare Services Group (HCSG) Director of Operations the observations and that the trash receptacle was soiled on the outside and needed cleaning.

Based on observation, record review and staff interview, the facility failed to maintain an infection control program during medication administration. These were random opportunities for discovery and had the potential to affect more than a limited amount of residents. Resident Identifiers: #90, #105, and #29. Facility Census: 118. Findings Include: a) Medication Administration On 07/02/26 at 8:35 AM, Registered Nurse (RN) #154 was observed during medication administration. RN #154 did not complete hand hygiene prior to preparing the medication for Resident #90. After preparing the medication, hand hygiene was not completed before entering the resident's room. RN #154 sat the Spiriva Inhaler box on the over-the-bed table without using a barrier. After medication administration to Resident #90, hand hygiene was not completed prior to preparing Resident #105's medication. Hand hygiene was not completed after preparing or administering the medication to Resident #105. RN #154, then, left the medication cart to obtain a medicated cream from the treatment cart. Upon returning to the medication cart, hand hygiene was not completed prior to or after medication administration to Resident #29. During this time of medication preparation, RN #154 touched multiple items and surfaces with bare hands. Hand hygiene was not completed at any time during this process. On 07/02/26 at 9:20 AM, RN #154 confirmed hand hygiene was not completed throughout the medication administration process. On 07/02/26 at approximately 9:30 AM, Corporate Registered Nurse (RN) #175 confirmed hand hygiene should be completed throughout the medication administration process and a barrier used when sitting medication and/or boxes on the resident's surfaces.

Based on observation and staff interview, the facility failed to ensure an effective pest control program was in place. This was discovered throughout the completion of the kitchen pathway during the Long-Term Care Survey Process. This failed practice had the potential to affect more than a limited number of residents. Facility census: 118.Findings Included: a) Pest Control Policy Healthcare Services Group (HCSG) Policy #29 titled Pest Control states: -A program will be established for the control of insects and rodents for the Dining Services Department.-The Dining Services Director coordinates with the Director of Maintenance to arrange pest control services on a monthly basis, or as needed.-All food preparation, service, and storage areas will be monitored regularly for any signs of pest / vermin. The center staff will be notified immediately of any concerns verbally and in writing.-Where applicable, bulk foods will be removed from their original packaging and stored in containers with tight-fitting lids. b) Kitchen Observation On 06/29/26 at 10:31 AM during the initial walkthrough of the kitchen, the State Agency Surveyor found four (4) packages of hamburger buns located on the bread rack in the dry storage room that had what appeared to be multiple bite markings from a rodent. The plastic and the hamburger buns had multiple chewing / bite marks and droppings. On 06/29/26 at 10:33 AM, the HCSG Regional Chef (RC) verified the surveyor's observations and noted he agreed a rodent created the damage to the hamburger buns on the bread rack. On 06/29/26 at 12:00 PM, during a follow-up visit to the kitchen the State Agency Surveyor noticed that the ceiling had multiple tiny dark spots consistent with digested organic waste left behind by drain flies. The HCSG Dietary Account Manager (DAM), at 12:01 PM, stated, I will put it in the TELS system for maintenance to be cleaned and painted.

Based on record review and staff interview, the facility failed to obtain informed consent for psychotropic medication for Resident #1 . This was true for two (2) of five (5) residents reviewed under the care area of unnecessary medications. Resident Identifier: #1 . Facility Census: 118. Findings Included: a) Resident #1 On 07/01/26 at 2:15 PM, a record review was completed for Resident #1. The review found the resident had been admitted to the facility on [DATE]. The resident was prescribed Cymbalta, an antidepressant. The facility did not obtain informed consent for the psychotropic medication. The resident did have medical-decision making capacity. On 07/02/26 at 9:35 AM, the Corporate Registered Nurse (RN) #175 confirmed the consent for Cymbalta had not been completed. The Corporate RN stated, We will get the consent right now.

Based on record review and staff interview, the facility failed to provide the required Skilled Nursing Facility Advanced Beneficiary Notice of Non-Coverage (SNF-ABN) form and/or the Notice of Medicare Non-Coverage (NOMNC) form to two (2) of three (3) residents reviewed for the facility's beneficiary protection notification practice throughout the Long-Term Care Survey Process. This failure placed the residents at risk of not being informed of their rights prior to the end of Medicare Part A covered services. Resident identifiers: #128 and #29. Census: 118.Findings included:a) Resident #128 Resident #128 was discharged to home following her last covered day of Part A Service on 03/06/26. There was no evidence in the electronic medical record that a NOMNC had been issued prior to the resident's discharge to home. b) Resident #29 Resident #29 remained in the facility following his last covered day of Part A Service on 03/01/26. There was no evidence in the electronic medical record that a SNF-ABN and a NOMNC had been issued prior to the resident's discharge from skilled care. c) Interview with Business Office Manager During an interview on 06/30/26 at 5:15 PM, the Business Office Manager (BOM) reported that the facility was unable to produce any evidence that the appropriate beneficiary notifications forms had been given to Resident #128 and Resident #29.

Based on record review and staff interview, the facility failed to provide evidence that it conveyed the required information to the hospital at the time of transfer. The facility was unable to provide documented evidence that the receiving health care institution received, at a minimum, residents' advance directives, physician orders, and comprehensive care plan upon transfer to a hospital as required for a safe transition of care. This was true for two (2) of two (2) residents reviewed under the hospitalization pathway throughout the Long-Term Care Survey Process. Resident Identifiers: #98 and #115. Facility census: 118. Findings included:a) Resident #98 An electronic medical record review, completed on 07/01/2026 at 7:08 PM, revealed Resident #98 had been admitted to the facility on [DATE]. Resident #98's eInteract Transfer form and progress notes indicated the resident was discharged to the hospital on [DATE]. The reason for the transfer form was listed as: Shortness of Breath (bronchitis, pneumonia). However, further review of the facility's progress notes and the eInteract transfer form revealed no documented evidence that the receiving health care institution received, at a minimum, the resident's advance directives, physician orders, and comprehensive care plan, as required for a safe transition of care. During an interview on 07/02/26 at 8:35 AM, the Interim Director of Nursing (DON) indicated that when a resident is sent to the hospital, the facility's process is to send documents such as the face sheet, advance directives, physician orders, and the Medication Administration Record (MAR). However, the Interim DON reported that there was no documentation in the medical records to accurately reflect what information had been sent. b) Resident #115 An electronic medical record review, completed on 07/01/2026 at 6:11 PM, revealed Resident #115 had been admitted to the facility on [DATE]. Resident #115's eInteract Transfer form and progress notes indicated the resident was discharged to the hospital on [DATE] due to a fall with hematoma (often referred to as a severe bruise, it usually forms a firm, rubbery lump under the skin). During an interview on 07/02/26 at 8:40 AM, the Interim Director of Nursing (DON) indicated that when a resident is sent to the hospital, the facility's process is to send documents such as the face sheet, advance directives, physician orders, and the Medication Administration Record (MAR). However, the Interim DON reported that there was no documentation in the medical records to accurately reflect what information had been sent.

Based on record review and staff interview, the facility failed to ensure an accurate Preadmission Screening and Resident Review (PASARR) was maintained to reflect a resident's diagnosed serious mental illness for one (1) of one (1) residents reviewed for PASARR requirements. Resident identifier: #28. Facility census: 118. Findings included:a) Resident identifier: #28Record review of the resident's clinical record revealed a diagnosis of Post-Traumatic Stress Disorder (PTSD) with a documented diagnosis date of 02/26/2026. Further review of the resident's PASARR, dated 03/05/2026, revealed PTSD was not identified or documented on the PASARR screening.During an interview, conducted on 06/30/2026 at approximately 10:10 AM, the Nursing Home Administrator (NHA) confirmed the resident had a diagnosis of PTSD and acknowledged the diagnosis was not reflected on the PASARR dated 03/05/2026.

Based on record review and staff interview, the facility failed to develop and implement a baseline care plan for each resident that included the instructions needed to provide effective and person-centered care of the resident. This was a random opportunity discovered during the completion of the Hospitalization and Discharge pathways conducted throughout the Long-Term Care Survey Process. Resident Identifiers: #115 and #117. Facility census: 118. Findings included:a) Resident #115 An electronic medical record review, completed on 07/01/2026 6:11 AM, revealed Resident #115 was admitted to the facility on [DATE] and discharged from the facility on 04/18/26. Resident #115's medical history included, but was not limited to, the following medical diagnoses:-METABOLIC ENCEPHALOPATHY-HYPOKALEMIA-DEHYDRATION-ATHEROSCLEROSIS OF CORONARY ARTERY BYPASS GRAFT(S) WITHOUT ANGINA PECTORIS-PERSONAL HISTORY OF TRANSIENT ISCHEMIC ATTACK (TIA), AND CEREBRAL INFARCTION-ACUTE KIDNEY FAILURE WITH TUBULAR NECROSIS-HYPOTHYROIDISM-HYPEROSMOLALITY AND HYPERNATREMIA-NEUROCOGNITIVE DISORDER WITH LEWY BODIES-DEMENTIA IN OTHER DISEASES CLASSIFIED ELSEWHERE, UNSPECIFIED SEVERITY, WITHOUT BEHAVIORAL DISTURBANCE, PSYCHOTIC-DISTURBANCE, MOOD DISTURBANCE, AND ANXIETY-PARKINSON'S DISEASE WITHOUT DYSKINESIA, WITHOUT MENTION OF FLUCTUATIONS-PULMONARY HYPERTENSION-DYSPHAGIA, OROPHARYNGEAL PHASE-UNSPECIFIED PROTEIN-CALORIE MALNUTRITION Review of Resident #115's Baseline Care Plan revealed there were blanks related to the level of assistance the resident would need in the areas of eating, toileting, dressing, grooming. and bathing. The baseline care plan had the following incomplete interventions listed:-Provide resident/patient with ______ (specify: set-up, supervision, Partial/Moderate, Substantial/maximal, Dependent assistance) assist of _____ (specify #) for eating. Date Initiated: 04/08/2026Created on: 04/08/2026-Provide resident/patient with _____ (specify: set up, supervision, Partial/Moderate, Substantial/maximal, Dependent assistance) assist of ______ (specify #) for toileting. Date Initiated: 04/08/2026Created on: 04/08/2026-Provide resident/patient with _____ (specify: set-up, supervision, Partial/Moderate, Substantial/maximal, Dependent assistance) assist of ______ (specify #) for dressing. Date Initiated: 04/08/2026Created on: 04/08/2026-Provide resident/patient with ______ (specify: set-up, supervision, Partial/Moderate, Substantial/maximal, Dependent assistance) assist of _____ (specify #) for personal hygiene (grooming). Date Initiated: 04/08/2026Created on: 04/08/2026 On 06/30/26 at approximately 4:30 PM, in the absence of the MDS Coordinator, the Interim Director of Nursing (DON) was interviewed regarding the blanks in the baseline care plan. The Interim DON acknowledged the care plan was not thoroughly completed and failed to specify the level of assistance Resident #115 required. b) Resident #119 An electronic medical record review, completed on 07/01/2026 6:40 AM, revealed Resident #119 was admitted to the facility on [DATE] and discharged from the facility on 05/25/26. Resident #119's medical history included, but was not limited to, the following medical diagnoses:-PARKINSON'S DISEASE-OTHER SEIZURES-CHRONIC OBSTRUCTIVE PULMONARY DISEASE-ESSENTIAL (PRIMARY) HYPERTENSION-ALTERED MENTAL STATUS,-HALLUCINATIONS, UNSPECIFIED-TREMOR-UNSPECIFIED PROTEIN-CALORIE MALNUTRITION Review of Resident #119's Baseline Care Plan revealed there were blanks related to the level of assistance the resident would need in the area ambulation. The baseline care plan had the following incomplete intervention listed:-Provide resident/patient with Partial/Moderate assistance) assist of _____ (specify #) for ambulation using a _______ (specify: walker, rolling walker, quadcane, straight cane, no device, etc.) _____ times per day. Date Initiated: 05/22/2026Created on: 05/22/2026 On 06/30/26 at approximately 4:33 PM, in the absence of the MDS Coordinator, the Interim Director of Nursing (DON) was interviewed regarding the blanks in the baseline care plan. The Interim DON acknowledged the care plan was not thoroughly completed and failed to specify the level of assistance Resident #119 required.

Based on record review and staff interview, the facility failed to develop care plan regarding the diagnosis of depression and the use of a psychotropic medication. This was true for one (1) of five (5) residents reviewed under the care area of unnecessary medications. Resident Identifier: #1. Facility Census: 118.Findings Included: a) Resident #1 On 07/01/26 at 2:15 PM, a record review was completed for Resident #1. The resident had been admitted to the facility on [DATE]. The review found the care plan had not been developed regarding the diagnosis of depression and the use of an antidepressant, Cymbalta. On 07/02/26 at 9:35 AM, the Corporate Registered Nurse (RN) #175 confirmed the care plan had not been developed regarding the diagnosis of depression and the use of an antidepressant, Cymbalta. The Corporate RN #175 stated, We will get this taken care of now.

Based on record review and staff interview, the facility failed to follow the physician's order regarding a monthly pharmacy recommendation for Resident #1. This was true for one (1) of five (5) residents reviewed under the care area of unnecessary medications. Resident Identifier: #1. Facility Census: 118. Findings Included: a) Resident #1 On 07/01/26 at 2:15 PM, a record review was completed for Resident #1. The review covered monthly pharmacy recommendations from 03/11/26 through 05/08/26. The monthly pharmacy review dated 03/11/26 included two (2) separate recommendations. The second recommendation concerned an alternate treatment using a Beta-3 agonist (Vibegron) instead of an anticholinergic medication for overactive bladder. The facility physician agreed to switch the therapy to the Beta-3 agonist Vibegron. The pharmacy recommendation and the facility physician's order were not followed as ordered. On 07/02/26 at 9:35 AM, the Corporate Registered Nurse (RN) #175 confirmed the second recommendation and the facility physician's order was not followed as ordered. The Corporate RN #175 stated, The second recommendation and facility physician's order got missed. the Nurse Practitioner did review it. It will be completed right away.

Based on observation, record review and staff interview, the facility failed to ensure freedom of significant medication errors during medication administration for Resident #105. This was true for one (1) of three (3) residents reviewed under the care area of medication administration. Resident Identifier: #105. Facility Census: 118.Findings Included: a) Resident #105On 07/02/26 at 9:00 AM, an observation of medication administration by Registered Nurse (RN) #154 for Resident #105. Resident #105 takes her medication crushed in applesauce. Upon preparation of Resident #105's medication, the resident received Cardizem CD (controlled dose) 120mg (milligrams) by mouth every day. The extended release medication cannot be crushed due to the special time-release mechanism causing the entire dose to hit the bloodstream at once. There is a risk of toxicity, overdose and rendering the medication ineffective for the rest of the day. On 07/02/26 at 9:10 AM, RN #154 did not review the Do not crush list provided by the facility. RN #154 stated, Oh, I forgot about that.On 07/02/26 at approximately 9:30 AM, Corporate Registered Nurse (RN) #175 was notified. Corporate RN #175 stated, We will provide education immediately.b) Medication Administration General GuidelinesOn 07/02/26 at 10:15 AM, the facility policy entitled, Medication Administration General Guidelines was obtained from the Interim Director of Nursing (IDON). Section 5f states, .Crush medications if indicated for this resident only after referring to the Medications Not To Be Crushed List. The Facility, also, provided the list entitled, Oral Medications That Should Not be Crushed or Altered. After reviewing the list, Cardizem CD was found on the list.

Based on observation, record review, and staff interview, the facility failed to prepare food in the form to meet the individual needs of Resident #62 as ordered by the physician. Resident #62 was ordered an Advanced Dysphagia diet and was served a regular diet. This was a random opportunity for discovery. Resident Identifier: #62. Facility Census: 118. Findings Included:a) Resident #62 Healthcare Services Group (HCSG) Policy #6 titled, Food Quality and Palatability states:-Food will be prepared by methods that conserve nutritive value, flavor, and appearance. Food will be palatable, attractive, and served at a safe and appetizing temperature.-Food and liquids are prepared and served at a safe and appetizing temperature.-The Dining Services Director and [NAME] are responsible for food preparation. Menu items are prepared according to the menu, production guidelines, and standardized recipes.-Food and liquids / beverages are prepared in a manner, form and texture that meets each resident's needs.b) Resident #62 Resident #62 was ordered a Dysphagia Advanced texture diet on 05/28/26. The resident was care planned for a Dysphagia Advanced texture diet.c) Lunch MealOn 06/29/26 at 12:26 PM, Resident #62 was served a regular texture lunch meal. The [NAME] Clerk Unit Employee #124 identified this error from the dietary staff and sent the tray back before Resident #62 could consume it. The Healthcare Services Group (HCSG) Director of Operations (DO) verified the consistency was wrong and sent a new tray with the correct consistency.

Based on record review and staff interview, the facility failed to ensure quarterly smoking safety assessments were completed in accordance with the facility's smoking policy for one (1) of one (1) residents reviewed for smoking safety. This failed practice had the potential to place residents at risk for smoking-related accidents and injuries. Resident Identifier: #38. Facility census: 118.Findings Included:a) Resident #38Record review, completed on 06/29/26, of the facility's smoking policy revealed, All residents upon admission, readmission, and with change in condition should have a smoking assessment completed if they wish to smoke in the facility. This assessment cannot have any missing documentation and must match the clinical admission assessment also completed upon admission. If they remain in the facility this will be done quarterly.Further record review of Resident #38's smoking assessments revealed the December 2025 quarterly smoking assessment was initiated; however, it was not completed or signed.During an interview with the Interim Director of Nursing (IDON), on 06/29/26 at approximately 3:00 PM, the IDON confirmed the quarterly smoking assessment for Resident #38 had not been completed.

Based on observation, resident interviews and staff interview, the facility failed to ensure hydration was available at bedside for Resident #11, Resident #31, Resident #88 and Resident #108. This was true for four (4) residents residing on the 300 and 400 halls. Resident Identifiers: #11, #31, #88 and #108. Facility Census: 110. Findings Include: a) 400 Hall On 05/27/26 at 11:40 AM, an initial interview was held with Resident #11. Resident #11 was asked, do you have any water? Resident #11 stated, no, I don't have any ice water. On 05/27/26 at 11:44 AM, Resident #31 was unable to be interviewed, however, no water was observed at bedside. On 05/27/26 at 12:00 PM, Nurse Aide (NA) #81 stated, I have passed some water but I haven't been able to finish, I have been doing showers. On 05/27/26 at 12:03 PM, Registered Nurse (RN) #39 stated, they didn't tell me they needed water. On 05/27/26 at 12:15 PM, the Corporate Nurse #158 was notified. Corporate Nurse #158 stated, they should have given the residents water on their drink pass this morning. b) 300 Hall On 05/27/26 at 11:50 AM, an interview was held with Resident #88 and Resident #37, who are roommates. Resident #88 stated, I don't have any. Resident #37 nodded her head in agreement with Resident #88. On 05/27/26 at 11:55 AM, an interview was held with Resident #108. Resident #108 stated, they never give us any .I would like to have some, I would drink it. On 05/27/26 at 12:07 PM, Licensed Practical Nurse (LPN) #15 confirmed the residents did not have water available to them. On 05/27/26 at 12:15 PM, the Corporate Nurse #158 was notified. Corporate Nurse #158 stated, they should have given the residents water on their drink pass this morning.

Based on observation, record review, caregiver interview and staff interview, the facility failed to ensure each resident maintains acceptable parameters of nutritional status, such as usual body weight or desirable body weight range and electrolyte balance, unless the resident's clinical condition demonstrates that this is not possible. This was true for four (4) of four (4) residents reviewed. This failed practice resulted in actual harm for Resident #64 who since the time of her admission has lost a severe amount of weight. The facility failed to track her consumption of meals, provide assistance at mealtimes and failed to implement the dietician's recommendation for a house supplement and the resident continued to lose weight. For Resident #119 #11 and #96 the facility failed to track their meal consumptions to identify any potential nutrition problems before the resident suffers weight loss or dehydration. Resident Identifiers; #119, #11, #96, and #64. Facility Census: 115.Findings Include: a) Resident #64 A review of Resident #64's medical record on 07/22/25 found the following weights recorded: 06/03/25- 117.8 pounds (lbs.) 06/10/25 - 118.4 lbs. 06/17/25 - 116 lbs. 06/24/25 - 111.6 lbs. 07/01/25- 111.4 lbs 07/09/25 - 109.7 lbs. 07/16/25 - 106.8 lbs. 0723/25 - 102 lbs. (this weight was obtained in the presence of the surveyor.) The percentage of weight loss was calculated using the following formula: (usual weight - actual weight) / (usual weight) x 100 = % of body weight loss For the first month in the facility the weights used were the weights from 06/03/25 and 07/01/25: (117.8-111.4)/117.8x100 = 5.43 percent. This is considered a severe weight loss in 30 days. Resident # 64 has continued to lose weight her most recent weight was 102 lbs. If the most recent weight is used to calculate weight loss since admission the following percentage is obtained: (117.8-102)/117.8X100=13.41 percent. Further review of the record found the following current orders pertaining to the residents nutritional status: Weekly weights x 4 weeks then monthly ordered on 07/02/25. House Supplement twice a day ordered on 0703/25. Both these orders came about when the Licensed Dietician reviewed the resident on 07/0225 after the severe weight loss in 30 days was captured. Further review of the record found the following progress notes and assessments related to Resident #64's weight loss. -- Progress note effective date 07/07/25 at 12:49 PM read as follows, :Weight warning Value: 111.4 Vital Date: 07/01/25. MDS -5.0 percent change over 30 days. Resident feed assist as she is blind and deaf. Care ongoing. -- Progress note with an effective date of 07/02/25 at 11:39 AM read as follows: Weight warning Value: 111.6 Vital Date 06/24/25 2:14 PM. -5.0 change over 30 days Resident is on regular diet with good PO intakes. Feeding ability varies. All meals served in bowl Kennedy cup to aid in self feeding. Resident is visually impaired and needs to be set up. Resident to continue current diet as ordered - appropriate with potential to meet needs. House Supp BID (twice a day) and weekly weights X4 weeks. Will follow for need to start further nutritional intervention. NP/MD/LD aware. The Licensed Dietician completed two (2) nutritional assessments on Resident #64 at of the time of this review. The first was on admission and was completed on 06/05/25 this assessment indicated that meal intakes since the time of admission the resident is eating 75 percent of her meals (Please note the resident was admitted on [DATE] and only had 4 meals documented prior to the LD's assessment. She was missing documentation for one (1) meal per day since her admission). The LD identified no nutritional concerns on admission. The second and final LD assessment was completed on 07/02/25 when the residents severe weight loss was identified. This assessment identified the resident had lost 5% of her body weight in one month. The LD noted the resident was consuming 75 percent of her meals in the seven day look back period. (Please note the intake for meals was only documented on 10 occasions during the 7 day look back period leaving 11 meals with no documentation entered and not available for the LD to review.) The LD made the following recommendations: House Supplement BID (twice daily) and weekly weights X4. Will follow for need to start further nutritional intervention. Review of the weekly weights found the resident continued to lose weight every week. The first week she lost 1.7 pounds. The second week she lost 2.9 pounds for a total of 4.6 pounds since the dieticians review. However, no additional notes or assessments were completed until after the surveyor [NAME] to question the residents weight loss. An interview with the LD in the afternoon of 07/22/25 confirmed she was aware of the residents weight loss. She stated, I am going to look at her again today. She indicated she recommended house supplements and to assist the resident with her meals. When asked how she could accurately assess the residents meal intake when the intakes are not consistently documented she stated, I can only work with what is available to me. A comprehensive review of meal intakes documented by the facility was completed by the surveyor on the afternoon of 07/22/25 found from 06/03/25 until 07/21/25 a total of 49 days. Resident #64 was served a total of 147 meals and the staff tracked the amount consumed on 76 occasions. At approximately 3:00 PM on 0722/25 the surveyor entered the room of Resident #64. The resident had a visitor who identified herself as the residents previous caregiver when she was at home. She stated, I have been here since about 12:15 pm. The surveyor asked the visitor if the resident had drank her shake. She stated, They have not brought her in anything like that. The MAR was reviewed prior to going to the room and 100 % of the supplement was documented as consumed. The surveyor then went to the kitchen and requested a list a of the supplements they send to the residents each day. The Dietary Manager (DM) provided the list and Resident #64 was not on the provided paper. The CDM confirmed the kitchen sends the supplements. She was asked if she could look and see if Resident #64 ever received a supplement. She looked at her computer and confirmed Resident #64 had never received a supplement from the kitchen. However a review of the medication administration record (MAR) at approximately 2:30 PM on 07/22/25 found on the following dates and times the nurses documented resident Resident #64 consumed 100 percent of her supplement despite never receiving it from the kitchen: 07/03/25 at 10:00 am and 2:00 pm. 07/04/25 at 10:00 am and 2:00 pm. 07/05/25 at 10:00 am and 2:00 pm. 07/10/25 at 10:00 am and 2:00 pm. 07/11/25 at 10:00 am and 2:00 pm. 07/12/25 at 10:00 am and 2:00 pm. 07/13/25 at 10:00 am and 2:00 pm. 07/14/25 at 10:00 am and 2:00 pm 07/15/25 at 10:00 am and 2:00 pm 07/16/25 at 10:00 am and 2:00 pm 07/17/25 at 10:00 am and 2:00 pm 07/18/25 at 10:00 am and 2:00 pm 07/19/25 at 10:00 am and 2:00 pm 07/20/25 at 10:00 am and 2:00 pm 07/21/25 at 10:00 am and 2:00 pm Observation of the morning meal on 07/23/25 beginning at 8:08 AM found the resident was sitting in her recliner in her room. The nurse aid took her in a cup of cranberry juice and told the resident she had brought her a cup of juice. The resident was then observed feeling around on her bed side table. She did not find the juice nor did she take a drink. At about 8:15 AM Registered Nurse (RN) #112 went in to the room and asked her how she was doing. The resident stated, I am just hungry. I am starved. The RN asked the resident if she wanted a drink of her juice and she assisted the resident in getting a drink. At 8:28 am the meal cart arrived on the floor from the kitchen. At 8:29 am Resident #64's roommate was served her meal and Resident #64's tray was left on the cart. The rest of the trays on the cart was served and Resident #64's tray was still on the cart. RN #112 was overheard asking Nurse Aide (NA) #86 if anybody needed assistance with their meal. The nurse aide stated. (Name of Resident #64) her tray is still on the cart we have to wait until the second cart comes out and the trays are all served. THe RN stated if her roommate has her food you need to go head and feed her. NA #86 then took her tray in at 8:35 am. The NA asked the resident if she was ready to eat and the resident stated, I have been ready for two (2) hours. The nurse aide was trying to assist her and the resident said, I usually just eat with my fingers honey. The resident told her to sit the eggs on her lap and she would get them with her fingers. She told the NA multiple times, that's how they always do it honey. At 8:45 am the attending physician went in to see the resident. He told her he was glad she was eating. She stated, I was starved. His reply was, Well you are. An additional observation of the noon time meal on 0723/25 found the resident resident eating her meal in the dining room on her unit. The observation began at approximately 12:30 PM. When the surveyor entered the dining room the resident was seated at a table with her meal in front of her. The meal consisted of a tuna salad sandwich (cut in half) a bowl of potato salad and a cup of sherbert. The resident was holding half of her sandwich and had just begun to eat it. She ate the entire half she was holding. Once finished with that half of her sandwich the resident felt around the table and found the second half of her sandwich. She attempted to pick it from bowl it was in. She only managed to get the slice of bread off the top of the sandwich. At this time Registered Nurse (RN) #94 who assisting other residents with their meal motioned to the Clinical Reimbursement Coordinator was standing near Resident #94 and told the CRC the resident needed help. At this time the CRC came over and cut up the remaining part of the tuna salad sandwich and put the residents spoon in it. Once the resident finished the top piece of bread she picked up from the sandwich she again felt around the table and found the bowl with the spoon in it she picked up the spoon which had no food on it and put it in her mouth. She then laid it down and began eating the remaining part of the tuna salad sandwich with her hands. She at only a couple more bites. She then felt around and found her potato salad she took a couple bites of it with her fingers. During this time no staff had assisted with her meal other than the one time the CRC cut up her sandwich. The LD then came over and the resident told her she did not like that potato salad. The LD put some salt and pepper on it but the resident stated she did not like it. The LD removed the potato salad from the table. At this time Resident 64 was observed feeling around for her sherbert she could not find it at first then the LD came over and helped her find it. The LD then stayed with the resident and helped her find sherbert after every bite and helped the resident ensure the sherbert was on her spoon. With the help of the LD the resident was able to eat her sherbert with her spoon. The resident requested for the staff to go to her room and bring her some muffins he son had brought. The staff did assist the resident with that request and the resident ate the entire bag of the mini muffins. At this time Nurse Aide (NA) #21 picked up the residents tray ticket and wrote something on it. The surveyor reviewed the ticket and found NA #21 had documented the resident had consumed 100 percent of her meal despite the fact the resident only hate a bit more than half her sandwich and did not eat her potato salad. An interview with the LD at 1:11 pm confirmed the resident did not eat 100 percent of her meal. She did state it was okay to give her credit for the muffins but that would still not be considered 100 percent. Further review of the tray ticket found the resident was to be assisted with all her meals. This meal observation was shared with the Nursing Home Administrator (NHA) and the Corporate Resource Nurse (CRN) #106 immediately after the interview with the LD. They agreed that what was describe would not be considered feeding assistant. CRN #106 stated they should sit down with her and help her. Findings Included: b) Resident #119 On 07/24/25 at 9:00 AM record review of Nutritional Assessments and meal intakes for Resident #119 shows insufficient documentation for an accurate nutritional assessment. According to the last Nutritional Assessment performed prior to the resident being transfered to the hospital it was stated that the resident did have a weight loss of 9%. It states per the Activities of daily living (ADL) documentation the resident was eating 44% of her meals. According to documentation of meal intakes for 03/01/25 through 04/01/25 (32 days) there were 44 missing documentations out of a possible 96 entries. It was reviewed with the Corporate Resource Nurse #106 on 07/24/25 at 10:10 AM when she agreed a more accurate nutritional assessment could be made with accurate meal intakes documented for every meal. Resident #11 On 07/23/25 at 2:00 PM, a record review was completed for Resident #11. The review included meal intake percentages for 06/23/25 through 07/22/25. The review found 42 of 90 meals were documented. Three refusals were noted as well. However, 45 meals were not documented in the resident record. A review found the resident's weight had remained stable. However, the facility physician and/or the registered dietician would not be able to evaluate the resident's meal consumption and nutritional needs. On 07/23/25 at approximately 3:30 PM, the Regional Corporate Nurse #106 was notified of the missing meal percentages. The Regional Corporate Nurse #106 confirmed all meals should be documented. Resident #96 On 07/23/25 at 2:40 PM, a record review was completed for Resident #96. The review included meal intake percentages for 06/23/25 through 07/22/25. The review found 44 of 90 meals were documented. However, 46 meals were not documented in the resident record. A review found the resident's weight has remained stable. However, the facility physician and/or the registered dietician would not be able to evaluate the resident's meal consumption and nutritional needs. On 07/23/25 at approximately 3:30 PM, the Regional Corporate Nurse #106 was notified of the missing meal percentages. The Regional Corporate Nurse #106 confirmed all meals should be documented.

Based on record review and staff interview, the facility failed to protect the resident's right to be free from neglect. The facility failed to care for the resident's skin conditions and percutaneous endoscopic gastrostomy (PEG). The facility also failed to ensure the resident received bathing activities. The resident was hospitalized for a wound infection. The resident's PEG tube was adhered to her skin. This caused actual harm to the resident. Resident Identifiers: #110. Facility census: 109. a) Resident #110 Resident #110 was discharged from the hospital and returned to the facility on [DATE]. On 03/25/25, Resident #110 was transferred back to the hospital. Hospital records stated upon admission to the hospital, the resident was generally soiled with dirt and feces in her skin folds. She also had yeast appearing exudate.The hospital record also stated the resident had heart monitor lead stickers from her last hospitalization ending 03/18/25. The emergency room physician's note written on 03/25/25 stated, I spoke with daughter by phone has [sic] comfortable with quality of care her [sic] facility either .I feel it is in the patient's best interest [to be] admitted to the hospital today [to] involve case management to try to find an alternative placement. Review of Resident #110's bathing activities from 03/19/25 through 03/25/25 showed no showers documented during this time. Bed baths were documented on 03/24/25 and 03/25/25. On 05/07/25 at 1:00 PM, the Center Nurse Executive (CNA) confirmed the bathing activities task reports for 03/19/25 through 03/25/25 showed no showers documented for Resident #110. Review of Resident #110's electronic health records showed the resident returned to the facility from the hospital on [DATE]. A nursing note written on 03/18/25 at 11:45 PM documented the resident had the following pressure ulcers: - Sacrum According to the nursing note, Skin issue has been evaluated. Location: Sacrum. Issue type: Pressure ulcer/injury. Progress: Improving: overall wound characteristics improved. Pressure ulcer staging: Stage 3 pressure ulcer/injury - full thickness skin loss. Wound was present on admission. Wound is new. Signs and symptoms of infection: None. Staged by: In-house nursing. Measurements not documented as part of this assessment. Reason measurements not documented as part of this assessment: will assess with Swift wound photo application. Undermining: No. Tunneling: No. Epithelial: 80%. Granulation: 20%. Exudate amount: Light. Exudate type: Serosanguinous.: mixture of serous and sanguinous fluid, typically pale, red and watery. Odor after cleansing: None. Other: pink or red. Periwound: Attached. Surrounding tissue: Erythema. Surrounding tissue: Excoriated. Surrounding tissue: Fragile. Induration: None present. Edema: No swelling or edema. Periwound temperature: Normal. - Left lateral foot According to the nursing note, Skin issue has not been evaluated .Pressure ulcer staging: Unstageable pressure injuries presenting as deep tissue injury. Wound was present on admission. Wound is new. Staged by: In-house nursing. Undermining: No. Tunneling: No. The nursing note also stated, Wounds dressed and assessed today. Issue signing on to SWIFT photo app on personal device and facility device. Will contact IT [information technology] to try and resolve issue so that wound photos can be taken. A skin evaluation performed on 03/24/25 reported the same pressure ulcers as on 03/18/25. The wounds were described exactly the same as they were described in the note written on 03/18/25. The note even contained the same notation that Issue signing on to SWIFT photo app on personal device and facility device. Will contact IT to try and resolve issue so that wound photos can be taken. Resident #110's Treatment Administration Record (TAR) showed the following pressure ulcer wound treatments written after the resident returned to the facility on [DATE]: Cleanse stage 3 pressure ulcer injury to sacrum with IHWC [wound cleanser]. Pat dry. Apply plurogel thoroughly to wound, ensuring application to small open area at top of sacrum, every day shift. The order had been written to start on 03/19/25. The order was discontinued 03/26/25. The treatment had not been signed off as performed on the TAR for any of the days. Cleanse stage 3 pressure ulcer injury to sacrum with IHWC [wound cleanser]. Pat dry. Apply plurogel thoroughly to wound, ensuring application to small open area at top of sacrum, every day shift. The order had been written to start on 03/24/25. The order was discontinued 03/26/25. The treatment had not been signed off as performed on the TAR for any of the days. Cleanse DTI [deep tissue injury] to left lateral foot with IHWC. [NAME] dry. Apply sureprep rapid dry to wound. Leave open to air. Notify provider and wound team with any changes in wound status immediately. The order had been written to start on 03/19/25. The order was discontinued 03/26/25. The treatment had not been signed off as performed on the TAR for any of the days. Cleanse DTI [deep tissue injury] to left lateral foot with IHWC. [NAME] dry. Apply sureprep rapid dry to wound. Leave open to air. Notify provider and wound team with any changes in wound status immediately. The order had been written to start on 03/24/25. The order was discontinued 03/26/25. The treatment had not been signed off as performed on the TAR for any of the days. The resident had the following focus on her comprehensive care plan, Resident/patient is resistive to care related to: Refusing wound treatments. The TAR did not indicate the resident had refused any of the treatments discussed above. The resident's comprehensive care plan also included the following focus, Resident at risk for skin breakdown related to incontinence, morbid obesity, decreased activity, limited mobility secondary to acute illness with recent hospitalization, h/o [history of] pressure injuries and multi-disease processes, h/o skin tears, actual pressure ulcer, frail fragile skin, impaired cognition, impaired sensation, incontinence, informed refusal to aspects of care, moisture, nutritional concerns, poor safety awareness, and shear/friction risks AND pressure to sacrum and left lateral foot. Skin tears to left elbow, right inner forearm, right antecubital space, left outer forearm, front right knee, front right lateral lower leg. The focus was created on 12/25/2021 and revised on 02/28/25. On 03/25/25, the resident was transferred to the hospital after having low blood pressure during her dialysis treatment. The resident's sacral pressure ulcer was found to be infected with the organisms proteus and enterococcus. The resident was also given a diagnosis of septic shock, which the physician believed was caused by a combination of pneumonia and sacral wound infection. The resident required antibiotics for the wound infection through 04/04/25. The resident remained in the hospital until 04/07/25. On 05/07/25 at 11:00 AM, the Center Nurse Executive (CNE) confirmed the resident's pressure ulcer care and dressing changes had not been signed off on the TAR to indicate the care and dressing changes had been performed. No further information regarding Resident #110's pressure ulcer dressing changes or assessments was provided by the facility during the investigation. Review of Resident #110's electronic health records showed the resident was receiving enteral feeding through a percutaneous endoscopic gastrostomy (PEG) tube. A PEG tube is a surgically-placed tube that allows a person to receive nutrition directly through the stomach. Review of Resident #110's Treatment Administration Records (TARs) for February and March 2025 showed no orders for PEG tube treatment. According to Medline Plus, an online health information resource maintained by The National Library of Medicine, PEG tube sites should be cleaned one (1) to three (3) times a day. On 03/25/25, Resident #110 was transferred to the hospital. Hospital records stated upon admission to the hospital, the resident's PEG tube dressing was adhered to the skin by drainage. A photograph taken at the hospital showed the PEG tube dressing with beige-colored dressing on it. On 05/07/25 at 11:00 AM, the Center Nurse Executive confirmed Resident #110 did not have an order for PEG tube care. Through the completion of the investigation, no documentation was provided that Resident #110's PEG tube site had been cleaned. Review of Resident #110's electronic health records showed the resident returned to the facility from the hospital on [DATE]. A nursing note written on 03/18/25 at 11:45 PM documented the resident had the following skin tear wounds: - Front right lateral lower leg. According to the nursing note, Skin issue has been evaluated .Type 1: No skin loss. Wound was present on admission. Wound is new .Staged by: In-house nursing. Measurements not documented as part of this assessment. Reason measurements not documented as part of this assessment: will assess with Swift wound photo application. Undermining: No. Tunneling: No. Epithelial: 50%. Granulation: 50%. Exudate amount: Moderate. Exudate type: Serosanguineous: mixture of serous and sanguineous fluid, typically pale, red and watery. Odor after cleansing: None. Other: bleeding. Periwound: Attached. Surrounding tissue: Fragile. Surrounding tissue: Denuded. Surrounding tissue: Excoriated. Induration: None present. Edema: No swelling or edema. Periwound temperature: Normal. - Right inner forearm. According to the nursing note, Skin issue has not been evaluated .Type 2: Partial flap loss. Wound was present on admission. Wound is new. Staged by: In-house nursing. Undermining: No. Tunneling: No. Additionally, an open lesion to the left chest was noted to be resolved, healed and/or closed. The nursing note also stated, Wounds dressed and assessed today. Issue signing on to SWIFT photo app on personal device and facility device. Will contact IT [information technology] to try and resolve issue so that wound photos can be taken. A skin evaluation performed on 03/24/25 reported the same non-pressure wounds as on 03/18/25. The wounds were described exactly the same as they were described in the note written on 03/18/25. The note even contained the same notation that Issue signing on to SWIFT photo app on personal device and facility device. Will contact IT [information technology] to try and resolve issue so that wound photos can be taken. Resident #110's Treatment Administration Record (TAR) showed the following non-pressure ulcer wound treatments written after the resident returned to the facility on [DATE]: - Cleanse open lesion to left chest with IHWC [wound cleanser]. Pat dry. Sureprep wound and then leave open to air every day shift. The order had been written to start on 03/19/25. The order was discontinued 03/26/25. The treatment had not been signed off as performed on the TAR for any of the days. - Cleanse open lesion to left chest with IHWC [wound cleanser]. Pat dry. Sureprep wound and then leave open to air every day and evening shift. The order had been written to start on 03/24/25. The order was discontinued 03/26/25. The order was not signed off as performed on 03/24/25. On 03/25/25 evening shift, the TAR indicated the resident was in the hospital. - Cleanse skin tear to front right lateral lower leg with IHWC. Pat dry. Apply sureprep to periwound and cover wound with calcium alginate sheet. Cover with super absorbent 6x6 foam dressing. If drainage is scant or not present, notify skin tear, every day and evening shift. The order had been written to start on 03/19/25. The order was discontinued 03/26/25. The treatment had not been signed off as performed on the TAR for any of the days. - Cleanse skin tear to front right lateral lower leg with IHWC. Pat dry. Apply sureprep to periwound and cover wound with calcium alginate sheet. Cover with super absorbent 6x6 foam dressing. If drainage is scant or not present, notify skin tear, every day and evening shift. The order had been written to start on 03/24/25. The order was discontinued 03/26/25. The treatment had not been signed off as performed on the TAR for any of the days. - Cleanse skin tear to right inner forearm with IHWC, pat dry, and apply sureprep to periwound and adhesive contact area. Cover with foam dressing every day shift. The order had been written to start on 03/19/25. The order was discontinued 03/26/25. The treatment had not been signed off as performed on the TAR for any of the days. - Cleanse skin tear to right inner forearm with IHWC, pat dry, and apply sureprep to periwound and adhesive contact area. Cover with foam dressing every day shift. The order had been written to start on 03/24/25. The order was discontinued 03/26/25. The treatment had not been signed off as performed on the TAR for any of the days. The resident had the following focus on her comprehensive care plan, Resident/patient is resistive to care related to: Refusing wound treatments. The TAR did not indicate the resident had refused any of the treatments discussed above. The resident's comprehensive care plan also included the following focus, Resident at risk for skin breakdown related to incontinence, morbid obesity, decreased activity, limited mobility secondary to acute illness with recent hospitalization, h/o [history of] pressure injuries and multi-disease processes, h/o skin tears, actual pressure ulcer, frail fragile skin, impaired cognition, impaired sensation, incontinence, informed refusal to aspects of care, moisture, nutritional concerns, poor safety awareness, and shear/friction risks AND pressure to sacrum and left lateral foot. Skin tears to left elbow, right inner forearm, right antecubital space, left outer forearm, front right knee, front right lateral lower leg. The focus was created on 12/25/2021 and revised on 02/28/25. On 03/25/25, the resident was transferred to the hospital after having low blood pressure during her dialysis treatment. The hospital records had an emergency room nursing note dated 03/25/25 at 4:22 PM, While performing pericare it is noted patient has other mepilex dressings on various areas of her skin, dressings are dated for 03/13/25. The hospital records included a photograph of a dressing dated 03/13/25 on what appeared to be the resident leg. The emergency room physician's note stated, Also there was concerned [sic] that patient has dressing from 03/13 is [sic] not been changed. On 05/07/25 at 11:00 AM, the Center Nurse Executive (CNE) confirmed the resident's skin tear care and dressing changes had not been signed off on the TAR to indicate the care and dressing changes had been performed. The CNE and the Administrator stated the facility was not aware of the hospital's allegation that skin tear dressing changes had not been performed.

Based on record review and staff interview, the facility failed to provide care and services for pressure ulcers in accordance with professional standards of practice. This deficient practice had the potential to affect three (3) of three (3) residents reviewed for pressure ulcers. Pressure ulcers were not assessed weekly for Residents #110, #58, and #90. Additionally, Resident #110's pressure ulcers were not treated as ordered. This deficient practice caused actual harm to Resident #110, who was admitted to the hospital with a pressure ulcer infection. The hospital physician also diagnosed the resident with septic shock, believed to be caused by a combination of pneumonia and sacral pressure ulcer wound infection. Resident identifiers: #110, #58, #90. Facility census: 109. Findings included: a) Policy review Review of the facility's policy and procedure titled, Skin Integrity and Wound Management, with effective date 07/01/01 and revision date 05/01/25 stated wound evaluations would be performed weekly. b) Resident #110 Review of Resident #110's electronic health records showed the resident returned to the facility from the hospital on [DATE]. A nursing note written on 03/18/25 at 11:45 PM documented the resident had the following pressure ulcers: - Sacrum According to the nursing note, Skin issue has been evaluated. Location: Sacrum. Issue type: Pressure ulcer/injury. Progress: Improving: overall wound characteristics improved. Pressure ulcer staging: Stage 3 pressure ulcer/injury - full thickness skin loss. Wound was present on admission. Wound is new. Signs and symptoms of infection: None. Staged by: In-house nursing. Measurements not documented as part of this assessment. Reason measurements not documented as part of this assessment: will assess with Swift wound photo application. Undermining: No. Tunneling: No. Epithelial: 80%. Granulation: 20%. Exudate amount: Light. Exudate type: Serosanguinous.: mixture of serous and sanguinous fluid, typically pale, red and watery. Odor after cleansing: None. Other: pink or red. Periwound: Attached. Surrounding tissue: Erythema. Surrounding tissue: Excoriated. Surrounding tissue: Fragile. Induration: None present. Edema: No swelling or edema. Periwound temperature: Normal. - Left lateral foot According to the nursing note, Skin issue has not been evaluated .Pressure ulcer staging: Unstageable pressure injuries presenting as deep tissue injury. Wound was present on admission. Wound is new. Staged by: In-house nursing. Undermining: No. Tunneling: No. The nursing note also stated, Wounds dressed and assessed today. Issue signing on to SWIFT photo app on personal device and facility device. Will contact IT [information technology] to try and resolve issue so that wound photos can be taken. A skin evaluation performed on 03/24/25 reported the same pressure ulcers as on 03/18/25. The wounds were described exactly the same as they were described in the note written on 03/18/25. The note even contained the same notation that Issue signing on to SWIFT photo app on personal device and facility device. Will contact IT to try and resolve issue so that wound photos can be taken. Resident #110's Treatment Administration Record (TAR) showed the following pressure ulcer wound treatments written after the resident returned to the facility on [DATE]: - Cleanse stage 3 pressure ulcer injury to sacrum with IHWC [wound cleanser]. Pat dry. Apply plurogel thoroughly to wound, ensuring application to small open area at top of sacrum, every day shift. The order had been written to start on 03/19/25. The order was discontinued 03/26/25. The treatment had not been signed off as performed on the TAR for any of the days. - Cleanse stage 3 pressure ulcer injury to sacrum with IHWC [wound cleanser]. Pat dry. Apply plurogel thoroughly to wound, ensuring application to small open area at top of sacrum, every day shift. The order had been written to start on 03/24/25. The order was discontinued 03/26/25. The treatment had not been signed off as performed on the TAR for any of the days. - Cleanse DTI [deep tissue injury] to left lateral foot with IHWC. [NAME] dry. Apply sureprep rapid dry to wound. Leave open to air. Notify provider and wound team with any changes in wound status immediately. The order had been written to start on 03/19/25. The order was discontinued 03/26/25. The treatment had not been signed off as performed on the TAR for any of the days. - Cleanse DTI [deep tissue injury] to left lateral foot with IHWC. [NAME] dry. Apply sureprep rapid dry to wound. Leave open to air. Notify provider and wound team with any changes in wound status immediately. The order had been written to start on 03/24/25. The order was discontinued 03/26/25. The treatment had not been signed off as performed on the TAR for any of the days. The resident had the following focus on her comprehensive care plan, Resident/patient is resistive to care related to: Refusing wound treatments. The TAR did not indicate the resident had refused any of the treatments discussed above. The resident's comprehensive care plan also included the following focus, Resident at risk for skin breakdown related to incontinence, morbid obesity, decreased activity, limited mobility secondary to acute illness with recent hospitalization, h/o [history of] pressure injuries and multi-disease processes, h/o skin tears, actual pressure ulcer, frail fragile skin, impaired cognition, impaired sensation, incontinence, informed refusal to aspects of care, moisture, nutritional concerns, poor safety awareness, and shear/friction risks AND pressure to sacrum and left lateral foot. Skin tears to left elbow, right inner forearm, right antecubital space, left outer forearm, front right knee, front right lateral lower leg. The focus was created on 12/25/2021 and revised on 02/28/25. On 03/25/25, the resident was transferred to the hospital after having low blood pressure during her dialysis treatment. The resident's sacral pressure ulcer was found to be infected with the organisms proteus and enterococcus. The resident was also given a diagnosis of septic shock, which the physician believed was caused by a combination of pneumonia and sacral wound infection. The resident required antibiotics for the wound infection through 04/04/25. The resident remained in the hospital until 04/07/25. On 05/07/25 at 11:00 AM, the Center Nurse Executive (CNE) confirmed the resident's pressure ulcer care and dressing changes had not been signed off on the TAR to indicate the care and dressing changes had been performed. No further information regarding Resident #110's pressure ulcer dressing changes or assessments was provided by the facility during the investigation. c) Resident #58 Resident #58 had a pressure ulcer to his left elbow that had healed and reoccurred several times. According to the Center Nurse Executive (CNE), the left elbow pressure ulcer reoccurred 03/17/25. At the last assessment on 05/02/25, the area was recorded as facility acquired, stage II, with measurements of 5.9 centimeters (cm) x 5.3 cm x 0.1 cm. Prior assessments could not be located in the resident's electronic health record. Per the Center Nurse Executive on 05/07/25 at 1:00 PM, no previous assessments were located in the medical record of the left elbow pressure ulcer that occurred 03/17/25. d) Resident #90 Resident #90 had a sacral pressure ulcer that developed 04/09/25. Upon discovery, the pressure ulcer was assessed and treatment was initiated. The pressure ulcer was reassessed on 04/16/25. On 04/24/25, a skin check was recorded but the sacral pressure ulcer was not assessed. The Nurse Practitioner assessed Resident #90's pressure ulcer on 04/29/25. On 05/07/25 at 11:30 AM, the Center Nurse Executive confirmed an assessment of Resident #90's pressure ulcer had not been documented between 04/16/25 through 04/29/25.

Based on record review and staff interview, the facility failed to ensure residents were free from neglect. This failed practice caused actual harm which resulted in a hospital stay. This was true for one (1) out of one (1) reviewed for neglect. Resident identifier: #100. Facility census: 112. Findings included: a. Resident #100 During a record review of a reportable made to the Office of Health Facilities Certifications and Licensure, (OHFLAC). It revealed Resident #100 was found unresponsive in her bed on 08/24/2020 at 3:23 PM (per nursing notes). Resident #100 was reported to have blue lips, experiencing shortness of breath and abnormal vital signs. Initially her Oxygen Saturation (O2 sat) (which measures to level of oxygen being carried by the red blood cell in the body), was in the 70's. Staff placed a Non-rebreather Mask on resident and 911 was called. While Local Emergency Ambulance Service (EMS) was treating Resident #100 it was discovered there were two (2) out of three (3) of the missing narcotic cards belonging to Resident # 98 one card (containing 20 Oxycodone 10 mg) and Resident #82 two cards (containing a total of 45 Norco 5/325). Local Emergency Ambulance Service arrived to facility on 08/24/20 at 2:37 PM. This information is from the ambulance service report. Upon arrival vital signs were as follows at 2:38 PM Blood Pressure (B/P) 121/95, pulse 96, respirations 6 breaths a minute, O2 sat 80% with supplemental oxygen. Intravenous access to give infusions and medications was establish at 2:46 PM, at this time a medication used to reverse the effects of narcotics (NARCAN) was given and again at 2:53 PM. The narrative portion of the report reading as followed: Patient found in bed roused only to painful stimulus. Staff states she was found unresponsive, with blue lips and they started a high flow oxygen supplement with continued dropping O2 sats. Noted pinpoint pupal. Questioned staff if she was on any narcotics for pain and told no. Noted pill papers hidden under her blanket and when the blanket was pulled back the staff noted with surprise that the pill packets were the narcotics that were missing. Staff reported 45 Norco and 20 Percocet's have been missing since yesterday. It was noted that all pill blisters were popped, and the pill removed. Local Hospital report states Resident #100 Emergency personal stated they found several empty pill wrappers used by the facility. Patient did respond to Narcan given by emergency personal given twice and had to have a repeat dose after arrival. Patient's urine drug screen was positive for opiates, oxycodone and benzodiazepines. Patient was admitted to Intensive Care Unit and Poison Control was consulted. Call received the nursing home stated they found a suicide note. Patient was discharged to return to the nursing home facility on 08/28/2020. During her hospital stay she received psychiatric services. Referring back to the reportable received from the facility it revealed, the staff discovered a handwritten note at her bedside, documenting her planned attempt to steal other resident's narcotic cards from the facility for an extended period of time. Resident had stolen narcotic cards belonging to two (2) other residents from the narcotic lockbox and taken them herself in an attempt to end her life. An interview on 09/21/2020 at 11:15 AM, Social Worker #6, stated, she thinks the resident took the narcotic cards from the medication cart while they were on the top of the cart, while the nurse was logging them into the logbook. She went on to say she was not notified of the missed narcotics until late Sunday night on 08/23/2020. She agreed that the report she made said, that there was a discrepancy found by Licensed Practical Nurse (LPN) #2 and LPN #7 at 7 AM on 08/23/2020. At 3:00 PM, during narcotic count between LPN #2 and Assistant Director Nursing (ADON) # 5 also confirmed that three (3) cards of narcotics containing a total of 65 pills were unaccounted for. The missing narcotics belonged to Resident #98 one card with 20 oxycodone 10 mg and Resident #82 two cards with 45 Norco 5/325. Social Worker #6 also reported, Resident #100 had a written plan watching for the nurse to leave the narcotic drawer open so she could take some narcotics from the cart to end her life During an interview on 09/21/2020 at 12:35 PM, LPN #3 was asked to explain how the narcotic were secured. He stated there was two sperate keys, one unlocks the cart, the other key would then unlock the lid to the narcotic drawer. It was noted that when the narcotic drawer is unlocked the lid would be opened like a trunk lid on a car and the drawer measuring about 12 inches wide and 18 inches deep would have to be fully pulled out. During a phone interview on 09/21/2020 at 12:08 PM, Assistant Director Nursing # 4 was asked if the third narcotic card was recovered. She said, the staff did a reach of the facility, however, the third card has not been found. Due to the facility's neglect/failed to properly secure medications, the resident was able to attempt suicide by taking an overdose of another resident's medications resulting in hospitalization . This resulted in actual harm to Resident #100.

Based on record review, and staff interview the facility failed to assure that medications were secure and inaccessible to unauthorized staff and residents. As a result, a resident accessed and ingested medications that caused clinically significant adverse consequences necessitating hospitalization to stabilize Resident #100. This failed practice resulted in actual harm to Resident #100 Facility census 112. Findings included: On 08/23/2020 at 7 AM the facility discovered three (3) missing medication cards containing narcotic medications: Resident #98 had one (1) card of Oxycodone 10 mg., with 20 pills. Resident #82 - two (2) cards containing Norco 5/325 mg. (One (1) card containing 15 pills and the second card containing 30 pills.) A total of 65 missing narcotic medications. On 08/24/2020 at 3:23PM, Resident #100 was found in her bed unresponsive. The facility called 911. The Emergency Medical Staff (EMS) attendant discovered two of the three missing narcotic cards under the Resident's blanket. The EMS attendant provided a written statement indicating staff told him the pill cards had been missing since yesterday. Resident #100 received Narcan on two (2) occasions while on the ambulance and again received Narcan in the emergency room at the hospital. The Resident was admitted to the hospital and placed in ICU. After the resident was sent to the hospital, facility staff found a suicide note on 08/24/20 in Resident #100's room. Contained in the suicide note was the statement, .Please let the drug cart be open tonight so I can get some drugs. (The suicide note was not dated.) The facility investigated the incident on 8/24/20 and determined a licensed nurse left the medication cart unlocked and unattended allowing Resident #100 access to other Resident's medications. Staff were educated and signed a policy titled, Maintenance of Controlled Drugs and dated 11/01/2019. The policy directed controlled medications were to be counted at the change of shifts by two (2) nurses and all controlled medications are to be double locked. The medication cart containing controlled medications is not to be left unlocked and unattended. Controlled medications are required to be secured under double locks. As a result, the resident obtained controlled medications belonging to other Residents. Resident #100 ingested the medications, became unresponsive and required hospitalization . The facility investigated and reported the incident to the proper state authorities and in-serviced staff. On 09/21/20 at 12:30 PM, observation found staff were not following the direction provided by the in-service. Observation, record review and staff interview on 09/21/2020 at 12:23 PM, revealed reconciliation of control substances were not being completed on each shift. The Director of Nursing (DON) verified from 09/05/20 to 09/21/20, there was no completed shift count by any nursing staff. When asked to see the shift count of controlled medications on 09/21/2020 at 12:30 PM, Licensed Practical Nurse (LPN) #1 stated, I don't do those I've never done those. I should have called in sick today, A review of the Shift Count sheet it revealed many empty lines, to indicate no count of the controlled medication where being done on every change of shift. The following dates were not signed by two (2) nurses. from a look back to 08/09/2020 to 09/21/2020. -08/09/2020 7am -08/09/2020 7pm -08/10/2020 7am -08/11/2020 7am -08/11/2020 7pm -08/12/2020 7pm -08/13/2020 7am -08/13/2020 7pm -08/14/2020 7am -08/14/2020 7pm -08/15/2020 7am -08/15/2020 7pm -08/16/2020 7am -08/16/2020 7pm -08/17/2020 7am -08/17/2020 7pm -08/18/2020 7am -08/18/2020 7pm -08/19/2020 7am -08/19/2020 7pm -08/21/2020 7am -08/22/2020 7am -08/22/2020 7pm -08/23/2020 7pm -08/24/2020 7am -08/24/2020 7pm -08/25/2020 7am -08/25/2020 7pm -08/26/20207am -08/26/2020 7pm -08/27/2020 7am -08/28/2020 7am -08/28/2020 7pm -08/29/2020 7am -08/29/2020 7pm -08/30/2020 7am -08/30/2020 7pm -08/31/2020 7am -08/31/2020 7pm -09/012020 7am -09/01/2020 7pm -09/02/2020 7am -09/02/2020 7pm -09/04/2020 7am -09/04/2020 7pm -09/05/2020 7pm -09/06/2020 7pm -09/07/2020 7am -09/07/2020 7pm -09/08/2020 7am -09/08/2020 7pm -09/09/2020 7am -09/09/2020 7pm -09/10/2020 7am -09/10/2020 7pm -09/11/2020 7am -09/11/2020 7pm -09/12/2020 7am -09/12/2020 7pm -09/13/2020 7am -09/13/2020 7pm -09/14/2020 7am -09/14/2020 7pm -09/15/2020/7am -09/15/2020 7pm -09/16/2020 7am -09/16/2020 7pm -09/17/2020 7am -09/17/2020 7pm -09/18/2020 7am -09/18/2020 7pm -09/19/2020 7am -09/19/2020 7pm -09/20/2020 7am -09/20/2020 7pm -09/21/2020 7a.m It should be noted that during a shift count on 08/23/2020 at 7 AM the staff discovered there was 65 missing narcotics, but still the staff failed to do a narcotic count at the change of each shift. On 09/21/2020 at 2:38 PM, Corporate Nurse agreed that the shift counts should have been done twice a day and signed by two (2) nurses each time. Reconciliation of controlled substances is still not being completed on every shift. This failure to ensure the staff were following the policies and guidelines caused actual harm to Resident #100. The facility has no way of knowing if controlled medications are missing.

Based on record review, staff interview, and policy review, the facility failed to ensure a resident received the treatment and care in accordance with professional standards of practice, the comprehensive care plan, and the resident's choices, related to pain management for one (1) of six (6) resident review for the care area of resident safety and falls. The facility failed to treat a resident's pain. In addition, the facility's staff failed to assess a resident's pain, the effectiveness of pain medication that was administered, notify the physician/FNP of recommendation from a consultant physician, which caused a delayed in treatment for one (1) resident in pain resulting in harm. Resident #5 was diagnosis at a acute care hospital as having a transverse fracture along the proximal tibial metadiaphysis. This failed practice resulted in physical and psychosocial harm to the resident due to a lack of pain management when the resident was verbally expressing excruitiating pain due to a fall.Resident identifier: #5. Facility cenus: 113. Findings included: a) Resident #5 A review of Resident #5's progress notes finds on 04/17/20 at 5:35 PM, the resident had a change of condition. The note revealed the resident had a fall. Registered Nurse (RN ) #1 documented on the change of condition form the resident has pain and is cognitively able to rate her pain. The nurse wrote the resident's pain level is a four (4), which a pain level of four (4) to five (5) pain scale represents moderate pain. The resident's location of pain was in her right hip, right leg, no bruising was noted, but the resident's knee was swollen below her right knee. The resident has an abrasion noted to her right lower back with scattered bruising. RN #1 wrote the resident is yelling out, Nurse Aide (NA), entered the room and found resident sitting on the floor, leaning against the air conditioner unit in the room. Resident attempted to get back in bed independently, two (2) staff assisted Resident #5 back into bed. The Family Nurse Practitioner (FNP) was notified at 5:40 PM. The RN #1 writes the NP's recommendation: Resident c/o (complains of) pain in right leg and hip, states, That is my leg that has been broken in the past. Stat ( means to obtain immediately) x-ray of right hip and right leg was ordered. The resident pain level prior to the fall on 04/17/20 at 12:20 PM was zero (0). A review of Resident #5's record on 08/19/20 at 1:00PM, reveals RN #1 documented Resident #5's pain level was four (4) on 04/17/20 at 5:35 PM. The record shows the resident had a order with the date of 02/08/20 for Tylenol 325 milligrams (mg), give 650 MG by mouth every six (6) hours as needed for hip pain, not to exceed three (3) gms every 24 hrs. The record finds RN #1 did not administered the Tylenol pain medication, or any non-pharmalogical intervention for Resident #5's pain. The RN did not ask the NP if the resident could have something else for pain. The record finds the NP did not give any orders for any other intervention for Resident #5's pain except to obtain a Stat x-ray of Resident #5's right hip and right leg. The x-ray company was notified on 04/17/20 at 6:13 PM for the Stat x-ray of Resident #5's right hip and right leg. The facility consulted with (physician name) to conducted a telemedicine video-call on 04/17/20 at 7:10 PM. The physician writes on the consultation note, Patient (Resident #5), had a fall at five (5) PM. The note revealed RN #4 texted to the consultation facility physician that the right hip x-ray ordered shows that its out of place. The physician's note reveals per RN in the facility the x-ray ordered shows the resident's right hip is dislocated. The consultant physician states that, he examined Resident #5 at the bedside. Resident #5 complains of excruciating pain in right knee and lower back on movement. The physician's examination reveals that Resident #5's right leg shows external rotation of leg with significant swelling in right knee and infrapatellar area with tenderness. The physician stated that, Possible fracture or injury to the right hip and knee. The consultant's (physician name) wrote an order at 7:36 PM on 04/17/20 to obtain a Stat x -ray of the resident's right knee including proximal fibula, tibia and to immobilize her limb until further instructions were given. The consultant (physician name) also wrote an order for Resident #5 to receive Tylenol 1,000 mg by mouth once, Oxycodone five (5) mg by mouth once, Percocet five (5)/325 mg tab, one (1) tab for moderate and two (2) tab by mouth for severe pain every four (4) hours PRN. Monitor for respiratory suppression with judicious use. Call back for any changes. If patient agreeable for ER transfer with worsening then call us. A review of Resident #5's medical record finds Licensed Practical Nurse (LPN) #1 obtained an order from the facility's NP on 04/17/20 at 9:53 PM, to give 1,000 MG of Tylenol by mouth Stat related to pain in Resident #5's right lower leg. No non-pharmalogical interventions documented in the record by LPN #1 to provide Resident #5 any relief for her pain. None of the other pain medication was ordered. A review of the medication administration record (MAR), reveals RN #1 did not administered Resident #5 anything for her pain on 04/17/20 at 5:35 PM following her fall with complaints of pain. Resident #5's pain was documented by this nurse as a four (4), a scale of 4 - 5 reveals moderate pain. RN #1 did not provide any pharmalogical or non-pharmalogical interventions. Resident #5 was not administered anything for her pain until LPN #1 on 04/17/20 at 9:53 PM, administered Tylenol 1,000 MG by mouth Stat (with no delays or immediately) related to the resident's pain in right lower leg. The consultant's (physician name) had given the facility staff orders for pain medication on 04/17/20 at 7:36 PM. LPN #1 administered the Stat Tylenol 1,000 MG by mouth two (2) hour and 16 minutes after the facility staff had received the order from the consultant (physician's name). Resident #5's pain level was a 10 on 04/18/20 at 9:53 PM, a level of 10 equals excruciating pain. Resident #5's pain went from a four (4) (moderate pain) at 5:35 PM in which no pain medication was administered and/or interventions to control Resident #5's pain. The resident's pain increased to a 10 ( (excruciating pain) by 9:53 PM on 4/17/20. The consultant's (physician) stated during his telemedicine video on 04/17/20 at 7:10 PM the resident complains of excruciating pain in her right knee and lower back on movement. No evidence was found the resident had received any pain medication or any intervention for Resident #5's when the 7:10 PM telemedicine video was conducted. A review of Resident #5's record found no documentation from the LPN #1 of what the effectiveness was after Resident #5's had received the Stat Tylenol 1,000 mg by mouth. Therefore there is no evidence Resident #5's pain was controlled. On 04/18/20 at 1:35 AM, LPN #1 wrote a nursing documentation note that Resident #5 had a fall earlier, with injuries. She has a bruise on her lower back and a significant amount of pain in her right lower extremities (RLE). The x-ray tech came this evening to do an x-ray of her right leg and hip. No fracture noted but resident does have a dislocated hip. The physician was notified. LPN #1 stated that, Resident had some pain medicine but continued to complain of pain. The record shows the resident received pain medication at 9:53 PM on 04/17/20. The nurse wrote the facility's physician stated that, Since that is where the majority of the pain is and its also very swollen. The physician ordered an x-ray of the right knee, tibia and fibula. No non-pharmalogical or pharmalogical intervention were documented by the LPN to help alleviate Resident #5's pain on 04/18/20 at 1:35 AM. This LPN informed the physician that, The resident had some pain medicine, but continued to complain of pain. There were no evidence the physician had given any new order to treat Resident #5's pain. LPN #1 documented in the nursing documentation note the resident pain level was a 10 on 04/18/20 at 1:35 AM when the LPN had talked to the physician. No evidence LPN #1 on 04/18/20 at 1:35 AM inform the facility's physician, or that the physician was made aware of the recommendation from the consultant's (physician name) for Resident #5's right knee to be immobilized until further instructions. The FNP did order a STAT x-ray of Resident #5'S right knee, including proximal tibia and fibula on 04/17/20 at 9:53PM. On 04/18/20 at 9:35 AM, RN #2 stated that Resident #5 was awake, in bed yelling out at times. Whenever needed (PRN) Tylenol given for pain. RN #2 writes X-ray (company name) here for s {sic] -ray of Resident #5's right lower leg related to fall on 4/17/20. Resident #5's pain level is documented in the nursing documentation note at a 10, Excruciating pain, with the date and time of 04/17/20 at 9:53 PM. Documentation did not show what Resident #5's pain was on 04/18/20 at 9:35 AM. There were no pain scale identified on the vital sign sheet for 04/18/20 at 9:35 AM. A review of Resident #5's MAR on 08/19/20 at 1:15PM, revealed no PRN Tylenol was sign off on the MAR for 04/18/20 at 9:35 AM. No re-assessment was found to determine what the effectiveness of the PRN pain medication (Tylenol) that RN #2 had said she had given to Resident #5. There is no evidence Resident #5 had received the PRN Tylenol according to the MAR for her Pain. On 04/18/20 at 9:45 AM, RN #2 wrote the x-ray company present to obtain x-ray of Resident's #5's right knee including proximal fibula and tibia. The 2nd x-ray was read by (company's name) and electronically signed by the physician on 04/18/20 at 9:29 AM, so the x-ray was obtained prior to the nursing note with the time of 9:45 AM. The x-ray was obtained 14 hours and nine (9) minutes from the time the order was recommended from the consultant (physician name). The FNP had given LPN #1 orders for the Stat x-ray on 04/17/20 at 9:53PM. On 04/18/20 at 12:30 PM, the facility wrote they were notified of X-ray results. Resident #5 has an acute fracture of proximal tibia. The consultant facility name was notified of the x-ray results. RN #2 noted new order to send the resident to an acute care hospital for evaluation. A review of the acute care hospital record for Resident #5 on 08/20/20 at 8:00 AM, found the hospital obtain an x-ray on 04/18/20 at 3:13 PM. The findings/impression is there is a relatively nondisplaced,comminuted, predominantly transverse fracture along the proximal tibial metadiaphysis. The attending FNP write in the emergency department note the patient is having pain at the right proximal tibia with swelling. Resident #5 received Fentanyl (used to relief pain) 50 microgram (MCG) Intravenously once at 2:40 PM, Resident #5's pain level was a eight (8). The resident received Percocet 7.5/325 one (1) tablet once at 3:27 PM and her pain was a eight (8). A knee immobilizer was applied on 04/18/20 at 3:40 PM. The emergency room nurse (ERN) writes right leg is shortened and rotated, pain with movement at 2:40 PM. The ERN documents the patient not complaining of pain at this time on 04/18/20 at 4:00PM. The resident is discharged to return back to the facility with order for Oxycodone - Acetaminophen 5/300 MG tablets one (1) tablet every eight (8) hours as needed and to keep the immobilizer on resident's right leg and follow up with an orthopedic. On 04/18/20 at 5:30 PM, the RN #2 wrote the resident returned to facility from acute care hospital for evaluation of abnormal x-ray of right lower leg. Resident positive for proximal tibia fracture.The resident returned with knee immobilizer to right leg. The order from the acute care hospital was to leave in place at all time, and non-weight bearing to right extremity. Orders from the hospital was for Norco 5/325 milligram (MG) prescribed by emergency room (ER) physician for pain management. Facility to schedule appointment with an orthopedic (physician name) . RN documents Resident #5's pain level as a 10 - excruciating pain. RN #2 then writes on 04/18/20 at 5:30PM again, resident returned to the facility,new order for Percocet 5/325 mg by mouth every six (6) hours PRN for pain and the order was faxed to the pharmacy. The physician at the emergency room order Percocet not Norco. No mention of any non-pharmalogical or pharmalogical intervention provided for Resident #5's pain of a 10, as described in this note on 04/18/20 at 5:30PM. On 04/18/20 at 5:35 PM the RN #2 wrote the resident resting in bed with knee immobilizer in place. No complaints of pain/discomfort at this time. Will monitor. The nurse indicated that the resident's pain level equaled 10, Excruciating pain. The nurse wrote another note at 5:45 PM, Resident #5 had Percocet 5/325 mg in ER for pain, but did not indicate what time the resident had received the pain medication. The nurse wrote that the Percocet prescription was received and sent to the facility's Pharmacy. A review of the acute care hospital emergency room record shows Resident #5 received the Percocet 7.5/325 MG once at 3:37 PM. RN #2 did not ask the acute care hospital when the resident had received pain medication (Percocet) last in the emergency room prior to returning back the the facility in order to know when the resident could receive pain medication next. In this note the nurse wrote no complaints of pain/discomfort at this time, but documented the resident's pain level equals 10. Therefore these statement state the opposite meaning of each other and it is unable to determine whether the resident is in pain or the resident has no pain. There is no non-pharmalogical or pharmalogical intervention noted in the record to address Resident #5's pain level of 10. On 04/19/20 at 1:35 AM, LPN #1 wrote, Resident had a fall with injuries yesterday. She has some bruising and swelling in her right leg, tried to look at back but patient was yelling and seemed to be in excruciating pain. The LPN states that, x-ray done this morning showed a break in her right leg from what I was told. Was sent to the ER and returned with an immobilizer on her RLE. Pedal pulses in BLE are strong. Resident appears comfortable as long as she does not move. Going to administer PRN pain medication and will continue to monitor. LPN #1 documented in this note the resident's pain level was 10, excruciating pain. A review of Resident #5's MAR on 08/19/20 at 1:30 PM, found LPN #1 administered the Percocet Tablet 5-325 MG (Oxycodone-Acetaminophen) one (1) tablet by mouth every six (6) hours as needed for pain at 7:06 AM for Resident's pain level of seven (7) on 04/19/20, even though LPN #1 wrote in her nursing documentation note that Resident #5 was yelling and seemed to be in excruciation pain, (pain level of 10) on 04/19/20 at 1:35 AM. No evidence found LPN #1 had administered the PRN Percocet pain medication as her note had stated on 04/19/20 at 1:35 AM, Going to administer PRN pain medication and will continue to monitor. A review of Resident #5's vital sign sheet on 08/19/20 at 1:40 PM, found only one (1) pain level documented from 04/17/20 - 04/19/20. This was on 04/17/20 at 9:53 PM which states Resident #5 pain level was a 10. In an interview with the Director of Nursing (DoN) on 08/19/20 at 3:30 PM, he was informed that when Resident #5 had fell RN #1 wrote in the progress notes the resident complained of pain in her right leg and hip. The DoN was asked, what would he expect the nurse to do. The DON stated that, he would expect the nurse to reposition the resident, be given pain medication, ask the physician what to do for the pain. The DoN was asked, did RN #1 provide any of theses interventions for Resident #5's pain, and the DoN said no. The DoN was asked why did LPN #1 wait until 9:53 PM on 04/17/20 to administer the Tylenol 1000 MG by mouth times one (1) to Resident #5 when the consultant (physician name) gave an order at 7:36 PM on 04/17/20. In addition to the prior question the DoN was also asked did LPN #1 re-assess what the effectivness of the pain medication (Tylenol 1,000 MG) that was given to Resident #5 on 04/17/20 at 9:53PM. No comment was made by the DoN. The DoN confirmed why Resident #5's nursing documentation notes for 04/18/20 at 1:35 AM, 04/18/20 at 9:35 AM, 04/18/20 at 5:35 PM, 04/19/20 at 1:35 AM, 04/19/20 at 9:30 AM, and for 04/19/20 at 5:30 PM, reveals the resident pain level is 10 with the date of 04/17/20 at 9:53 AM. The DoN stated something had happen where the nurse is to document the resident pain level so the only pain level that is on the notes all say 10, except for when the resident had fell and this pain assessment revealed at the time the resident fell her pain was a four (4) and at 9:53 PM on 04/17/20, when LPN #1 documented Resident #5's pain level was a 10. The DoN stated that he had no evidence the nursing staff had assessed or re-evaluated Resident #5's pain.The DoN said from then on the nurses did not document what Resident #5's pain level was on theses dates and times. The DoN stated that, he did know that Resident #5's pain level remains what was put in there last, which was a pain level of 10 on 04/17/20 at 9:53 PM. The DoN confirmed the nursing staff did not conducted pain assessments and re-evaluated the effectiveness of the pain medication for Resident #5. When the DoN was asked whether he could find any information out about whether the facility's physician was made aware of the consultant's (physician name) recommendation on 04/17/20 at 7:10 PM, of the immobolization of the limb until further instructions. The facility did not provide any evidence at the time of exit related to immobolizing of Resident #5's right knee. The DoN was asked why the Stat x-ray on 04/17/20 at 9:53 PM was ordered but not obtained until the next day. No comment was made. The DoN was questioned about if they had any evidence to provide related to RN #2 had written on 04/18/20 at 9:35 AM that she provided the PRN Tylenol to Resident #5. There were no documentation in the MAR that Resident #5 had received the PRN Tylenol and no re-evaluation assessment of the effectivness of Resident #5's pain.The DoN stated that, he had asked this nurse, (RN #2) whether she had administered the PRN Tylenol and all she says is that she did but she did not document she had administered the pain medication in the MAR nor re-assess the effectiveness of the PRN Tylenol that was given. The DoN confirmed that the nurses must document medication given in the MAR what medication a resident receives. The DoN was asked whether he had any evidence that Resident #5 had received the PRN Tylenol medication, and the DoN stated no. The DoN confirmed that he could not find any evidence Resident #5 had received the PRN Tylenol as RN #2 had stated in her note on 04/18/20 at 9:35 AM. RN #2 stated in her nursing documentation note that on 04/18/20 at 5:35 PM the RN #2 wrote Resident #5 has no complaints of pain/discomfort at this time. This Nurse also wrote in this same note the resident's pain level was 10. The DoN was asked to clarify whether the resident had no pain/discomfort or did the resident have a pain level of 10. In addition, the DoN was asked did RN #2 provide any non-pharmalogical intervention for Resident #5's pain level of 10. The DoN said that he could only read what was documented in the chart and he made no further comment. The Don was informed that LPN #1 documented on 04/19/20 at 1:35 AM that while she was looking at Resident #5 back, the resident had yelled out and seemed to be in excruciating pain and the LPN wrote she was going to administer PRN pain medication and continue to monitor, but a review of Resident #5's record shows the resident did not receive any pain medication from LPN #1 until 7:06 AM on 04/19/20. That was five (5) hours and 31 minutes later. The DoN was asked, why did the nurse delay administering Resident #5 pain medication until 7:06 AM on 04/19/20 when this nurse documented the resident was having pain at 1:35 AM on 04/19/20. No comment was made by the DoN. The DoN was asked for Resident #5's twice a day pain monitoring assessment which is located on the MAR, and any further documentation the nursing staff wrote on the pain monitoring form related to Resident #5's pains. The DoN stated that he was unable to provide these assessment. The facility's pain management policy with the revision date of 11/01/19, finds patients receiving intervention for pain will be monitored for the effectiveness and side effects (e.g., constipation, sedation) in providing pain relief. Document: non-pharmalogical interventions and effectiveness; effectiveness of PRN medication; ineffectiveness of routine or PRN medication, including interventions, follow - up and physician and APP ((advance practice provider) notification. This failed practice resulted in physical and psychosocial harm to the resident due to a lack of pain management when the resident was verbally expressing excruitiating pain due to a fall.

Based on personnel file review, staff interview, and review of the facility's policy for screening of employees, the facility failed to verify fourteen (14) of fifteen (15) direct care staff hired by a staffing agency and used by the facility were thoroughly screened for a history of abuse, neglect, exploitation, and/or any applicable criminal activity that would identify the individual as unfit to work in a long-term care facility. The facility failed to ensure fourteen (14) of the fifteen (15) individuals were screened through the West Virginia Clearance for Access and Employment Screening (WV CARES) system, a program initiated by the Centers for Medicare and Medicaid Services (CMS) National Background Check Initiative. After consultation with the State Agency, a determination of immediate jeopardy was made based on the facility's failure to thoroughly screen the backgrounds of three (3) Licensed Practical Nurses (LPNs) and eleven (11) nurse aides (NAs). This practice had the potential to affect all residents residing in the facility. Notice of the Immediate Jeopardy (IJ) was given to the Center Executive Director (CED) on 05/17/18 at 5:15 PM. An acceptable plan of correction (P[NAME]) was received from the CED on 05/17/18 at 7:00 PM. After verification of the implementation of the plan of correction, the immediate jeopardy was abated at 7:00 PM. Employee identifiers: #58, #59, #60, #61, #62, #63, #64, #65, #66, #67, #68, #69, #70, and #72. Facility census: 111. Findings included: a) On 05/17/18 at 12:50 PM, a review of employee background checks with Human Resources Manager (HRM) #20 revealed the facility had employed 15 agency employees. Three (3) of the agency employees were LPNs and eleven (11) were nurse aides (NAs). HRM #20 said she would locate the background checks for the agency employees. According to the facility's records, the employees provided by an agency began working in the facility on the following dates: - LPN #58 - 01/03/18 (the start date was listed at 01/03/18, but when the facility printed the work history she had worked in (MONTH) (YEAR)) - NA #59 - 03/19/18 - NA #60 - 03/26/18 - NA #61 - 03/28/18 - NA #62 - 04/02/18 - LPN #63 - 04/02/18 - NA #64 - 04/04/18 - NA #65 - 04/09/18 - NA #66 - 04/09/18 - NA #67 - 04/09/18 - NA #68 - 04/15/18 - NA #69 - 04/15/18 - NA #70 - 04/15/18 - LPN #71 - 04/30/18 (This was the only agency person for which the facility had a letter from WV CARES) - LPN #72 - 05/07/18 Review of when the agency staff had worked since their hire dates found the following. - NA #60 had worked 42 days between 03/27/18 and 05/17/18. - LPN #58 had worked 86 days between 10/16/17 and 05/17/18. - NA #59 had worked 38 days between 03/19/18 and 05/17/18. - NA #61 had worked 29 days between 03/28/18 and 05/17/18. - NA #62 had worked 35 days between 04/02/18 and 05/17/18. - LPN #63 had worked 27 days between 04/02/18 and 05/17/17. - NA #64 had worked 34 days between 04/04/18 and 05/17/18. - NA #65 had worked 23 days between 04/09/18 and 05/17/18. - NA #66 had worked 27 days between the dates of 04/09/18 and 05/17/18. - NA #67 had worked 28 days between 04/10/18 and 05/17/18. - NA #68 had worked 23 days between 04/15/18 and 05/17/18. - NA #70 had worked 13 days between 04/15/18 and 05/17/18. - LPN #72 had worked 2 days between 05/13/18 and 05/17/18. On 05/17/18 at 6:20 PM, the CED and HRM #20 could not provide any information on the background checks for the listed employees. They said these individuals were employed by an agency and they were under the impression the agency had checked the criminal backgrounds prior to them coming to work at their facility. They verified they had not checked to make sure the agency had in fact completed the background checks with the WV CARES system prior to employees working in the building. (Note: WVCARES does the state/federal background checks and all registry checks for the facility.) On 05/17/18 at 7:09 PM, HRM #20 said she could look in the WV CARES system and see where LPN #72 and NAs #66 and #68 had clearance letters in WV CARES. However, HRM #20 did not know how to find the letters from WV CARES showing these three (3) employees were eligible to work in the facility. The facility only had one (1) agency staff member (LPN #71) who had a letter from WV CARES showing that individual's eligibility to work in the facility. When the Center Executive Director and HRM were asked to provide the clearance letters, for LPN #72 and NA #66 and #68, they could not. HRM said, because she did not enter LPN #72, NA #66 and NA #68 into the WVCARES system, she could not get the letters from WVCARES. The facility was given ample time to contact their agency to get this information, but no further information was forthcoming. The Center Executive Director said they had trusted the agency to do the background checks and they were not done. She said she should not have trusted them instead she should have verified they were done. The employee who hired these agency staff members and who was responsible for this verification no longer worked at the facility. The facility's policy included, The Center will screen potential employees for a history of abuse, neglect, or mistreating patients, including attempting to obtain information from previous employers and/or current employers, and checking with the appropriate licensing boards and registries. (Refer to Human Resources Policies and Procedures, Background Investigations policy.) 2.1 The Center will not employ or otherwise engage individuals who: 2.1.1 Have been found guilty by a court of law of abuse, neglect, exploitation, misappropriation of property, or mistreatment; or 2.1.2 Have had a finding entered into the state nurse aide registry concerning abuse, neglect, exploitation, mistreatment of [REDACTED]. 2.1.2.1 Knowledge of actions by a court of law against an employee, which would indicate unfitness for service will be reported to the state nurse aide registry or licensing authority; 2.1.3 Have had a disciplinary action in effect against his/her professional license by a state licensure body as a result of a finding of abuse, neglect, exploitation, mistreatment of [REDACTED]. The facility's failure to follow its policy, and to obtain or verify background checks were completed through the WVCARES system to determine whether these employees were eligible to work with the nursing home residents, placed all resident of the facility at risk for serious harm. After consultation with the State Agency, a determination of immediate jeopardy was made based on the facility's failure to thoroughly screen the backgrounds of three (3) Licensed Practical Nurses (LPNs) and eleven (11) nurse aides (NAs). This practice had the potential to affect all residents residing in the facility. Notice of the Immediate Jeopardy (IJ) was given to the Center Executive Director (CED) on 05/17/18 at 5:15 PM. An acceptable plan of correction (P[NAME]) was received from the CED on 05/17/18 at 7:00 PM. After verification of the implementation of the plan of correction, the immediate jeopardy was abated at 7:00 PM. No deficient practice remained for this requirement after removal of the immediate jeopardy. b) The facility's plan of correction May 17, (YEAR) 6:23pm Administrator immediately removed the identified agency CNA's (2), from the floor at 2:00pm on (MONTH) 12, (YEAR). Staffing was immediately adjusted accordingly to meet resident needs. All residents of the facility have the potential to be effected. No residents of the facility have experienced any negative outcome. A list of all Agency Employee's was immediately compiled by the Human Resources Manager, on (MONTH) 17, (YEAR) at 2:15pm. All Agency Employee's identified were immediately notified by the Administrator/Designee to come to the Center to complete the WV Cares Application to initiate the background check process. Agency personnel who have no submitted their application and completed their fingerprints will not be place on the schedule to work. Administrator/designee will re-educate Human Resources Manager/designee on the WV Clearance for Access (WV Cares) and Employment Screen System as required by Centers for Medicare and Medicaid Services (CMS) with a post-test to validate understanding. Administrator/Designee with complete a review of New Hire/Agency personnel files on (MONTH) 17, (YEAR) to ensure an application and fingerprints have been initiated prior to new hire beginning work in the Center to ensure completion of the WV Cares with confirmed eligibility to work in the Center for 30 days. Trends identified will be reported by the Administrator/Designee monthly to the Quality Improvement Committee for any additional follow-up until the issue is resolved and randomly thereafter as determined by QIC.

Based on policy review, resident interview, medical record review, staff interview, and observation of Resident #35, the facility failed to ensure one (1) of three (3) cigarette smokers was capable of safely smoking independently. The resident was observed smoking outside on the sidewalk alone on 05/15/18 at 9:05 a.m. He could not be readily observed by staff inside the building. It was also noted the resident was smoking in an area where a sign was posted prohibiting smoking. The wind was blowing and ashes would blow back on the resident and his clothing. When the ashes would land on his clothing, he appeared unaware of the ashes and made no attempt to brush them off. He was not wearing a smoking apron and there were noticeable holes in the sweatpants he wore. Further investigation found this severely cognitively impaired resident kept his cigarettes and his lighter on his person at all times. These findings were determined to pose a potential for serious harm to the safety and well-being of Resident #35 and to other residents residing in the facility. The Chief Executive Officer (CEO) was informed these findings constituted an immediate jeopardy to the safety and well-being of Resident #35 and to the facility's other residents on 05/15/18 at 9:24 a.m. Written notification of the findings leading to the determination of immediate jeopardy and request for a plan of correction were provided to the CEO. The facility provided an acceptable plan of correction and after verifying implementation of its plan, the immediate jeopardy was abated at 4:30 p.m. on 05/15/18. After removal of the immediate jeopardy, no deficient practice remained for this requirement. Resident identifiers: #35 and the other facility residents. Facility census: 111. Findings included: a) Resident #35 Observations on 05/15/18 at 9:05 a.m., found the resident seated in a wheelchair outside on the front sidewalk smoking a cigarette. No staff were monitoring the resident. Closer observation noted holes in his sweatpants that looked like burn holes from cigarette ashes. Accompanied by another surveyor, the resident was observed again. The wind was blowing and ashes were falling from the cigarette onto his sweat pants. The resident appeared unaware of the ashes falling onto his clothing as he made no attempt to brush the ashes from his clothing. There was no ashtray or receptacle for ashes and cigarette butts near the resident. The area where the resident was smoking had a No smoking allowed within 15 feet of an exit door and near operable windows sign posted. At 9:30 a.m., accompanied by the Chief Executive Officer (CEO), a third observation of Resident #35 found he had moved to another area of the sidewalk. He was not smoking, but the CEO could see the holes in the resident's sweatpants. During the afternoon of 05/15/18, review of the facility's smoking policy, with a revision date of 06/17/17, found the policy directed smoking supplies were to be stored by staff with the resident's name and room number in a suitable cabinet in the nursing station. Additionally, the policy stated in individual special circumstances, the resident might need to wear a smoking apron during smoking. If the resident was cognitively able, the resident could secure all smoking materials in a locked compartment. According to the policy, residents were not allowed to keep lighters or matches. Review of the resident's minimum data set (MDS) assessments, an annual with an assessment reference date (ARD) of 09/09/17 and two (2) subsequent quarterly assessments with ARDs of 12/08/17 and 03/08/17, found his Brief Interview for Mental Status (BIMS) identified he score 6 on all 3 assessments. A score of 6 indicated he had severe cognitive impairment. The quarterly assessments also identified he resisted care 1 to 3 days during the assessment look back periods. The resident's behaviors were addressed in his care plan. Observation on 05/15/18, and by resident and staff interviews, found the resident always kept his lighter and cigarettes on his person in the waistband of his clothing. He did have a compartment in his room to store his smoking materials, but refused to use the compartment A smoking evaluation dated 01/04/18, identified the resident as safe to hold a cigarette, put out ashes, and he did not need a smoking apron. The care plan identified him as being able to smoke according to his smoking assessment which stated he demonstrated safe independent smoking. This care plan, implemented 06/13/16, had the most recent revision on 01/14/18. An interview with the CEO and director of nursing on 05/15/18 at 1:15 p.m. revealed he had a change of condition recently. On 05/04/18, he began pushing and kicking, rejecting care and making disruptive sounds. The CEO and Director of Nursing (DON) reported the resident was known to have paranoid [MEDICAL CONDITION] and behavior changes with increased agitation. Additional interview with the CEO on 05/15/18 at 3:30 p.m., revealed the staff felt the resident had been determined to be safe to smoke independently and had not been seen to be unsafe during his smoking assessment. The resident was known to wear the pants with holes frequently, but the CEO was unaware of the holes in the clothing until the immediate jeopardy was brought to her attention. findings were determined to pose a potential for serious harm to the safety and well-being of Resident #35 and to other residents residing in the facility. The Chief Executive Officer (CEO) was informed these findings constituted an immediate jeopardy to the safety and well-being of Resident #35 and to the facility's other residents on 05/15/18 at 9:24 a.m. Written notification of the findings leading to the determination of immediate jeopardy and request for a plan of correction were provided to the CEO. The facility provided an acceptable plan of correction and after verifying implementation of its plan, the immediate jeopardy was abated at 4:30 p.m. on 05/15/18. After removal of the immediate jeopardy, no deficient practice remained for this requirement. b ) The facility's plan of correction May 15, (YEAR) 12:15pm 1) The Administrator immediately assigned 1:1 supervision to resident #35, on (MONTH) 15, (YEAR) at approximately 9:15am to observe resident for safe use of lighter and smoking materials and to offer/encourage use of safety garment to ensure resident sustains no injury or causes no harm to other residents. He will remain on 1:1 supervision until he is compliant with Smoking Policy. Resident will be encouraged to move 15 foot away from building. Resident #35 will be offered a smoking blanket on his next smoking activity. He and responsible party will be reeducated on smoking policy and desigated area. Administrator identified holes in pants, but nature of cause could not be determined. Resident has very limited clothing and could not determine age of holes. Skin Assessment was attempted, but refused by resident #35. A Skin Assessment had previously been completed on (MONTH) 15, (YEAR), with no skin integrity issues identified. Resident continued to smoke safely, with 1:1 supervision, due to noncompliance with smoking materials and smoking area at 2:30 Social Worker and Administrator explained need for all smoking material and retrieved smoking material at 3:30pm. Staff will continue to provide 1:1 supervision for 24 hours and re-assess at that time. Resident #35, assessment will reflect supervised smoking required, including wearing apron/blanket. 2) At 9:30am the Administrator had all resident rooms checked for smoking materials. No additional smoking material was found at this time. All residents of the facility who smoke have the potential to be effected. No residents of the facility have experienced any negative outcome. The Administrator/designee will re-educate smoking residents/responsible party regarding facilities Smoking Policy on (MONTH) 15, (YEAR), and upon admission and readmission. 3) The Administrator/designee will re-educate all center staff to ensure residents smoking supplies are secured at all times, including lighters, with a post-test to validate understanding, on (MONTH) 15, (YEAR). Staff not available during this time frame will be provided re-education including post-test by Practice Development Specialist/Designee upon return to work. New staff during orientation will be provided education including post-test by PDS/designee. 4) Independent resident smoking materials will be maintained in the medication room, on each unit and signed out by resident/staff and signed back in with the nurse/designee at the completion of the smoke break across all shifts, 7 days per week. Audits will be conducted by Director of Nurses/designee daily across all shifts x 2 weeks then 3 x per week x 2 weeks then randomly thereafter to ensure that smoking materials are secured. 5) Trends identified will be reported by the Director of Nurses/designee monthly at the Quality Improvement Committee (QIC) for any additional follow up and/or in servicing until the issue is resolved and randomly thereafter as determined by the QIC committee.

Based on medical record review, observation, resident interview, and staff interview, the facility failed to ensure nine (9) of twenty-three (23) residents, reviewed during Stage 2 of the Quality Indicator Survey (QIS), received care and services to attain or maintain the highest practicable level of well-being, in accordance with their individual comprehensive assessments and plans of care. For Resident #71, the facility failed to initiate its bowel protocol and also failed to assess and effectively treat the resident's pain related to vertebral (spinal) compression fractures. These failures resulted in actual harm to the resident. For Residents #29, #111, #187 and #48, the facility failed to initiate the bowel protocol when the residents had no documented bowel movements for three (3) consecutive days . The facility failed to ensure the corroboration of Resident #150's care with the [MEDICAL TREATMENT] center, and failed to follow its policy for care of a resident receiving [MEDICAL TREATMENT] services. For Resident #84, the facility failed to obtain a physician ordered test for an ankle-brachial index (ABI) test (a test used to diagnose [MEDICAL CONDITION] (PAD). The ABI compares blood pressure in the ankle to blood pressure in the arm. This test shows how well blood is flowing in the limbs) in a timely manner. The facility failed to follow a physician's orders [REDACTED]. For Resident #23, who required the removal of an ingrown toenail, the facility failed to schedule a timely appointment with a podiatrist. Resident identifiers: #71, #29, #111, #187, #48, #150, #84, #72 and #23. Facility census: 117. Findings include: a) Resident #71 1. Bowel Management Review of Resident #71's medical records, on [DATE] at 1:00 p.m., found the resident was admitted to the facility on [DATE]. The resident's [DIAGNOSES REDACTED]. The resident's Brief Interview for Mental Status (BIMS), completed on the admission Minimum Data Set (MDS) with an assessment reference date (ARD) of [DATE] score was 13, indicating the resident was cognitively intact. On [DATE] at 1:30 p.m., review of Resident #71's Activities of Daily Living Record (ADL) since admission on [DATE], found the record reflected the following bowel movements (BM): -- [DATE] on the 11:00 p.m. - 7:00 a.m. shift - a small soft formed BM, -- [DATE] on the 11:00 p.m. - 7:00 a.m. shift - a medium soft formed BM, -- [DATE] on the 3:00 p.m.-11:00 p.m. shift - a medium soft formed BM, --[DATE] on the 7:00 a.m.-3:00 p.m. shift- a medium soft formed BM On [DATE] at 2:30 p.m., review of Resident #71's Medication Administration Record [REDACTED]. The MAR for [DATE], revealed on [DATE] at 4:56 a.m., the hospital physician recommended to start [MEDICATION NAME] (stool softener) 100 milligrams (mg) by mouth (PO) twice a day (BID). The facility physician approved the order for [MEDICATION NAME] and staff administered the medication at 9:00 a.m. on [DATE]. On [DATE] at 8:56 p.m., Nurse Practitioner (NP) #129 saw Resident #71 and wrote an order to discontinue [MEDICATION NAME] and start Senna concentrate/[MEDICATION NAME] (Senna-S) 8XXX,[DATE] mg - give two (2) tablets PO at night (HS). The Senna-S was started on [DATE] at 9:00 p.m. Resident #71 was transported to a hospital emergency room (ER) on [DATE] at 9:40 p.m., due to complaints of back pain. During the ER visit, the resident had a radiology imaging (x-ray) completed. Two (2) views of the abdomen showed retained fecal debris likely causing ileus (Inability of the intestine (bowel) to contract normally and move waste out of the body.) Resident #71 was administered one (1) 300 milliliter (ml) bottle of Magnesium [MEDICATION NAME] for relief of constipation 2. Pain Management In an interview, on [DATE] at 9:45 a.m., Resident #71 voiced she experienced severe pain in her lower back and abdomen when she attempted to sit on the commode to have a bowel movement the previous evening ([DATE]). She reported she had to be sent to a local emergency room for treatment of [REDACTED]. Upon inquiry, she rated her pain during the interview as a six (6), on the zero (0) to ten (10) scale, with zero (0) being no pain and ten (10) being the worst possible pain imaginable. She stated she had just been given a pain pill. Review of the resident's MAR indicated [REDACTED]. The medication should have been effective at the time of the interview. Observation of Resident #71, on [DATE] at 1:15 p.m., found her in bed. Her skin was pale in color and facial grimacing was noted. The resident had slid down in the bed with her back brace intact. The back brace had slid up under her armpits and was not providing support to the lower back as intended. There was an abrasion on the resident's right outer ankle, and her foot was slightly swollen and discolored. During this observation, Resident #71 expressed she was having severe pain in her back and her right foot. She rated her pain at ten (10), on the zero (0) to ten (10) scale. At 9:20 a.m. on [DATE], a review of the Minimum Data Set (MDS) assessments revealed an admission MDS assessment, with an assessment reference date (ARD) of [DATE]. Section J, Health Conditions, Item J0100 Pain Management, has a 5-day reference period. Section J of the resident's assessment indicated she had: -- not received scheduled pain medication in the last five (5) days -- had received as needed (PRN) pain medication in the last five (5) days, and -- had received non-medication interventions for pain in the last five (5) days. The Pain Assessment Interview, J0300, Pain Presence, indicated the resident had pain or hurting in the last five (5) days, almost constantly. Item J0500 - Pain Effect on Function, indicated the pain over the last five (5) days had made it hard to sleep at night and had limited her day-to-day activities. Pain Intensity, J0600 A. Numeric Pain Rating, indicated the resident had rated her pain at a five (5), on the zero (0) to ten (10) scale. At 11:00 a.m. on [DATE], review of the physician orders [REDACTED].#71: -- Order date [DATE] for [MEDICATION NAME] ,[DATE] mg by mouth every six (6) hours as needed (PRN) for pain. The order was discontinued on [DATE]. -- Order date [DATE] for Tylenol tablet 325 mg - give two (2) tablets to equal 650 mg by mouth every eight (8) hours for two (2) days PRN for pain. The order was discontinued on [DATE]. -- Order date [DATE] for [MEDICATION NAME] ,[DATE] mg tablet by mouth every six (6) hours PRN for pain. The order was discontinued on [DATE]. -- Order date [DATE] for [MEDICATION NAME] tablet ,[DATE] mg by mouth every six (6) hours PRN for pain. The order was discontinued on [DATE]. -- Order date [DATE] for [MEDICATION NAME] 7XXX,[DATE] mg by mouth every four (4) hours PRN for back pain. The order was discontinued on [DATE]. -- Order date [DATE] for [MEDICATION NAME] ,[DATE] mg by mouth every four (4) hours PRN for pain. The order was discontinued on [DATE]. -- Order date [DATE] for [MEDICATION NAME] ,[DATE] mg by mouth every four (4) hours PRN for pain. The order was discontinued on [DATE]. -- Order date [DATE] for [MEDICATION NAME] 7XXX,[DATE]mg tablet by mouth every eight (8) hours PRN for pain. The order was discontinued on [DATE]. -- Order date [DATE] for [MEDICATION NAME] 7XXX,[DATE]mg tablet by mouth every six (6) hours PRN for pain. On [DATE] at 11:30 a.m., a review of the progress notes revealed the following entries related to the resident's pain status: -- [DATE] at 15:43 (3:43 p.m.), Registered Nurse (RN) #3 wrote, . abdomen swollen and painful to touch -- [DATE] at 16:10 (4:10 p.m.), Licensed Practical Nurse (LPN) #100 noted, . patient describes the pain 6 out of ,[DATE] scale to the abdominal area. Patient states the pain radiates to lower back area -- [DATE] at 17:02 (5:02 p.m.), LPN #100 documented, resident transferred to emergency room due to abdominal distention, abdominal pain and infection to choledocholithiasis (the presence of at least one gallstone in the common bile duct ) drainage tube site -- [DATE] at 12:50 (12:50 p.m.), RN #1 noted, . complaints of abdominal pain, prn medication given as ordered effective -- [DATE] at 02:36 (2:36 a.m.), RN #42, noted, . medicated one time for abdominal pain with effectiveness -- [DATE] at 18:18 (6:18 p.m.), LPN #82 wrote, Pain medication continues prn with positive effects -- [DATE] at 10:36 (10:36 a.m.), LPN #29 wrote, . prn pain medication given with effectiveness -- [DATE] at 20:45 (8:45 p.m.), LPN #82 documented, . Called to room by the nursing assistant, the patient stated that her back was killing her, she rates the pain a 10, and the patient stated I need to go to the hospital . resident transferred to the emergency room -- [DATE] at 04:56 (4:56 a.m.), LPN #67 noted, resident returned to facility . with [DIAGNOSES REDACTED]. -- [DATE] at 12:56 (12:56 p.m.), by LPN #82, documented, .patient continues [MEDICATION NAME] prn . has requested [MEDICATION NAME] twice this morning with positive effects . however resident refuses to get out of bed -- [DATE] at 20:43 (8:43 p.m.), Nurse Practitioner (NP) #129 wrote, .currently prescribed [MEDICATION NAME] ,[DATE] mg one tablet by mouth every four (4) hours prn and continues to complain of low back pain which she rates at 10 on scale of ,[DATE]. Describes pain as sharp, constant and worse with movement -- [DATE] at 11:29 (11:29 a.m.), the attending physician wrote, Compression [MEDICAL CONDITION] lumbar vertebrae - no fractures noted on lumbar x-rays last month, this may be the reason for some of her increased pain, will increase [MEDICATION NAME] and order an MRI- kyphoplasty (a surgical procedure to stabilize the spine) may be an option. -- [DATE] at 10:57 (10:57 a.m.), NP #129 noted, resident request to be transferred to emergency room due to low back pain. She rates pain 10 on ,[DATE] scale, describes as constant, sharp, and non-radiating. On [DATE] the attending physician increased [MEDICATION NAME] to ,[DATE] mg one by mouths every four (4) hours prn (has asked for the medication every four (4) hours -- [DATE] at 10:58 (10:58 a.m.), LPN #82 noted, . resident requesting to go to hospital due to uncontrolled back pain -- [DATE] at 22:04 (10:04 p.m.) by LPN #82, wrote, . patient returned from the hospital at this time .TSLO (thoracolumbar sacral orthosis) back brace in place -- [DATE] at 10:18 (10:18 a.m.), LPN #82, documented, .patient complaining of right foot pain . right foot is mildly [MEDICAL CONDITION] and has an abrasion on the right ankle -- [DATE] at 11:32 (11:32 a.m.), NP #129, NP noted, . resident complains of right foot pain which she rates at a 10 on ,[DATE] scale. She report initially the pain in right foot started last night however, asked a few minutes later and she states pain began one week ago (inconsistent in her story) Symptoms were not present on [DATE] when she was evaluated by myself. She describes pain as sharp and constant rates 10 on ,[DATE] scale . redness and slight [MEDICAL CONDITION] noted to the right ankle with a superficial abrasion to the right ankle . will obtain an x-ray of the right foot ., -- [DATE] at 14:51 (2:51 p.m.) by LPN #82, wrote, . X-ray of right foot is normal . patient rates pain at 10 on follow-up On [DATE] at 10:00 a.m., a review of the resident's care plan identified the following focus areas: -- Focus - Resident exhibits or is at risk for alteration in comfort related to chronic pain, generalized pain, abdominal pain, and [MEDICAL CONDITION]. -- Goals - Resident will achieve acceptable level of pain control through next review. -- Interventions - Evaluate pain characteristics: quality, severity, location, precipitating/relieving factors. Utilize pain scale, evaluate resident's past coping mechanism to determine what measures work best (relaxation, diversional activities, visualization). Medicate resident as ordered for pain and monitor for effectiveness and monitor for side effects, report to physician as indicated. Monitor for non-verbal signs/symptoms for pain and medicate as ordered. Complete pain assessment per protocol. Monitor for change in mood or mental status. Review of the MAR indicated [REDACTED] [MEDICATION NAME] ,[DATE]mg was administered on the following dates and times: -- [DATE] at 2:30 p.m., -- [DATE] at 6:00 a.m., 12:00 p.m. and 9:30 p.m., and -- [DATE] at 9:00 a.m. [MEDICATION NAME] ,[DATE] mg was administered on the following dates and times: -- [DATE] at 9:00 a.m. and 5:00 p.m., -- [DATE] at 9:00 p.m., --[DATE] at 2:00 a.m., 10:00 a.m., 5:00 p.m. and 11:00 p.m., -- [DATE] at 9:00 a.m. and 5:00 p.m., -- [DATE] at 2:00 p.m., -- [DATE] at 8:00 p.m., -- [DATE] at 8:00 a.m., -- [DATE] at 5:00 p.m., -- [DATE] at 5:00 p.m., -- [DATE] at 10:30 p.m., -- [DATE] at 8:30 a.m., -- [DATE] at 5:00 p.m., and -- [DATE] at 8:00 a.m., 1:30 p.m. and 5:30 p.m. [MEDICATION NAME] ,[DATE] mg was administered on the following dates and times: -- [DATE] at 9:30 p.m., and -- [DATE] at 1:30 a.m. and 12:00 p.m. [MEDICATION NAME] ,[DATE] mg was administered on the following dates and times: -- [DATE] at 12:00 a.m., 4:00 a.m., 8:00 a.m., 12:00 p.m., 4:00 p.m. and 10:00 p.m., -- [DATE] at 2:30 p.m., --[DATE] at 3:00 a.m., 8:00 a.m., 1:00 p.m. and 5:00 p.m., and -- [DATE] at 2:00 am, 8:00 a.m. and 2:00 p.m. [MEDICATION NAME] 7XXX,[DATE] mg was administered on the following dates and times: -- [DATE] at 3:00 p.m., and -- [DATE] at 2:30 a.m. There was no evidence which indicated the use of non-pharmacological interventions prior to the administration of the pain medication. In addition, there was no evidence of pain rating prior to and/or after the pain medication was administered. An interview with NP #129, on [DATE] at 11:15 a.m., revealed there was no evidence staff attempted non-pharmacological interventions prior to the administration of pain medication. During the interview, after reviewing the MARs, she confirmed there was no evidence nurses consistently assessed the resident's pain rating before and after the administration of medications. b) Resident #29 Review of Resident #29's medical records on [DATE] at 2:00 p.m., found the resident was admitted to the facility on [DATE]. His [DIAGNOSES REDACTED]. Review of Resident #29's Activities of Daily Living (ADL) Records for the months of August and [DATE], on [DATE] at 2:30 p.m., found his record identified he had bowel movements on: -- [DATE], on the 7:00 a.m.-3:00 p.m. shift - a large soft formed, and -- [DATE], on the 7:00 a.m.-3:00 p.m. shift - a medium soft formed. On [DATE] at 2:25 p.m., review of the resident's MARs for August and [DATE] found no medication was used to treat constipation (laxatives and/or stool softeners). c) Resident #111 On [DATE] at 2:30 p.m., review of Resident #111's ADL Record for the month of [DATE] found the following documented bowel movements: -- [DATE] on the 3:00 p.m.-11:00 p.m. shift - a large soft formed BM -- [DATE] on the 7:00 a.m.-3:00 p.m. shift - a medium soft formed BM Further review of Resident #111's medical record, on [DATE] at 2:45 p.m., found no evidence of a medication used to treat constipation (laxatives and/or stool softeners) documented on the [DATE] MAR. d) On [DATE] at 2:45 p.m., Director of Nursing (DON) #35 provided the facility's bowel protocol. The bowel protocol directed: 1. 11:00 p.m. - 7:00 a.m. shift will check the bowel movements and make a list for residents not having a medium or larger bowel movement in the last three (3) days. 2. If no bowel movement - give Milk of Magnesia at 6 a.m. 3. If no relief, give [MEDICATION NAME] suppository at 2 p.m. 4. If no relief follow-up with a Fleets enema once at 10:00 p.m. 5. If no results the 7:00 a.m.- 3:00 p.m. shift will call the physician for further orders. In an interview on [DATE] at 3:20 p.m., DON #35 confirmed Resident #71, #29, and #111 had no and/or only a small bowel movement (small not counted as per the protocol) documented [DATE] through [DATE] (8 days) and [DATE] through [DATE] (7 days). She stated, The bowel protocol should have been initiated after three (3) consecutive days without a bowel movement. e) Resident #187 Resident #187 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On [DATE] at 1:45 p.m., review of the Section G - Functional Status of the Significant Change Minimum Data Set (MDS) assessment with an assessment reference date (ARD) of [DATE], found Item G0110, ADL Assistance indicated the resident was totally dependent, requiring the assistance of one (1) staff member for toileting. Section H, the Bladder and Bowel section, H0400 (Bowel Continence) was marked as not rated, not assessed. The Resident Assessment Instrument (RAI) Version 3.0 Manual coding instructions for Section H0400 include, Code 9, not rated if during the seven (7) day look-back period the resident had an ostomy or did not have a bowel movement for the entire seven (7) days. (Note that these residents should be checked for fecal impaction and evaluated for constipation.) At 2:30 p.m. on [DATE], a review of the care plan for Resident #187 identified the focus area, . at risk for gastrointestinal (GI) symptoms or complications related to constipation, created on [DATE]. The goal stated the resident would not develop GI complications through the next review. Interventions for the focus area included: -- Administer medications as ordered and observe for effectiveness and side effects and report to the MD (medical doctor) as indicated, -- Monitor and record bowel movements, -- Assess for signs and symptoms of constipation Review of the ADL flow sheets for July, August, and [DATE], on [DATE] 2:45 p.m., found no evidence Resident #187 had a bowel movement for three (3) or more days on ten (10) occurrences. The dates included: [DATE]: -- [DATE] through and including [DATE] - seven (7) days, -- [DATE] through and including [DATE] - four (4) days, -- [DATE] through and including [DATE] - three (3) days, and -- Between [DATE] through and including [DATE], a ten (10) day time span, only one (1) incontinent, medium, soft, loose bowel movement was identified as occurring on [DATE]. [DATE] -- [DATE] through and including [DATE] - seven (7) days, -- [DATE] through and including [DATE] - three (3) days, -- [DATE] through and including [DATE] - three (3) days, and -- [DATE] through and including [DATE] - five (5) days. [DATE] -- [DATE] through and including [DATE] - five (5) days, -- [DATE] through and including [DATE] - three (3) days, and -- [DATE] through and including [DATE] - six (6) days. At 3:00 p.m. on [DATE], a review of Resident #187's physician's orders [REDACTED]. Also identified was an order dated [DATE], to administer [MEDICATION NAME] 2 mg (milligrams), two (2) tablets by mouth after the first loose stool, but no more than four (4) tablets in 24 hours, to be administered as needed for three (3) days. On [DATE] at 3:10 p.m., a review of the resident's MARs for the months of July, August, and [DATE] found the ordered Milk of Magnesia (MOM) had never been marked as administered to the resident. The medication [MEDICATION NAME] was administered on [DATE] at 1:00 p.m., and noted as effective. At 10:20 a.m. on [DATE], when asked if the facility had a bowel protocol or policy, Licensed Practical Nurse (LPN) #67 said the facility had a bowel protocol. Upon inquiry, LPN #67 said, If a resident has gone three days without a BM, the resident was given 30cc of MOM at 6:00 a.m. If during the day shift the resident still had no BM, the resident was given a suppository, and if still no BM on the evening shift, the resident was given a Fleets enema. If the resident still had not had a BM by the next morning, the physician was notified. When asked how the nurses were aware of the residents' BM status, she said the night shift nurses reviewed the ADL sheets every night. The LPN said if a resident had gone three (3) days without a BM, the bowel protocol was initiated and MOM was administered at 6:00 a.m. On [DATE] at 10:50 a.m., the care plan, progress notes, ADL flow sheets for July, August, and [DATE], the Kardex (used to communicate the resident's care needs to direct care staff), and the MARs for August and [DATE] were reviewed with Registered Nurse (RN) #87. The review found no evidence to indicate the facility initiated the bowel protocol during this time for Resident #187. At 1:00 p.m. on [DATE], the findings regarding Resident #187 were reviewed with Director of Nursing (DON) #35. She verified there was no evidence the facility's bowel protocol was initiated when the resident did not have a BM for greater than three (3) days. She further verified there was no evidence which indicated the resident was checked for a fecal impaction or constipation when the resident had gone as many as seven (7) days without a BM. On [DATE] at 1:30 p.m., the ADL flow sheets regarding the resident's bowel patterns were reviewed with the facility's Certified Nurse Practitioner (NP) #129. She stated she was not made aware of the resident's bowel patterns. She said her first notification related to the resident's bowel status was on [DATE], when the husband told her the resident had an occurrence of diarrhea. The NP stated she wrote the order for [MEDICATION NAME] in response to the husband's report of diarrhea. Upon review of the ADL flow sheets and the MARs for Resident #187, the NP verified there had been a potential for fecal impaction related to the resident's bowel patterns, and the bowel protocol should have been initiated on several occurrences. f) Resident #150 1. A review of the resident's medical records, beginning on [DATE] at 2:15 p.m., found Resident #150 was readmitted to the facility on [DATE], after a hospital admission for an acute illness. The resident was readmitted to the facility as a new [MEDICAL TREATMENT] patient. On [DATE] at 2:25 p.m., a review of the admission orders [REDACTED] a. The resident was to receive [MEDICAL TREATMENT] on Tuesdays, Thursdays, and Saturdays, with a pick up time of 6:00 a.m. The [MEDICAL TREATMENT] center's telephone number was included in the order. b. No blood pressures were to be taken in the resident's right arm, every shift. c. To monitor the Permacath (a catheter inserted to allow vascular access for [MEDICAL TREATMENT]) site to the resident's right chest for bleeding, signs and symptoms (S/S) of infection and pain, every shift. d. The facility was to obtain weights and communication forms from [MEDICAL TREATMENT], and document post [MEDICAL TREATMENT] weights, every day shift on Tuesdays, Thursdays, and Saturdays. e. A snack was to be sent with the resident for every [MEDICAL TREATMENT] treatment. At 2:40 p.m. on [DATE], the communication forms shared by the facility and the [MEDICAL TREATMENT] center were reviewed. The facility was to complete the top half of the form, which included the resident's vital signs, including weight, before the resident left the facility for [MEDICAL TREATMENT], an examination of the access site, the time of the resident's last meal, medications given prior to [MEDICAL TREATMENT], the resident's general condition, and special instructions. The [MEDICAL TREATMENT] center was to complete the bottom half of the form which also included obtaining vital signs, including weight after [MEDICAL TREATMENT], lab (laboratory) work done, medications given, intake and output, monitoring of the access site, as well as any change in condition or other pertinent information. Neither the facility, nor the [MEDICAL TREATMENT] center consistently recorded the resident's information before and after the [MEDICAL TREATMENT] treatments. At the time of review, Resident #150 had been scheduled to receive [MEDICAL TREATMENT] on six (6) occasions. The resident received [MEDICAL TREATMENT] on [DATE], [DATE], [DATE], [DATE], [DATE], and [DATE]. Four (4) [MEDICAL TREATMENT] communication forms were identified for review. Review of the four (4) [MEDICAL TREATMENT] communication forms found the resident's pre and post [MEDICAL TREATMENT] vital signs, including weights and other information, were not recorded by the facility or the [MEDICAL TREATMENT] center. No communication forms were located for [DATE] and [DATE]. 2. On [DATE] at 3:00 p.m. a review of the resident's current care plan, created on [DATE], identified the focus area, Resident exhibits or is at risk for impaired renal function and is at risk for complications related to CKD ([MEDICAL CONDITION]), and [MEDICAL TREATMENT]. The goal was for the resident to avoid fluid overload through the next review. Interventions associated with this focus area included: a. Do not take BP (blood pressure) in right arm b. Monitor external [MEDICAL TREATMENT] catheter and site for catheter integrity, excessive redness, swelling, pain at site, signs and symptoms of infection and excessive bleeding from site, and report to physician as indicated c. Monitor for signs and symptoms of fluid overload i.e. increased SOB (shortness of breath), increased fatigue, significant weight gain, [MEDICAL CONDITION], etc. and notify physician of any significant changes d. Request pre and post weight from [MEDICAL TREATMENT] center At 3:15 p.m. on [DATE], a review of the MAR indicated [REDACTED]. The boxes on the form for [DATE], [DATE], [DATE], and [DATE] were blank, with no initials or weights indicated. On [DATE] at 3:45 p.m., when asked, Resident #150 said she had not missed a [MEDICAL TREATMENT] treatment since they were started. When asked what the facility did related to the [MEDICAL TREATMENT] treatments, the resident said a snack was sent with her, and she was always transported by 6:30 a.m. When asked about her [MEDICAL TREATMENT], and how the nurses monitored the site, the resident stated, None of the nurses here have ever asked to look at it, everything is done when I go to [MEDICAL TREATMENT]. Observation of the resident's Permacath to the right chest revealed a dry, intact dressing covered the site. There were no initials or dates indicated on the dressing. The skin surrounding the dressing was pink and intact. At 4:05 p.m. on [DATE], the findings regarding the [MEDICAL TREATMENT] review, including physician's orders [REDACTED].#95. The RN verified the [MEDICAL TREATMENT] communication forms were incomplete. A review of the MAR indicated [REDACTED]. Upon inquiry, RN #95 verified the resident was alert and oriented, and demonstrated the capacity to make medical decisions. On [DATE] at 8:40 a.m., Director of Nursing (DON) #131 was made aware of the [MEDICAL TREATMENT] findings. She agreed the communication forms were not completed. She stated the sheets were sent with the resident, and returned with the resident; however, the [MEDICAL TREATMENT] center was not consistent with filling out or retuning the forms. She said a new, lime-green folder, which contained the [MEDICAL TREATMENT] communication forms, were to be sent with each resident when leaving the facility for [MEDICAL TREATMENT] treatment. DON #131 said the facility had been in contact with the [MEDICAL TREATMENT] center, and both parties had agreed to look for the folder, and complete both halves of the communication form. If the necessary information was not on the forms, the facility nurses were to call the [MEDICAL TREATMENT] center for the necessary information needed to complete the forms. g) Resident #84 Closed record review at 8:30 a.m. on [DATE], found this eighty-seven (87) year old female resident was admitted to the facility on [DATE] and expired at the facility on [DATE] at 6:56 p.m. Upon admission, the physician determined the resident lacked capacity to make medical decisions; therefore, her medical power of attorney (MPOA) completed the resident's admission paper work. Review of the resident's Physician order [REDACTED]. In addition, the MPOA designated Llimited interventions: use medical treatment, antibiotics, IV fluids, and cardiac monitoring as indicated. Do not use intubation or mechanical ventilation. Transfer to hospital if indicated. Avoid intensive care unit. The resident's admitting [DIAGNOSES REDACTED]. She was not receiving Hospice services, nor was there an indication she had a life expectancy of six (6) months or less. According to the medical record, the resident received physical, occupational, and speech therapy. The resident was receiving [MEDICATION NAME] 40 milligrams, two (2) times a day for a [DIAGNOSES REDACTED]. Resident noted to have +3 [MEDICAL CONDITION] to BLE (bilateral lower extremities). Tips of toes are noted to cyanotic (bluish color due to poor circulation or oxygenation). Bilateral pedal pulse is not palpable at this time. Bilateral posterior tibial pulse is weak . skin is cool The entry contained observations by the nurse, Regular apical heart rhythm, the same as previous state regular breathing pattern lungs clear absent right pedal pulse, absent left pedal pulse, non pitting right LE (lower extremity) [MEDICAL CONDITION], non pitting left LE [MEDICAL CONDITION], normal to ethnicity nail bed color, right LE cyanotic, left LE cyanotic, right LE cool, left LE cool The nurse notified the resident's physician and responsible party of the change in condition. Upon notification, certified family nurse practitioner (NP) #129 examined the resident. At 1:29 p.m. on [DATE], the NP wrote, Staff request I eval (evaluate) (name of resident) due to discoloration to the feet and [MEDICAL CONDITION]. The [MEDICAL CONDITION] has been chronic however, the discoloration was noted today. No report of pain, injury, fever or SOB (shortness of breath) On [DATE], the NP ordered ABIs (Ankle-Brachial Index - used to predict the severity of [MEDICAL CONDITION]) of the resident's bilateral lower extremities. On [DATE], a physician's orders [REDACTED]. An appointment was

I Based on medical record review, review of the facility's abuse and neglect reports, review of the facility's incident reports, abuse and neglect policy review, and staff interview, the facility failed to administer medications as ordered by the physician resulting in actual harm to Resident #222. This resident was admitted on [DATE] with a [DIAGNOSES REDACTED]. After a condition change was experienced 12/14/12, it was identified his diabetic medication had not administered as ordered by the physician since his admission. Failure to administer this medication resulted in the resident experiencing a critically high glucose level of eight hundred and thirty eight (838) milligrams per deciliter (mg/ml) resulting in hospitalization with a [DIAGNOSES REDACTED]. The failure to ensure medications were properly transcribed from the physician's orders [REDACTED]. On 03/13/13 at 12:55 p.m., the facility was notified the lack of an effective system to ensure medications were correctly administered to residents as ordered by the physician, after admission or readmission was determined to be an Immediate Jeopardy (IJ) situation and placed other residents at risk for harm. At 4:57 p.m. on 03/13/13, it was determined the facility had removed the jeopardy and ensured the safety of the residents. The facility reviewed the resident's physician orders [REDACTED]. A process for identifying medication orders which were not completely transcribed to the MAR indicated [REDACTED]. The facility educated all nurses present at the facility on 03/13/13. They also initiated a plan to educate all other nurses on the new process to ensure medications were administered as ordered, before these nurses would be permitted to work. The facility also was going to review new admission orders E." Findings include: a) Resident #222 This resident was admitted to the facility on [DATE]. His discharge summary from the hospital revealed he had problems with his blood glucose during his hospitalization . Due to this, adjustments were made to his insulin, and he was also placed on a sliding scale insulin regimen at the hospital. His discharge instructions from the hospital, dated 12/11/12, included instructions for the resident to receive "Insulin [MEDICATION NAME] ([MEDICATION NAME]) 100 unit/ml solution 45 units subcutaneous daily every evening." This was verified and ordered by the physician at the nursing home. In addition, the physician at the nursing gave instructions to "Notify the MD (medical doctor) if blood sugar less than 60 or greater than 400." The Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. Even though the hospital records indicated the resident's blood sugars had not been well controlled, and there was an order to notify the doctor if his blood sugars were below 60 or above 400, the MAR indicated [REDACTED]. A nursing note, written on 12/14/12 at 12:25 p.m., stated, "CNA (certified nursing assistant) reported resident to be vomiting large amount of brown emesis. NP (nurse practitioner) aware. N.O. (new order) [MEDICATION NAME] 25 mg po (by mouth) q (every) six (6) hours." According to the medical record, the nurse practitioner examined the resident on 12/14/12 at 1:06 p.m. She recorded in her progress notes the chief complaint as, "Resident was with nausea, vomiting today. He has vomited a large amount of food and fluid. He and CNA both report that he has had excessive thirst today as well, he is drinking two water pitchers at a time. He states this symptom just started today. He does have a history of DM (diabetes mellitus)." The plan established by the NP (nurse practitioner) stated, " Will check STAT labs today: CMP (comprehensive metabolic panel), CBC (complete blood count), HgbA1C (hemoglobin A1C), serum osmolality and urine for UA (Urinalysis) C/S (culture and sensitivity and Osmolality, [MEDICATION NAME] 25 mg orally every six (6) hours as needed for N/V (nausea/vomiting). I am concerned that he could possibly be in DI (diabetes insipidus) urine in Foley appears very dilute." There was no evidence the NP was aware the resident had not been receiving his insulin. The medication was recorded on the physician orders [REDACTED]. The laboratory (lab) results were called to the facility, on 12/14/12 at 19:38. This call alerted the facility the resident's blood glucose was at a critical level. It was 838 mg/ml (normal glucose level 70-108 mg/ml). The lab also reported the resident's lab values indicated he was dehydrated and his osmolality (relative concentration of solute) was elevated. A nursing entry, dated 12/14/12 at 8:00 p.m., noted the physician was aware of the blood glucose level of 838. New orders were received for, "20 units of [MEDICATION NAME] R (regular) x (times) 1 (one) Now and recheck in two (2) hours if over 400 give 10 units if under 400 use s/s coverage. New order was also received for accu-checks TID (three times a day) with meals use sliding scale coverage per orders." At 11:45 p.m. on 12/14/12, another nursing note stated, "Resident given regular insulin at 8:00 p.m. finger stick still registered HI at 10:00 p.m. Physician made aware order to send resident to the hospital for [MEDICAL CONDITION]." The resident was admitted to the hospital with [REDACTED].) The incident report for Resident #222 was reviewed. The report stated the time of discovery for the error was 11:45 p.m. on 12/14/12. A signature on the incident report indicated it was completed, for the medication error, on 12/21/12. The report read, "CNA reported resident to be vomiting large amount of brown emesis. Upon checking blood sugar it was 838 with a new order for insulin per order and recheck in 2 (two) hours. Upon reassessment of blood sugar it was resulted in a high reading. Resident was then sent out for assessment to (the hospital). Upon further investigation it was discovered that the resident had no orders for SSI (sliding scale insulin) and had not up until this point had orders printed off for his insulin. Resident had been without his insulin from 12/11/12 until this point." During an interview with Employee #87, a registered nurse, on 03/12/13, she stated she completed the incident report when this issue was discovered. She stated facility staff thought the resident got his insulin because his insulin vial was open in the medication cart. Employee #87 said facility staff thought it was given, and had just not recorded it on the resident's medication record. She was unable to provide evidence an investigation was completed to further explore this incident. It was determined an Immediate Jeopardy situation existed on 03/13/13 at 12:45 p.m. The facility Administrator (Employee #98) was informed at that time. She was notified actual harm had occurred due to the facility's neglect to administer medications as ordered. She was informed the facility had knowledge of the situation, but failed to investigate the incident, and failed to implement corrective measures to ensure this did not happen to other residents. The administrator was instructed the facility was required to present a plan of correction for the Immediate Jeopardy, to submit for approval at the Office of Health facility Licensure and Certification. She was informed once the plan of correction was accepted, implemented, and the surveyors were satisfied the plan protected the residents, the Immediate Jeopardy would be considered corrected. On 3/13/2013 at 4:57 p.m., the immediate jeopardy was abated, and the scope and severity was reduced to an "E." The Administrator demonstrated the Immediate Jeopardy situation was corrected. The medical records for all admissions since 12/14/12 that were still in the facility were reviewed. It was verified there were 49 residents still residing in the building, who were admitted or readmitted since 12/14/12, who could be affected by this practice. The facility reviewed each of their records. There was also a new process developed for reviewing medication orders and verifying the ordered were transcribed correctly. The facility also was going to review this at each morning meeting. A training plan was implemented starting with the staff in the facility at 03/13/13. . II Based on medical record review and staff interview, the facility failed to provide care and services to maintain the highest practicable well-being for two (2) of forty-four residents reviewed for quality of care in Stage II of the survey. Resident #16 continued to receive a dose of a diuretic medication ([MEDICATION NAME]) for more than six (6) months after the dosage was discontinued by the physician. In addition, this resident was provided medications which were noted as allergies [REDACTED]. Resident #222 did not have a physician's orders [REDACTED]. Additionally, his care plan for the Foley catheter did not contain pertinent information related to the catheter use. Resident identifiers: #16 and #222. Facility Census: 113. Findings include: . a) Resident #16 1) A medical record review for Resident #16 was completed at 9:00 a.m. on 03/12/13. This review revealed the physician wrote an order on 08/07/12 which reduced the resident's daily dosage of [MEDICATION NAME] from 120 milligrams (mg) daily to 80 mg daily. The 40 mg dose at 4:00 p.m. was discontinued. The Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. The 40 mg dose of [MEDICATION NAME] was discontinued as ordered. The resident only received 80 mg daily at 9:00 a.m. for the remaining days in the month of August 2012. Review of the September 2012 monthly orders revealed the 40 mg dose of [MEDICATION NAME] at 4:00 p.m. was on the orders. The order was highlighted in yellow, with a handwritten note on the order which indicated this dose was discontinued on 08/07/12. The MAR for September 2012 was reviewed. The MAR indicated [REDACTED]. The October 2012, November 2012, December 2012, January 2013, February 2013, and March 2013 monthly physician's orders [REDACTED]. The MARs for October 2012, November 2012, December 2012, January 2013, February 2013 and March 2013 revealed the resident received the 40 mg dose of [MEDICATION NAME] at 4:00 p.m., as well as the 80 mg dose of [MEDICATION NAME] at 9:00 a.m. daily. There was no evidence in the medical record which suggested the physician had given an order, after 08/07/12, to increase the resident's [MEDICATION NAME] dosage back to 120 mg daily. In addition, there was no evidence the BMP was obtained on 08/10/12 as ordered on [DATE]. As of 03/12/13, there also was no evidence of monitoring the use of the [MEDICATION NAME] after the order for a BMP on 08/07/12. At 3:12 p.m. on 03/12/13, an interview was conducted with the Director of Nursing (DON). At that time, the DON confirmed the facility did not obtain the ordered BMP on 08/10/12. An interview was conducted with Employee #107, Licensed Practical Nurse (LPN), Unit Manager, at 3:20 p.m. on 03/12/13. Employee #107 reported there was no order to begin giving the [MEDICATION NAME] 40 mg at 4:00 p.m. to Resident #16. He reported she should have only been receiving the [MEDICATION NAME] 80 mg at 9:00 a.m., as of the physician's orders [REDACTED]. . 2) The medical record review for this resident, at 9:00 a.m. on 03/12/13, also revealed the physician's orders [REDACTED]. There was also a focus on the resident's care plan which indicated the resident was allergic to these medications. One of the interventions on the care plan was, "Avoid noted medications and related drugs." These allergies [REDACTED].[REDACTED] Further review of the resident's MARs indicated the resident was receiving medications which contained [MEDICATION NAME] and [MEDICATION NAME]. The physician's orders [REDACTED]. Each physician's orders [REDACTED]. The MARs for the same months revealed the resident received a medication containing [MEDICATION NAME] and/or [MEDICATION NAME] during each of the aforementioned months. In August 2012, September 2012, October 2012, November 2012 December 2012, January 2013, February, and through March 12, 2013, the resident received two (2) to four (4) doses of [MEDICATION NAME] 7.5-500 every day. Each [MEDICATION NAME] 7.5-500 contains 500 mg of [MEDICATION NAME]. Additionally, in February 2013, the resident received four (4) doses of [MEDICATION NAME] 400 mg in addition to the [MEDICATION NAME] 7.5-500. An interview was conducted with the Director of Nursing (DON), Employee #70, at 9:29 a.m. on 03/12/13. The DON confirmed the resident's allergy list contained [MEDICATION NAME] and [MEDICATION NAME]. The DON also confirmed the resident was receiving both of these medications, and had been receiving them both for "...some time." She reported she would talk to the resident and clarify her allergies [REDACTED]. At 9:34 a.m. on 03/12/13 the DON interviewed Resident #16 about her allergies [REDACTED]. The resident was provided medications, which were noted as allergies [REDACTED]. The facility was not aware, until 03/12/13 during the survey, the resident was not allergic to [MEDICATION NAME] and [MEDICATION NAME]. . b) Resident #222 This resident was admitted to the facility on [DATE]. He used a catheter prior to admission to the facility. A medical record review was conducted on 03/12/13. This revealed a care plan, dated 12/12/12,which stated this resident required a Foley catheter related to the [DIAGNOSES REDACTED]." There was nothing written in the blanks to instruct what sizes were to be used. The care plan indicated the catheter would be observed for signs and symptoms of a urinary tract infection and the catheter would be changed every 30 days and as needed. The physician orders [REDACTED]. During an interview with Employee #107, a nurse, at 2:30 p.m. 03/12/13, he verified if the catheter, catheter size and balloon size were not included on the orders when the resident was admitted , the nurse should have told the physician they were not ordered and should have obtained the order. The treatment record was reviewed. There was no evidence the facility was monitoring the catheter for complications, and there was no evidence of a scheduled time for changing the catheter. The use of this catheter was not recorded on the treatment record. According to information from the Centers for Disease Control and Prevention guidelines, the use of a catcher must be monitored for early recognition of signs and symptoms of a urinary tract infection. The facility did not have a plan to monitor this resident's catheter use. .

Based on observation, medical record review, resident interview, staff interview, and a review of the facility's pain management program, the facility failed to adequately assess a cognitively impaired resident who was experiencing pain due to poor dental status. There was no evidence the facility had a process to ensure this cognitively impaired resident was assessed daily to identify if she was suffering from pain and/or to ensure she was getting proper pain relief. The resident had pain when eating and during oral care. There was no evidence this pain was assessed and addressed. The resident's pain medication was ordered as needed (PRN), meaning she could receive pain medication upon request. This cognitively impaired resident experienced confusion, and was not consistently able to verbalize pain, the location of the pain, and/or request pain medication. The facility had no method in place to assess pain in residents who were unable to verbally express pain to staff, creating a potential for the resident to suffer from untreated pain. This was found for one (1) of three (3) sample residents who was reviewed for quality of care. Resident identifier: #81. Facility Census: 113. Findings include: a) Resident # 81 During an interview with Resident #81, on 05/14/13 at 2:00 p.m., several of her teeth were observed missing. The teeth that were present were observed black, broken and decayed. She did not open her mouth very much when she spoke. She was questioned about her teeth and she stated she was getting ready to get them all pulled. She was asked if she had mouth pain, and if her teeth and gums hurt. She stated, "Oh my God yes." When questioned about pain medication, she stated she could not get anything for the mouth pain. The resident stated "Those have to be drawn from the bank and they do not have the money here." The resident then continued saying nonsensical things, and did not answer anymore questions which were asked of her. The medical record was reviewed. This revealed Resident #81 had a physician's orders [REDACTED]. Review of the Medication Administration Record [REDACTED]. Further review of the medical record confirmed that there was no assessment for pain and no evidence this resident had verbalized her teeth and gums hurt. In April 2013, there was nothing documented regarding the resident's teeth except the nurse practitioner's examination of the resident and subsequent suggestion for a dental referral. There was nothing documented in May 2013 regarding the resident's teeth, until 05/14/13 after the issue was brought to the attention of the facility during this survey. There was a note dated 04/30/13, which described the nurse practitioner (NP) examined the resident. The NP recorded the chief complaint as an "acute visit." The note stated, " Resident has very poor dentition and is now complaining of pain when she tries to eat. She has obvious dental caries and decayed teeth and is missing some teeth as well." The plan for treatment stated the residents would be referred to the dentist for evaluation. The NP also stated, "She does have Tylenol available every four (4) hours as needed for pain. Continue to monitor." The resident received a dental consultation. The report from the dentist was reviewed on 05/07/13. It confirmed the resident had decayed teeth. The dentist stated, "The resident's remaining teeth were fractured, decayed and non-restorable." He referred the resident to an oral surgeon for extraction of her remaining teeth. Further review of the record revealed the resident had an appointment scheduled for teeth extraction on 06/27/13. The social worker (SW), Employee #37, was interviewed on 05/14/13 at 2:15 p.m. Accompanied by the social worker, the resident was visited in her room at that time. The SW asked the resident if her mouth bothered her, and the resident stated "yes." The SW asked when it hurt worse. The resident said it hurt worse in the morning and when she ate. When asked, on a scale of one (1) to seven (7), "where" the pain was, the resident pointed to her teeth and said "right there" pointing to her gums. She was questioned about how long she had this pain in her mouth, and she said about a month or so. The resident stated she went to the dentist and they were going to pull her teeth soon. The SW asked the resident if she ever asked for pain medicine. The resident said, "yes but you can't get anything." The resident began saying nonsensical things, but all the while she continued talking about going to the dentist and that she was getting her teeth pulled. The SW told the resident she would have the nurse get her something for pain. After the conversation with the resident, the SW agreed the resident was confused and unable to carry on a conversation, but she was consistent in saying her mouth was hurting. On 05/14/13 at 4:30 p.m., observation revealed registered nurse (RN), Employee #47, approached the resident and asked her if she was having pain. The resident stated, "yes my arms hurt." She proceeded to tell the nurse her arms hurt, as well as her wrist. The nurse asked her about the pain on a scale of one (1) to ten (10). The resident stated that it was a ten (10). The nurse told the resident she had some pain medication for her. The resident asked what the medication was . When the nurse told her it was Tylenol. The resident then said "Tylenol is worthless." The nurse told the resident if the Tylenol did not work, she would call the doctor and get her something else. At 5:00 p.m. the nurse returned to the resident's room and the resident said she was not having any pain. At that time, she not mention anything about mouth pain. At that time, the nurse stated she would consult the nurse practitioner about scheduling the resident's Tylenol so she would not have to ask for it. Review of the medical record revealed a physician's orders [REDACTED]. An interview was conducted with Employee #1, on 05/15/13 at 8:30 a.m. She verified she was the nursing assistant (NA) who took care of Resident #81. When questioned about this resident's mouth pain, Employee #1 stated the resident complains of pain in her mouth when she (the NA) does her oral care. The NA said she had told the nurse, but did not remember when it was, or who she told. Employee #15 was also interviewed on 05/15/13 at 8:30 a.m. He confirmed he was this resident's licensed practical nurse (LPN) that day . When asked about this resident's pain, he stated she was hard to assess. He said she would say she was having pain, yet when approached with medicine, she would say she was not having pain. He was questioned about the facility's process for assessing confused residents for ordered as needed (PRN) pain medications. He stated there was no formal process for this, they just knew to do it. Employee #15 said there was documentation for the administration of scheduled pain medications, but there was no daily assessment for the PRN medications. He stated there was no system in place to document whether or not a resident was having pain. The LPN said nurses depended on the nursing assistants to tell them when a resident such as Resident #81 had evidence of pain. When asked about this resident's pain in the last two (2) weeks, Employee #15 stated he had been on vacation and had not really worked with the resident very much. An interview was conducted with the NP on 05/15/13 at 11:30 a.m. An inquiry was made regarding her note dated 04/30/13 regarding the resident's dental concerns. She was asked how she became aware this resident had mouth pain and/or was complaining of pain when she was eating. The NP stated the nurses had a change of condition book in which they record pertinent information. The NP said that book contained documentation of the resident's pain, and asked for her to see the resident. Permission was obtained to accompany the NP during an examination of the resident on 05/15/13 at 1:45 p.m. The NP asked the resident if she was having pain, and the resident said "yes." Upon further attempts to get information regarding the pain, the resident was not able to tell her the exact location. She changed the location from her heels, her mouth, and her thigh all within a minute. The NP examined the resident and discussed the resident's pain with her. She asked the resident if the pain medication she was receiving was helping, and the resident stated "no." The NP told the resident she would see about getting her something else. The resident stated, "If it is not stronger than Tylenol do not bother." Following the examination of the resident on 05/15/13, the NP wrote a note indicating she and the resident's physician discussed the Tylenol was ineffective for the resident. An order was then written to start [MEDICATION NAME] 5/500 one tablet every twelve (12) hours. A copy of the facility's pain management policy was requested from the director of nursing (DON), Employee #72, on 05/15/13 at 10:30 a.m. The document, titled "Pain Management Program" was reviewed . It was last revised July 2010. There was nothing in this policy to indicate how to assess cognitively impaired residents to assure they are not experiencing pain. The DON confirmed there was nothing in the policy, but stated the nurses were supposed to observe the residents to see if they were having pain. She verified there was not a process to record their observations. The DON also verified if a resident was having pain, this information should be recorded when pain medication was administered. .

Based on medical record review, staff interview, family interview, review of the facility's internal investigations into allegations of abuse / neglect, and confidential staff interviews, the facility failed to provide services to one (1) of fourteen (14) sampled residents to protect the resident from physical harm. Resident #119, who exhibited physically and verbally abusive behaviors towards others, was admitted for inpatient psychiatric care on 05/11/11. Prior to this hospitalization , she had shared a room with Resident #95 and had directed some of her abusive behaviors towards this roommate. Prior to her return, nursing staff expressed concern to administrative personnel that Resident #95 was not able to defend herself against Resident #119, and that Resident #119 should not be returned to the same room. When Resident #119 returned from a psychiatric unit to the facility on [DATE], she was placed in the same room as Resident #95. On 05/31/11, Resident #95's daughter voiced a concern to nursing staff, reporting that Resident #95 had told her she awoke that morning with Resident #119 standing over Resident #95's bed with her hands around her throat and making verbal threats to her. This concern was also reported to the facility's social worker that same day. Later in the day on 05/31/11, Resident #119 threw a cup at Resident #95. On 06/02/11, Resident #119 threw an object at Resident #95 resulting in a laceration to Resident #95's forehead, which required emergency room (ER) treatment. Administrative personnel were aware of Resident #119's physically and verbally abusive behaviors toward others (including her roommate) and failed to implement measures to protect Resident #95 from harm. Resident identifiers: #95 and #119. Facility census: 116. Findings include: a) Resident #95 1. Medical record review for Resident #95 revealed this [AGE] year old female was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. According to her Medicare 30-day minimum data set assessment (MDS) with an assessment reference date (ARD) of 05/03/11, her cognitive status was severely impaired, her speech was clear, she was usually able to make herself understood to others, and she usually understood what was communicated to her. She was totally dependent on staff for bed mobility, locomotion, dressing, toilet use, personal hygiene, and bathing, and she required extensive assistive from staff with transferring, walking, and eating. -- 2. Further review of Resident #95's medical record revealed the following nursing notes (quoted as written): - On 05/31/11 at 2:00 p.m. - "Pt's (patient's) family member came to desk and stated 'my mom told me that her roommate woke her up with her hands around his throat yelling - 'If you don't quit sleeping /c (with) my husband, I will kill you'. Daughter stated 'Mom is very afraid of her roommate and asked for a room change. Asked for a grievance form and assisted to the social services office. Explained the situation to the social service director and commented about the dangers of the two residents in the same room. Will continue to monitor." - On 05/31/11 at 3:15 p.m. - "Roommates continue to argue. Assisted resident to nurses desk to ensure safety." - On 05/31/11 at 5:20 p.m. - "Resident was sitting in recliner and 'dodged' a empty coffee cup that the roommate had thrown. Continue to have conflict and social services notified of continuing conflict." - On 06/02/11 at 7:00 a.m. - "Called to residents room by CNA (certified nursing assistant). Resident found in bed bleeding from laceration on (R) (right) side of forehead. Resident stated someone hit her /c (with) a glass. Cleaned forehead & notified MPOA the sent to (hospital) ER for eval." On a change in condition documentation form dated 06/02/11 was written (quoted as written): "6/2 7 AM called to residents resident had laceration to (R) side of forehead. Resident stated someone threw a cup @ (at) her. Sent to (hospital) ER for sutures." - On 06/02/11 at 12:00 p.m. - "Back to facility from ER. Laceration was glued using surgical glue with instructions not to get wet & cover /c bandaid, monitor for pain, vomiting headaches." --- b) Resident #119 1. Medical record review for Resident #119 revealed this [AGE] year old female was originally admitted to the facility on [DATE], and was most recently readmitted to the facility from an inpatient psychiatric stay on 05/24/11. According to her Medicare 5-day MDS with an ARD of 05/31/11, her active [DIAGNOSES REDACTED]. Her cognitive status was severely impaired, her speech was clear, she was usually able to make herself understood to others, and she usually understood what was communicated to her. According to Section E (Behavior), she exhibited the following behaviors one (1) to three (3) days during the seven-day reference period ending on 05/31/11: physical behavioral symptoms directed towards others (e.g., hitting, kicking, pushing, scratching, grabbing, abusing others sexually); verbal behavioral symptoms directed toward others (e.g., threatening others, screaming at others, cursing at others); and other behavioral symptoms not directed toward others (e.g., physical symptoms such as hitting or scratching self, pacing, rummaging, public sexual acts, disrobing in public, throwing or smearing food or bodily wastes, or verbal / vocal symptoms like screaming, disruptive sounds). Review of her most recent comprehensive MDS, an annual assessment with an ARD of 11/23/10, revealed in Section E that, during the assessment reference period ending on 11/23/10, the resident did not exhibit any behavioral symptoms. Review of an abbreviated quarterly MDS with an ARD of 02/23/11 found in Section E that, during that assessment reference period ending on 02/23/11, the resident again did not exhibit any behavioral symptoms. -- 2. Further review Resident #119's medical record found the following nursing notes from 04/13/11 through 05/11/11 (quoted as written): - On 04/13/11 at 6:30 p.m. - "Resident sitting in lobby and will not come to her room. States someone is coming to meet her." On a change in condition documentation form dated 04/13/11 at 8:00 p.m. was written: "8pm Resident continues to remain in lobby & make attempts to go outside. CNA has been assigned to do one-on-one supervision. Call to Dr. (name) @ this x (time). 8:20pm Dr. (name) made aware of resident exit seeking & staying in lobby. Order for [MEDICATION NAME] 0.5 mg PO (by mouth) q6(symbol for 'hours') (every six hours) for exit seeking , yelling, resisting care. MPOA (name) made aware of status & new order. 10:15pm Resident back in room @ this time. Will monitor for further behaviors. ..." - On 04/19/11 at 11:00 a.m., 04/25/11 at 6:00 p.m., 04/26/11 at 10:00 a.m., and 04/27/11 at 9:50 a.m., nurses documented that the resident refused all medications and that the attending physician was aware. - On 04/27/11 at 2:00 p.m. - "Dr. (name) in facility @ this time. New order [MEDICATION NAME] 4.6 mg q24hrs (every twenty-four hours). (Name of MPOA) notified." - On 04/27/11 at 10:45 p.m. - "Resident combative /c (with) nurse when [MEDICATION NAME] applied, /c hitting & yelling." - On 04/30/11 at 10:00 a.m. - "Refused all AM (morning) meds MD aware." - On 05/03/11 at 10:30 a.m. - "Resident has (arrow up) agitation, yelling, going thru roommates belongings, going thru belongings of resident in room (#). Staff attempting to redirect still continues behavior. [MEDICATION NAME] given at this time." - 05/04/11 at 03:00 p.m. - "Gave PRN (as needed) [MEDICATION NAME] earlier this shift d/t (due to) anxiety AEB (as evidence by) hitting, yelling & refusing care. Effective at this time. ..." - 05/07/11 at 05:00 a.m. - "N/O (new order) written for appt (appointment) to be scheduled /c (hospital) for psych eval per Dr. (name) on 5/4/11 at 8pm." - 05/07/11 at 6:35 a.m. - "Res (arrow up) in w/c (wheelchair) in Activities at door pushing on bar. This nurse attempted to move res w/c from door et (and) res grabbed this nurses arm et bit (L) (left) forearm. Res then grabbed the flowers on decorative tree, pulling them. Res reached over to table et pulled tablecloth off et threw it in the floor. Then began propelling her w/c to several more table, pulling off table clothes et throwing them into floor. Res then exits Activities room into hallway et goes into her room et gets into bed." - 05/07/11 at 09:30 a.m. - "... Gave PRN [MEDICATION NAME] this AM d/t anxiety AEB hitting staff, throwing waste on staff and unable to redirect. Did take PO medication this AM /s (without) difficulty, but them threw water on 100 hall nurse. [MEDICATION NAME] effective at this time. ..." - 05/08/11 at 9:30 a.m. - "Resting in bed. Anxiety noted this AM AEB hitting, throwing cups /c water. Attempted redirection /s success, gave PRN [MEDICATION NAME] this AM. Effective at this time. ..." - 05/08/11 at 8:00 p.m. - "Walked into residents room to give meds. Resident sat up in bed and knocked cup of pills out of LPN's hand. ..." - 05/09/11 at 8:00 a.m. - "Resident has (arrow up) anxiety this AM. Removing clothes, throwing objects in room. [MEDICATION NAME] given this AM." - 05/09/11 at 10:00 a.m. - "[MEDICATION NAME] effective. Spoke /c Dr. (name). N/O CBC (complete blood count) / BMP (basic metabolic panel) / UA (urinalysis) C&S (culture and sensitivity) in AM. MPOA aware." - 05/09/11 at 4:00 p.m. - "Refused all meds @ this time attempt x 3." - 05/10/11 at 02:30 a.m. - "Resident combative hitting, slapping staff. Refusing straight cath. quote, 'You all are not nurses, get out, get out, I'm not letting you look at me your trash.' Unable to obtain cath for UA C &S." Addendum: "Resident began screaming, help help." - 05/10/11 at 4:00 a.m. - "Labs drawn for CBC, BMP (R) (right) AC (antecubital) By lab tech. Resident again refusing straight cath for UA C&S asked resident if go to restroom and void resident refused. ..." - 05/10/11 at 9:00 a.m. - "Resident refused all meds this AM ... Resident refuses to dress, wearing only robe. Attempt x 3 to cath for urine she continues to refuse." - 05/10/11 at 11:00 a.m. - "Staff attempting to straight cath resident /s success. She is hitting staff in face / slapping staff / kicking staff. ..." - 05/10/11 at 5:00 p.m. - "Refused all meds attempt x 3." - 05/11/11 at 3:30 a.m. - "UA obtained via straight cath method D/T (due to) behaviors." - 05/11/11 at 8:40 p.m. - "Resident out to (hospital) ER for direct admit to psyche unit D/T behaviors. ..." - Review of Resident #119's care plan dated 02/24/11 found the following handwritten entries dated 05/09/11 (quoted as written): Focus: "Behaviors of hitting, biting throwing items." Goals: "(Arrow down) Episodes of behaviors. Will not hurt self or others." Interventions: "1) MD to look at meds. 2) Offer activities appropriate for resident. 3) Labs per orders. 4) Psyche consult." - A confidential interview with staff, in the presence of two (2) nurse surveyors on 06/28/11, revealed that, prior to her hospitalization on [DATE], Resident #119 had lived at the facility for years and had never acted like this before. No comprehensive assessment was conducted to address this significant change in Resident #119's behavior. -- 3. Review of the nursing notes for Resident #119 from 05/24/11 through 06/02/11 found (quoted as written): - On 05/24/11 at 4:15 p.m. - "admitted to skilled services of Dr. (name) for care ..." - On 05/25/11 at 6:50 a.m. - "Unable to give TB test. Resident very combative and refused to even let nurse touch her. ... ADD: Resident was spitting in aid's faces. She was throwing items around the room. She was hitting and kicking aids during care. Resident was also throwing items toward her roommate. Aids have expressed to this nurse how they feel unsafe while trying to give care to this resident. Resident also scratched one of the aids leaving a scratch mark on her (L) forearm. It took 3 aids to provide care for this resident." - On 05/25/11 at 1:50 p.m. - "Throwing Objects @ Roommate, (arrow up) agitation. [MEDICATION NAME] x i (times one) given, med taken well. Re-directed @ sink basin Washing up." - 05/26/11 at 10:00 a.m. - "Resident refused all am (morning) meds smacking meds & water out of this nurses hand across hallway. Will monitor." - 05/26/10 at 9:50 p.m. - "... Resident refused all 9P meds slapping out of nurses hand grabing nurses clothing tuging yelling get out." - 05/26/11 at 11:50 p.m. - "Resident screaming, (arrow up) in w/c insists not going back to bed in her room insists there is invisible person in there that was trying to choke her. Currently (arrow up) at nurses station sitting in w/c. Will continue to monitor." - 05/27/11 at 8:00 a.m. - "... Has been combative /c staff since re-admit from psyche. ..." - 05/27/11 at 10:15 a.m. - "Resident refused all meds, spitting them out & throwing water & pitcher across the room. Will contact physician." - 05/28/11 at 10:00 a.m. - "Resident took AM medicine but then started hitting @ me and cursing. Administered PRN [MEDICATION NAME] without success, resident still combative. Will continue to monitor." - 05/30/11 at 9:00 a.m. - "Resident yelling in hallway @ staff & other residents. Attempted to redirect without success Resident refuses to put clothes on, exposing self to staff and other residents. [MEDICATION NAME] given this AM." - 05/30/11 at 1:00 p.m. - "Continues to scream @ staff and other residents. Threw coffee @ housekeeping staff. Picks up tissues and throws them into hallway." - 05/30/11 at 1:15 p.m. - "Walking up the hallway /c back of gown open and refusing to allow us to cover her. Smacks the nurse and an aide while attempting to assist her." - 05/30/11 at 1:30 p.m. - "Administered PRN IM (intramuscular injection) [MEDICATION NAME] medication in (L) arm. Resident spit & smacked @ staff members." - 05/30/11 at 4:10 p.m. - "Resident began screaming and kicking wall when staff was checking on her. Gave PRN [MEDICATION NAME] po (by mouth) to calm resident." - 05/30/11 at 8:20 p.m. - Res (arrow up) in w/c in hallway, yelling at staff et other residents. Res agitated, resisting care et hitting at staff from w/c when trying to move w/c so res can pass at move from doorway." - 05/30/11 at 10:00 p.m. - "Res continues to be agitated, yelling et hitting at staff. PRN [MEDICATION NAME] given. Res took ? meds et refused to finish meds. Will monitor." - 05/30/11 at 11:30 p.m. - "Res noted to have throw several objects at room mate, water pitchers et Kleenex, pictures. Res roommate fearful of resident. Res sitting (arrow up) on BS. Res given PRN IM [MEDICATION NAME] to (R) deltoid. Res (arrow up) in w/c at present in hallway. Continues to throw things, pulled 100 MAR (medication administration record) from med cart et threw it in the floor." - 06/02/11 at 12:30 p.m. - "N/O noted to send (hospital) ER for medical clearance for psych family aware." - 06/02/11 at 1:00 p.m. - "OOF (out of facility) to (hospital) ER via (transport service) for medical clearance to admit to psych." -- 4. Review of the May 2011 MAR for PRN medications found the following entries: - On 05/25/11 at 1:50 p.m. - [MEDICATION NAME] was administered for "Throwing Objects @ Roomt (roommate)" - On 05/29/11 at 1:00 p.m. - [MEDICATION NAME] was administered for "Throwing objects@ people, yelling, walking down hall naked" - On 05/30/11 at 11:20 p.m. - [MEDICATION NAME] was administered for "throwing objects at roommate, hitting staff, yelling in hallway" -- 5. Review of Resident #119's care plan dated 05/25/11 revealed the following entries: Focus: "Hx of Resisting treatment / care AEB refusing showers, refusing ADL's (activities of daily living), related to: Cognitive Impairment / dementia, unspecified [MEDICAL CONDITION]." An undated handwritten addendum to this focus was "AEB, Hitting staff throwing items." Goals: "Resident will comply with care routine, showers and ADLs." Interventions: "Administer medication for cognition as ordered. Document care being resisted on behavior monitoring flow sheet. If resident refused care, leave resident and return in 5-10 minutes. Praise / reward resident for demonstrating consistent desired / acceptable behavior." All of these interventions were dated as having been created on 06/29/10. An undated handwritten addendum to this list of interventions was "[MEDICATION NAME] as ordered." Review of the aforementioned nursing notes from 04/13/11 through 05/11/11 revealed the interventions that had been in place since 06/29/10 were not effective in addressing the resident's behaviors, and no new interventions (e.g., increased staff supervision) were added - beyond the administration of [MEDICATION NAME] "as ordered" - to address this resident's physically / verbally abusive behaviors toward staff and other residents (including her roommate). --- c) An interview on 06/28/11 at 10:00 a.m. the administrator reviewed the nursing notes for Resident #95 for 05/31/11 and denied any prior knowledge of the grievance made on behalf of Resident #95 or the incidents reflected in the nursing notes for that day. He provided a statement, on 06/28/11 at 4:40 p.m., to include this same information. -- d) In an interview with Resident #95's daughter on 06/28/11 at 4:15 p.m., she confirmed having filled out a report on 05/31/11 regarding her mother's roommate (Resident #119) standing over her, "pulling her hair", and saying, "You stole my husband." She and the nurse (Employee #41) and took the report to the social worker (Employee #39). According to the daughter, Employee #39 told her they were full to capacity and there was no where to put her. She said the administrator called her at 7:30 a.m. on 06/28/11 and wanted to discuss this with her, and she came into the facility and spoke with him. -- e) Review of the facility's records of abuse / neglect allegations, which were provided by the facility's administrator, found the following witness statement obtained by the facility from the social worker on 06/28/11 (quoted as written): "I was not aware of an incident where resident's roommate had her hands around her neck and was yelling at resident. I was also not aware of an incident on the same day that an empty coffee cup was thrown at resident. Resident's daughter had talked about a room change based on cognitive functioning of the resident's roommate prior to the incident on 6-2-11. ..." Review of the facility's records of abuse / neglect allegations, which were provided by the facility's administrator, found the following witness statements obtained by the facility on 06/28/11, all of whom attested to hearing Resident #95 ' s daughter expressing concerns about Resident #95 alleging to the daughter that her roommate (Resident #119) had tried to choke her (all quoted as written): - Employee #106 (medical records) - "I was at the fax machine at Maple. (Resident #95's) daughter come to the desk & told (Employee #41) the nurse 'I don't know if this is true or not but mother said roommate tried to choke her last night.' (Employee #41) said would you like to file a grievance. (Employee #41) asked me for one. I couldn't find 1 so (Employee #108) reached into file cabinet & handed the grievance to the daughter. The daughter sat in the chair & (Employee #108) told her how to fill it out. She filled it out and asked what to do /c (with) it. (Employee #41) said to give to social worker. Daughter asked where that is & (Employee #41) said I will show you. (Employee #41) brought the daughter around the hallway towards social service office. Later on that day I asked her if she documented on it & told her she needed to. I asked her what the outcome was & she said the daughter said (Employee #39) said there were no empty beds." - Employee #108 (licensed practical nurse - LPN) - "Standing at nurses station on May 31, 2011. Dau (daughter) comes up to NS (nurses' station) & said that her mother had told that her room mate had choked her. I 'do not know if it really happened or not.' but mother is terrorized of her room mate. Gave her a grievance form to fill out. Hall nurse brought dau up to talk with (Employee #39). Came back to floor and said (Employee #39) had told her them we were full and could not do a room change." -- f) Confidential interviews with staff, conducted in the presence of two (2) nurse surveyors on 06/28/11, revealed that, when Resident #119 was ready to return from the hospital for inpatient psychiatric care on 05/24/11, staff expressed concern to the admission coordinator that Resident #119 should not be returned to the room occupied by Resident #95, due to concerns for Resident #95's safety. Confidential interviews with staff also revealed that the daughter's report, on 05/31/11, of her concerns about Resident #119's behavior toward Resident #95 were discussed in one (1) or more morning stand-up meetings prior to 06/02/11, when Resident #95 sustained injuries after being hit in the forehead by an object thrown by Resident #119. The facility was aware of Resident #119's abusive behaviors toward others (including Resident #95) and failed to implement measures to protect Resident #95 from harm. .

Based on closed record review and staff interview, the facility failed to assure one (1) of seven (7) sampled residents received appropriate services necessary to avoid physical harm. The facility's certified nurse practitioner (CNP) performed an invasive surgical procedure (incision and drainage of a large hematoma) on a high-risk resident with multiple comorbidities and on anticoagulation therapy, without evidence of having obtained informed consent from the resident, consulting with the resident's attending physician, and informing an interested family member (whom the resident designated to serve as her medical power of attorney representative - MPOA) prior to performing the procedure. This invasive procedure resulted in harm to the resident, who experienced increased pain, anxiety, and bleeding, which necessitated a transfer to the hospital emergency room for additional procedures and which may have been a factor in her death less than seventy-two (72) hours later. Resident identifier: #118. Facility census: 117. Findings include: a) Resident #118 1. A review of Resident #118's closed medical record revealed this [AGE] year old female was originally admitted to the facility on [DATE], and her [DIAGNOSES REDACTED].#), history of venous [MEDICAL CONDITION] (blood clots) and embolism (a mass, such as a detached blood clot, that travels through the bloodstream and becomes lodged in a vessel, obstructing blood flow), [MEDICAL CONDITION], embolism and [MEDICAL CONDITION] of unspecified artery, [MEDICAL CONDITION], and coronary [MEDICAL CONDITION] unspecified type vessel native graft. This resident had been determined by her attending physician to have the capacity to understand and make informed healthcare decisions, and she was described in her nursing notes daily as being alert / oriented and able to make her needs known. In an interview with the social worker (Employee #3) at 3:15 p.m. on [DATE], she verified Resident #118 had capacity, although she stated Resident #118's son / MPOA was involved in the resident's care, usually assisted her in decision making, received notices of the care plan conferences, and was notified of changes in her care and health status. This was reflected in her medical record by his signature on various consent forms (e.g., flu vaccine, etc.), her readmission papers after hospitalization , bedhold notices, and notations in nursing notes showing him being notified about changes in her status and/or treatment. -- 2. The resident's cardiovascular disease was being treated with long-term [MEDICATION NAME] therapy, which included regular monitoring of her [MEDICATION NAME] time (PT) and INR. PT evaluates the ability of blood to clot properly; INR (International normalized ratio) is a system established by the World Health Organization (WHO) and the International Committee on [MEDICAL CONDITION] and Hemostasis for reporting the results of blood coagulation (clotting) tests. The lab's normal ranges for these tests were PT - 9.2 to 11.8 and INR - 2.0 to 3.0. Record review revealed the following lab results and adjustments made to her [MEDICATION NAME] order in November and [DATE]: Date - [MEDICATION NAME] Dosage - PT / INR - New Order [DATE] - 2.5 mg daily - 42.1 / 4.3 - hold x 2 days [DATE] - ([MEDICATION NAME] held) - 39.8 / 4.1 - [MEDICATION NAME] 2.0 mg daily [DATE] - 2.0 mg daily - 34.5 / 3.4 - [MEDICATION NAME] 1.5 mg daily [DATE] - 1.5 mg daily - 25.8 / 2.4 - same [DATE] - 1.5 mg daily - 27.3 / 2.5 - same [DATE] (at 12:00 p.m.) - 1.5 mg daily - 23.0 / 2.0 - same [DATE] (at 8:10 p.m.) - 1.5 mg daily - 23.3 / 2.3 - same On [DATE], the physician gave orders to discontinue the [MEDICATION NAME] and obtain a repeat PT/INR. -- 3. At 10:55 a.m. on [DATE], Resident #118 complained of leg pain and was found to have a hematoma (pocket or localized collection of blood outside of a blood vessel) on her left lower leg which the resident stated was due to being held there by staff while she was given catheter care. An incident report was completed, the resident's allegation was reported to the State survey and certification agency, and the facility conducted an internal investigation into the origin of the hematoma. The facility's internal investigation was unable to determine the cause of the injury, but the CNP and the resident's MPOA were notified of the incident. The CNP, who was present in the facility, assessed the hematoma and ordered a stat (immediate) PT/INR and ice packs to the area. The physician was notified of the laboratory results per the nursing notes, but there was no evidence that he was made aware of the presence of the hematoma. -- 4. A review of the medical record found that, at 3:00 p.m. on [DATE], the CNP performed an incision and drainage (I&D) on Resident #118's hematoma while at the facility, with two (2) incisions being made. There was no evidence in the medical record that the attending physician had been notified of either the initial assessment of a large hematoma on the resident's lower leg on [DATE], or of the decision to proceed with the I&D on [DATE], even though the resident had been on long-term [MEDICATION NAME] therapy, had a [DIAGNOSES REDACTED]. - A progress note, dated [DATE] and electronically signed by the CNP at 5:34 p.m. on [DATE], stated under the heading "Physical Exam", "... general appearance, obese and alert oriented x 3 female in mild amount of distress due to pain left leg-inner aspect. ..." Under the heading "Plan", the CNP recorded, "A return visit is indicated in 1 day. Resident is stable - hematoma not enlarging at present. ? (unknown) etiology but appears no significant trauma. Most likely due to capillary fragility and [MEDICATION NAME] (sic) tx (treatment). No severe pain. Will elevate and Ice (sic) area and fu (follow-up) (sic) 24 hours and will treat conservatively." - A subsequent progress note, dated [DATE] and electronically signed by the CNP at 5:40 p.m. on [DATE], stated under the heading "Chief Complaint", "FU (follow-up) hematoma left leg. Resident evaluated yesterday for hematoma (etiology unknown) - reevaluated today. Resident was complaining of increased pain, hematoma had doubled in size, and skin was cold to touch. INR 2.1. Stated had increased pain if moved leg or pressure applied." Under the heading "ROS" (review of systems) was recorded, "I reviewed the medical, surgical, family, social, medication, food allergy and patient code status histories. ..." Under the heading "Physical Exam" was recorded, "... general appearance, obese and alert oriented x 3-very pleasant female in distress due to pain left lower leg. ... Large hematoma which has at least doubled in size since initial evaluation yesterday. Skin is extremely taunt (sic) and area is exquisitely tender to palpation. Area measures 5 cmx4cm (sic) and is circumfrential (sic). ..." Under the heading "Services Performed", the CNP recorded, "Resident is stable but (sic) am concerned about swelling, pain and coolness of skin over hematoma. (15:00) (3:00 p.m.) Residents (sic) vs (vital signs) stable - INR 2.0 (done this am). Due to fact resident may be developing [DIAGNOSES REDACTED], I attempt (sic) to aspirate hematoma. I clean (sic) hematoma with [MEDICATION NAME] (sic) and attempt to make small incision to drain collected blood. I am (sic) successful in draining about 30 cc's but area is still very large and painful. A small incision is made (sic) posterior aspect of hematoma and (sic) am able to evaluate large amount of formed clots from hematoma. ... area is packed ... Sterile dressing was applied with mild amount of pressure. Hemostasis is obtained and resident states (sic) has complete pain relief. ... 16:45 (4:45 p.m.) call (sic) son (name) and discuss (sic) treatment - he agrees to evacuation of hematoma and packing area. Also agrees with dose of antibiotic. Resident is reevaluated at 17:00 (5:00 p.m.) - No bleeding from area. ... Due to fact resident has multiple comorbidities and is on [MEDICATION NAME] (sic), it is determined by Dr. (name) and myself, (sic) that resident would be better evaluated if was at hospital. Son was notified and I discussed this with resident, who agrees to go ... Will be transferred by EMS (emergency medical services)." - There was no evidence in either progress note that the CNP consulted with the attending physician prior to incising and draining the resident's hematoma. -- 5. A nursing note entered by a licensed practical nurse (LPN - Employee #6) at 3:00 p.m. on [DATE] stated, "... NP requested the pain med during I&D of hematoma to L (left) extremity. I administered pain (med) and left room while procedure was taking place. (After) procedure pt's (patient's) leg kept elevated with dressing in place. Pedal pulse checks (+)." Subsequent nursing notes on [DATE] stated: - At 6:15 p.m., Employee #6 wrote, "Verbal consent to evacuate hematoma to LLE (left lower extremity) by (name) MPOA ..." - At 6:30 p.m., Employee #8 (another LPN) wrote, "VSS (vital signs stable) - ,[DATE], HR 74, R - 18, Temp 97.2. Resident exhibited an episode of vomiting - reports (symbol for 'no') nausea at this time. Pedal pulses present and easy palpable. (Symbol for 'no') c/o (complaint of) pain, (symbol for 'no') numbness or tingling in L lower extremity. Exhibits ability to move all toes on L foot. L leg remains elevated with application of ice as ordered, (symbol for 'no') [MEDICAL CONDITION] noted, (symbol for 'no') redness, (symbol for 'no') bleeding. Small amount of serosanguiness (sic) (serosanguineous drainage) noted on external bandage / ice pack. Nurse Practitionor (sic) was aware of PT/INR lab drawn [DATE] - (Symbol for 'no') N/O (new orders) at this time - MPOA aware of information - Call light in reach of resident, in bed resting." Employee #6 also wrote the following late entry for [DATE], "7P (7:00 p.m.) late entry for [DATE] Pt (patient) was aware of procedure I and D and consented for procedure." - During a telephone interview with Employee #6 at 1:25 p.m. on [DATE], he stated he had no knowledge of the procedure prior to being instructed to administer pain medication at 3:00 p.m. on [DATE], which he did, documenting that the resident complained of pain at a level "8" on a scale of "1 to 10" and that she was crying. He stated he then left the room and was not present during the procedure, as the CNP was being assisted by a NP student who was with her. He stated he did not hear the procedure discussed with the resident nor did he have any knowledge of the resident giving consent for the procedure, and he reported the resident's MPOA was notified by him after the procedure was completed. He stated that, in his entries into the record, he had written the resident and her MPOA gave consent to the procedure (as noted in the nursing notes by Employee #6 referenced above). However, Employee #6 stated to this surveyor that he wrote these entries because the CNP told him that she had received permission although, after talking to the MPOA, he realized the consent of the MPOA had not been received prior to the procedure. Employee #6 did not witness Resident #118 giving informed consent for the CNP to perform the procedure. Employee #6 stated that, when he assessed the resident after the procedure at 6:30 p.m. on [DATE], she had a dressing to her left lower leg which was elevated, and she told him the pain medication had helped. He stated that, shortly after he returned to the nurse's station, a nursing assistant (Employee #9) notified him that the resident's dressing was saturated with blood. He told the CNP, and the CNP and the NP student went in and redressed the wound. (Note there was no mention anywhere in the resident's record, by either the LPNs or the CNP, that the resident's dressing was saturated with blood or that her surgical wounds needed to be redressed.) Employee #6 reported having been told by the CNP that she had contacted the resident's attending physician and had received orders to transfer the resident to the hospital emergency room (ER) for evaluation. An ambulance was called, and the resident was transported at 7:00 p.m. on [DATE]. -- 6. The ER record dated [DATE] stated, "... palm sized hematoma left medial calf area, not circumferential ... (two incision sites ... packing removed, no active bleeding, both cavities probed, 4 cm deep and no apparent tunneling between the two. Both cavities irrigated with normal saline until clear return noted on multiple irrigations, repacked with [MEDICATION NAME] gauze to help maintain tamponade effect, dressing applied)." At 8:35 p.m. on [DATE], the resident's white blood count was high (19.7, with normal range of 3.0 - 11.0) and her PT was 23.3. -- 7. The resident returned to the facility at 1:00 a.m. on [DATE] with instructions for a revisit in two (2) days. At 7:00 a.m. on [DATE], a nursing note stated, "Dressing to incision site left leg soaked thru with serosanguineous fluid. Replaced old dressings." At 11:45 a.m. on [DATE], the attending physician was notified of the dressing change and gave telephone orders for dressing changes, to discontinue [MEDICATION NAME], and to obtain a repeat PT/INR on Monday. The MPOA was notified of these orders. At 6:00 p.m. on [DATE], the physician, when notified that "... area to left leg slightly red warm and hard around wound", gave telephone orders for an antibiotic. The vital sign sheet from [DATE] to [DATE] recorded her temperature between 96.1 and 98.3 degrees Fahrenheit (F) and her blood pressures between ,[DATE] - ,[DATE]. At 11:50 a.m. on [DATE], the physician visited the resident and wrote new orders to include discontinuing the [MEDICATION NAME] (again) and starting [MEDICATION NAME]-coated aspirin 325 mg by mouth daily. A physician's progress note, dated [DATE], stated, "Came in to inspect hematoma and incisions. I was informed of incision /p (symbol for 'after') it was done." After the physician was notified of the I&D at approximately 6:30 p.m. on [DATE], all further treatment was done by him. Thereafter, there were only routine entries in the resident's medical record until 1:45 a.m. on [DATE], when the resident was found unresponsive and had expired. The death certificate stated the cause of death was "Acute [MEDICAL CONDITION]". No autopsy was performed to ascertain the cause of the acute [MEDICAL CONDITION]. -- 7. According to Medline Plus, a service of the U.S. National Library of Medicine, National Institutes of Health, a [MEDICAL CONDITION] (or stroke) "is a medical emergency. [MEDICAL CONDITION] happen when blood flow to your brain stops. Within minutes, brain cells begin to die. There are two kinds of stroke. The more common kind, called ischemic stroke, is caused by a blood clot that blocks or plugs a blood vessel in the brain. ..." (Internet reference - <http://www.nlm.nih.gov/medlineplus/stroke.html>) -- 8. During an interview with the director of nurses at 12:40 p.m. on [DATE], she reported the CNP's services were terminated immediately after the facility learned of this incident and that the CNP had not notified either the resident's family (MPOA) or the physician prior to performing the procedure. She acknowledged Resident #118's record contained no evidence that informed consent was obtained prior to the procedure being done. She acknowledged that the record indicated Resident #118 had several [DIAGNOSES REDACTED]. She also stated this and the resident's resulting transfer to the ER were the reasons she had the event reported to the State survey and certification agency as an "unusual occurrence". She agreed, after discussion with the surveyor, that the facility would amend their report to an allegation of neglect and do a formal investigation. The termination of the services of the CNP was confirmed by the administrator during the exit conference. .

Based on closed medical record review, review of facility policies and procedures, review of records from an area hospital and the ambulance service, and staff interviews, the facility failed to ensure one (1) of six (6) sampled residents received care and services necessary to attain or maintain her highest level of physical well-being and to avoid physical harm. Resident #119, who was admitted to the facility on [DATE] for Medicare-covered skilled nursing and rehabilitation services to include observation and assessment of her care plan, began exhibiting an acute change in condition. The facility's licensed nursing staff failed, in accordance with the facility's policy and procedures, to provide on-going assessment / monitoring, administer interventions when ordered by the physician extender, and/or obtain timely medical intervention as the resident's condition continued to decline. A registered nurse (RN) first recorded in the medical record that Resident #119 was lethargic at 5:10 p.m. on [DATE]; prior to that time, the resident had been noted to be free of signs and symptoms of distress and discomfort. A licensed practical nurse (LPN) first recorded in the medical record, in an entry dated 5:00 a.m. on [DATE], Resident #119 had vomited three (3) times during the 11:00 p.m. to 7:00 a.m. (,[DATE]) shift. After this entry, there was no evidence of any physical assessment data having been contemporaneously collected and recorded in the resident's medical record related to the resident's level of consciousness (LOC), vital signs, respiratory status, and/or vomiting until the certified nurse practitioner (CNP - Employee #123) employed by the facility evaluated the resident and recorded a progress note that was electronically signed at 11:59 a.m. on [DATE]. In addition to the absence of evidence that physical assessment data was being contemporaneously collected and recorded with respect to Resident #119's acute change in condition, routine assessment data of the resident's respiratory status were not collected every four (4) hours before and after each inhalation treatment that had been administered at 8:00 a.m., 12:00 p.m., and 4:00 p.m. on [DATE]. No interventions were ordered to address the resident's vomiting until about 1:00 p.m. on [DATE], when, according to information contained in a late entry recorded a week later by the desk nurse (Employee #19) on [DATE] at 3:27 p.m., Employee #19 received orders from the CNP for [MEDICATION NAME] (an antiemetic to treat nausea / vomiting), [MEDICATION NAME] (a protein pump inhibitor to treat [MEDICAL CONDITION] reflux), and [MEDICATION NAME] (a stool softener). Once ordered, there was no evidence to reflect any of these medications was administered. According to information contained in a late entry recorded on [DATE] at 3:27 p.m. by Employee #19, after the CNP reviewed the results of some labs that had been sent to the facility, to start intravenous (IV) fluids, start supplemental oxygen, administer a stat dose of [MEDICATION NAME] (an antibiotic), and obtain a chest x-ray for possible pneumonia, Employee #19 received a second set of orders from the CNP at about 2:00 p.m. on [DATE]. According to information contained in a late entry recorded on [DATE] at 12:35 p.m. by the nurse assigned to care for Resident #119 from 7:00 a.m. to 7:00 p.m. on [DATE] (Employee #79), she started an IV shortly thereafter, applied supplemental oxygen at about 2:45 p.m., and collected physical assessment data at 4:00 p.m. noting the resident was alert with confusion, lethargic, with decreased lung sounds, with [MEDICAL CONDITION] in lower extremities, and with an oxygen saturation level of 88%. However, there was no contemporaneous documentation in the nursing notes related to insertion of the IV and no evidence of any physical assessment data having been contemporaneously collected and recorded in the resident's medical record related to the resident's LOC, vital signs, respiratory status, and/or vomiting after the entry made by the CNP at 11:59 a.m. earlier that morning. Interviews with nursing assistants (Employees #59, #54, and #67) revealed the resident continued to vomit on [DATE] during both the 7:00 a.m. to 3:00 p.m. (,[DATE]) shift and the 3:00 p.m. to 11:00 p.m. (,[DATE]) shift. However, there was no evidence of any physical assessment data having been contemporaneously collected and recorded in the resident's medical record related to the resident's LOC, vital signs, respiratory status, and/or vomiting after the entry made by the CNP at 11:59 a.m. earlier that morning. Interviews with staff revealed Employee #54, at the start of her ,[DATE] shift, found Resident #119 had vomited a brownish-colored liquid on her clothes, and she and another nursing assistant (Employee #67) cleaned her up. Employee #54 went to the nurse's station and told Employee #79 that Resident #119 had vomited. Employee #67 reported that, at that time, the resident was talking and her breathing sounded "OK". About thirty (30) minutes later, the resident vomited again. Employee #67 reported that, after Resident #119 vomited a third time, the resident started gurgling and was struggling to breathe, and she grabbed Employee #67 by the arm. According to Employee #67, Employee #54 left the room saying she was going to find out if the nurse would suction her. Interview with Employee #54 revealed she had gone to the nurse's station to ask the nurse if Resident #119 was a full code, and she told the nurse she thought the resident was dying. According to Employee #67, two (2) nurses then came to the room and "looked at the resident, then turned around and left the room", and one (1) of the nurses stated, "I'm sending her out of here. I'm leaving at 7:00." There was no evidence that interventions were provided in an effort to clear the resident's airway. According to information contained in late entries recorded by Employees #19 and #79, the resident's IV stopped flowing. At 5:00 p.m., an ambulance crew was called in the re-start the IV. The ambulance crew arrived and, at 6:20 p.m., was attempting to restart an IV. Employee #79 recorded, in her late entry on [DATE] at 12:35 p.m., that at 6:20 p.m., Resident #119 was alert with labored respirations and had vomited tea-colored fluid; in the same late entry, Employee #79 recorded that, at 6:40 p.m., a nurse aide came to her to ask about the resident's code status, at which time Resident #119 was having difficulty breathing, with decreased LOC, no response to verbal stimuli, raspy breath sounds, and "eyes not reactive to light accommodation". However, again, there was no evidence of any physical assessment data having been contemporaneously collected and recorded in the resident's medical record related to the resident's LOC, vital signs, respiratory status, and/or vomiting after the entry made by the CNP at 11:59 a.m. earlier that morning. The resident was transported from the facility at 7:22 p.m. on [DATE] to the hospital, where she expired at 9:50 p.m. that same evening; her cause of death was listed on the death certificate as [MEDICAL CONDITION] due to aspiration due to [MEDICAL CONDITION]. Resident identifier: #119. Facility census: 118. Findings include: a) Resident #119 1. Review of Resident #119's closed medical record revealed this [AGE] year old female resident was initially admitted from the hospital to the nursing facility at 1:08 p.m. on [DATE], with [DIAGNOSES REDACTED]. Further review of her record revealed that, during her extended hospital stay prior to admission to the facility, she was treated for [REDACTED]. According to multiple entries in the nursing notes made contemporaneously on [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], and [DATE], the resident was admitted for the purpose of receiving Medicare-covered skilled services for observation and assessment of her care plan and rehabilitative therapies. According to her admission minimum data set assessment, with an assessment reference date of [DATE], she was alert, could hear with minimal difficulty, had clear speech, was usually understood when she verbally expressed ideas to others, was usually able to understand what was said to her when spoken to, and was able to participate in the interviews during the assessment process. She was totally dependent upon staff for bed mobility, transferring, and locomotion, she required extensive physical assistance with dressing, toilet use, and personal hygiene, and she required set-up assistance with eating. -- 2. Review of Resident #119's nursing notes found a contemporaneous entry, dated [DATE] at 3:00 a.m., stating, "Skilled services continue. (Symbol for 'no') S/S (signs / symptoms) of distress or discomfort @ this time. Meds taken /s (without) difficulty. In bed /c (with) eyes closed. Call light in reach." The next consecutive entry, dated [DATE] at 5:10 p.m., stated, "N/O (new order) noted. CBC (complete blood count), BMP (basic metabolic panel), sed (sedimentation) rate d/t (due to) lethargy. Family aware." Between 3:00 a.m. and 5:10 p.m. on [DATE], there was no documentation in the nursing notes of any observations and/or nursing assessments of Resident #119's health status completed by the facility's licensed nursing staff. The next consecutive entry in the nursing notes, dated [DATE] at 5:00 a.m., stated, "Resident vomited x 3 this shift. Will monitor." This is the first mention in the resident's record of her having vomited. There was no description of the characteristics of the emesis (e.g., color, quantity, consistency, etc.), and no vital signs (e.g., temperature, blood pressure, heart rate, respirations) were recorded either in the nursing notes or a separate vital signs flow sheet. There was no documentation to indicate nursing staff notified the resident's responsible party, attending physician, or the CNP employed by the facility, of this change in the resident's condition. There was also no discussion of whether the resident remained lethargic, as had been noted at 3:00 a.m. on [DATE] and for which the CNP had previously ordered lab studies. The next consecutive entry in the nursing notes, dated [DATE], at 10:00 a.m., stated, "Weekly care team IDT (interdisciplinary team) review: Tylenol Q 8 ATC x 7 days. F/U (follow-up appointment) Dr. (name) on [DATE]. [MEDICATION NAME] & [MEDICATION NAME] for dementia. OT (occupational therapy), PT (physical therapy) as ordered. ST (speech therapy) as ordered. [MEDICATION NAME] to groin & breasts. Dry drsg (dressing) to Lt (left) knee." This interdisciplinary note was recorded by an RN, but it did not contain any mention of acute changes in condition exhibited by the resident in the previous twenty-four (24) hour period (e.g., lethargy or vomiting). The next consecutive entry in the nursing notes, dated 1:05 p.m. on [DATE], stated, "N.O. (new order) Bilateral heels off bed /w (with) pillows @ (at) all x's (times) for prevention. N.O. Sure Prep to bilateral heels 2x's QD (twice daily) on NS (night shift), DS (day shift) for prevention." This entry was not signed by its author. The next consecutive entry in the nursing notes, dated [DATE] at 4:-0 p.m. (the exact time of the entry was illegible), stated, "N/O for chest x-ray d/t cough & congestion, Attempts x 3 to call MPOA (medical power of attorney) /s success. This entry was recorded by Employee #19, an LPN. There was no mention of the resident's level of consciousness with respect to whether she remained lethargic, there was no mention of whether she had continued to vomit, and even though this was the first mention of the resident having exhibited any cough or congestion, there was no quantitative or qualitative description of her respiratory status (e.g., rate of respirations, blood oxygen saturation level, presence or absence of adventitious sounds in her lung fields, difficulty or ease of breathing, etc.) or her vital signs. The next consecutive entry in the nursing notes, made by LPN Employee #19 and dated [DATE] at 5:25 p.m., stated, "QMI (name of mobile imaging company) on site; CXR (chest x-ray) done." The next consecutive entry in the nursing notes, made by Employee #19 and dated [DATE] at 7:00 p.m., stated, "MPOA notified of decline; wish (sic) to send to TMH (area hospital)." The next consecutive entry in the nursing notes, made by Employee #19 and dated [DATE] at 7:22 p.m., stated, "KCA (local ambulance service) on site to transport to KCA (sic) /c (with) accompanied (sic) on ii (2) attendants." The next consecutive entry in the nursing notes, dated [DATE] at 8:00 a.m., stated, "Expired @ TMH ER (emergency room ) @ 9:50 p.m. [DATE]." This entry was then followed by a series of late entries recorded at 12:35 p.m. on [DATE] by Employee #79 (the LPN assigned to care for Resident #119 from 7:00 a.m. to 7:00 p.m. on [DATE]), which was then followed by another series of late entries recorded by Employee #19 (the desk nurse who worked on [DATE]) at 3:27 p.m. on [DATE] a week after the resident had expired. (See also citation at F514.) -- 3. In addition to the absence of evidence that physical assessment data was being contemporaneously collected and recorded with respect to Resident #119's acute change in condition, routine assessments of the resident's respiratory status were not performed every four (4) hours before and after each inhalation treatment that had been administered on [DATE]. (See also citation at F281.) Review, on [DATE], of Resident #119's [DATE] MAR indicated [REDACTED]. Review of the resident's care plan, which had been initiated on [DATE], revealed the following problem statement: "Short of breath / difficulty breathing related to: [MEDICAL CONDITION]." Interventions to address this problem included: "Administer medication as ordered. ... Notify physician of increased complaints of difficulty in breathing. Obtain oxygen saturation levels. Obtain vital signs. Provide nebulizer treatments as ordered." Review of documentation recorded in the resident's nursing notes and on the October MAR found no evidence that any physical assessment data regarding the resident's respiratory status had been collected and recorded either prior to and after each nebulizer treatment. Review of the facility's policy "Aerosolized Medication (Neb Med)" (with a revision date of [DATE]) found the following under Item #4 under guidelines: "h. Assess the Resident "(1) Note the resident's skin color and temperature, skin characteristics (warm and dry vs. cold and clammy; elastic vs. [MEDICAL CONDITION]), pattern and effort of breathing, ability to take a deep breath and cough and quality of breath sounds. If medication is being given for wheezing, note quality and intensity so as to be prepared to document post-[MEDICATION NAME][MEDICATION NAME] effects. "(2) Check respiratory rate prior to treatment." According to the policy, after the nebulizer treatment ceases, the following steps were to be completed: "n. Assess the resident to determine therapeutic outcome. ... "r. Document medication, [MEDICATION NAME], dose, pulse and breath sounds before and after the treatment, O2 (oxygen) liter flow, cough, color and consistency of sputum, resident (sic) subjective response and any adverse reactions and action taken." During an interview on [DATE] at 3:30 p.m., the director of nursing (DON - Employee #81) revealed that any documentation related to the implementation of this policy would be recorded in the resident's nursing notes. During an interview on [DATE] at 4:15 p.m., the LPN (Employee #79) who initialed Resident #119's MAR indicated [REDACTED]#119's respiratory status before and after administering each of these nebulizer treatments. -- 4. Review of the run sheet completed by personnel from the emergency medical services (EMS) that transported Resident #119 from the facility to the hospital on the evening of [DATE] revealed, under pertinent findings, the primary signs and symptoms necessitating EMS was "Respiratory Arrest"; other signs and symptoms included "Decreased LOC". In the narrative section on page 1 of 6 was recorded, "Patient found by staff (sic) decreased LOC (sic) Upon arrival found thw (sic) patient snoring resp 3 breaths amin (sic) ..." Under event chronology beginning on page 3 of 6, a physical assessment by EMS personnel found her eyes / pupils were reactive to light when assessed at 1914 (7:14 p.m.) on [DATE]. At 1915 (7:15 p.m.), her B/P was ,[DATE] and her respiratory rate was 3 breaths per minute and labored with an oxygen saturation of 85%. The resident was intubated, and the ambulance left the scene at 1930 (7:30 p.m.). Her care was transferred to the ER at 1942 (7:42 p.m.) -- 5. According to notes from the hospital ER, Resident #119 arrived and was triaged at 1942 (7:42 p.m.) on [DATE]. When assessed at 1952 (7:52 p.m.), her B/P was ,[DATE], heart rate 134, respiratory rate 14, temperature 98.7 degrees F, oxygen saturation at 96%, and she was not alert. At 2041 on [DATE], a note recorded, "Daughter states Pt is DNR (do not resuscitate) and as MPOA requests that all 'artificial life support and tx (treatment) for [MEDICAL CONDITION]' be dc'd (discontinued). (MPOA) also spoke these requests to Dr,. (name), ER attending." Resident #119 was subsequently extubated, and she expired at 9:50 p.m. on [DATE]. -- 6. A copy of Resident #119's certificate of death, which was obtained from the hospital, revealed her time of death was 2150 (9:50 p.m.) on [DATE], and her cause of death was [MEDICAL CONDITION] due to aspiration, due to [MEDICAL CONDITION]. -- 7. Review of the facility's policy on Change of Condition of a Resident (policy # CL-,[DATE], with an effective date of ",[DATE]") revealed the following: "Policy Statement - It is the policy of the center to take appropriate action and provide timely communication to the resident's physician and responsible party relating to a change in condition of a resident." "Procedure - Action Steps "1. The Licensed nurse determines if there has been a change in condition of a resident. (Attachment E) "2. The Licensed Nurse notified, via telephone, the attending physician and the resident's responsible party of the specific nature of the change in condition. - The primary mode of urgent communication is by telephone. ... - The Medical Director will be contacted in the event that the attending physician is not available for consultation. - If unable to reach either the attending physician or the medical director, the resident will be transported immediately via 911, the DNS (director of nursing services) / designee will be notified. "3. The Licensed Nurse initiates action to ensure the immediate safety of the resident. "4. The Licensed Nurse confers with the Physician / Physician Extender to determine what actions may be necessary to meet the immediate needs of the resident. "5. The Physician / Physician Extender providers orders to direct the care of the resident. (Attachment A) "6. The Licensed Nurse / designee implements the physician's orders [REDACTED]. "7. The Licensed Nurse documents in the interdisciplinary progress notes and on the 24 Hour Report of Resident change in Condition Book: (Attachment B, C, D, E) - The condition of the resident - Whom was notified and when - Care & treatment orders dictated by the physician - Implementation of physician orders - Care interventions in the resident's plan of care - Residents (sic) response to interventions." According to page 3 of 8 of the policy, the forms to be used when implementing this procedure are as follows: - Attachment A - Physician Telephone Orders (form #,[DATE]) - Attachment B - Interdisciplinary Progress Notes (form #,[DATE]) - Attachment C - 24 Hour Report of Resident Change in Condition Book (form #,[DATE]) - Attachment D - ICP (interdisciplinary care plan) Goals and Approaches (form # ,[DATE]) - Attachment E - Change of Condition Documentation (form # ,[DATE]) Review of Resident #119's closed record found no use of the Change in Condition Documentation form, which would have prompted the licensed nurse completing the form to collect and record data under the headings objective / underlying illness / symptoms (including vital signs and food / fluid intake in the last 24-hours), general appearance (including the presence of lethargy), and physical evaluation (including a change in mental status, the presence of a cough, the presence of adventitious breath sounds, oxygen saturation levels with and without the use of supplemental oxygen, and if vomiting is present, a description). Resident #119's interdisciplinary progress notes (also known as "nursing notes") did not contain documentation to indicate nursing staff notified the resident's responsible party, attending physician, or the CNP employed by the facility when the resident vomited three (3) times on the ,[DATE] shift ending on the morning of [DATE] documentation to indicate the resident continued to vomit on both the ,[DATE] shift and the ,[DATE] shift of the same day. There was no ICP in her closed record addressing her acute change in condition with respect to her decreased LOC (lethargy) and vomiting. While orders were written by the physician extender (Employee #123, the CNP), not all of the orders were implemented by the licensed nurses. Review of the facility's 24 Hour Report of Resident Change in Condition Book for the time period of [DATE] through [DATE], found the first mention of Resident #119 on an undated page found between [DATE] and [DATE], which noted she was to have a CBC, BMP, and sed rate. Although there were columns under the heading of "Change in Condition" in which check marks could be placed to indicate such things as the presence of vomiting, there was no evidence Resident #119 was identified on the 24 Hour Report as requiring monitoring related to her vomiting, which (according to a nursing note) began on the ,[DATE] shift ending on the morning of [DATE] and which (according to staff interviews) continued through both the ,[DATE] shift and the ,[DATE] shift on [DATE]. The next mention of Resident #119 on the 24 Hour Report was an entry a the page dated [DATE], which stated, "to (sic) ER d/t fixed pupils & severe congestion - MPOA stated, 'send (sic) her to ER.' Expired 9:50 p.m. @ ER." The facility's licensed nursing staff did not follow the facility's policy and procedures when Resident #119 exhibited an acute change of condition. -- 8. Medical record review revealed Resident #119 was seen by the facility's CNP on [DATE], [DATE], and [DATE]. A CNP progress note dated [DATE] (and electronically signed at 1:25 p.m. on [DATE]) identified, under review of symptoms, the patient denied fever and chills and shortness of breath. Under physical examination, the CNP recorded the resident as being "frail and alert oriented x 2" and her lungs were clear to auscultation bilaterally. Her vital signs were assessed as follows: "blood pressure at Left Arm while Sitting is ,[DATE] mm/Hg 96 bpm (beats per minute) regular 98.0F 139 pounds clothed." At the end of this progress note was written: "Resident does have discomfort during PT-family (sic) requests that Tylenol be schedules, rather thatn (sic) prn (as needed). Will schedule and observe -possible (sic) will have to order [MEDICATION NAME] prior to PT. Dementia increases difficulty in assessing resident. Comorbidities stable and resident is stable." - A CNP progress note dated [DATE] (and electronically signed at 2:46 p.m. the same day) identified that Resident #119 presented with lethargy and "the symptom started 7 days ago." (Although this note indicated the lethargy started seven (7) days ago (which would have been [DATE]), there was no mention of lethargy in the CNP's progress note for [DATE] and no mention of lethargy in any of the nursing notes recorded in Resident #119's closed record during the time period from [DATE] to [DATE].) Under review of symptoms, the CNP recorded, "The patient complained of malaise and lethargy but denied fever and chills" and she "denied cough". Under physical examination, the CNP recorded Resident #119's pharynx was clear and her lungs were clear to auscultation bilaterally. Under services ordered, the CNP recorded a CBC, BMP, and RBC sed rate. At the end of the progress note was written: "Resident appears to be stable. Will obtain labs and reevaluate. If normal labs, will consider adjusting medication." - A CNP progress note dated [DATE] (and electronically signed at 11:59 a.m. the same day) revealed, under chief complaint, "(Resident #119) presented with vomiting. It is described as acute. The symptom is sudden in onset. The symptom started 4 hours ago. The complaint is mild. Episodes occur in the morning. ... In addition, she presented with shortness of breath. It is described as stable. The symptom is gradual in onset. ... Patient denies apnea, cough, [MEDICAL CONDITION] and sputum production. ... Evaluated yesterday for lethargy-today (sic) having episodes of vomiting. Reevaluation." Under review of symptoms, the CNP recorded, "The patient complained of lethargy but denied fever and chills", "patient denied difficulty swallowing, sore throat and headache", "patient denied sOB (sic) and cough", and "patient complained of nausea, vomiting (small amount x 3) and decreased appetite but denied diarrhea and constipation". Under physical examination, the CNP recorded the resident's pharynx was clear, her respiratory system was "CTA (clear to auscultation) Bilaterally (diminished), left lower lung field: (sic) diminished, right lower lung field: diminished and rales (faint)." The CNP recorded the resident's vital signs as: "blood pressure at Left Arm while Sitting is ,[DATE] (sic) mm/Hg 121 bpm regular 97.6F 139 pounds clothed." Under prescriptions, the CNP recorded: "[MEDICATION NAME] 10 mg Rectal Suppository, 1 Unit Dose and RTL. [MEDICATION NAME] 40 mg Cap, Delayed Release, 1 Capsule(s), PO and QD. [MEDICATION NAME] 12.5 mg Rectal Suppository, 1 Unit Dose, RTL, Q6 PRN, 5 days start on [DATE] and end on [DATE]. [MEDICATION NAME] 1 gram Solution for Injection, 1, InVt, QD, 7 days, start on [DATE] and end on [DATE]." Under services ordered, the CNP recorded a chest x-ray. At the end of the progress note was written: "Resident has hx. of Reflux but currentlyl (sic) is not on PPI. Will order [MEDICATION NAME]. O2 2 liters nc and observe closely. Will start IV fluids @ 50 cc/hr until obtain chest x ray and stat dose [MEDICATION NAME]." - The result of the sedimentation rate study was called to the facility at 9:55 a.m. on [DATE], with no abnormal finding. The results of the CBC and BMP were sent to the facility at 12:23:52 (12:23 p.m.) on [DATE] (according to the date / time stamp recorded at the top of each page of the report), with abnormal results including: glucose - 126 (normal range 83 - 110); BUN - 35 (normal range 6 - 20); white blood cells - 14.5 (normal range 4.8 - 10.8); red blood cells - 3.65 (normal range 4.2 - 5.4); hemoglobin - 10.7 (normal range 12.0 - 16.0); and hematocrit - 34.2 (normal range 36 - 48). - A second CNP progress note dated [DATE] was identified as having been an amendment to the earlier progress note at 1:57 p.m. on [DATE]. This amendment, which was electronically signed by the CNP at 10:44 a.m. on [DATE], contained the exact same information as found on the earlier note for [DATE] under the headings chief complaint, review of symptoms, physical examination, diagnoses, prescriptions, services performed, and services ordered. At the end of the progress note was written: "Resident has hx. (history) of Reflux but currentlyl (sic) is not on PPI (protein pump inhibitor). Will order [MEDICATION NAME]. O2 2 liters nc (via nasal cannula) and observe closely. Will start IV fluids @ 50 cc/hr until obtain chest xray and stat dose [MEDICATION NAME]. REceived (sic) labs - WBC 14.5 BMP BUN (blood urea nitrogen) 35 otherwise WNL (within normal limits). Stronger evidence of pneumonia. Have consulted Resp. Tx. (respiratory therapy) for evaluation and treatment." - The CNP progress note timed at 11:59 a.m. on [DATE] was the only evidence to reflect Resident #119 was seen / assessed by the CNP that day. - Two (2) sheets of orders handwritten by the CNP were found for [DATE]; none of the orders contained a time to indicate at what time on this date they were actually written, and neither sheet contained notations to indicate what time the desk nurse noted having received the orders. The first sheet of orders contained two (2) sets of entries as follows: "[MEDICATION NAME] 10 mg suppository now. [MEDICATION NAME] 40 mg po reflux. [MEDICATION NAME] 12.5 mg suppository Q 8 (symbol for hours) PRN nausea x 5 days vomiting." and "IV: ,[DATE] NSS (sterile normal saline) i (1) liter @ 50 cc/hr. [MEDICATION NAME] i Gm IV now & daily x 7 days. O2 3 Liters n/c (via nasal cannula)." The second sheet of orders contained one (1) set of entries as follows: "IV: 0.9 NSS i liter @ 50 cc/hr - (arrow pointing up) HR (heart rate). [MEDICATION NAME] 1 Gm IV STAT & QD (daily) x 7 days - (arrow pointing down) O2 sat (oxygen saturation). O2 3 L (liters) per N/C. [MEDICATION NAME] 12.5 mg suppository Q 6 (symbol of hours) PRN (as needed) nausea x 5 days. [MEDICATION NAME] 40 mg i daily po (by mouth) - reflux. [MEDICATION NAME] 10 mg suppository today. Resp Tx eval & treat - (arrow pointing down) O2 sat. Chest x-ray STAT - (arrow pointing down) O2." - An interview was conducted on [DATE] at 12:45 p.m. with the facility's CNP (Employee #123). The CNP reported she had been at the facility all day on [DATE] and had provided care for Resident #119. The CNP stated she initially wrote orders thinking the resident may have had an obstruction, but after receiving further assessments from the nurses and receiving the results of labs that had previously been ordered, it became evident to her the resident probably had pneumonia. The CNP further stated it was her role to provide all the care at the facility, so that she could to prevent trips by residents to the hospital. She also stated the nurses were "too accustomed to picking up the phone and calling EMS". - An interview was conducted on [DATE] at 12:15 p.m. with Employee #19, who was the desk nurse on [DATE]. Employee #19 stated she received a first set of orders from the CNP at 1:00 p.m. on [DATE] (for the [MEDICATION NAME], and [MEDICATION NAME]). Employee #19 said she later received a second set of orders from the CNP (for the [MEDICATION NAME], IV fluids, supplemental oxygen, and chest x-ray). According to Employee #19, when she questioned the CNP about what to do with the first set of orders, the CNP stated the resident had possible pneumonia and the most important thing at this point was to start the IV fluids and get the chest x-ray. - Further review of the resident's closed record, including nursing notes and medication administration records, found no evidence the stat dose of [MEDICATION NAME] had been given or that Resident #119 received a single dose of [MEDICATION NAME] to treat her nausea / vomiting prior to her transfer to the hospital at 7:22 p.m. on [DATE]. -- 9. In an interview conducted on [DATE] at 4:15 p.m., Employee #79 (who was the LPN assigned to care for Resident #119 from 7:00 a.m. to 7:00 p.m. on [DATE]) reported she was first made aware of the resident vomiting when a ,[DATE] shift nursing assistant came to her and informed her of the vomiting and inquired about the resident's code status. Employee #79 reported she "went immediately to the resident's room, recognized the resident's condition, and went immediately to the phone to call EMS." This nurse also stated, during an earlier interview conducted on [DATE] at 12:05 p.m., she believed the res