Every finding on record at Edgewater at Waterman Village

Based on observation, interview, and record review, the facility failed to ensure staff used appropriate Personal Protective Equipment (PPE) while providing high-contact care for 1 of 3 residents reviewed for enhanced barrier precautions (Resident #111) and failed to ensure staff followed infection control procedures during medication administration for 1 of 5 residents observed (Resident #79) and during handling laundry in the laundry unit to prevent the possible spread of infection and communicable diseases.Findings include: 1) During an observation on 3/10/2026 at 2:00 PM, Staff H, Registered Nurse (RN) Unit Manager, entered Resident #111's room, performed hand hygiene, and donned gloves. Staff H did not wear a gown. Staff J, Occupational Therapy Assistant, was in the room assisting resident reposition in the bed. Staff J was wearing gloves and no gown. Staff J called for assistance to position the resident in bed. Staff I, Certified Nursing Assistant (CNS), entered Resident #111's room and donned gloves and no gown. Staff J and Staff I pulled Resident #111 up in the bed. Staff I covered the resident. Staff H proceeded to flush the IV [intravenous] needleless connector, connected the IV tubing to the needleless connector and began the IV infusion. During an interview on 3/10/2026 at 3:05 PM, Staff H, RN Unit Manager, stated. I should have donned a gown. During an interview on 3/10/2026 at 3:09 PM, Staff J, Occupational Therapy Assistant, stated, I just forgot [Resident #111's name] was EBP [enhanced barrier precautions]. Review of Resident #111's care plan initiated on 2/13/2026 read, I am on Enhanced Barrier Precautions because I am at risk for infections or worsening infection as evidenced by midline for iv abt [antibiotics]. During an interview on 3/11/2026 at 3:11 PM, the Director of Nursing stated, Staff are to wear gloves and a gown when providing direct care and when administering medication via the IV. Review of the facility policy and procedures titled Enhanced Barrier Precautions with the last review date of 7/25/2025 read, Policy: Enhanced barrier precautions (EBPs) are utilized to prevent the spread of multi-drug resistant organisms (MDROs) to residents. Policy Interpretation and Implementation: 2. EBPs employ targeted gown and glove use during high contact resident care activities when contact precautions do not otherwise apply. 5. Examples of high-contact resident care activities requiring the use of gown and gloves for EBPs include: a. dressing; b. bathing/showering, c. transferring; d. providing hygiene; e. changing linens; f. changing briefs or assisting with toileting; g. device care or use (central line, urinary catheter, feeding tube, tracheostomy/ventilator, etc.; and h. wound care. 2) During an observation on 3/11/2026 at 8:31 AM, Staff K, Licensed Practical Nurse (LPN), was pouring the medication for Resident #79. Losartan tablet fell out of the blister pack onto the top of the medication cart. Staff K picked up Losartan tablet without wearing gloves and placed the medication into the medication cup. Staff K entered Resident #79's room and administered the medication. Review of Resident #79's physician order dated 1/10/2026 read, Losartan Potassium Oral Tablet 25 MG [milligram] (Losartan Potassium), Give 1 tablet by mouth one time a day for HTN [Hypertension]. During an interview on 3/11/2026 at 8:42 AM, Staff K, LPN, stated, I should not have given [Resident #79's name] the medication. I should have tossed it and gotten a new one. I should not touch medication without wearing gloves. During an interview on 3/11/2026 at 3:11 PM, the Director of Nursing stated, The staff should have gotten rid of the medication when it fell onto the medication cart and not administer it to the resident. Medication should be handled with gloves. Review of the facility policy and procedures titled Administering Medications with the last review date of 7/25/2025 read, Policy Interpretation and Implementation: 11. Appropriate infection control procedure must be followed during the administration of medications (e.g.: hand washing, antiseptic technique, gloves, etc.) 3) During a tour of the laundry area on 3/10/2026 at 2:30 PM, the door between the soiled linen room and the clean linen room was propped open. The door had a sign on both sides that read, Keep doors closed at all times. During an interview on 3/10/2026 at 2:20 PM, Staff B, Laundry Aid, stated that the door was propped open because she was in the middle of cleaning the area, but the door should have been closed. During an interview on 3/10/2026 at 2:33 PM, the Operations Manager stated, The door should be closed at all times. During an interview on 3/10/2026 at 2:34 PM, the Housekeeping Supervisor stated, The door should remain closed at all times. During a tour of the laundry area on 3/10/2026 at 2:35 PM, two Laundry Aids were folding clean resident bed linens. The Laundry Aids were not utilizing the folding table, but were holding the sheets in the air, allowing several inches of the clean sheets to rest on the floor while they were folding them. During an interview on 3/10/2026 at 2:36 PM, the Operations Manager stated that clean linens were not to touch the ground, as they were then considered contaminated or soiled. The linens should be folded on the folding table. During an observation of the laundry facility/area on 3/11/2026 at 9:00 AM, the exit door used for transporting clean laundry out of the laundry area, was propped open, and the entrance door into the soiled laundry room was also standing open. Both doors had signage that read, Keep doors closed at all times. (photographic evidence obtained) During an interview on 3/12/2026 at 1:25 PM, the Director of Nursing (DON) stated that the entry door, exit door, and door between the soiled and clean laundry areas were to remain closed. The doors needed to be closed to minimize the potential of contamination and to maintain infection control standards. The staff, while folding clean linens, should not allow the linens to touch the ground or other contaminated surfaces, to minimize the risk of contamination and to maintain infection control standards. Review of the facility policy and procedures titled Infection Control with the last review date of 7/25/2025 read, Policy: The primary purposes of this facility's infection control policies and procedures are to establish guidelines to follow to provide a safe and sanitary and comfortable environment and to help prevent the development and transmission of disease and infection. Review of the facility policy and procedures titled Plant Operations– Housekeeping with the last review date of 7/25/2025 read, Areas Affected: Housekeeping, Laundry. Purpose: The Plant Operations staff shall perform their assigned tasks in a safe and efficient manner. Policy and/or Purpose: A. The following safety rules shall be followed: 18. Keep drawers and doors closed when not in use.

Based on record review and interview, the facility failed to ensure medical records were complete and accurate for 1 of 9 residents reviewed for medication management (Resident #95).Findings include:Review of Resident #95's physician order dated 11/29/2025 read, Midodrine HCl [Hydrochloride] Oral Tablet 5 MG [milligram] (Midodrine HCl), Give 5 mg by mouth three times a day for hypotension hold if systolic BP [Blood Pressure] above 130.Review of Resident #95's Medication Administration Record (MAR) for administration of Midodrine HCl for December 2025 showed the medication was administered with no blood pressure documented from 12/1/2025 through 12/8/2025, and from 12/10/52025 through 12/31/2025 at 9:00 AM; from 12/1/2025 through 12/8/2025, from 12/10/2025 through 12/11/2025, and from 12/12/2025 through 12/31/2025 at 1:00 PM; and from 12/1/2025 through 12/6/2025, from 12/8/2025 through 12/11/2025, and from 12/13/2025 through 12/31/2025 at 5:00 PM.Review of Resident #95's MAR for administration of Midodrine HCl for January 2026 showed the medication was administered with no blood pressure documented from 1/1/2026 through 1/5/2026, and from 1/7/2026 through 1/30/2026 at 9:00 AM; from 1/1/2026 through 1/6/2026, from 1/8/2026 through 1/18/2026, and from 1/19/2026 through 1/31/2026 at 1:00 PM; and from 1/1/2026 through 1/12/2026, from 1/15/2026 through 1/17/2026, from 1/19/2026 through 1/29/2026, and on 1/31/2026 at 5:00 PM.Review of Resident #95's MAR for administration of Midodrine HCl for February 2026 showed the medication was administered with no blood pressure documented from 2/1/2026 through 2/28/2026 at 9:00 AM, 1:00 PM, and 5:00 PM.Review of Resident #95's MAR for administration of Midodrine HCl for March 2026 showed the medication was administered with no blood pressure documented from 3/1/2026 through 3/4/2026, and from 3/6/2026 through 3/11/2026 at 9:00 AM; from 3/1/2026 through 3/11/2026 at 1:00 PM; and from 3/1/2026 through 3/11/2026 at 5:00 PM.Review of Resident #95's progress notes from 12/1/2025 through 3/9/2026 revealed no documentation regarding blood pressure monitoring, hypotension, or the administration of Midodrine.During an interview on 3/11/2026 at 12:40 PM, Staff A, Registered Nurse (RN), stated that the expectation was that blood pressure would be checked before administering Midodrine, and the blood pressure readings should be documented. She confirmed that blood pressures were not being documented for Resident #95 for administration of Midodrine.During an interview on 3/11/2026 at 12:48 PM, the Director of Nursing (DON) stated that the expectation was that for all blood pressure medications, the blood pressure was to be obtained before the medication was administered and it should be documented.During an interview on 3/11/2026 at 4:22 PM, Physician #1 stated that all blood pressure medications, whether for hypertension or medications such as Midodrine, were to have blood pressure taken before it was administered.During an interview on 3/12/2026 at approximately 11:30 AM, the Risk Manager (RM) stated that they did not have a policy regarding parameters for medication administration, and they expected the nurses to adhere to appropriate standards for following physician orders pertaining to obtaining vital signs or stated parameters.

Based on observation, interview, and record review, the facility failed to ensure drugs and biologicals used in the facility were stored in accordance with accepted professional principles in 1 of 2 halls.Findings include: 1) During an observation on 3/9/2026 at 10:19 AM, there was one box of Alka Seltzer on top of Resident #64's bedside table. Resident #64 was not in her room (Photographic evidence obtained).During an interview on 3/9/2026 at 11:35 AM, when asked if Resident #64 was able to self-administer medications, Staff F, Licensed Practical Nurse (LPN), stated, Not to my knowledge.During an observation on 3/9/2026 at 11:35 AM, Staff F, LPN, entered Resident #64's room and removed the box of Alka Seltzer.2) During an observation on 3/9/2026 at 10:48 AM, Resident #62 was sitting in her room. There was one bottle of nasal decongestant Oxymetazoline HCl [hydrochloride] on top of her bedside table (Photographic evidence obtained).During an interview on 3/9/2026 at 10:48 AM, Resident #62 stated, I will administer the nasal mist myself. The doctor said I can have it.During an interview on 3/9/2026 at 10:51 AM, Staff G, LPN, stated, The nasal mist is not something I bring to her. Maybe it is something family brought in. Residents are not allowed to have anything at bedside. I will have to get an order for the nasal mist.During an observation on 3/9/2026 at 10:51 AM, Staff G, LPN, entered Resident #62's room and removed the nasal mist from the room.3) During an observation on 3/9/2026 at 10:55 AM, Resident #15 was sitting in her room. There was one bottle of 91% isopropyl alcohol on top of the nightstand.During an interview on 3/9/2026 at 10:55 AM, Resident #15 stated, I use it [91% isopropyl alcohol] on my skin.During an interview on 3/9/2026 at 11:00 AM, Staff G, LPN, stated, I did not know [Resident #15's name] has a bottle of isopropyl alcohol in her room. We do not have orders for that.During an observation on 3/9/2026 at 11:00 AM, Staff G, LPN, entered Resident #15's room and removed the bottle of 91% isopropyl alcohol from the nightstand. During an interview on 3/11/2026 at 2:59 PM, the Director of Nursing stated, Medication should not be left unattended in residents' rooms. We will provide residents, who are able to self-administer, boxes with a lock to store the medication.Review of the facility policy and procedures titled Medications- Storage of with the last review date of 7/25/2025 read, Policy: Medications and biologicals shall be stored in a safe, secure, and orderly manner. Policy Interpretation and Implementation: 6. Compartments containing medications and biologicals are locked when not in use, and trays or carts used to transport such items are not left unattended. (Compartments include, but not limited to, drawers, cabinets, rooms, refrigerators, carts, and boxes.)

Based on record review and interview, the facility failed to ensure residents were free of significant medication errors for 1 of 9 residents reviewed for medication management (Resident #123).Findings include:Review of Resident #123's physician order dated 3/7/2026 read, NovoLog FlexPen Subcutaneous Solution Pen-injector 100 unit/ml [milliliter] (Insulin Asparat), Inject as per sliding scale if 1-150= 2 units; 200-249= 4 units; 250-299= 6 units; 300-349= 8 units; 350-400= 10 units, subcutaneously three times a day for DM II [type II diabetes mellitus].Review of Resident #123's Medication Administration Record (MAR) for March 2026 for administration of Insulin Asparat showed 2 units of insulin were administered on 3/9/2026 at 9:00 AM for a blood glucose reading of 62 and 1:00 PM for a blood glucose reading of 122.During an interview on 3/9/2026 at 1:30 PM, the Director of Nursing reviewed the sliding scale insulin order for Resident #123 and stated that the sliding scale was not the typical sliding scale utilized at the facility and that she would contact the physician to verify the order.During an interview on 3/0/2026 at 1:48 PM, the Director of Nursing stated that after reviewing the order with Physician #3, the sliding scale insulin order for Resident #123 was incorrect and that the order should have started at 150 rather than 1.During an interview on 3/10/2026 at 9:25 PM, Physician #3 stated that the incorrect sliding scale was likely the result of a transcription error during the admission medication reconciliation process.During an interview on 3/10/2026 at 1:28 PM, Staff C, Licensed Practical Nurse (LPN), stated, I administered the insulin according to the sliding scale order in the record. The sliding scale order is not the typical sliding scale used at the facility.During an interview on 3/12/2026 at 10:43 AM, Staff D, LPN, stated, I entered the NovoLog insulin sliding scale order into the electronic medical record for [Resident #123's name]. The order was placed on hold until the resident arrived from the hospital. Once the resident arrives, the nurse assigned to the resident is responsible for reviewing the admission orders prior to making them active. The sliding scale was likely entered incorrectly during transcription.

Based on record review and interview, the facility failed to ensure residents' drug regimens were free from unnecessary medications for 2 of 9 residents reviewed for medication management (Residents #3 and #77).Findings include: 1) Review of Resident #77's physician order dated 2/25/2026 read, Midodrine HCl [Hydrochloride] Oral Tablet 10 mg [milligram] (Midodrine HCl), Give one tablet by mouth every 8 hours for Hypotension, Hold for SBP [Systolic Blood Pressure] of > [higher than] 100. Review of Resident #77's Medication Administration Record (MAR) for March 2026 for administration of Midodrine HCl showed the medication was administered on 3/1/2026 at 2:00 PM for BP (Blood Pressure) of 105/63, 3/4/2026 at 10:00 PM for BP of 127/78, 3/5/2026 at 6:00 AM for BP of 116/72, 3/6/2026 at 6:00 AM for BP of 123/64, 3/7/2026 at 6:00 AM for BP of 108/63, 3/8/2026 at 6:00 AM for BP of 109/68, and 3/10/2026 at 6:00 AM for BP of 110/62. During an interview on 3/11/2026 at 10:29 AM, Staff A, Registered Nurse (RN), stated that she administered Midodrine and was not aware of the parameters associated with the physician order. During an interview on 3/11/2026 at 10:24 AM, Physician #2 stated that he did not believe the resident experienced any adverse outcome as a result of the medication being administered outside the ordered parameters. He stated his expectation would be for the nursing staff to follow his orders. 2) Review of Resident #3's physician order dated 12/30/2025 read, Metoprolol Succinate ER [Extended Release] Oral Tablet Extended Release 24 Hour 25 mg (Metoprolol Succinate), Give 1 tablet by mouth every 12 hours for htn [hypertension] Hold sys [systolic] < [less than]120, dyst [diastolic] < 50, P [pulse] < 60. Review of Resident #3's MAR for March 2026 for administration of Metoprolol Succinate ER showed the medication was administered on 3/2/2026 at 9:00 AM for the pulse of 59, 3/2/2026 at 9:00 PM for the systolic blood pressure of 116, 3/3/2026 at 9:00 AM for the pulse of 57, on 3/4/2026 at 9:00 AM for systolic blood pressure of 115 and the pulse of 58, 3/5/2026 at 9:00 AM for the pulse of 54, 3/7/2026 at 9:00 AM for the pulse of 57, 3/8/2026 at 9:00 AM for the pulse of 56, 3/9/2026 at 9:00 AM for the pulse of 51, 3/9/2026 at 9:00 PM for the pulse of 59, 3/10/2026 at 9:00 AM for the pulse of 58, and 3/11/2026 at 9:00 AM for the pulse of 55. During an interview on 3/11/2026 at 12:41 PM, Staff L, Licensed Practical Nurse (LPN), stated, I don't recall [Resident #3's name] having parameters for her metoprolol. If one of the parameters are out of the range, the medication would need to be held. I should not have administered the medication when her heart rate was less than 60. During an interview on 3/11/2026 at 1:40 PM, the Director of Nursing stated, Nursing staff should check vital signs and if it is out of the parameters ordered, it should not be administered. During an interview on 3/11/2026 at 2:30 PM, Physician #4 stated, I would expect nurses to follow all parameters. Heart rate is the most important since the medication is a beta blocker. If the heart rate is less than 55, it should not be given. There have not been any medical issues with [Resident #3's name] cardiac health. Review of the facility policy and procedures titled Administering Medications with the last review date of 7/25/2025 read, Policy: Medications will be administered in a timely manner and as prescribed by the resident's attending physician or the facility's Medical Director in accordance with our established policies. Policy Interpretation and Implementation: 3. Medications must be administered in a timely manner and in accordance with the attending physician's written/verbal orders. 24. Should there be any doubt concerning the administering of medication (s), the physician's order must be verified before the medication is administered.

Based on record review and interview, the facility failed to ensure the physician/prescriber documented the rationale for declining the pharmacist's recommendation and failed to ensure physician's order was implemented upon pharmacist's recommendations for 2 of 9 residents reviewed for medication management (Residents #3 and #6).Findings include: 1) Review of Resident #6's consultation report with the recommendation date of 10/14/2025 read, Comment: [Resident #6's name] has a PRN [as needed] order for an anxiolytic, without a stop date: Lorazepam. Recommendation: Please discontinue PRN Lorazepam, tapering as necessary (e.g. decreasing the dose by no more than 25%, or 10-12% in high-risk residents, every 2 weeks). If the medication cannot be discontinued at this time, please document the indication for use, the intended duration of therapy, and the rationale for the extended time period. Physician's Response: [checked box] I decline the recommendation(s) above and do not wish to implement any changes due to the reasons below: PRN only. The form was signed by Physician #1 on 10/15/2025. Review of Resident #6's consultation report with the recommendation date of 12/2/2025 read, Comment: [Resident #6's name] has a PRN order for an anxiolytic, without a stop date: Lorazepam. Recommendation: Please discontinue PRN Lorazepam, tapering as necessary (e.g. decreasing the dose by no more than 25%, or 10-12% in high-risk residents, every 2 weeks). If the medication cannot be discontinued at this time, please document the indication for use, the intended duration of therapy, and the rationale for the extended time period. Physician's Response: [checked box] I decline the recommendation(s) above and do not wish to implement any changes due to the reasons below: [No rationale documented]. The form was signed by Advance Practice Registered Nurse (APRN) #1. Review of Resident #6's consultation report with the recommendation date of 12/16/2025 read, Comment: [Resident #6's name] has a PRN order for an anxiolytic, without a stop date: clonazepam. Recommendation: Please discontinue PRN clonazepam, tapering as necessary (e.g. decreasing the dose by no more than 25%, or 10-12% in high-risk residents, every 2 weeks). If the medication cannot be discontinued at this time, please document the indication for use, the intended duration of therapy, and the rationale for the extended time period. Physician's Response: [checked box] I decline the recommendation(s) above and do not wish to implement any changes due to the reasons below: [No rationale documented]. The form was signed by APRN #1. Review of Resident #6's progress notes from 10/10/2025 through 12/28/2025 revealed no physician/provider documentation of the rationale for the continued use of Clonazepam on a prn basis. Review of Resident #6's progress notes from 10/10/2025 through 1/1/2026 revealed no physician/provider documentation of the rationale for the continued use of Lorazepam on a prn basis. During an interview on 3/11/2026 at 11:40 AM, the Director of Nursing (DON) stated that when the pharmacist's recommendations were presented to the providers, it was up to the providers as to whether they replied or entered a rationale for declining the pharmacist's recommendations. During an interview on 3/11/2026 at 4:22 PM, Physician #1 stated he kept Resident #6 on prn Lorazepam because it was needed on a prn basis in addition to the scheduled doses for her agitation. He stated he had addressed the reasons for continuation in some of his notes. During an interview on 3/11/2026 at 5:23 PM, APRN #1 stated that he did not address the rationale for continuing Resident #6's prn Lorazepam and prn Clonazepam because she was being seen by a psychiatric provider. He usually wrote a rationale for not following the pharmacist's recommendations, but did not with either recommendation for Resident #6 in December 2025. 2) Review of Resident #3's consultation report with the recommendation date of 10/26/2025 read, Comment: [Resident #3's name] receives insulin and a sulfonylurea, Glimepiride concomitantly, increasing the risk of hypoglycemia. Recommendation: Please discontinue Glimepiride. Physician Response. [checked box] I accept the recommendation(s) above, please implement as written. DC [discontinue] Glimepiride. Signature. Date: 11/05/25. Review of Resident #3's physician order dated 3/18/2025 read, Glimepiride Oral Tablet 2 MG [milligram] (Glimepiride), Give 1 tablet by mouth in the morning for DM [Diabetes Mellitus]. Order Status: Active. Review of Resident #3's Medication Administration Record (MAR) for February 2026 for administration of Glimepiride 2 mg showed the medication was administered from 2//1/2026 through 2/14/2026 and from 2/17/2026 through 2/28/2026. Review of Resident #3's MAR for March 2026 for administration of Glimepiride 2 mg showed the medication was administered was administered from 3/1/2026 through 3/11/2026. During an interview on 3/11/2026 at 1:40 PM, the Director of Nursing stated, Glimepiride was not discontinued. Usually, the unit secretary will give it to the unit manager or myself to transcribe. I am not sure what happened. I will contact the provider to see if they would want the medication discontinued. Review of the facility policy and procedures titled Medication Regimen Reviews with the last review date of 7/25/2025 read. Policy: The consultant pharmacist shall review the medication regimen of each resident at least monthly. Policy Interpretation and Implementation: 1. A review of the resident's medication regimen is made by the consultant pharmacist at least monthly. 2. The purpose of this review is to: f. Identify any medication or documentation errors. 3. Notations of the findings and recommendations shall be recorded on the monthly medication regimen review report. The absence of notations on the report indicates that no irregularities were found.

Based on record review and interview, the facility failed to develop and implement a comprehensive care plan for 1 of 9 residents reviewed for medication management (Resident #3).Findings include:Review of Resident #3's progress note dated 2/2/2026 read, Insulin Glargine Solostar Subcutaneous Solution Pen injector 100 unit/ml [milliliter], Inject 15 unit subcutaneously at bedtime for DM [Diabetes Mellitus]. bg [blood glucose] 160 pt [patient] refused med stated if bg below she is not taking it.Review of Resident #3's Medication Administration Record (MAR) for February 2026 for administration of Insulin Glargine showed code 2 (Drug Refused) was documented on 2/3/2026, 2/6/2026, 2/8/2026, 2/12/2026, 2/13/2026, 2/16/2026, 2/20/2026, 2/22/2026, 2/25/2026, 2/26/2026, and 2/27/2026 at 9:00 PM. Further review of the MAR showed the blood sugar value of 120 and staff initials for administration of the medication on 2/18/2026 at 9:00 PM.Review of Resident #3's MAR for January 2026 for administration of Insulin Glargine showed code 9 was documented on 3/3/2026, and code 2 was documented on 3/6/2026, 3/9/2026, and 3/10/2026 at 9:00 PM.Review of Resident #3's administration note dated 2/18/2026 read, Insulin Glargine Solostar Subcutaneous Solution Pen injector 100 unit/ml, Inject 15 unit subcutaneously at bedtime for DM. refused because blood glucose 120.Review of Resident #3 administration note dated 3/3/2026 read, Insulin Glargine Solostar Subcutaneous Solution Pen injector 100 unit/ml, Inject 15 unit subcutaneously at bedtime for DM. blood glucose72. Patient refused.Review of Resident #3's care plan did not document a focus for refusals of insulin.During an interview on 3/11/2026 at approximately 2:30 PM, Staff E, Case Manager, stated, [Resident #3's name] care plan does not include the refusals of insulin. It should be reflected in her care plan.During an interview on 3/11/2026 at 2:59 PM, the Director of Nursing stated, I would expect [Resident #3's name] to be care planned for her refusals.Review of the facility policy and procedures titled Care Plan- Comprehensive with the last review date of 7/25/2025 read, Policy: A comprehensive care plan shall be developed for each resident that includes measurable objectives and timetables to meet the resident's medical, nursing, and psychological needs. Policy Interpretation and Implementation: 2. The comprehensive care plan has been designed to: a. Incorporate identified problem areas.

Based on observation, interview, and record review, the facility failed to ensure Minimum Data Set (MDS) assessments were accurate for 1 of 2 residents reviewed for positioning and mobility (Resident #19), 1 of 9 residents reviewed for medication management (Resident #3), and 1 of 6 residents reviewed for behavior/mood (Resident #1). Findings include: 1) During an observation on 3/10/2026 at 10:23 AM, there was a mechanical lift pad underneath Resident #19, who was sitting in her wheelchair. During an interview on 3/10/2026 at 10:23 AM, Resident #19 stated that she needed two-person assist for transfer from mechanical lift to wheelchair, but she could self-propel wheelchair when needed. During an interview on 3/12/2026 at 9:32 AM, Resident #19 stated, I haven't been able to walk since my stroke, and I am weak on my left side. I can eat independently, but I must use wheelchair for mobility. Review of Resident #19's MDS assessment dated [DATE] showed Section GG0115- Functional Limitation in Range of Motion was coded as no impairment for lower extremities. Durin an interview on 3/12/2026 at 12:06 PM, Staff M, MDS Coordinator, stated that Resident #19 was impaired on one side of the lower extremities. 2) Review of Resident #3's annual MDS assessment dated [DATE] read, Section E- Behavior. E0800. Rejection of Care-Presence and Frequency. Did the resident reject evaluation or care (e.g., bloodwork, taking medications, ADL [Activities of Daily Living] assistance) that is necessary to achieve the resident's goals for health and well-being. 0. Behavior not exhibited. Review of Resident #3's progress note dated 2/2/2026 read, Insulin Glargine Solostar Subcutaneous Solution Pen injector 100 unit/ml [milliliter], Inject 15 unit subcutaneously at bedtime for DM [Diabetes Mellitus]. Review of Resident #3's Medication Administration Record (MAR) for February 2026 for administration of Insulin Glargine showed code 2 (Drug Refused) was documented on 2/16/2026 and 2/20/2026 at 9:00 PM during the lookback period of MDS. During an interview on 3/11/2026 at approximately 2:30 PM, Staff E, Case Manager, stated, [Resident #3's name] MDS needs to be corrected. The behavior was coded by mistake. [Resident #3's name] did refuse insulin. 3) Review of Resident #1's Significant Change in Status MDS assessment dated [DATE] showed no anxiety disorder documented under Section I- Active Diagnoses. Review of Resident #1's admission record showed the resident was initially admitted on [DATE] and readmitted on [DATE] with diagnoses to include unspecified anxiety disorder with onset date of 1/26/2026. Review of Resident #1's psychology services note dated 3/26/2025 read, Diagnostic Impressions: Other Specified Anxiety Disorder. Review of Resident #1's psychological consultation note dated 4/2/2025 read, Why is this service Medically Necessary: Because this patient has a psychiatric illness of: Other Specified Anxiety Disorder. Review of Resident #1's physician order dated 1/27/2026 read, Lorazepam Oral Tablet 0.5 MG [milligram], Give 1 tablet by mouth every 4 hours as needed for Anxiety for 12 months. Review of Resident #1's MAR for January 2026 showed Lorazepam was administered on 1/27/2026 at 11:41 AM, 1/27/2026 at 7:32 PM, and on 1/31/2026 at 8:15 AM. Review of Resident #1's MAR for February 2026 showed Lorazepam was administered on 2/1/2026 at 10:44 PM. During an interview on 3/11/2026 at 4:47 PM, Staff M, MDS Coordinator, stated, [Resident #1's name] MDS needs to be corrected to document the resident has a diagnosis of anxiety. During an interview on 3/12/2026 at 10:00 AM, the Risk Manager stated, The facility follows the RAI [Resident Assessment Instrument] manual.

Based on record review and interview, the facility failed to provide laboratory services to meet the needs for 1 (Resident #1) of 3 residents reviewed. Findings include: Review of Resident #1's clinical record showed the resident was admitted on [DATE] with diagnoses that included Stage 3 chronic kidney disease, and malignant neoplasm of prostate. Review of Resident #1's physician order dated 10/4/2024 read, CBC [Complete Blood Count]; CMP [Complete Metabolic Panel]; UA C&S [Urinalysis Culture and Sensitivity]. Review of Resident #1's UA C&S results read, Collection Date: 10/05/2024 00:00 [12:00 AM], Received date: 10/05/2024 10:05 [10:05 AM], Reported Date: 10/07/2024 13:15 [1:15 PM] . Source: Urine. Organism 1 > [more than] 100,000 CFU/ML [Colony Forming Units per Milliliter] Enterococcus faecalis. Sensitivity MIC ORG [microorganism] #5. Ampicillin <= [less than equals to] 2 S [Susceptible], Ciprofloxacin <=1 S, Nitrofurantoin <=32 S, Penicillin 2 S, Tetracycline >8 R [Resistant], Vancomycin 2 S. Review of Resident #1's clinical records revealed no lab results reported with reported to the physician. Review of the email sent from Infection Preventionist to the interdisciplinary team on 10/8/2024 at 10:21 AM read, [Resident #1's name] UA +[positive], needs ABT [antibiotic therapy]. During an interview on 11/6/2024 at 2:07 PM, the Infection Preventionist stated, I review cultures/urine results every morning. On 10/7/24, there were no result, the culture was still pending. I do not check the results again until the next day. The nurse assigned to the patient is supposed to follow up with abnormal labs during their shift. The next day [10/8/2024], I reviewed the results and [Resident #1's name] results were back. The urinalysis was positive and I sent an email to the IDT [Interdisciplinary team] directing that the resident needed antibiotics, but by that time the patient had already been sent to the hospital. During a telephonic interview on 11/6/2024 at 12:49 PM, Staff A, Licensed Practical Nurse (LPN), stated, I do not remember the patient. I do not know if the results were given to the providers or not. During a telephonic interview on 11/6/2024 at 5:08 PM, the Advance Practice Registered Nurse (APRN) stated, He [Resident #1] was confused on admission and had a history of UTIs. When the urinalysis was ordered, if he was symptomatic, I would have given him 3 days of IM [intramuscular] Rocephin. No Rocephin was ordered so he was not symptomatic, so I will wait for the sensitivity report. I was never informed of the urinalysis report. I do not feel harm was caused for him not being medicated on 10/7/2024 after sensitivity was received. During an interview on 11/6/2024 at 4:07 PM, the Director of Nursing confirmed the urinalysis and culture sensitivity report result received on 10/7/2024 at 1:15 PM was positive and not reported to the physician, and stated, The primary nurse is responsible to call the physician when the urinalysis is reported as abnormal. We receive the results via fax now. Review of the facility policy and procedure titled Test Results revised on 7/6/2010 read, Policy: The resident's attending physician shall be notified of the results of diagnostic tests. Policy Interpretation and Implementation . 2. Should the test results be provided to the facility, the attending physician ARNP [Advanced Registered Nurse Practitioner] shall be promptly notified of the results. 3. The Unit Manager or the nurse receiving the test results shall be responsible for notifying the physician of the test results. Noting the tests results by initially dating them. 4. Signed and dated reports of all diagnostic services shall be made a part of the resident's medical record.

Based on interview and record review, the facility failed to ensure resident records were complete and accurate for 1 (Resident #1) of 3 residents reviewed. Findings include: Review of Resident #1's clinical record showed the resident was admitted on [DATE] with diagnoses that included Stage 3 chronic kidney disease, and malignant neoplasm of prostate. Review of Resident #1's physician order dated 9/23/2024 read, Prostat AWC every shift for wounds. Review of Resident #1's physician orders dated 9/19/2024 read Senna S Oral tablet 8.6- 60 MG [milligrams], Give 1 tablet by mouth every 12 hours for constipation. Review of Resident #1's physician order dated 9/19/2024 read, Carbidopa-Levodopa Oral Tablet 10-100 MG, Give 2 tablet by mouth four times a day for Parkinson's. Review of Resident #1's Medication Administration Record (MAR) for October 2024 revealed no documentation on 10/7/2024 at night shift for administration of Prostat AWC, no documentation on 10/7/2024 at 9:00 PM for administration of Senna S and Carbidopa-Levodopa. During a telephonic interview on 11/6/2024 at 2:03 PM, Staff B, LPN, stated, I did not have many medications and I gave him his medications on 10/7/2024, but forgot to chart them. During an interview on 11/6/2024 at 4:07 PM, the Director of Nursing stated that the medication should be given as ordered and documented in the resident chart as given by the nurse. Review of the facility policy and procedure titled Administering Medications revised on 7/13/2015 read, Policy Interpretation and Implementation . 9. The individual administering the medication must initial the resident's MAR on the appropriate line and date for that specific day before administering the next resident's medication. Review of the facility policy and procedure titled Medical Record Documentation revised on 4/16/2023 read, Policy: All services provided to the resident, or any changes in the resident's condition, shall be recorded in the resident's medical record. Policy Interpretation and Implementation: 1. All treatments and medications shall be ordered by the physician and documented on the resident's MAR/TAR [Treatment Administration Record] . 11. Documentation in the resident's Medical Record and the Resident Care Plan is the responsibility of every nurse.

Based on record review, and interview, the facility failed to ensure the residents received medication as ordered in accordance with professional standards of practice for 1 (Resident #1) of 3 residents reviewed. Findings include: Review of Resident #1's clinical record showed the resident was admitted on [DATE] with diagnoses that included Stage 3 chronic kidney disease, and malignant neoplasm of prostate. Review of Resident #1's physician order dated 9/19/2024 read, Bisacodyl Rectal Suppository 10 MG [milligrams] (Bisacodyl), Insert 1 suppository rectally at bedtime for constipation. Review of Resident #1's Medication Administration Record (MAR) for October 2024 revealed no documentation on 10/2/2024 and 10/7/2024 for administration of Bisacodyl rectal suppository. During a telephonic interview on 11/6/2024 at 2:03 PM, Staff B, Licensed Practical Nurse (LPN), stated, I did not give the suppository because he had a bowel movement. I should have given the suppository routinely like the orders are written. I did not call the doctor. During a telephonic interview on 11/6/2025 at 5:08 PM, the Advance Practice Registered Nurse (APRN) stated, The physician orders needed to be followed unless the resident refuses and then the refusal should be documented and I should be notified. I was not notified that the medication was not given. During an interview on 11/6/2024 at 4:07 PM, the Director of Nursing stated, The suppository should have been given as ordered. If it is not given, then the physician needs to be notified. Review of the facility policy and procedure titled Administering Medications revised on 7/13/2015 read, Policy: Medications will be administered in a timely manner and as prescribed by the resident's attending physician or the facility's Medical Director in accordance with our established policies . Policy Interpretation and Implementation . 3. Medications must be administered in a timely manner and in accordance with the attending physician's written/verbal orders. 4. Should a dosage seem excessive considering the resident's age and medical condition, or a medication order seems to be unrelated to the resident's current diagnosis or medical condition, the person preparing/administering the medication shall contact the resident's attending physician or the facility's Medical Director for further instruction.

Based on observation, interview, and record review, the facility failed to ensure the comprehensive care plans were implemented for 2 of 4 residents reviewed for positioning, Residents #73 and #74. Findings include: 1) During an observation on 9/23/2024 at 9:59 AM, Resident #74 was resting with her eyes closed. The resident's feet were not offloaded while in bed. There was a yellow pillow with white cover on top of the wheelchair. During an observation on 9/23/2024 at 12:14 PM, Resident #74 was lying in bed with her eyes closed. The resident's feet were not offloaded while in bed. During an observation on 9/23/2024 at 12:53 PM, Resident #74 was lying in bed with her eyes closed. The resident's feet were not offloaded while in bed. During an observation on 9/24/2024 at 7:45 AM, Resident #74 was lying in bed with her eyes closed. The resident's feet were not offloaded while in bed. There was a yellow pillow with white cover on top of the wheelchair. During an observation on 9/24/2024 at 8:40 AM, Resident #74 was sitting up in bed with breakfast tray in front of her. The resident's feet were not offloaded. There was a yellow pillow with white cover on top of the wheelchair. During an observation on 9/24/2024 at 11:06 AM, Resident #74 was resting with her eyes closed. The resident's feet were not offloaded while in bed. There was a yellow pillow with white cover on top of the wheelchair. Review of Resident #74's care plan dated 7/12/2024 showed it read, Approaches. Float heels when in bed. 2) During an observation on 9/23/2024 at 10:00 AM, Resident #73 was lying in bed, with the bed being at the lowest position. The resident's feet were not offloaded while lying in bed. During an observation on 9/23/2024 at 12:15 PM, Resident #73 was lying in bed, with the bed at being the lowest position. The resident's feet were not offloaded while lying in bed. During an observation on 9/24/2024 at 7:46 AM, Resident #73 was resting with her eyes closed. The resident's feet were not offloaded while in bed. There was a pillow on top of the chair in the room. During an observation on 9/24/2024 at 8:41 AM, Resident #73 was sitting up in bed. The resident's feet were not offloaded. There was a pillow on top of the chair in the room. During an observation on 9/24/2024 at 11:07 AM, Resident #73 was lying in bed with her eyes closed. The resident's feet were not offloaded. There was a pillow on top of the chair in the room. Review of Resident #73's care plan dated 4/16/2024 showed it read, Approaches. Float heels when in bed. During an interview on 9/24/2024 at 11:10 AM, Staff A, Licensed Practical Nurse (LPN), stated, I would have to look for [Resident #73's name and Resident #74's name] to see if they have orders to offload feet while in bed. During an observation on 9/24/2024 at 11:10 AM, Staff A, LPN, entered Resident #74's room and woke the resident up and asked her if she could place the pillow that was on the chair under her feet. Resident #73 stated, Sure, I do not care. Staff A placed the pillow under the resident's feet. Staff A returned to the medication cart and reviewed orders for Resident #73. During an interview on 9/24/2024 at 11:12 AM, Staff A, LPN, stated, [Resident #73's name] and [Resident #74's name] both have orders for floating heels. Both residents are hard to follow command. We have to provide a lot of education, and they are very confused and combative at times. You might do something and then not be there. During an interview on 9/25/2024 at 7:50 AM, the Director of Nursing stated, If a resident is care planned for offloading, it should be done. Review of the facility policy and procedure titled Care Plan- Comprehensive with the last review date of 7/19/2024 showed it read, Policy Interpretation and Implementation. 1. An interdisciplinary assessment team, in coordination with the resident and his/her family or representative (sponsor), develops and maintains a comprehensive care plan for each resident.

Based on observation, interview, and record review, the facility failed to ensure the drugs and biologicals used in the facility were stored in accordance with currently accepted professional principles. Findings include: 1) During an observation on 9/23/2024 at 9:44 AM, Resident #46 was sitting in her wheelchair in her room. There was a bottle of Biofreeze fast-acting menthol pain relief gel roll-on on top of the nightstand (Photographic evidence obtained). During an interview on 9/23/2024 at 9:44 AM, Resident #46 stated, I have arthritis and have the girls put it on at night for me. 2) During an observation on 9/23/2204 at 10:08 AM, Resident #2 was sitting up in her bed. On top of the resident's bedside table, there were one bottle of Biofreeze fast-acting menthol pain relief gel roll-on, one Voltaren cream, and one Lotrimin Clotrimazole cream. During an interview on 9/23/2024 at 10:08 AM, Resident #2 stated, I use the Biofreeze for my neck and the cream is a muscle relaxer that I use. During an observation on 9/24/2024 at 11:15 AM with Staff A, Licensed Practical Nurse (LPN), there were one bottle of Biofreeze, one Voltaren cream and one Lotrimin Clotrimazole cream on top of Resident #2's bedside table. During an interview on 9/24/2024 at 11:15 AM, Staff A, LPN, stated, Sometimes the family will bring in medication without us knowing. Medication should not be at the bedside. 3) During an observation on 9/23/2024 at 10:10 AM, Resident #41 was lying in bed. There were two bottles of eye drops in the resident's cabinet. During an interview on 9/23/2024 at 10:10 AM, Resident #41 stated, I cannot reach the eye drops. I am not sure what they are for. During an observation on 9/24/2024 at 8:40 AM, Resident #41 was lying in bed. There was one bottle of eye drops on top of the resident's cabinet (Photographic evidence obtained). During an interview on 9/24/2024 at 8:40 AM, Resident #41 stated, Yesterday, they took one of the eye drop bottles and only left that one. During an observation on 9/24/2024 at 11:18 AM with Staff A, LPN, there was one bottle of eye drops on top of the Resident #41's cabinet. There was no one in the resident's room. During an interview on 9/24/2024 at 11:18 AM, Staff A, LPN, stated, As far as I know, [Resident #41's name] does not have orders for eye drops. During an interview on 9/25/2024 at 7:48 AM, the Director of Nursing stated, Medication should not be left at the bedside. Review of the facility policy and procedure titled Storage of Medication with the last review date of 7/19/2024 showed it read, Policy: Medications and biologicals shall be stored in a safe, secure, and orderly manner. Policy Interpretation and Implementation . 6. Compartments containing medications and biologicals are locked when not in use, and trays or carts used to transport such items are not left unattended. (Compartments include, but not limited to, drawers, cabinets, rooms, refrigerators, carts, and boxes.)

Based on observation, interview, and record review the facility failed to ensure care and services for central venous access devices in accordance with professional standards of practice for 2 (Resident #237 and #238) of 2 residents reviewed with a central venous access devices. Findings include: 1). During an observation on 5/30/2023 at 11:45 AM Resident #237 was lying in bed with a single lumen midline with gauze under the transparent dressing. The dressing was dated 5/28/2023. During an observation on 5/31/2023 at 1:00 PM, Resident #237 was lying in bed with a single lumen midline with gauze under the transparent dressing. The dressing was dated 5/28/2023. During an observation on 6/01/2023 at 8:20 AM Resident #237 was lying in bed with single lumen midline with gauze under the transparent dressing. The dressing was dated 5/28/2023. During an interview on 6/1/2023 at 8:20 AM Staff C, License Practical Nurse (LPN), stated, [Resident #237's name] has a midline dressing dated 5/28/2023 with gauze under the transparent dressing. Normally IV [intravenous] dressings are changed weekly. I do not know if the dressing should be changed at a different time; dressings are done by the Registered Nurses. Review of Resident #237's admission record documented an admitted [DATE] with diagnoses that included osteomyelitis, severe sepsis with septic shock, peripheral vascular disease, and type 2 diabetes mellitus without complications. Review of Resident #237's physician's order dated 5/19/2023 read Heparin Sod (Pork) lock flush Intravenous Solution 10 unit/ml (milliliters) (Heparin Sodium (Porcine) Lock Flush) Use 1 dose intravenously one time a day for after midline flush at completion of IV antibiotic therapy. Review of Resident #237's physician's order dated 5/19/2023 read Normal Saline Flush Intravenous Solution 0.9% (Sodium Chloride Flush) Use 1 dose intravenously one time a day for Flush line before and after IV antibiotic therapy dose. Review of Resident #237's physician's order dated 5/27/2023 documented, Ertapenem Sodium Injection Sodium Reconstituted 1 GM (gram) (Ertapenem Sodium) Use 1 dose intravenously one time a day for Osteomyelitis until 06/30/2023. Review of Resident #237's physician's order revealed no dressing change orders for midline venous device. During an interview on 6/01/2023 at 8:36 AM the Director of Nursing stated, I would have to look up when a dressing should be changed when it has a gauze under the transparent dressing. I do not see any dressing orders for [Resident #237's name] for his midline. I would have to question the unit manager to see, I am not seeing any orders. 2). During an observation on 5/30/2023 at 11:20 AM Resident #238 was lying in bed, right hand single lumen midline noted. The transparent dressing had gauze under the dressing and was dated 5/28/2023. During an observation on 5/31/2023 at 1:10 PM Resident #238 was lying in bed, right hand single lumen midline noted. The transparent dressing had gauze under the dressing and was dated 5/28/2023. During an observation on 6/1/2023 at 8:10 AM with Staff C, LPN, Resident #238 was lying in bed, right hand single lumen midline noted. The transparent dressing had gauze under the dressing and was dated 5/28/2023. During an interview on 6/1/2023 at 8:11 AM with Staff C, LPN, stated, I am not sure if the dressing is dated 5/28/2023. I would have to look in the system to see when it was last changed. Normally midline dressings are changed weekly. Typically, LPNs do not do dressing changes it would be a Registered Nurse. Review of Resident #238's admission record documented an admitted [DATE] with diagnoses including transient cerebral ischemic attack, cellulitis of right upper limb, type 2 diabetes and chronic kidney disease stage 3. Review of Resident #238's physician's order dated 5/28/2023 read Change Right Midline catheter site dressing as needed for Midline IV (intravenous). Review of Resident #238's physician's order dated 5/28/2023 read Change Right Midline catheter site dressing one time a day every 7 day(s) for Midline IV. Review of Resident #238's physician's order dated 5/28/2023 read Normal Saline Flush Solution 0.9% (Sodium Chloride Flush) use 10 ml (milliliters) intravenously one time a day for Midline IV after medication administration. Review of Resident #238's physician's order dated 5/28/2023 read Normal Saline Flush Solution 0.9% (Sodium Chloride Flush) use 10 ml (milliliters) intravenously one time a day for Midline IV before medication administration. Review of the policy and procedure titled Midline Catheter Dressing Change,' revised date 2/2018, read Guidance. 2. When a transparent dressing is applied over a sterile gauze dressing it is considered a gauze dressing and is change: 2.2 Every two days.

Based on observation, interview, and record review, the facility failed to ensure residents received respiratory care services consistent with professional standards of practice for 3 of 6 residents (#71, #238, and #239) reviewed. Photographic Evidence Obtained Findings include: 1). During an observation on 5/30/2023 at 9:39 AM, Resident #71 was observed lying in bed and not wearing her nasal cannula which was observed to be wrapped around the right handrail of the bed. The nasal cannula was not bagged. During an observation on 6/1/2023 at 7:52 AM, Resident #71's nasal cannula was wrapped around the right handrail of the bed. The nasal cannula was not bagged. During an interview with Staff A, Licensed Practical Nurse (LPN) on 6/1/2023 at 8:11 AM, Her tubing was not bagged. During an interview with the Director of Nursing on 6/1/2023 at 9:23 AM, Ultimately, staff are expected to bag and date all oxygen tubing. 46523 2). During an observation on 05/30/23 at 11:20 AM Resident #238 was lying in bed, nasal cannula wrapping on top of oxygen concentrator machine and tubing had no date. During an observation 05/31/2023 at 1:10 PM Resident #238 was lying in bed, nasal cannula wrapping on top of oxygen concentrator machine and tubing had no date. During an observation on 6/1/2023 at 8:10AM with Staff C, LPN, nasal cannula wrapping on top of oxygen concentrator machine and tubing had no date. During an interview on 6/1/2023 at 8:07AM with Staff C, LPN stated, Tubing should be dated and it should be bagged when not in used. Review of Resident #238 admission record documented Resident was admitted on [DATE] with diagnosis including transient cerebral ischemic attack, cellulitis of right upper limb, type 2 diabetes and chronic kidney disease stage 3. Review of Resident #238 physician order dated 5/27/2023 documented, Oxygen: 2 Liters via NC Q HS and weekly tubing change at bedtime and every night shift every Sun (Sunday) change tubing. 3). During an observation on 5/30/23 at 11:20 AM Resident #239 was lying in bed, passive nebulizer mask placed on top of nebulizer machine without a bag and tubing was observed with no date. During an observation 5/31/2023 at 9:00 AM Resident #239 was lying in bed, passive nebulizer mask placed on top of nebulizer machine without a bag and tubing was observed with no date. During an observation on 6/1/2023 at 8:06 AM with Staff C, LPN, passive nebulizer mask placed on top of nebulizer machine and tubing was dated with what appear to be 2/19/2023. During an interview on 6/1/2023 at 8:07 AM with Staff C, LPN stated I am not able to read the date on the tubing. The nebulizer mask should be bagged, and the tubing should be changed weekly on Sunday. Review of Resident #239's admission record documented resident was admitted on [DATE] with diagnoses including multiple subsegmental pulmonary emboli without acute cor pulmonale, dyspnea, and interstitial pulmonary disease. Review of Resident #239's physician's order dated 5/26/2023 read, Nebulizer: tubing change weekly Sunday 7p-7a every night shift Sun. Review of the policy and procedure titled, Administering Medications through a Small Volume (Handheld) Nebulizer last reviewed 1/20/2023 read, Steps in the Procedure. 27. When equipment is completely dry, store in a plastic bag with the resident's name and the date on it. 28. Change equipment and tubing every seven days, or according to the facility protocol.

Based on record review and interview, the facility failed to ensure an accurate assessment reflective of a resident's status at the time of the assessment for 1 (Resident #84) of 3 residents reviewed for discharge. Findings include: Review of Resident #84's admission record documented, Date of Discharge 03/26/2023. Review of Resident #84's physician's order dated 3/25/23 read May DC [discharge] home when arrangements made. Review of Resident #84's Minimum Data Set (MDS), Resident Assessment and Care Screening titled Discharge Return not anticipated dated 3/26/2023 read, Summary Section A - Identification Information Target, the discharge date [Section A2000} read 3/26/2023 and the discharge status [Section A2100] read Acute hospital. During an interview on 5/31/23 at 1:35 PM Staff D, Case Manager stated, This resident [Resident #84] went home with home health care. He went home with his daughter. The MDS is incorrect. He did not go to the hospital. He went home. During an interview on 6/1/23 at 1:30 PM the Administrator stated, We do not have a policy and procedure for MDS assessments. We follow the RAI (Resident Assessment Instrument) manual.

Based on record review and interview the facility failed to ensure the arbitration agreements presented to 3 (Resident #66, Resident #237 and Resident #240) of 3 residents reviewed were given 30 days to rescind the arbitration agreement. Findings include: Review of the facility Arbitration Agreements presented to Resident #66 on 10/17/2021, presented to Resident #237 on 5/7/2023 and presented to Resident #240 on 5/21/2023, read, This agreement shall remain in full force and effect not withstanding the termination, cancellation or natural expiration of the Resident Admission Agreement. If this Arbitration Agreement is not rescinded within three (3) business days of signing as provided for in the final paragraphs of this Agreement, this Agreement shall remain in effect for and shall be binding on the Facility and Resident for this and all of the Resident's other admission or re-admission to the Facility (if any) without any need for further renewal. During an interview on 6/1/2023 at 1:05 PM the Administrator stated, I spoke to the risk manager and we did have three days written in the arbitration agreement, but it should have been 30 days. Since we print documents via Docusign maybe it was a typo. In practice we don't hold Residents to that agreement.

Based on observation, interview, and record review the facility failed to ensure the medication storage rooms were free from expired medications for two of two medication storage rooms. Findings include: During an observation on 5/31/23 at 10:12 AM of medication storage room one, there was one bottle of normal saline with an expiration of 12/4/21, four bottles of normal saline with an expiration date of 10/29/22, one bottle of normal saline with an expiration date of 1/17/23, two bottles of normal saline with an expiration date of 3/31/23, three bottles of normal saline with an expiration date of 3/25/22, and two bottles of unopened Sterile Water with expiration date of 3/15/23. During an observation on 5/31/23 at 10:30 AM of medication storage room two, there was two Irrigation Tray Piston Syringe containers with an expiration date of 5/22/22 and one Irrigation Tray Piston Syringe container with an expiration date of 1/11/22. During an interview on 5/31/23 at 11:00 AM the Director of Nursing stated, those items (one bottle of normal saline with an expiration of 12/4/21, four bottles of normal saline with an expiration date of 10/29/22, one bottle of normal saline with an expiration date of 1/17/23, two bottles of normal saline with an expiration date of 3/31/23, three bottles of normal saline with an expiration date of 3/25/2, two bottles of Sterile Water with expiration date of 3/15/23, two Irrigation Tray Piston Syringe containers with an expiration date of 5/22/22, one Irrigation Tray Piston Syringe container with an expiration date of 1/11/22) are expired. The Unit Managers try to do a monthly check. I don't know why those expired items were not discarded. During an interview on 5/31/23 at 11:05 AM Staff B, Unit Manager, stated, Central Supply goes through and spot checks the expiration dates. It is ultimately nursing's responsibility to ensure no expired medications are in the medication room. I do not know why there are expired items in the medication storage room. Review of the policy and procedure titled, Storage of Medication last reviewed 1/20/2023 read, Policy Interpretation and Implementation. 4. Drug containers that have missing, incomplete, improper, or incorrect labels are returned to the pharmacy for proper labeling before storing. Discontinue, outdated, or deteriorated drugs or biologicals are returned to the dispensing pharmacy or destroyed.

Based on observation, interview, and record review, the facility failed to ensure residents who needed respiratory care were provided such care consistent with professional standards of practice for 2 of 3 residents reviewed for respiratory care, Residents #44 and #362, in a total sample of 30 residents. Findings: 1. Review of the physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Order Summary: Oxygen: 2 liters via N/C [Nasal Canula] PRN [as needed] every shift and as needed. During an observation on 1/24/2022 at 10:27 AM, Resident #44 way lying in her bed receiving oxygen via nasal cannula. Resident #44's oxygen concentrator gauge showed she was receiving oxygen at 3 liters via nasal cannula. During an observation on 1/25/2022 at 8:47 AM, Resident #44 was lying in her bed receiving oxygen via nasal cannula. Resident #44's oxygen concentrator gauge showed she was receiving oxygen at 2.5 liters via nasal cannula. During an interview on 1/25/2022 at 8:47 AM, Resident #44 stated, I did not adjust the gauge on my oxygen concentrator. I let them do it. During an interview on 1/26/2022 at 7:54 AM, Staff A, Licensed Practical Nurse (LPN)/ Unit Manager, confirmed Resident #44's physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . During an observation on 1/26/2022 at 7:56 AM with Staff A, LPN, Unit Manager, Resident #44's oxygen concentrator gauge was adjusted between 2.5 and 3 liters. During an interview on 1/26/2022 at 7:56 AM, Staff A, LPN, Unit Manager, confirmed Resident #44's oxygen concentrator gauge showed a higher rate than the prescribed 2 liters via nasal cannula. 2. During an observation on 1/24/2022 at 11:10 AM, Resident #362's oxygen delivery tubing was dated 1/16/2022 and the nebulizer tubing was dated 1/9/2022 (Photographic evidence obtained). Review of Resident #362's admission records revealed the resident was admitted on [DATE] with the diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] Review of Resident #362's Minimum Data Set (MDS) dated [DATE] read, Section O. Special Treatments, Procedures, and Programs: C. Oxygen 1. While Not a Resident: Yes, 2) While a Resident: Yes. Review of the physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Order Date: 01/06/2022. Order Summary: Oxygen: Change oxygen tubing every week as needed for O2 [oxygen] therapy. Order Date: 01/06/2022. Order Summary: Oxygen: Change oxygen tubing every week every night shift every Sun for O2 therapy. every night shift every Sun for O2 (oxygen) therapy. During an observation on 1/25/2022 at 1:44 PM, Resident #362's oxygen delivery tubing attached to the oxygen tank was dated 1/16/2022 and the nebulizer tubing was dated 1/9/2022 (Photographic evidence obtained). During an observation on 1/25/2022 at 2:53 PM, Resident #362's oxygen delivery tubing attached to the oxygen tank was dated 1/16/2022 and the nebulizer tubing was dated 1/9/2022 (Photographic evidence obtained). During an interview on 1/25/2022 at 2:53 PM, Staff D, LPN, Unit Manager, confirmed that the Resident #362's nebulizer tubing was dated 1/9/2022 and oxygen tubing was dated 1/16/2022. She stated, It is the facility expectation that oxygen tubing and nebulizer tubing is changed weekly on Sundays. Nebulizer tubing was due to be changed on 1/16/2022 and oxygen tubing was due to be changed on 1/23/2022.

Based on observation and interview, the facility failed to ensure medications were labeled when opened on 2 of 3 medication carts in a total of 7 medication carts and failed to ensure expired medications were not stored with working stock in 1 of 2 medication storage rooms. Findings include: On 09/14/2020 at 11:40 AM, an observation of medication cart 2 on the [MEDICATION NAME] Unit showed one 1.5 ML (milliliter) bottle of [MEDICATION NAME] 0.2% eye drops in the working stock drawer that was not documented with the date the eye drops were opened for Resident #21. The label instructions read to discard 28 days after opening. One 0.5 ML bottle of refresh tears eye drops in the working stock drawer that was not documented with the date the eye drops were opened for Resident #21. The label instructions read to discard 28 days after opening. One bottle of [MEDICATION NAME] Propionate nasal spray was opened on 03/05/2020 for Resident #44. Review of the manufacturer's instructions read to discard opened bottle after 90 days. Three 0.5 ML bottles of refresh tears eye drops in the working stock drawer that was not documented with the date the eye drops were opened for Resident #44. The label instructions read to discard 28 days after opening. One vial of refresh Laci-lube eye ointment in the working stock drawer that was not documented with the date the eye ointment was opened for Resident #44. The label instructions read to discard 28 days after opening. One 2.5 ml vial of Latanoprost ophthalmic eye drops in the working stock drawer that was not documented with the date the eye drops were opened for Resident #65. The label instructions read to discard 42 days after opening. During an interview on 09/14/2020 at 11:52 AM, Staff D, Licensed Practical Nurse (LPN) stated, I don't know why the eye drops and eye ointment were opened and undated in the working stock drawer of the medication cart. The eye drops should have shown the date they were opened. The nasal spray was expired and should not have been in the draw. On 09/14/2020 at 12:00 AM, an observation of medication cart 3 on the [MEDICATION NAME] Unit showed one pack of 27 [MEDICATION NAME] 0.5 MG (milligrams) expired on 04/30/2020 for Resident #60. During an interview on 09/14/2020 at 12:20 PM, Staff E, LPN, stated, I just overlooked the expiration date on the narcotic. I just forgot to check it this morning for the expiration date. On 09/14/2020 at 12:23 PM, an observation of the medication storage room on the [MEDICATION NAME] Unit showed one 1500 ML bottle of Glucerna 1.2 Cal expired on 05/01/2020. During an interview on 12:28 PM, the [MEDICATION NAME] hallway Unit Manager stated, I see the Glucerna expired as of 05/01/2020. On 09/14/2020 at 12:30 PM, an observation of medication cart 4 on the Transitional Care Unit (TCU) showed one pill pack containing [MEDICATION NAME]-[MEDICATION NAME] 5-325 MG for Resident #28 expired on 07/18/2020. One bottle of 0.5 ML refresh tears in the working stock drawer that was not documented with the date the eye drops were opened for Resident #43. The label instructions read to discard 28 days after opening. One bottle of 0.5 ML refresh ointment in the working stock drawer that was opened on 07/11/2020 for Resident #43. The label instructions read to discard 28 days after opening. During an interview on 09/14/2020 at 12:36 PM, Staff E, Registered Nurse (RN), stated, I just overlooked the expiration date on the [MEDICATION NAME]-[MEDICATION NAME] 5-325 MG. I forgot to check the expiration date this morning. I don't know why the eye ointment and eye drops were opened and undated in the working stock drawer of the medication cart. On 09/14/2020 at 12:41 PM, an observation of cart 1 cart on the TCU unit showed one 1.8 oz ML bottle of [MEDICATION NAME] ophthalmic ointment 0.5% in the working stock drawer that was not documented with the date the eye drops were opened for Resident #58. The label instructions read to discard 28 days after opening. One (5) ML bottle of [MEDICATION NAME]/[MEDICATION NAME]) ophthalmic suspension 0.3- 0.1% in the working stock drawer that was not documented with the date the eye drops were opened for Resident #58. The label instructions read to discard 28 days after opening. During an interview on 09/14/2020 at 12:46 PM Staff G, RN, stated, I don't know why the eye drops in the working stock drawer of the medication cart are expired. The medications are supposed to be checked on the cart by the nursing staff each shift.

Based on observation, medical record and interview, the facility did not ensure that the environment remained free of hazards for 1 of 16 sampled residents, Resident #38. The facility failed to prevent or deter entrance to the resident #38's room during renovations, allowing the resident to freely reenter the room and subsequently fall, resulting in injury to the resident's face with a non-displaced fracture. Findings: An observation of Resident #38 was initially conducted on 2/14/2011 at 1:45 PM. The resident was observed to have bruising from the level of the resident's nose to the hairline, including both eyes. Another visit was made to the resident on 2/15/2011 at 8:45 AM. The resident was seated in a reclining chair in his room. The resident was interviewed at this time and was able to explain how the injuries had been sustained. The resident stated, during interview on 2/15/2011 at 8:45AM, that renovations were being made to his room, so he was moved temporarily to another room in the facility. He stated staff did assist him in packing the belongings he wanted to take with him during the time he would be out of his normal room. Resident #38 stated he returned to his room (evening of 2/09/2011) to obtain some underwear, which was in a small 3-drawer cabinet. It was confirmed at this time by the resident, that the outer door to the room had not been locked, nor was there any indication on the outside of the door not to enter. There had been no barrier to his entering the room, as explained by him. The resident entered the room, finding the small cabinet had been rolled into the shower stall in the bathroom. The resident stated he placed his hand onto the toilet seat to steady himself as he went to reach into the stall to open the 3-drawer cabinet. At this time, not knowing the toilet and grab bars had been disconnected from the wall as part of the renovation, he placed his hand on the toilet seat, the toilet tipped and he landed face first into the shower stall and onto the tile floor. He stated staff responded promptly when they heard him yelling for help. A review of the medical record revealed the resident was alert and oriented, independent in cognition and was able to make decisions for himself. The resident was self ambulating with the assistance of a cane. There was no history of ambulating falls prior to the incident on 2/09/2011 per the Unit Manager on 2/17/2011 at 10:36 AM. Review of the falls assessment completed on 2/11/2010 indicated the resident with a score of 12 or high risk for falls, with a score of 11 on the previous assessment dated [DATE]. An interview was conducted with the unit Licensed Practical Nurse ( LPN) on 2/14/2011 at 2:46 PM. The LPN stated, " The resident fell on [DATE] when he entered his bathroom during repairs being done to his room. He had been instructed not to enter the room. All belongings that he wanted during this time had been moved to a temporary room while the repairs were being done. In the bathroom, he was leaning on the rails in the bathroom, which had been loosened during repairs and he fell and hit his head in the shower." The LPN was asked at 3:28 PM on 2/14/2011, if the door had been locked or if there had been any deterrent placed at the door frame to discourage entrance into the room. The LPN stated she did not remember any deterrent in place at the time to include use of a "do not enter" sign, yellow stripes/tape across the door or a lock placed on the door to prevent access. An interview was conducted with the facility Risk Manager and facility Administrator on 2/15/2011 at 3:35 PM. The interviews revealed, "The incident occurred at 8:55 PM on 2/09/2011. The Risk Manager was notified by staff at 10:00 PM. She arrived at the building at 4:50 AM to interview the staff on duty at that time." She confirmed the shift is a 12-hour shift from 7 PM to 7 AM and that resident #38 is ambulatory, alert & oriented. She stated that staff heard the resident call out from the room. The resident had selected items he wanted moved to the temporary room, and reported to staff that, "he'd come over to get a pair of underwear for the morning." Per the facility Administrator, renovations which were to be done in his room included painting and redoing floors to room and bathroom. The plan was to remove the painting carts each day from the room. However, the handle bars which were attached to toilet, were no longer secured when the toilet was loosened during the renovations. There was a "wet paint sign" on the door at the time of the incident. The room door had not been locked at the time of the incident or after the resident had moved out of the room, and there was no locking mechanism on the door. Per the Administrator, the door handle was the same as is standard on all resident doors with a non-locking type door handle. It was confirmed there was no facility policy nor established procedure for the renovation of rooms and the securing of the doors to prevent entry during that time. The resident returned to the facility on [DATE]. Review of the discharge summary from the hospital indicated, "The only abnormality found on the head CT was a non-displaced fracture of the right sub-cortical superior orbital rim with involvement of both the anterior and posterior walls of the right frontal sinus; additionally no apparent fracture nor dislocation of the cervical spine." The resident did return to the facility with the cervical collar in place for precautionary purposes. The resident was wearing the cervical collar during observations of the resident on 2/14/2011 at 1:45PM and 2/15/2011 at 8:45AM.

Based on record review and interview, the facility failed to provide appropriate care and services to identify and respond to indicators of possible complications to one (#2) of three sampled residents upon return from the hospital following a head injury. The failure to identify and respond timely to signs of complication from the head injury resulted the the resident being found unresponsive and requiring emergent transport to the hospital. Findings: Review of the discharge instructions in the record for resident #2 reveals that the resident suffered a head injury after a fall on 08 ,[DATE] at 3:35AM and was discharge from the emergency room back to the facility on [DATE] at 9:05AM with instructions to "seek immediate medical care if there is confusion or drowsiness" or "you can not awaken the injured person" The nursing note dated [DATE] at 12:30 PM states that resident is eating lunch and does not have a headache or blurry vision. Blood pressure is ,[DATE] making the pulse pressure 21. The pulse is recorded as 76. Widening pulse pressure (difference between systolic and diastolic pressures.) may be indicative of increasing intercranial pressure (ICP). Review of the nursing note dated [DATE] and timed at 10:00 PM reveals that the resident is "alert and oriented to self with periods of confusion." Record review of the nursing note dated [DATE] at 12:45 PM reveals that resident #2 was assessed to be unresponsive and the physician was notified. The note further reveals that the physician ordered emergency services to be called. Blood pressure is recorded as ,[DATE] making the pulse pressure 100. The pulse is recorded as 45. The nursing note dated [DATE] and timed 15 minutes later reveals that emergency services were notified. Resident was transferred to the hospital on [DATE] at 1:25PM The note dated [DATE] and timed at 10:15 AM reveals that the adult child of the resident came to the facility to pick up the resident's belonging and at that time informed the facility that resident expired during the night. No nursing notes are entered between the note on [DATE] at 10:00 PM and the note on [DATE] at 12:45 PM. No other assessments of the resident's status were identified. Review of the Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]"patient sleepy' and "patient unable to take" Telephone interview on [DATE] at 12:21 PM with the nurse who was caring for the resident on [DATE] during the morning hours reveals, that she found the resident to be sleepy on the morning of [DATE] and that she had to hold the resident's medications. She also stated that she had had this problem before. When questioned why no other days were marked that the medication was held she stated "I don't know". When asked if she preformed any further neurologic assessments after determining that the resident was lethargic she stated "no". She also stated that she had instructed the nursing assistant to let the resident sleep. During telephone interview with the with the child of resident #2 on [DATE] at 1:00 PM, he/she reveals that the he/she had attempted to call the resident multiple times that morning ([DATE]) and had been told that the resident was sleeping. The interviewee also indicated that concern prompted a visit to the facility and that upon arrival resident #2 was unable to be awakened and the nurse was notified. The interviewee stated that the nurse's initial response was that the resident was sleepy. The interviewee stated that at that point a demand was made to see the resident at which time the nurse visited the resident and confirmed that the resident was not responding and told the interviewee that the resident's vitals were stable. The interviewee then stated that she had to demand that the doctor be notified. The interviewee also stated that a demand had to be made to call emergency services immediately as the nurse stated that she had to complete the paperwork prior to calling. Review of the facility provided policy entitled "Charting and Documentation" reveals that "All observations, medications administered, services performed, etc. must be documented in the resident's clinical record." and "All incidents, accidents, or changes in the resident's condition must be recorded." Review of the facility provided policy entitled "Change in a resident's Condition or Status" reveals that "The Nurse Supervisor/Charge Nurse will notify the resident's Attending Physician or On-Call Physician when there has been:" " D. a significant change in the resident's physical/mental condition; E. A need to alter the resident's medical treatment significantly;" Review of the facility provided policy entitled "Neurological Assessment" reveals that "The purpose of this procedure is to perform a neuro vital sign assessment 1) upon physician order; 2) when following an unwitnessed fall; 3) subsequent to a fall with a suspected head injury; or 4) when indicated by resident condition. Neurological assessments are the responsibility of licensed nursing personnel. And "1. Particular attention should be paid to widening pulse pressure (difference between systolic and diastolic pressures.) This may be indicative of increasing intercranial pressure (ICP). 2. Any change in vital/neuro vital signs in a previously stable resident, should be reported to the physician immediately." The extended survey was conducted on [DATE] and no deficiencies were identified. Sufficient staffing protocol was completed and no deficiencies were identified. Corrective Actions taken by the facility to remove the Immediate Jeopardy and correct the deficiency: 1. The nurse caring for resident #2 on [DATE] was terminated on [DATE]. 2. Facility developed a new neurological guideline on [DATE] 3. Tool developed for each unit manager to fill out on each resident that experiences a significant change in condition. This tool is then reviewed each business day in a morning meeting for proper notification of physician and quality of care provided to the resident. This review also includes all new incident reports. 4. Inserviced all nursing staff related to new neurological assessment guidelines, assessment of changes in condition, notification of the physician, and new reporting tool utilized by unit managers on [DATE] 5. Inserviced all nursing staff on accurate and complete documentation, holding of medication and notification of the physician for the hold and a second review of the new neurological assessment guidelines on [DATE]. 5. A new 72 hours follow-up Neurological Assessment form with corresponding protocol was developed and implemented. All Nursing staff was inserviced on [DATE]-[DATE]. 6. Inservice for Certified Nursing Assistance (CNA) on notification of changes and safety of residents on [DATE]. 7. The Director of Nursing (DON), on a weekly basis, audits the charts to ensure that the tools are being completed as required beginning on [DATE] ongoing. Interviews with 5 Nurses on [DATE] representing all units and shifts revealed that they were aware and able to verbalize the new policies and guidelines for Neurological Assessment. The need for prompt identification, complete assessments and notification of the physician of changes in condition of a resident to include those that require neurological assessments and follow-up. Interview with 5 CNAs representing all units and shifts revealed they were aware and able to verbalize the new policies and guidelines for Neurological Assessment, the need to promptly notify nursing of all changes in resident condition, safety of residents, and accurate and complete documentation. Review of 2 of 2 current resident records for residents requiring Neurological assessment and monitoring revealed that both residents received care in accordance with the new policies and guidelines. Nureochecks were completed as required. Resident condition was clearly documented and complete assessments were conducted. The physician was notified immediately of all changes in condition. Changes to care plans were made as necessary. The residents and provision of care to them was reviewed in the morning meeting as per facility protocol. Interview with 5 residents including the resident council president revealed that they received all necessary care and services. Staff respond promptly to requests and changes. No problems were identified during these interviews.

Based on record review and interview, the facility failed to appropriately assess a resident for a change in condition after return from the hospital following a fall with head injury for one (#2) of three sampled residents. The failure to assess and take timely action upon identification of possible signs of complication from the head injury resulted the the resident being found unresponsive and requiring emergent transport to the hospital. Findings: Review of the discharge instructions in the record for resident #2 reveals that the resident suffered a head injury after a fall on 08 ,[DATE] at 3:35AM and was discharge from the emergency room back to the facility on [DATE] at 9:05AM with instructions to "seek immediate medical care if there is confusion or drowsiness" or "you can not awaken the injured person" The nursing note dated [DATE] at 12:30 PM states that resident is eating lunch and does not have a headache or blurry vision. Blood pressure is ,[DATE] making the pulse pressure 21. The pulse is recorded as 76. Widening pulse pressure (difference between systolic and diastolic pressures.) may be indicative of increasing intercranial pressure (ICP). Review of the nursing note dated [DATE] and timed at 10:00 PM reveals that the resident is "alert and oriented to self with periods of confusion." Record review of the nursing note dated [DATE] at 12:45 PM reveals that resident #2 was assessed to be unresponsive and the physician was notified. The note further reveals that the physician ordered emergency services to be called. Blood pressure is recorded as ,[DATE] making the pulse pressure 100. The pulse is recorded as 45. The nursing note dated [DATE] and timed 15 minutes later reveals that emergency services were notified. Resident was transferred to the hospital on [DATE] at 1:25PM The note dated [DATE] and timed at 10:15 AM reveals that the adult child of the resident came to the facility to pick up the resident's belonging and at that time informed the facility that resident expired during the night. No nursing notes are entered between the note on [DATE] at 10:00 PM and the note on [DATE] at 12:45 PM. No other assessments of the resident's status were identified. Review of the Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]"patient sleepy' and "patient unable to take" Telephone interview on [DATE] at 12:21 PM with the nurse who was caring for the resident on [DATE] during the morning hours reveals that she found the resident to be sleepy on the morning of [DATE] and that she had to hold the resident's medications. She also stated that she had had this problem before. When questioned why no other days were marked that the medication was held she stated "I don't know" . When asked if she preformed any further neurologic assessment after determining that the resident was lethargic she stated "no". She also stated that she had instructed the nursing assistant to let the resident sleep. During telephone interview with the with the child of resident #2 on [DATE] at 1:00 PM, he/she reveals that he/she had attempted to call the resident multiple times that morning ([DATE]) and had been told that the resident was sleeping. The interviewee also indicated that concern prompted a visit to the facility and that upon arrival resident #2 was unable to be awakened and the nurse was notified. The interviewee stated that the nurse's initial response was that the resident was sleepy. The interviewee stated that at that point a demand was made to see the resident at which time the nurse visited the resident and confirmed that the resident was not responding and told the interviewee that the resident's vitals were stable. The interviewee then stated that she had to demand that the doctor be notified. The interviewee also stated that a demand had to be made to call emergency services immediately as the nurse stated that she had to complete the paperwork prior to calling. Review of the facility provided policy entitled "Charting and Documentation" reveals that "All observations, medications administered, services performed, etc. must be documented in the resident's clinical record." and "All incidents, accidents, or changes in the resident's condition must be recorded." Review of the facility provided policy entitled "Change in a resident's Condition or Status" reveals that "The Nurse Supervisor/Charge Nurse will notify the resident's Attending Physician or On-Call Physician when there has been:" " D. a significant change in the resident's physical/mental condition; E. A need to alter the resident's medical treatment significantly;" Review of the facility provided policy entitled "Neurological Assessment" reveals that "The purpose of this procedure is to perform a neuro vital sign assessment 1) upon physician order; 2) when following an unwitnessed fall; 3) subsequent to a fall with a suspected head injury; or 4) when indicated by resident condition. Neurological assessments are the responsibility of licensed nursing personnel. And "1. Particular attention should be paid to widening pulse pressure (difference between systolic and diastolic pressures.) This may be indicative of increasing intercranial pressure (ICP). 2. Any change in vital/neuro vital signs in a previously stable resident, should be reported to the physician immediately." The extended survey was conducted on [DATE] and no deficiencies were identified. Sufficient staffing protocol was completed and no deficiencies were identified. Corrective Actions taken by the facility to remove the Immediate Jeopardy and correct the deficiency: 1. The nurse caring for resident #2 on [DATE] was terminated on [DATE]. 2. Facility developed a new neurological guideline on [DATE] 3. Tool developed for each unit manager to fill out on each resident that experiences a significant change in condition. This tool is then reviewed each business day in a morning meeting for proper notification of physician and quality of care provided to the resident. This review also includes all new incident reports. 4. Inserviced all nursing staff related to new neurological assessment guidelines, assessment of changes in condition, notification of the physician, and new reporting tool utilized by unit managers on [DATE] 5. Inserviced all nursing staff on accurate and complete documentation, holding of medication and notification of the physician for the hold and a second review of the new neurological assessment guidelines on [DATE]. 5. A new 72 hours follow-up Neurological Assessment form with corresponding protocol was developed and implemented. All Nursing staff was inserviced on [DATE]-[DATE]. 6. Inservice for Certified Nursing Assistance (CNA) on notification of changes and safety of residents on [DATE]. 7. The Director of Nursing (DON), on a weekly basis, audits the charts to ensure that the tools are being completed as required beginning on [DATE] ongoing. Interviews with 5 Nurses on [DATE] representing all units and shifts revealed that they were aware and able to verbalize the new policies and guidelines for Neurological Assessment. The need for prompt identification, complete assessments and notification of the physician of changes in condition of a resident to include those that require neurological assessments and follow-up. Interview with 5 CNAs representing all units and shifts revealed they were aware and able to verbalize the new policies and guidelines for Neurological Assessment, the need to promptly notify nursing of all changes in resident condition, safety of residents, and accurate and complete documentation. Review of 2 of 2 current resident records for residents requiring Neurological assessment and monitoring revealed that both residents received care in accordance with the new policies and guidelines. Nureochecks were completed as required. Resident condition was clearly documented and complete assessments were conducted. The physician was notified immediately of all changes in condition. Changes to care plans were made as necessary. The residents and provision of care to them was reviewed in the morning meeting as per facility protocol. Interview with 5 residents including the resident council president revealed that they received all necessary care and services. Staff respond promptly to requests and changes. No problems were identified during these interviews.