Every finding on record at Elizabeth Adam Crump Health and Rehab

Based on observation, staff interview, and facility document review, the facility staff failed to serve palatable pureed food in one of one kitchen during lunch on 8/10/2026. The findings include:On 8/10/2026 at 1:10 PM, a test tray was requested in the main kitchen. A sample of all foods served to residents at lunchtime was requested. At 1:28 PM, the final tray from the final lunch cart was served and the Regional Dietary Manager accompanied two surveyors to taste all the food on the test tray. The pureed mixed vegetables, pureed bread and pureed turkey were tasted by all three individuals; both surveyors agreed that the pureed turkey, pureed mixed vegetables and pureed bread were starchy, bland and unidentifiable in taste to what they were supposed to be. The food was determined to be not palatable. The Regional Dietary Manager stated that he could taste asparagus hints in the mixed vegetables and the turkey if you really dig into it. A review of the facility policy, Food: Quality and Palatability documented in part, 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 . On 8/11/2026 at approximately 4:00 PM, the Administrator and Director of Nursing were informed of these concerns. No additional information was provided prior to exit.

Based on observation, staff interview and facility document review, it was determined that the facility staff failed to store steam tray pans in a sanitary manner in one of one kitchen and store food in accordance with food safety standards of practice in one of three nourishment rooms. The findings include:On 8/10/2026 at 11:21 AM, an observation was made of the facility kitchen with the regional dietary manager. Observation of the kitchen area revealed a four shelf wire unit with baking sheets, muffin pans and steam tray pans stored. Observation of the steam tray pans revealed four pans stacked inside each other sitting upside down on the wire rack. The second steam tray pan was observed to have visible water droplets inside the bottom of the pan touching the bottom of the third steam tray pan that was nesting inside of it. The regional dietary manager stated that they were six inch steam pans and that they should have been air dried completely prior to stacking them together for storage. On 8/10/2026 at 11:31 AM, an observation was made of the facility nourishment room on Unit C. Observation of the freezer revealed a pint of butter pecan gelato approximately 1/2 full without a date or resident name, a 12 ounce bag of mixed vegetables without a date or resident name and a plastic grocery bag with a bag of pizza rolls inside another plastic grocery bag without a date or resident name. On 8/10/2026 at 11:43 AM, an interview was conducted with licensed practical nurse (LPN) #3 who stated that the nursing staff put a name and date on any food that was put in the refrigerator for the resident and it was thrown away if not used in three days. She stated that the kitchen staff checked the refrigerator each morning and disposed of anything that was past the date or not labeled or dated. LPN #3 observed the freezer in the nourishment room and stated that the gelato did not have a name or date and needed to be discarded, the pizza rolls had been opened but did not have a name or date and should have had one on them and the frozen vegetables did not have a name or date on them. On 8/10/2026 at 11:47 AM, an interview was conducted with the regional dietary manager who stated that dietary services maintained any food items that they stocked in the nourishment rooms on the nursing units, but the nursing staff maintained any resident food items and were responsible for dating and putting the resident name on the items. He stated that the dietary staff checked the nourishment rooms twice a day when providing snacks. The facility policy Warewashing documented in part, .All dishware will be air dried and properly stored . The facility policy Use and Storage of Foods Brought to Residents by Family and Vistors documented in part, .Food item(s) will be labeled with the resident's name, content, the date it was prepared, if known, and a discard/use by date . On 8/11/2026 at approximately 4:00 PM, the Administrator and Director of Nursing were made aware of the concern. No further information was provided prior to exit.

Based on observation, staff interview and facility document review, it was determined that the facility staff failed to provide residents with the correct amount of food according to the facility's menu in one of one facility kitchens during lunch on 8/10/2026. The findings include:On 8/10/2026 at 1:29 PM, an observation of the facility regular diet lunch tray revealed a turkey and cheese sub served on a plate with a side of coleslaw and mashed potatoes during a test tray conducted with the regional dietary manager. Observation of the sub revealed two thinly sliced pieces of turkey and one slice of American cheese on a sub roll approximately six inches long. Observation of the turkey slices revealed the sub roll length disproportionate to the round turkey slices with approximately 1 inch of bread on each end of the roll left uncovered by turkey or cheese. At that time the regional dietary manager stated that the subs were all made with two slices of turkey and one slice of cheese, and the subs may have been more proportionate with a roll, but the recipe had called for a sub roll. On 8/10/2026 at 1:50 PM, an interview was conducted with the dietary manager. When asked how staff knew what the serving of turkey was to be placed on the subs that were served at lunch. She stated that she bought the turkey pre-sliced and the staff used the Production Counts sheet as a guide when preparing the subs. She pointed to a printed out production counts sheet and stated that according to the sheet there should be four ounces of turkey and cheese on the subs. When asked how they measured four ounces of turkey, she stated that they did not have a scale to measure weight of food and had never been asked about that before. She stated that they used the pre-packaged turkey and proceeded to retrieve a 40 ounce package of sliced turkey which was labeled to contain 20 servings with one serving being three slices of turkey. When asked if putting two slices of turkey on the sub was providing a full serving per the packaging, she stated, No, I see what you are saying. The facility's Production Counts for lunch on 8/10/2026 documented in part, Wk 3-Monday-8/11/2026 [sic] Lunch-Hot Foods . Turkey & Cheese for Hoagie, 4 Oz (ounce) . Turkey & Cheese for Hoagie, 3 Oz . Turkey & Cheese for Hoagie 1 Sandwich . On 8/10/2026 at approximately 2:15 PM, the regional director of dietary stated that the Production Counts sheet documenting the 4 ounces was the total weight of the turkey and cheese sub, with the bread included, not just the turkey or the cheese portion. He stated that he thought that the staff had sliced the turkey with the deli slicer that morning and was unaware that pre-sliced turkey was used. The regional director of dietary stated that they did not have any scale to measure the 4 ounces weight for the subs to determine if they were following the production counts. On 8/11/2026 at 11:01 AM, an interview was conducted with the registered dietitian (RD) who stated that the portion information for the turkey and cheese used on the subs during lunch on 8/10/2026 should be on the recipe information and the staff should be measuring it. The RD reviewed the Production Counts sheet and stated that the 4 ounce serving was for pureed diets and a scoop should be used to portion it, the 3 ounce serving was for ground diets and a scoop should be used and the regular diet serving was one sandwich on the production sheet. The RD stated she would return with the recipe information. On 8/11/2026 at 11:35 AM, the RD returned with the recipe information for the Turkey & Cheese subs served during lunch on 8/10/2026. It documented in part, .Ingredient: Roll, Hoagie, 6-7 . Procedures: 1. Thinly slice turkey into 1 oz. slices using a meat slicer. 2. To assemble sandwich, place 2 slice of cheese and 2 ounces of turkey between 2 slices of bread.The [Name of Dietary and Healthcare Food Services Company] policy Meal Distribution: Infection Control Considerations failed to evidence guidance on following the recipe. The facility policy Food: Quality and Palatability documented in part, .The Dining Services Director and Cook(s) are responsible for food preparation. Menu items are prepared according to the menu, production guidelines and standardized recipes . On 8/11/2026 at approximately 4:00 PM the Administrator and Director of Nursing were made aware of the above findings. No further information was provided prior to exit.

Based on observation, resident interview, staff interview, clinical record review and facility document review, it was determined that the facility staff failed to provide ADL (activities of daily living) care to dependent residents for three of 76 residents in the survey sample, Residents #173, #76 and #6.The findings include: 1. For Resident #173 (R173), the facility staff failed to provide showers during January, February and March of 2025. R173 was admitted to the facility with diagnoses that included but were not limited to morbid obesity, congestive heart failure (1) and diabetes mellitus (2). On the most recent minimum data set (MDS), an annual assessment with an assessment reference date (ARD) of 9/15/2025, the resident scored 15 out of 15 on the BIMS (brief interview for mental status) assessment, indicating they were cognitively intact for short-term recall and oriented to month/day/year. The assessment documented no refusals of care and R173 being dependent for bathing/showering. The comprehensive care plan for R173 documented in part, I sometimes have behaviors which include- Refusal of skin checks/showers/ADL Care/meds. keeps bed in high position. I throw my soiled briefs/linen on the floor. Date Initiated: 03/31/2025. Review of the ADL documentation for R173 failed to evidence a shower provided during January, February and March of 2025. The documentation showed a bed bath completed five times in January, six times in February and four times in March of 2025. One refusal was documented on 3/21/2025. Review of the progress notes for R173 failed to evidence documentation of refusals for showers during January, February and March of 2025. On 6/24/2026 at 10:45 AM, an interview was conducted with licensed practical nurse (LPN) #3 who stated that they remembered working with R173. She stated that showers were offered twice a week according to a schedule and documented if the resident refused. On 6/24/2026 at 11:05 AM, an interview was conducted with certified nursing assistant (CNA) #17 who stated that she did not remember R173, but showers were given twice a week at a minimum and more if requested. She stated that if a resident refused they reapproached them later and documented it if they still refused. CNA #17 stated that they also reported this to the nurse so they could attempt to speak with the resident. The facility policy ADL care effective 2/1/2026 documented in part, It is the policy of this Facility to provide ADL care for residents to ensure all ADL needs are met daily . Residents will receive a tub/shower bath as often as needed, but not less than twice weekly . On 6/25/2026 at approximately 5:30 PM, the Administrator, the Director of Nursing and the Regional Director of Clinical Services were made aware of the concern. No further information was provided prior to exit. Reference: (1) Heart failure means that your heart can't pump enough oxygen-rich blood to meet your body's needs. Heart failure doesn't mean that your heart has stopped or is about to stop beating. But without enough blood flow, your organs may not work well, which can cause serious problems . This information was obtained from the website: Heart Failure | Congestive Heart Failure | CHF | MedlinePlus (2) Diabetes, also known as diabetes mellitus, is a disease in which your blood glucose, or blood sugar, levels are too high. Glucose is your body's main source of energy. Your body can make glucose, but it also comes from the food you eat. Insulin is a hormone made by your pancreas. Insulin helps move glucose from your bloodstream into your cells, where it can be used for energy . This information was obtained from the website: Diabetes | Type 1 Diabetes | Type 2 Diabetes | MedlinePlus 2. For Resident #76 (R76), the facility staff failed to provide assistance with bathing, dressing and incontinence care. 06/25/26 at 11:05 AM, an observation was conducted with R76. R76 was lying on his bed with his legs hanging off the bed and his hand was hanging off the bed and appeared to be reaching down tor the call bell. The call bell was lying on the floor underneath his bed. R76 appeared to be trying to call for assistance and could not find the call bell. During the observation he was pointing down and was asked if he needed assistance and he shook his head. During the observation, R76 was visibly soiled, his incontinent brief appeared full and saturated with yellowish and brownish material that had leaked out of his incontinent brief on to the sheets. His legs and arms were hanging off the bed and he was only wearing a white shirt. R76 was not covered by a sheet or blanket at the time of the observation. On 6/25/26 at 11:10 AM, an observation was made by the Director of Education and Clinical Services. She came to the room to answer the activated call bell, and she observed the call bell on the floor, the resident visibly soiled and stated the call bell should not be there it should be within the resident's reach. She said, the resident should not be in this way and I will get it taken care of right away. On 6/25/26, a clinical record review was conducted. R76's care plan had that he requires assistance with all activities of daily living, dependent on staff for care, and is incontinent of bowel and bladder. On 6/25/25, a review of the facility documentation was conducted. The facility policy titled, ADL [activities of daily living] Care, read in part, .It is the policy of this facility to provide ADL care for residents to ensure all ADL needs are met daily. 1. Each resident will be provided with daily personal attention and care, including skin, nail, hair, and oral hygiene, in addition to any specific care ordered by the physician/physician extender. Daily personal care provided will be documented in the resident's medical record. On 6/25/26 at 5:34 PM, a end of day meeting was held with the Administrator and Director of Nursing. They were informed of the above concerns. No additional information was provided prior to the exit of the survey. 3. For Resident #6 (R6), the facility failed to ensure the resident received personal hygiene in regard to showers and/or baths. Diagnoses for R6 include cerebral infarction, hemiplegia and hemiparesis, heart failure, diabetes mellitus, autistic disorder, anxiety disorder, and PTSD. On the most recent Minimum Data Set (MDS), a significant change assessment with an assessment reference date (ARD) of 6/5/26, R6 scored a 15 out of 15 on the Brief Interview for Mental Status (BIMS) indicating that R6 was cognitively intact. In section GG of this MDS, R6 was noted to be dependent on staff for showering/bathing. Review of R6's clinical record showed that R6 did not receive a shower or bath between the dates of 5/6/26-5/15/26, 5/20/26-5/26/26, 5/31/26-6/6/26, and 6/6/26-6/17/26. The clinical record was marked not-applicable for shower/bath. On 6/24/26 at 9:17 AM, R6 was observed in their bed. R6's hair was dull, dingy, and oily. R6 stated that her hair was dirty as the staff had not given her a shower in a long time. R6 stated that she was frightened to be transferred out of bed by staff for showers because she had been dropped a while back during a transfer, and she suffered from Post Traumatic Stress Disorder (PTSD). During an interview with Certified Nursing Assistant (CNA) #7 on 6/23/26 at 12:24 PM, CNA #7 stated that R6 utilizes a shower lift for showering. CNA #7 was unsure when the last time R6 had received a shower. CNA #7 stated that if a resident refuses a shower it is documented in the clinical record. CNA #7 referred to a shower schedule that showed that R6 was to receive a shower or bath twice a week. During an interview with Licensed Practical Nurse (LPN) #3 on 6/24/26 at 12:29 PM, LPN #3 stated that it had been over a week since R6 had been out of bed. LPN #3 was unsure why R6 refused to transfer out of bed, and that the staff encourages her to get up, but do not inquire as to the reason why she is refusing. Review of the facility policy titled ADL Care with a date of 2/1/2026 revealed residents will receive a tub/shower bath as often as needed, but not less than twice weekly. The above information was presented to facility leadership on 6/24/26 at 4:30 PM. No further information was provided prior to exit.

Based on observation, resident interview, staff interview, facility document review and clinical record review, the facility staff failed to provide a clean, comfortable, homelike environment for eleven of seventy-six residents in the survey sample, on one of three units and in one of sixty-five rooms (Residents #45, #81, #5, #101, #118, #181, #55, #73, #76, #74, #156, C-wing, room A-4). The findings include 1. The sink in Resident #45's room leaked and the cold-water faucet handle would not turn. Resident #45 (R45) was admitted to the facility with diagnoses that included COPD (chronic obstructive pulmonary disease), dementia, dysphagia, psychosis, hypertension and cognitive communication deficit. The minimum data set (MDS) dated [DATE] assessed R45 with severely impaired cognitive skills. On 6/23/26 at 8:30 a.m., R45 was observed in the foyer area to her room at the installed sink. R45 stated the sink leaked underneath when the water was running and that she was unable to turn on the cold water. R45 turned on the water and water was observed leaking from the drain pipes underneath the sink. The resident had a trash can placed under the sink to catch the leaking water. Cold water was not accessible at the sink as the faucet handle did not turn in either direction. R45 stated the sink had been in disrepair for a long time. On 6/23/26 at 8:50 a.m., the director of plant operations was shown the sink and interviewed about the leak and dysfunctional handle. The director of plant operations stated the sink should not be leaking and that the cold-water knob would have to be replaced. On 6/25/26 at 7:54 a.m., the maintenance director was interviewed about R45's sink. The maintenance director stated he was not sure what was wrong with the sink or how long it had been in disrepair. The maintenance director stated there had been no work order entered for the sink. The maintenance director stated rounding was performed weekly to identify items in need of repair. The maintenance director stated staff members were supposed to enter work orders for items in need of repair. The facility's policy titled Maintenance Request Policy (revised 11/2020) documented the policy was, To ensure that all maintenance problems identified within the facility are reviewed and addressed in a timely fashion and on a priority basis. The Maintenance Director will act with due diligence in addressing facility requests for maintenance; and will ensure that all appropriate building and safety codes are adhered to . All facility requests for maintenance, regardless of complaint/request type, building or affected area, must be submitted to the Maintenance Director via TELS work order by entering information in the maintenance log book stored at the nurses station . The request will be reviewed and a determination will be made as to the scope of work, priority, required trade(s), and whether or not the request requires an immediate response . This finding was reviewed with the administrator, director of nursing and regional nurse consultant during a meeting on 6/24/26 at 4:35 p.m. with no further information presented prior to the end of the survey. 2. For Resident #81 (R81), the facility failed to provide a safe, homelike, environment in the resident's bathroom. Diagnoses for R81 include malignant neoplasm of the mouth, acute and chronic respiratory failure with hypoxia, pneumonitis due to inhalation of food and vomit, repeated falls, contracture of muscles multiple sites, dysphagia, disorder of teeth and supporting structures, cognitive communication deficit, and unspecified traumatic total brain injury. On the most recent Minimum Data Set (MDS), a significant change assessment with an assessment reference date (ARD) of 4/29/26, R81 scored a nine out of 15 on the Brief Interview for Mental Status (BIMS) indicating that R81 has moderate cognitive impairment. On 6/23/26 at 12:45 PM, the sink in R81's restroom was observed to have water running freely from the faucet to the basin. There were no residents or staff present in the bathroom or in R81's room. Attempts to shut the water off at the faucet were not successful. On 6/23/26 at 3:53 PM the water in R81's bathroom sink was again observed running freely with no residents or staff present. On 6/23/26 at 5:30 PM, the facility leadership was asked to provide a work order for the running water in R81's bathroom sink. The facility provided a work order dated 6/23/26 at 6:27 PM to the survey team on 6/24/26 at 9:00 AM. On 6/24/26 at 9:11 AM, R81 was observed in their wheelchair in their room. The bathroom sink was again observed to be running freely. There were no residents or staff present. During an interview with R81 that occurred on the same date at the same time, R81 stated that the water in the bathroom sink had been running like that for a couple of months and nothing has been done for it. On 6/25/26 at 9:07 AM, the water in R81's bathroom sink was observed to still be running freely. This information was provided to facility leadership on 6/25/26 at 4:30 PM. No additional information was provided prior to exit. 3. For Resident #5 (R 5), the facility staff failed to maintain a functional bed. R 5's most recent MDS (minimum data set) and quarterly assessment with an ARD (assessment reference date) of 05/16/2026, coded R 5 as scoring a 15 out of 15 on the brief interview for mental status (BIMS) score, indicating the resident is oriented to person, place and time and has unimpaired immediate recall. On 06/22/2026 at 12:50 p.m., 06/23/2026 at 9:25 a.m., and 06/23/2026 at 4:05 p.m., R 5's bed was also observed to be broken. The foot board edges were coming apart, a metal mattress securing device was lying in the window and at one time, the mattress would not lower to be flat and remained at about a 45-degree incline. On 06/24/2026 at 10:15 AM, the Maintenance Director observed the broken bed and stated he would have to get the bed fixed. The Administrator, Director of Nursing and Regional Director of Clinical Services were made aware of the concern on 06/24/2026 at 5:15 p.m. No additional information was provided prior to exit. 4. For Resident #101 (R 101), the facility staff failed to maintain a home-like bathroom. R 101's most recent MDS (minimum data set) and quarterly assessment with an ARD (assessment reference date) of 05/25/2026, coded R 101 as scoring a 12 out of 15 on the brief interview for mental status (BIMS). On 06/22/2026 at 12:50 p.m., 06/23/2026 at 9:25 a.m., 06/23/2026 at 4:05 p.m., observation was made of the bathroom in R 101's room. The bathroom was observed to have significant visible damage to the wall exposing the sheetrock, including where the toilet connected to the wall, and around the sink. Other visible discoloration was also observed around the fixtures in the bathroom. On 06/24/2026 at 10:15 AM, an interview was conducted with the Maintenance Director who stated that any repairs that were needed were put into the maintenance work order system on the computer by the staff and were sent directly to him. He stated that he was able to see all the repairs that were needed and complete them and there had been some issues in the past that had been fixed but several rooms still had issues that required renovation. He stated that rooms that did not have holes in the walls were lower on the priority list. The Maintenance Director observed the bathroom in R 101's room and stated he inherited an old building, they are working on repairs, and there are only three maintenance staff for two buildings. He added that R 101's bathroom used to have holes in the wall and there is still work that needs to be done and was not homelike. The Administrator, Director of Nursing and Regional Director of Clinical Services were made aware of the concern on 06/24/2026 at 5:15 p.m. No additional information was provided prior to exit. 5. For Resident #118 (R118), the facility staff failed to maintain a homelike bathroom. On the most recent minimum data set (MDS), a quarterly assessment with an assessment reference date (ARD) of 5/4/2026, the resident scored 14 out of 15 on the BIMS (brief interview for mental status) indicated they were cognitively intact for orientation to year, month, day and short-term recall. Section GG coded R118 utilizing a manual wheelchair, requiring substantial/maximal assistance for toileting and toilet transfers. On 6/22/2026 at approximately 2:18 PM, an observation was made of the bathroom in R118's room. The bathroom was observed to have visible wall damage to the wall exposing the sheetrock where the toilet connected to the wall. The baseboard behind the commode was observed to be missing with caulking along the border between the wall and the floor. The sink area was observed to have visible wall damage between the mirror and the top of the sink exposing peeling wall, and a green colored wall surface. The sides and underneath the sink were observed to have visible wall damage including the appearance of water damage, exposed sub wall surface, with a pink wash basin (approximately 7 quart sized) observed underneath the exposed piping of the sink with approximately one-quarter filled with water inside. At that time, an interview was conducted with R118 who stated that she used the bathroom when needed and the basin was there to catch the water that leaked from the sink. Additional observations of R118's bathroom were made on 6/23/2026 at 8:11 AM, 5:28 PM, and 6/24/2026 at 8:25 AM. The observations remained as described above. On 6/24/2026 at 10:13 AM, an interview was conducted with the Maintenance Director who stated that any repairs that were needed were put into the maintenance work order system on the computer by the staff and were sent directly to him. He stated that he was able to see all the repairs that were needed and complete them and there had been some plumbing issues in the past and several rooms had issues that required renovation. He stated that rooms that did not have holes in the walls were lower on the priority list. The Maintenance Director observed the bathroom in R118's room and stated that it needed some attention and was not homelike. On 6/24/2026 at 5:00 PM, the Administrator, Director of Nursing and Regional Director of Clinical Services were made aware of the concern. No further information was provided prior to exit. 6. For Resident #181 (R181), the facility staff failed to maintain a homelike bathroom environment. The MDS (minimum data set) assessment was not due at the time of the survey. The admission nursing assessment for R181 dated 6/21/2026 documented the resident being alert and moderately impaired for short- and long-term recall. On 6/22/2026 at 1:27 PM, an observation was made of the bathroom in R181's room. The bathroom was observed to have a baseboard heater along the right wall. The heater was observed with visible rust on top along the length approximately four feet. All baseboards were missing with visible wall damage along the wall at the floor level except for a single baseboard along the left wall which showed visible buckling and wall damage above it. Wall damage appearing to be water damage was observed approximately 20 inches from the floor up the wall on the wall where the toilet was attached to the wall. Beneath the sink and toilet, the wall was observed with visible wall damage and cracked and peeling paint exposing brown/black/grey colored wall exposing the sub wall. Portions of the flooring were missing exposing the flooring underneath near the toilet. At that time, an interview was conducted with R181 who stated that she had just arrived at the facility a few days before and was set to start therapy that day. She stated that she previously used the bathroom before her recent hospital stay and planned to have therapy to get her strength back and go back home. She stated that she was using the bedpan until therapy got her up later today and planned to start using the restroom in the room. Additional observations of R181's bathroom were made on 6/23/2026 at 8:13 AM, 5:27 PM, and 6/24/2026 at 8:28 AM. The observations remained as described above. On 6/24/2026 at 10:13 AM, an interview was conducted with the Maintenance Director who stated that any repairs that were needed were put into the maintenance work order system on the computer by the staff and were sent directly to him. He stated that he was able to see all the repairs that were needed and complete them and there had been some plumbing issues in the past and several rooms had issues that required renovation. He stated that rooms that did not have holes in the walls were lower on the priority list. The Maintenance Director observed the bathroom in R181's room and stated that it was one that needed a total renovation and they needed the money to do it. He stated that it was not homelike. On 6/24/2026 at 5:00 PM, the Administrator, Director of Nursing and Regional Director of Clinical Services were made aware of the concern. No further information was provided prior to exit. 7. For Resident #55 (R55), the facility staff failed to maintain a homelike bathroom. On the most recent MDS (minimum data set), a quarterly assessment with an ARD (assessment reference date) of 5/18/2026, the resident was assessed as scoring 14 out of 15 on the BIMS (brief interview for mental status) assessment, indicating they were cognitively intact for orientation to year, month and day and short-term recall. On 6/22/2026 at 2:18 PM, an interview was conducted with R55 in their room. R55 stated that they had no care concerns but stated Look at my bathroom, it is a mess. R55 stated that the bathroom had been leaking for a long time and wanted to have it fixed. She stated that she used the bathroom as needed. Observation of R55's bathroom revealed visible wall damage underneath the sink and two pink basins (approximately 7 quart sized) underneath the sink under the visible pipes with visible dripping observed from the sink pipe into the pan on the right side. The basin on the right was observed to be approximately one-half filled with water. Additional observations of R55's bathroom were made on 6/23/2026 at 8:14 AM, 5:26 PM, and 6/24/2026 at 8:22 AM. The observations remained as described above. On 6/24/2026 at 10:13 AM, an interview was conducted with the Maintenance Director who stated that any repairs that were needed were put into the maintenance work order system on the computer by the staff and were sent directly to him. He stated that he was able to see all the repairs that were needed and complete them and there had been some plumbing issues in the past. The Maintenance Director observed the bathroom in R55's room and stated that it was not homelike. On 6/24/2026 at 5:00 PM, the Administrator, Director of Nursing and Regional Director of Clinical Services were made aware of the concern. No further information was provided prior to exit. 8. For Resident #73 (R73), the facility staff failed to provide a comfortable environment free from excessive heat. On the most recent MDS (minimum data set), an annual assessment with an ARD (assessment reference date) of 4/13/26, R73 was coded as being mildly cognitively impaired for immediate recall and orientation to person, place, and situation. His diagnoses included heart failure and lung dysfunction. On 6/22/26 at 1:31 p.m., R73 was observed sitting up on the side of his bed. The room felt hot and stuffy. R73 stated that the air conditioning on his entire hallway had been out for at least two weeks, and that it was too hot in his room. He stated he had not been able to sleep well at night due to the heat. R73 had two portable fans blowing air directly on him. On 6/22/26 at 5:36 p.m., R73 was observed sitting up on the side of the bed eating dinner. The room temperature was unchanged from the observation earlier in the afternoon. He stated: I'm still hot. I've been hot since before the weekend. On 6/23/26 at 8:26 a.m., R73 was observed sitting up in bed watching television. He stated he did not sleep well the previous evening due to the heat. On 6/23/26 at 9:59 a.m., the Maintenance Director was asked to take the temperatures in R73's room. The Maintenance Director measured the temperatures with a laser thermometer. The ceiling temperature was 82.8 degrees and the floor temperature was 82.9 degrees. The Maintenance Director stated he was unaware of a maximum allowable temperature in the facility. He stated he is a relatively new employee, and the air conditioner on this unit (Unit C) had been broken since he began work in April 2026. He stated he has attempted to get multiple contractors to the facility to fix the air conditioner but so far has been unsuccessful. He stated he was not aware of anything other than repair orders that could be done to keep residents cool until the unit could be repaired. He stated that portable units cost money and they are out of my realm. He stated the Administrator was aware of the broken air conditioner, but she had not offered portable units as a solution. On 6/25/26 at 1:38 p.m., the Director of Plant Operations was interviewed. He stated he is corporate employee who is responsible for the building and grounds of several buildings. He stated he visits this building approximately once a week and that when he was in the building last week, the air conditioner was functioning fine. He stated when he arrived at the building this week, the air conditioner was broken and he ordered three portable units. He admitted that the residents complained to him last week that the air conditioning chillers were not working correctly. He stated that the maintenance staff does not take room temperatures every day but only do this when the temperatures seem higher than normal. He stated he did not have records of the temperatures when he arrived at the building on 6/23/26. On 6/25/26 at 5:34 p.m., the Administrator and Director of Nursing were informed of these concerns. On 6/26/26 at 9:30 a.m., the Administrator was interviewed. She stated that in June 2025, the air conditioner broke. She explained that the resident rooms on Unit C are directly above the kitchen and laundry room and that these rooms get especially hot when the air conditioner is not working. She stated the unit is old and it takes vendors a while to get replacement parts for it. She stated last June when the facility put portable air conditioners on the unit, It was still hot on Unit C just because of the location of the rooms. She stated she received one report from a resident last week about the excessive temperatures and added: We corrected it. She stated she had identified on Monday morning, 6/22/26, before the survey team's arrival, that Unit C was hot again. However, no portable units were put into place until 6/23/26 in the late afternoon. She stated that when the facility is unable to repair the air conditioner right away, she offers residents the options to move to another unit temporarily. She added that most residents refuse this offer. The Administrator was asked to provide evidence of interventions offered to residents on 6/22/26 and 6/23/26 prior to the portable units being put into place. No additional information was provided prior to exit. 9. For Resident #76 (R76), the facility staff failed to provide an environment with clean floors. On 6/22/26 at 2:20 p.m., R76 was observed sitting up in bed. The floor around his bed had scattered loose debris and dirt. Several areas of smeared brown material were observed on the floor near the foot of the bed. The floor between the resident's bed and the wall contained three large clumps of fuzzy, black debris. On 6/22/26 at 5:39 p.m., 6/23/23 at 8:34 a.m., 1:29 p.m. and 2:47 p.m., and 6/24/26 at 9:14 a.m. and 10:24 a.m., the floor conditions remained unchanged from the initial observation on 6/22/26. On 6/25/26 at 3:58 p.m., the District Environmental Services Manager was interviewed. He stated that all resident rooms are touched daily, including sweeping and mopping the floors. He stated floors are both dust mopped and wet mopped each day. He stated that if a resident's floor becomes soiled after the housekeepers leave for the day, the nurses have access to brooms and mops in the basement housekeeping supplies area. He explained, After hours, it is up to the nursing staff. He stated a resident's room is not home like or clean if the floor is soiled with the same debris and smears for three days. He stated he would not leave his own floor at home soiled like that for three days. On 6/25/26 at 5:34 p.m., the Administrator and Director of Nursing were informed of these concerns. No additional information was provided prior to exit. 10. For Resident #74 (R74), the facility failed to maintain a comfortable environment free from excessive heat. On the most recent MDS (minimum data set), a quarterly assessment with an ARD (assessment reference date) of 4/1/26, R74 was coded as having no cognitive impairment for immediate recall or orientation to person, place, or situation. On 6/22/26 at 1:51 p.m., R74 was observed sitting up in bed. He stated he had not slept for many nights because of the excessive temperatures in his room. He stated the nursing staff told him the air conditioner had been broken on and off since last year, and there was nothing they could do about the heat. At that time, the room felt hot and humid. On 6/22 26 at 5:37 p.m., the room temperature felt warmer than at the 1:51 p.m. observation and R74 stated, I cannot sleep in this. On 6/23/26 at 8:32 a.m., R74 was observed sitting up in bed eating breakfast. He stated that it was so hot last night, he could not sleep. On 6/23/26 at 10:04 a.m., the Maintenance Director was asked to take the temperatures in R74's room. The Maintenance Director measured the temperatures with a laser thermometer. The ceiling temperature was 84.9 degrees and the floor temperature was 82.9 degrees. The Maintenance Director stated he was unaware of a maximum allowable temperature in the facility. He stated he is a relatively new employee, and the air conditioner on this unit (Unit C) had been broken since he began work in April 2026. He stated he has attempted to get multiple contractors to the facility to fix the air conditioner but so far has been unsuccessful. He stated he was not aware of anything other than repair orders that could be done to keep residents cool until the unit could be repaired. He stated that portable units cost money and they are out of my realm. He stated the Administrator was aware of the broken air conditioner, but she had not offered portable units as a solution. On 6/25/26 at 1:38 p.m., the Director of Plant Operations was interviewed. He stated he is corporate employee who is responsible for the building and grounds of several buildings. He stated he visits this building approximately once a week and that when he was in the building last week, the air conditioner was functioning fine. He stated when he arrived at the building this week, the air conditioner was broken and he ordered three portable units. He admitted that the residents complained to him last week that the air conditioning chillers were not working correctly. He stated that the maintenance staff does not take room temperatures every day but only do this when the temperatures seem higher than normal. He stated he did not have records of the temperatures when he arrived at the building on 6/23/26. On 6/25/26 at 5:34 p.m., the Administrator and Director of Nursing were informed of these concerns. On 6/26/26 at 9:30 a.m., the Administrator was interviewed. She stated that in June 2025, the air conditioner broke. She explained that the resident rooms on Unit C are directly above the kitchen and laundry room and that these rooms get especially hot when the air conditioner is not working. She stated the unit is old and it takes vendors a while to get replacement parts for it. She stated last June when the facility put portable air conditioners on the unit, It was still hot on Unit C just because of the location of the rooms. She stated she received one report from a resident last week about the excessive temperatures and added: We corrected it. She stated she had identified on Monday morning, 6/22/26, before the survey team's arrival, that Unit C was hot again. However, no portable units were put into place until 6/23/26 in the late afternoon. She stated that when the facility is unable to repair the air conditioner right away, she offers residents the options to move to another unit temporarily. She added that most residents refuse this offer. The Administrator was asked to provide evidence of interventions offered to residents on 6/22/26 and 6/23/26 prior to the portable units being put into place. No additional information was provided prior to exit. 11. For Resident #156 (R156), the facility staff failed to provide an environment with clean floors. On 6/22/26 at 2:22 p.m., R156 was observed sitting up in a wheelchair in his room. The floor on R156's side of the room had scattered loose dirt, debris, clumps of fuzzy black material, and a partially eaten mandarin orange. On 6/22/26 at 5:41 p.m. and 6/23/23 at 9:01 a.m., and 6/24/26 at 8:06 a.m., the floor conditions remained unchanged from the initial observation on 6/22/26. On 6/25/26 at 3:58 p.m., the District Environmental Services Manager was interviewed. He stated that all resident rooms are touched daily, including sweeping and mopping the floors. He stated floors are both dust mopped and wet mopped each day. He stated that if a resident's floor becomes soiled after the housekeepers leave for the day, the nurses have access to brooms and mops in the basement housekeeping supplies area. He explained, After hours, it is up to the nursing staff. He stated a resident's room is not home like or clean if the floor is soiled with the same debris and smears for three days. He stated he would not leave his own floor at home soiled like that for three days. On 6/25/26 at 5:34 p.m., the Administrator and Director of Nursing were informed of these concerns. No additional information was provided prior to exit. 12. On Unit C, the facility staff failed to maintain common areas at a comfortable temperature. On 6/23/26 at 9:58 a.m., the Maintenance Director was asked to take the temperatures in the hallway and dining room of Unit C. The Maintenance Director measured the temperatures with a laser thermometer. At 9:58 a.m., the temperatures in the hallway outside of room [ROOM NUMBER] were measured. The floor temperature was 82 degrees; the ceiling temperature was 84 degrees. At 10:10 a.m., the temperatures in the dining room were measured. The floor temperature was 82.4 degrees; the ceiling temperature was 89.9 degrees. At this time, six residents were seated in the dining room eating breakfast. The Maintenance Director stated he was unaware of a maximum allowable temperature in the facility. He stated he is a relatively new employee, and the air conditioner on this unit (Unit C) had been broken since he began work in April 2026. He stated he has attempted to get multiple contractors to the facility to fix the air conditioner but so far has been unsuccessful. He stated he was not aware of anything other than repair orders that could be done to keep residents cool until the unit could be repaired. He stated that portable units cost money and they are out of my realm. He stated the Administrator was aware of the broken air conditioner, but she had not offered portable units as a solution. On 6/25/26 at 1:38 p.m., the Director of Plant Operations was interviewed. He stated he is corporate employee who is responsible for the building and grounds of several buildings. He stated he visits this building approximately once a week and that when he was in the building last week, the air conditioner was functioning fine. He stated when he arrived at the building this week, the air conditioner was broken and he ordered three portable units. He admitted that the residents complained to him last week that the air conditioning chillers were not working correctly. He stated that the maintenance staff does not take room temperatures every day but only do this when the temperatures seem higher than normal. He stated he did not have records of the temperatures when he arrived at the building on 6/23/26. On 6/25/26 at 5:34 p.m., the Administrator and Director of Nursing were informed of these concerns. On 6/26/26 at 9:30 a.m., the Administrator was interviewed. She stated that in June 2025, the air conditioner broke. She explained that the resident rooms on Unit C are directly above the kitchen and laundry room and that these rooms get especially hot when the air conditioner is not working. She stated the unit is old and it takes vendors a while to get replacement parts for it. She stated last June when the facility put portable air conditioners on the unit, It was still hot on Unit C just because of the location of the rooms. She stated she received one report from a resident last week about the excessive temperatures and added: We corrected it. She stated she had identified on Monday morning, 6/22/26, before the survey team's arrival, that Unit C was hot again. However, no portable units were put into place until 6/23/26 in the late afternoon. She stated that when the facility is unable to repair the air conditioner right away, she offers residents the options to move to another unit temporarily. She added that most residents refuse this offer. The Administrator was asked to provide evidence of interventions offered to residents on 6/22/26 and 6/23/26 prior to the portable units being put into place. No additional information was provided prior to exit. 13. Facility staff failed to maintain a bathroom in a clean and sanitary manner. During observation of room #A4's bathroom on 6/22/26 at approximately 3:45pm, revealed a dry, crusty, brownish-black substance was observed accumulated, covering the bottom surface of the bathtub. An odor consistent with sewage was also present in the bathroom area. An interview was conducted with the Maintenance Director on 6/22/26 at approximately 3:50. The Maintenance Director was shown the brownish-black substance observed in the bathtub and was asked about the odor present in the bathroom. The Maintenance Director stated he did not know what the substance was. During an interview with an CNA#4 (Certified Nursing Assistant) on 6/24/26 at approximately 1:43pm, CNA#4 stated Bedroom bathtubs are not in use, she doesn't think they are suitable for use. Everyone uses shower room. During

Based on observation, resident interviews, staff interviews, clinical record reviews, and facility documentation review, the facility failed to ensure that the accommodation of resident needs and preferences was provided for six of 76 residents in the survey sample, Residents #5, #101, #118, #81, #40 and #117. The findings include:1. For Resident #5 (R 5) Facility staff failed to accommodate resident needs by failing to ensure the resident had access to a call bell. R5 was originally admitted to the facility 09/26/2022. Diagnoses included but are not limited to, chronic kidney disease, type 2 diabetes mellitus, morbid (severe) obesity, primary osteoarthritis, hemiplegia unspecified affecting left nondominant side, other lack of coordination, muscle weakness, contracture of muscle left hand, cognitive communication deficit, unsteadiness on feet, unsteadiness on feet, pain unspecified, anxiety disorder, and essential hypertension. R 5's most recent MDS (minimum data set) and quarterly assessment with an ARD (assessment reference date) of 05/16/2026, coded R 5 as scoring a 15 out of 15 on the brief interview for mental status (BIMS) score, indicating the resident is oriented to person, place and time and has unimpaired immediate recall. Observation on 06/22/2026 at 12:50 p.m., 06/23/2026 at 9:25 a.m., 06/23/2026 at 4:05 p.m., and 06/24/2026 at 9:45 a.m. revealed R 5's call bell was intertwined with his roommate's call bell and was lying on the floor under the left side of the head of R 5's bed. On 06/24/2026 at 9:45 a.m., Certified Nursing Assistant (CNA) #7 was asked the purpose of a call bell, and she stated it is so a resident can call the nurse or CNA for assistance. When asked if she uses the call bell to know a resident needs assistance, she said Yes, I use it to know the residents need help. At the time of speaking with CNA #7, the call bells were still intertwined on the floor under the left side of the head of R 5's bed and the call well was still not illuminating outside the room. Review of facility policy titled Call Light: Accessibility did not include information on a call bell being within reach for residents. The Administrator, Director of Nursing and Regional Director of Clinical Services were made aware of the concern on 06/24/2026 at 5:15 p.m. No additional information was provided prior to exit. 2. For Resident #101 (R 101) Facility staff failed to accommodate resident needs by failing to ensure the resident had access to a call bell. R101 was originally admitted to the facility 02/26/2026. Diagnoses include but are not limited to autistic disorder. Observation on 06/22/2026 at 12:50 p.m., 06/23/2026 at 9:25 a.m., 06/23/2026 at 4:05 p.m., and 06/24/2026 at 9:45 a.m. revealed R 101's call bell was intertwined with his roommate's call bell and was lying on the floor under the left side of the head of his roommate's bed. On 06/22/206 at 3:24 p.m. R101 was asked how he would call for help if he fell out of bed and he stated his call bell was Right over there, and pointed toward the middle of the room, and attempted to get the call bell and was unable to. R 5 said it is all crisscrossed. On 06/24/2026 at 9:45 a.m., CNA #7 was asked the purpose of a call bell and she stated it is so a resident can call the nurse or CNA for assistance. When asked if she uses the call bell to know a resident needs assistance, she said Yes, I use it to know the residents need help. At the time of speaking with CNA #7, the call bells were still intertwined on the floor under the left side of the head of R 5's bed and the call well was still not illuminating outside the room. CNA #22 was asked if R101 had been in his bed, on the floor by his bed, or anywhere on his side of the room, would he have been able to call for help. CNA #22 confirmed the resident would not have been able to use his call light to call for help and said R101 would not have had access to his bell because it was tangled up under his roommate's bed. The Administrator, Director of Nursing and Regional Director of Clinical Services were made aware of the concern on 06/24/2026 at 5:15 p.m. No additional information was provided prior to exit. 3. For Resident #118 (R118), the facility staff failed to provide a bathroom call bell that would be accessible from the floor. On the most recent minimum data set (MDS), a quarterly assessment with an assessment reference date (ARD) of 5/4/2026, the resident scored 14 out of 15 on the BIMS (brief interview for mental status) indicated they were cognitively intact for orientation to year, month, day and short-term recall. Section GG coded R118 utilizing a manual wheelchair, requiring substantial/maximal assistance for toileting and toilet transfers. The comprehensive care plan for R118 documented in part, I have physical functioning deficit related to: Some assistance required from staff with ADLs, episodes of weakness, Dx of Dementia with behavioral disturbance, HTN (hypertension), DM (diabetes mellitus), Glaucoma. Date Initiated: 1/18/2011. On 6/22/2026 at approximately 2:18 PM, an observation was made of the bathroom in R118's room. The bathroom was observed to contain a call bell which contained a button that could be activated by pulling a lever down, however there was no pull cord to activate the call bell from the floor if the resident were to have a fall while in the bathroom. The call bell button was observed to be above the toilet paper dispenser to the right side of the toilet and at the level of the top of the grab bar on the wall approximately six feet from the bathroom entrance. At that time, an interview was conducted with R118 who stated that she used the bathroom when needed and pressed the call button when she needed staff assistance. R118 stated that she had not had any falls in the bathroom but thought she may be able to reach the button if she tried but was not sure. Additional observations of R118's bathroom were made on 6/23/2026 at 8:11 AM, 5:28 PM, 6/24/2026 at 8:25 AM, and 10:30 AM. The observations remained as described above. On 6/24/2026 at 10:45 AM, an interview was conducted with licensed practical nurse (LPN) #3 who stated that if a resident was in the bathroom and needed staff they pulled the call bell. She stated that they should all have a string to pull if they fell in the floor and if they could not reach it they could scream for staff. On 6/24/2026 at 11:05 AM, an interview was conducted with certified nursing assistant (CNA) #17 who stated that residents rang their call bell if they needed assistance in the bathroom. She stated that they activated the call bell by pulling the string attached to the call bell and it should be long enough for them to reach it if they were to fall in the floor. On 6/24/2026 at 5:00 PM, the Administrator, Director of Nursing and Regional Director of Clinical Services were made aware of the concern. No further information was provided prior to exit. 4. For Resident #81 (R81), the facility failed to ensure the resident's call bell was within reach at all times. Diagnoses for R81 include malignant neoplasm of the mouth, acute and chronic respiratory failure with hypoxia, pneumonitis due to inhalation of food and vomit, repeated falls, contracture of muscles multiple sites, dysphagia, disorder of teeth and supporting structures, cognitive communication deficit, and unspecified traumatic total brain injury. On the most recent Minimum Data Set (MDS), a significant change assessment with an assessment reference date (ARD) of 4/29/2026, R81 scored a nine out of 15 on the Brief Interview for Mental Status (BIMS) indicating that R81 has moderate cognitive impairment. On the same MDS, R81 was noted to have functional impairment to both lower extremities and utilizes a wheelchair. R81 was noted to be dependent on staff for all Activities of Daily Living (ADLs) except eating. A care plan for R81 was created on 2/1/2019 for physician functioning impairment with an intervention stating to keep the call bell within reach. On 6/23/26 at 9:11 AM, R81 was observed sitting in their wheelchair on the right side of the bed facing the wall. An overbed table was in front of R81 containing breakfast and R81 was feeding themselves. The call light was observed to be clipped to the left corner of the bed by the wall out of the reach of R81. During an interview with certified nursing assistant (CNA) #6 on 6/23/26 at 9:29 AM, CNA #6 stated that call bells should be kept in reach of the residents. Review of the facility policy titled Call Light: Accessibility dated 2/1/2026 revealed that with each interaction in the resident's room or bathroom, employees will ensure the call light is within reach of the resident and secure, as needed. The above information was provided to facility leadership on 6/24/26 at 4:30 PM. No addition information was provided prior to exit. 5. The facility staff failed to ensure Resident #40's (R40) call bell was in reach of the resident. On 6/25/26 at 10:50 AM, an observation was made of R40 trying to reach her call bell that was out of reach and lying on the floor under her bed. R40 was observed reaching down trying to find her call bell to be able to call for staff assistance. R40 stated that she was blind and was not able to find the call bell, but she liked it to be clipped to her pillow, so she would be able to reach the call bell to call for staff assistance. On 6/25/26 at 10:55 AM, an interview was conducted with a licensed practical nurse, LPN2, the unit manager of C Wing. LPN2 came into R40's room and observed the call bell lying on the floor under her bed. LPN2 stated that the call bell should not be on the floor or under the bed. She stated that the call bell should be clipped to or in reach of the resident to be able to call for assistance. On 6/25/26 at 5:34 PM, an end of the day meeting was held with the Administrator and Director of Nursing. They were informed of the above concerns. No additional information was provided prior to the end of the survey. 6. The facility failed to ensure Resident #117's (R117) call bell was accessible for use if he needed assistance. On 6/25/2026 at 10:37 AM, an observation was made of R117's call bell behind the headboard of the bed and was tied around a fall mat that was between the headboard and the wall. On 6/25/26 at 10:40 AM, an interview was conducted with LPN8. LPN8 answered the call bell that was activated when she entered R117's room, she observed the call bell tied around the fall mat and it was all behind the headboard. She stated she did not know why it was like that and it should not be tied around the fall mat or behind the headboard. She stated the call bell should be in reach of the resident. On 6/25/26 at 5:34 PM, an end of the day meeting was held with the Administrator and Director of Nursing. They were informed of the above concerns. No additional information was provided prior to the end of the survey.

Based on observations, staff interview, clinical record review, and facility documentation review, the facility staff failed to ensure pressure relieving device was in place to prevent pressure ulcers for one resident, Resident #112 (R112) out of a survey sample of 76 residents. The findings included:For resident R112, the facility staff failed to provide ear protectors on R112's oxygen tubing to prevent pressure ulcers. 06/22/2026 at 3:51 PM, an observation was conducted. R112 was lying on her bed with her oxygen tubing around her ears and no ear protectors in place on the tubing. 06/23/2026 at 12:47 PM, a second observation was conducted. R112 was lying on her bed with her oxygen tubing around her ears and no ear protectors in place on the tubing. 06/24/2026 at 12:48 PM, a third observation was conducted. R112 was lying on her bed with her oxygen tubing around her ears and no ear protectors in place on the tubing. 06/24/2026 at 12:49 PM, an interview was conducted with a licensed practical nurse, LPN12. LPN12 entered R112's room and she observed that R112 was not wearing ear protectors on the oxygen tubing. LPN12 went to the nurses station and looked up the orders for R112. She stated that R112 should have the ear protectors and said, I will see if we have the protectors and correct these things. 06/25/26 at 11:00 AM, an observation was made of R112 lying in bed with her oxygen setting corrected and being administered per physician's orders. R112 remained without the ear protectors behind her ears after bringing it to the attention of her nurse, LPN12 yesterday. On 6/25/26, a facility documentation was reviewed. The facility document titled, Pressure Injury Prevention Guidelines, read in part, .to prevent the formation of avoidable pressure injuries and to promote healing of existing pressure injuries, it is the policy of this Facility to implement evidence-based interventions for all residents who are assessed at risk or who have a pressure injury, and in accordance with physician/physician extender. 3. Interventions will be documented in the care plan and communicated to all relevant employees. 06/25/26 at 4:15 PM, a meeting was held with the Administrator. She was given an update on concerns with R112's ear protectors were still not being provided even after being brought to the attention of her nurse yesterday. The Administrator stated she would check into this situation and get this corrected. On 6/26/26 at 9:00 AM, R112 was observed with her ear protectors being provided to prevent pressure ulcers. No additional information was provided prior to the end of the survey.

Based on staff interview, facility document review and clinical record review, the facility staff failed to notify the physician and/or responsible party for a change in condition for two of 76 residents in the survey sample, Residents #174 and 175.The findings include: 1. For Resident #174 (R174) the facility staff failed to notify the physician and the responsible party for a medication not available for administration at the scheduled time. R174 was admitted to the facility on [DATE] with diagnoses that included but were not limited to: hypothyroidism. The physician order dated 9/10/2024 documented, Levothyroxine Sodium Oral Tablet (1) 50 MCG (micrograms); Give 1 tablet by mouth in the morning related to hypothyroidism. The MAR (medication administration record) for September 2024, documented the above order. For 9/10/204 at 6:00 a.m. a 14 was documented. A 14 indicates, Medication not available. The nurse's note dated 9/10/2024 at 5:26 a.m. documented, New admit waiting on pharmacy. Review of the backup pharmacy contents for 2024 was provided by the pharmacy. Levothyroxine is not listed. An interview was conducted with LPN (licensed practical nurse) #1 on 6/24/26 at 1:50 p.m. When asked what the process is when a medication is not available for the scheduled time of administration, LPN #1 stated first you call the pharmacy, then call the physician to see if they want to order something else or if they want to change the time of administration for that day. LPN #1 stated the facility receives three deliveries of medications each day. LPN #1 stated all of the actions you take should be documented in a nurse's note. The facility policy, Notification of Change of Condition documented in part, The purpose of this policy is to ensure the Facility promptly informs the resident, consults the resident's physician/physician extender, and notified the resident's legal representative when there is The Administrator and Director of Nursing were made aware of the above findings on 6/24/2026 at approximately 5:00 p.m. No further information was provided prior to exit. 2) For Resident #175 (R175), the facility staff failed to notify the physician of a change in condition on 9/14/2024. R175 was admitted to the facility with diagnoses that included but were not limited to end stage renal disease (1), diabetes mellitus (2), peripheral vascular disease (3), and gout (4). On the most recent MDS (minimum data set), a quarterly assessment with an ARD (assessment reference date) of 7/19/2024, the resident scored 13 out of 15 on the BIMS (brief interview for mental status) assessment, indicated they cognitively intact for orientation of year, month and date and short-term recall. The assessment documented no skin concerns. A skin assessment for R175 dated 9/13/2024 documented Skin clear, no change of condition assessed. The progress notes for R175 documented in part, - 9/14/2024 18:30 (6:30 PM) Situation: Res (resident) c/o (complains of) left great toe pain and small amount of bloody drainage. Background: Res has a h/o (history of) gout. Assessment: Writer observed small amount of drainage from left great toe nail bed. Response: Note placed in MD (medical doctor) communication book for further assessment. Standing order treatment initiated. - 9/15/2024 18:28 (6:28 PM) Note Text: Dry dsg applied to left great toe, small amount of drainage noted. Res cont to c/o toe pain and discomfort. Minimal relief from scheduled pain meds. Will cont to monitor. - 9/16/2024 11:09 (AM) Situation: Left great toe swelling and painful. Background: history of gout and pain. Assessment: left great toe painful still after being treated for gout. Response: NP [Name of nurse practitioner] gave orders to start Keflex (5) 500mg (milligram) bid (twice a day) for 10 days for cellulitis (6). Resident aware and agrees with orders. - 9/16/2024 11:17 (AM) Physician note . Asked to see patient for evaluation due to complaints of pain. Staff reports patient is complaining of great toe pain. Patient is seen, sitting up in a wheelchair prior to leaving for hemodialysis (7). She notes that she has pain to her left great toe. She notes that the pain is constant and unalleviated with any current measures . SKIN: Warm and dry, normal color for ethnicity **Left great toe noted with bloody drainage and tenderness to palpate to the entire toe. Mild warmth to palpation . ASSESSMENT/PLAN (reviewed w/ patient): 1) Pain - I suspect she has some underlying cellulitis. There is some erythema and tenderness to the site. Will continue with supportive measures and treat underlying infection. 2) Cellulitis - ? Ingrown toenail versus superficial laceration. Will treat with antibiotics and monitor closely . The dialysis communication record for R175 dated 9/16/2024 documented under the section Dialysis Center to Complete for the Facility in part, .Any issues during treatment? Lt (left) foot infection & pain . The eTAR (electronic treatment administration record) for R175 dated 9/1/2024-9/30/2024 documented in part, Cleanse left great toe with NS (normal saline) or wound cleanser, apply dry dsg (dressing) qd (every day) until healed. one time a day for Pain. It documented the treatment completed 9/15/2024 and 9/16/2024 at 9:00 AM. On 6/24/2026 at 11:28 AM, an interview was conducted with LPN (licensed practical nurse) #2, unit manager, who stated that they remembered R175 when they resided at the facility. She stated that the nurses who wrote the progress notes documented above no longer worked at the facility and the nurse practitioner who examined R175 on 9/16/2024 was on vacation and not available. LPN #2 stated that she was unsure about standing treatment orders but thought that they were to clean the wound and notify the physician if the nurse felt that they needed to go further than that. She stated that she never saw R175's toe but normally the staff would clean and dress a wound, write it in the physician communication book and notify the facility wound nurse to assess the area. LPN #2 stated that the physician or nurse practitioner came in every day except the weekends and then there was a provider on call. She stated that if there was no change or if there was no relief then she would have contacted the on-call physician for guidance when R175 was continuing to complain of pain in the toe with the drainage present. On 6/25/2026 at approximately 2:35 PM, the Administrator stated that they did not have any standing treatment orders during 9/14/2024 timeframe. The facility policy Notification of Change of Condition effective 2/1/2026, documented in part, The purpose of this policy is to ensure the Facility promptly informs the resident, consults the resident's physician/physician extender; and notified the resident's legal representative when there is a change requiring notification . On 6/25/2026 at approximately 5:30 PM, the Administrator, the Director of Nursing and the Regional Director of Clinical Services were made aware of the concern. No further information was provided prior to exit. Reference: (1) End-stage kidney disease (ESKD) is the last stage of long-term (chronic) kidney disease. This is when your kidneys can no longer support your body's needs. End-stage kidney disease is also called end-stage renal disease (ESRD) . This information was obtained from the website: End-stage kidney disease: MedlinePlus Medical Encyclopedia (2) Diabetes, also known as diabetes mellitus, is a disease in which your blood glucose, or blood sugar, levels are too high. Glucose is your body's main source of energy. Your body can make glucose, but it also comes from the food you eat. Insulin is a hormone made by your pancreas. Insulin helps move glucose from your bloodstream into your cells, where it can be used for energy . This information was obtained from the website: Diabetes | Type 1 Diabetes | Type 2 Diabetes | MedlinePlus (3) Your peripheral arteries and veins carry blood to and from your arm and leg muscles and the organs in and below your stomach area. PVD may also affect the arteries leading to your head (see Carotid Artery Disease). When PVD affects only the arteries and not the veins, it is called peripheral arterial disease (PAD). The main forms that PVD may take include blood clots (for example, deep vein thrombosis or DVT), swelling (inflammation), or narrowing and blockage of the blood vessels . This information was obtained from the website: Peripheral Vascular Disease | The Texas Heart Institute (4) Gout is a common type of inflammatory arthritis. It causes pain, swelling, and redness in one or more joints. It usually happens as a flare, which can last for a week or two and then gets better. The flares often begin in your big toe or a lower limb . This information was obtained from the website: Gout | [NAME] Arthritis | MedlinePlus (5) Cephalexin is used to treat certain infections caused by bacteria. Cephalexin is in a class of medications called cephalosporin antibiotics. It works by killing bacteria. Antibiotics such as cephalexin will not work for colds, flu, or other viral infections. Using antibiotics when they are not needed increases your risk of getting an infection later that resists antibiotic treatment . This information was obtained from the website: Cephalexin: MedlinePlus Drug Information (6) Cellulitis is an infection of the skin and deep underlying tissues. Group A strep (streptococcal) bacteria are the most common cause. The bacteria enter your body when you get an injury such as a bruise, burn, surgical cut, or wound. Symptoms include: Fever and chills; Swollen glands or lymph nodes; A rash with painful, red, tender skin. The skin may blister and scab over. Your health care provider may take a sample or culture from your skin or do a blood test to identify the bacteria causing infection. Treatment is with antibiotics. They may be oral in mild cases, or intravenous (by IV) for more severe cases . This information was obtained from the website: Cellulitis | Cellulitis Treatment | MedlinePlus (7) Dialysis treats end-stage kidney disease (also called kidney failure). It removes waste from your blood when your kidneys can no longer do their job. There are different types of kidney dialysis. This article focuses on hemodialysis . This information was obtained from the website: Dialysis - hemodialysis: MedlinePlus Medical Encyclopedia

Based on Resident interview, facility staff interviews, clinical record review, and facility documentation review, the facility staff failed to maintain a safe, clean comfortable home-like environment for 2 of 3 nursing units (Unit A, Unit B) and in a survey sample of 13 Residents. The findings included: 1. For Resident #2, and unit A, the unit was dirty, in disrepair, and was not safe, not clean, nor homelike. 2. For Resident #3, and unit B, the unit was dirty, in disrepair, and was not safe, not clean, nor homelike. 1. Resident #2 Was admitted to the facility on [DATE] with diagnoses including femur fracture with surgical repair, asthma, pneumonia, anxiety, depression, and Hepatitis C. The Resident required minimal to moderate assistance on 1 staff member for all activities of daily living such as hygiene, and bathing. The Resident's daughter was her responsible party, and decision maker. Resident #2 was found to be alert and oriented to person, and place. The Resident had mild observable cognitive impairment. The Resident was conversational and appropriate in response to questioning. 2. Resident #3 Was admitted to the facility on [DATE] with diagnoses including stroke, anemia, gout, heart attack, diabetes, asthma, atrial fibrillation, and vertigo. The Resident required extensive assistance or was fully dependent on 1 to 2 staff members for all activities of daily living such as hygiene, and bed mobility. The Resident was her own responsible party and found to be alert and oriented to person, place, time, and situation. The Resident had no observable cognitive impairment. The Resident was conversational and appropriate in response to questioning and was a good historian.During an initial tour of the facility and during interviews with Residents on 10-28-25, at 11:40 a.m., multiple Residents complained that their rooms were nasty and falling apart, and that showers were avoided because the showers are so nasty dirty. The surveyors then immediately walked to the shower room for an initial observation and found it to be dirty, mildewed/moldy, foul smelling, had a strong odor of urine and feces, trash and debris littered the floor, tile was chipped, and the grout was black in places on the floor, a white crusted substance was on the floor and walls. None of the shower areas looked as though they were wet or had been used that day to shower Residents. Immediately following the shower room observation, the Resident's rooms were examined. The Resident's room tours included but were not limited to the following being observed; Broken vinyl window blinds were seen. The free standing chests of drawers and hospital bed head and foot boards were broken, swollen in places from moisture and splitting, with rotten splinters and chunks of disintegrating wood and wood particles on the room floors and bed linens. The sinks and toilets were dirty, water would not drain from the sink clogged drains and was left with dirt and debris in them. Floors were dirty and sticky underfoot, encrusted with crumbs, brown debris, and black particles, and made a sucking sound as one walked across it. The base board was peeling and drooping over in places with debris in corners and broken base boards and moldings were also present. Bed divider curtains had brown stains and smeared brown substances on them. A few rooms had no television, no clock, no telephone, no radio and the room had no personal items (other than clothes in the chests of drawers) and nothing personal on the walls. There were holes in walls, spackling compound over some holes and no paint had been applied to cover those repairs with dust on the floor from the sanding of the compound. On 10-29-25 the Director of Maintenance was interviewed and stated he was new to the job and had only been there 2.5 weeks. He agreed that shared maintenance staffing for the 2 buildings (this nursing facility and the Assisted Living facility on the same grounds) had been tight. He further stated that a new technician was hired, and a second one would be coming shortly. This revealed that even with full staff there would only be 3 employees completing all repairs and maintenance for 2 large buildings. The nursing facility had 160 beds. It is unknown how many individual apartments were contained in the larger assisted living building. The maintenance Director stated they were starting to get some priorities taken care of in the facility now as staffing had improved just recently. On 10-29-25, and 10-30-25 during a meeting with the Administrator, Director of Nursing, and Corporate clinical support consultant, the facility staff were made aware of the above concerns and that the living units were not safe, clean and comfortable. At the time of the survey exit the facility Administrator, and Director of Nursing stated they had nothing further to provide.

For Resident #2 the facility staff failed to order and administer the correct dose of quetiapine fumarate (Seroquel, an antipsychotic) causing the resident to be given double the amount ordered on 2 occasions, and furthermore failed to notify the physician, or consult with the pharmacy when alerts for drug-to-drug interactions appeared. Resident #2 was admitted to the facility on [DATE] with diagnoses that include but were not limited to fracture of left femur, COPD (Chronic Obstructive Pulmonary Disease), asthma, chronic respiratory failure, abscess of lung, major depressive disorder, generalized anxiety disorder, acute hepatitis C, and insomnia. Resident #2 had a BIMS (Brief Interview of Mental Status) Score of 11 out of a possible 15 indicating moderate cognitive impairment. Resident #2 was admitted to the facility on [DATE] with orders that read:Page 2/8 of discharge summary Anxiety Depression Insomnia- Reported memory problems will require outpatient evaluation. Nursing staff reported that the pt was expressing suicidal thoughts; cleared by psych to come off 1:1 on 8/18/25. Appreciate psychiatry service evaluation Escitalopram 20 mg daily was DISONTINUED Continue Fluoxetine 25 mg daily Continue Seroquel low dose to assist with sleep. A review of the clinical record revealed that on admission to the facility the order for Escitalopram 20 mg was initiated by attending physician, (In spite of the order by hospital psychiatrist to discontinue Escaltiapram and Fluxetine was not ordered)The discharge order on page 5 of the discharge summary read: Start taking these medications:Melatonin 3 mg at night for insomniaQuetiapine Fumarate 25 mg. in the evening for mood take 0.5 tab. [12.5 mg]On 9/5/25 during the admission process the order for Quetiapine Fumarate was written as follows: Quetiapine fumarate oral tablet 25 mg give 1 tablet by mouth in the evening for mood. 9/5/25 The resident received the incorrect dosage twice (9/6/25 and 9/7/25) before the correction was made to read 0.5 of a 25 mg tablet to equal 12.5 mg, thus causing the resident to be given twice the amount of medication on 2 separate occasions.On admission to the facility the following medications were entered into the pharmacy system: Escitalopram Oxalate oral tablet 20 mg. Give 1 tablet by mouth 1 time a day for depression order date 9/5/25 at 10:47 pmFamotidine oral tablet Give 1 tablet by mouth in the morning for acid reflux order date 9/5/25 at 10:47 pmOmeprazole 20 mg. give 1 tablet by mouth in the morning for acid reflux order date 9/5/25 at 10:47 pmAzithromycin oral tablet 500 mg Give 1 tablet one time a day for infection 28 days 9/5/25 Melatonin Oral table 3 mg Give 1 tablet by mouth at bedtime for insomnia order date 9/5/25 at 9:39 pmTrazodone HCL oral tablet 50 mg give one tablet by mouth at bedtime for depressionQuetiapine fumarate oral tablet 25 mg Give 1 tablet by mouth in the evening for mood order date 9/5/25 at 9:39 pm Upon entering the above-mentioned medication orders, the following alert from pharmacy came up in the system and is printed in the progress notes: 9/6/25 12:21 am - The order you have entered Escitalopram Oxalate 20 mg tablet give 1 tablet one-time for depression has triggered the following drug protocol alerts / warningsDrug to drug interactions:The system has identified a possible drug interaction with the following orders:Omeprazole oral tablet delayed release 20 mg Give 1 tablet by mouth in the morning for Acid RefluxSeverity: ModerateInteraction: Omeprazole may increase the serum concentration of Escatalopram. Additive serotonergic effects may occur during coadministration, and the risk of developing serotonin syndrome may be increased Quetiapine Fumarate oral tablet 25 mg. Give 1 tablet by mouth in the evening for moodSeverity: SEVEREInteraction: Additive QT interval prolongation [qt prolongation is an abnormally long interval between the q and t waves on an electrocardiogram, representing the time it takes the hearts ventricles to contract and relax) may occur during coadministration of escitalopram, a moderate risk QT prolonging agent and Quetiapine Fumarate oral tablet. Azithromycin oral tablet 500 mg Give 1 tablet one time a day for infection 28 daysSeverity: ModerateInteraction: Additive QT interval prolongation may occur during coadministration of escitalopram a moderate risk QT prolonging agent and Azithromycin.Trazadone HCL 50 mg give 1 tablet by mouth at bedtime for depressionSeverity: SEVEREInteraction: Additive serotonergic effects may occur during coadministration of selective serotonin uptake inhibitors (SSRI) and trazodone HCl and the risk of developing serotonin syndrome may be increased. The record revealed that there was no documentation for physician notification of the warnings.On 9/8/25 when the order for Quetiapine was corrected on 9/8/25 the above warnings appeared in the system again. On 9/8/25 the physician also ordered Tramadol 50 mg (a controlled substance; opioid pain medication), and the following warning appeared. The order you have entered tramadol HCL oral tablet 50 mg two times a day related to fractured left femur has triggered the following drug protocol warnings:The system has identified possible drug interactions with the following orders:Trazodone HCL 50 mg tablet give 1 tablet at bedtime for depressionSeverity: SEVEREInteraction Serotonergic effects of this combination may be additive. The risk for serotonin syndrome / toxicity may be increased. Additionally additive CNS [Central Nervous System] depression may occur. [CNS depression may cause respiratory depression this already compromised patient who has a lung abscess, COPD, asthma, and chronic respiratory failure.] The system raised the following alert on 9/15/25 when the Psych Nurse Practitioner ordered buspirone HCL 7.5 mg by mouth 2 times a day. for major depressive disorder. The order you have entered buspirone HCL 7.5 mg by mouth 2 times a day. for major depressive disorder has triggered the following drug protocol warnings:Drug to Drug interactionTramadol 50 mg gives 50 mg 2 times per day for fractured femurSeverity: SEVEREInteraction: Additive serotonergic effects may occur during coadministration of buspirone and escitalopram oxalate 20 mg tramadol HCl and trazadone and the risk of developing serotonin syndrome may be increased. Serotonin syndrome (SS) is a potentially life-threatening drug reaction. It causes the body to have too much serotonin, a chemical produced by some nerve cells.Serotonin Syndrome most often occurs when two or more medicines or drugs that affect the body's level of serotonin are taken together at the same time. The medicines cause too much serotonin to be released or to remain in the brain area. Common SSRIs include Citalopram (Celexa) Escitalopram (Lexapro) Fluoxetine (Prozac) Paroxetine (Paxil)Other drugs that increase serotonin levels include Tramadol, meperidine, fentanyl, omeprazole and dextromethorphan (found in many over-the-counter cough medicines). No documentation was present that the MD had been notified, or the pharmacy had been consulted regarding these alerts of drug-to-drug interactions. On 10/30/25 at approximately 11:30 am an interview was conducted with the Psych NP who stated that he did not order the admission medications they were done by the hospital and the attending physician at the facility. He stated that he ordered the Buspar on 9/15/25 for anxiety. H stated that he was not notified by the staff of warnings of concomitant use of several of the medications, he stated that the facility staff did not contact him regarding pharmacy warnings of drug-to-drug interactions. He stated that he did not order the other medications, so he was not aware of any issues with them. On 10/30/25 an interview was conducted with LPN B who stated that pharmacy alerts will appear when orders are entered into the system that are conflicting or have drug to drug interactions or if a patient has an allergy. LPN B stated that the nurses are supposed to notify the physician to see if the physician wants to keep the medicine or change it to something else. She further stated that they also should consult with the pharmacist as well. On the afternoon of 10/30/25 an interview was conducted with the DON who stated that it is her expectation that nurses are to contact physicians when they have pharmacy alerts for drug to drug interactions and or allergy alerts. The DON also stated that notifying the physicians allows the physician to decide whether the benefit of taking the drug outweighs the risks. On 10 /30/25 during the end of day meeting the Administrator was made aware of the finding and no further information was provided.

Based on interview, clinical record review and facility documentation, the facility staff failed to ensure that residents were free from unnecessary medications for 1 Resident (#2) in a survey sample of 13 residents.For Resident #2 the faciltiy staff failed to ensure that the resident was free from unnecessary drugs related to duplicate drug therapy.Resident #2 was admitted to the facility on [DATE] with diagnoses that include but were not limited to fracture of left femur, COPD (Chronic Obstructive Pulmonary Disease), asthma, chronic respiratory failure, abscess of lung, major depressive disorder, generalized anxiety disorder, acute hepatitis C, and insomnia. Resident #2 had a BIMS (Brief Interview of Mental Status) Score of 11 out of a possible 15 indicating moderate cognitive impairment. Resident #2 was admitted to the facility on [DATE] with orders that included the following:Escitalopram 20 mg daily was DISONTINUED Continue Fluoxetine 25 mg daily Continue Seroquel low dose to assist with sleep. A review of the clinical record revealed that on admission to the facility the order for Escitalopram 20 mg was ordered by attending physician. The discharge order on page 5 of the discharge summary read: Start taking these medications:Melatonin 3 mg at night for insomniaQuetiapine Fumarate 25 mg. [an anti-psychotic] in the evening for mood take 0.5 tab. [1/2 of a tablet or 12.5 mg] On 9/5/25 during the admission process the order was written as follows: Quetiapine fumarate oral tablet 25 mg give 1 tablet by mouth in the evening for mood. 9/5/25 The resident received the incorrect dosage twice (9/6/25 and 9/7/25) before the correction was made to read 0.5 of a 25 mg tablet to equal 12.5 mg, thus causing the resident to be given twice the amount of medication on 2 separate occasions.The Psych Nurse Practitioner ordered the Buspar on 9/15/25 and the following warning was flagged by the pharmacy system The system raised the alert again on 9/15/25 when the physician ordered buspirone HCL 7.5 mg by mouth 2 times a day for major depressive disorderHas triggered the following drug protocol alerts / warningsDrug to Drug interactionInteraction: Additive serotonergic effects may occur during coadministration of buspirone and escitalopram oxalate 20 mg tramadol HCl and trazadone and the risk of developing serotonin syndrome may be increased.No documentation was present that the MD had been notified, or the pharmacy had been consulted regarding these alerts of drug-to-drug interactions. On 10/30/25 at approximately 11:30 am an interview was conducted with the Psych NP who stated that he did not order the admission medications they were done by the hospital and the attending physician at the facility. He stated that he ordered the Buspar on 9/15/25 for depression. When asked if he was made aware of the warnings of concomitant use of several of the medications, he stated that the facility staff did not contact him regarding pharmacy warnings of drug-to-drug interactions. He stated that he did not order the other medications, so he was not aware of any issues with them. On 10/30/25 an interview was conducted with LPN B who stated that pharmacy alerts will appear when orders are entered into the system that are conflicting or have drug to drug interactions or if a patient has an allergy. LPN B stated that the nurses are supposed to notify the physician to see if the physician wants to keep the medicine or change it to something else. She further stated that they also should consult with the pharmacist as well. On the afternoon of 10/30/25 an interview was conducted with the DON who stated that it is her expectation that nurses are to contact physicians when they have pharmacy alerts for drug to drug interactions and or allergy alerts. The DON also stated that notifying the physicians allows the physician to decide whether the benefit of taking the drug outweighs the risks. When asked if the physicians have access to the progress notes where the pharmacy alerts are written she stated that they did.On 10 /30/25 during the end of day meeting the Administrator was made aware of the finding and no further information was provided.

Based on observations, staff and resident interviews and record review, the facility staff failed to ensure appropriate resident care and services were provided in accordance with accepted professional standards of care for 3 residents (Resident #4, #5 and #6) in a survey sample of 13 residents.Findings included:For Residents #4, #5 and #6, the facility staff failed to ensure residents' medications were administered by the physician's orders as evidenced by observing medications at the resident's bedside.For Residents #4, #5 and #6, the facility staff failed to ensure residents' medications were administered by the physician's orders as evidenced by observing medications at the resident's bedside.For Resident #4, she was admitted to the facility on [DATE] with diagnoses including but not limited to: major depressive disorder, hypertension, pain, generalized anxiety, presence of cardiac pacemaker, history of COVID, cardiomyopathy, retention of urine, combined systolic and diastolic congestive heart failure, fibromyalgia, Type 2 diabetes mellitus, atrial fibrillation, ulcerative colitis, old myocardial infarction, non-ST elevation myocardial infarction, chronic ischemic heart disease, asthma, overactive bladder and post-traumatic stress disorder. Resident #4's most recent MDS (Minimum Data Set Assessment) Quarterly Assessment with an ARD (Assessment Reference Date) of 8/21/25 coded the resident as having a BIMS (Brief Interview of Mental Status) score of 15 out of a possible 15 indicating no cognitive impairment. On 10/28/25 at 12:15PM during initial rounds, 2 medicine cups were observed on Resident #4's bedside table. One (1) medicine cup contained 10 round, white tablets and the second medicine cup had 3 green tablets and 1 round red tablet. An interview was conducted with Resident #4 and when asked what was in the medicine cups, she replied, those white tablets are my Tylenol and I don't want all that Tylenol, I am a nurse and I have told them I do not want all that Tylenol, the green tablets are calcium and I just don't need it everyday and the red one is a vitamin. I have told them over and over that I don't want them that much, I told my doctor too. It's malpractice here. I give this place an F the food is poor quality, and the kitchen staff is under educated. When asked if the nurses observed her swallowing her medicines she replied, Oh, honey, I am a nurse and they know I can take it, they sit it down on my table here. I just take what I want and throw the rest in the trash can over there (pointing to the trash can across the room). When asked her how long the pills had been on her overbed table she replied Oh, just past couple days.A review of Resident #4's Medication Administration Record for October was completed which revealed that the resident had an order for, initialed by nurses as taking the medications and confirmed by nurse in the medication cart as: Tylenol Extra Strength Oral Tablet 500 MG give 1000 mg by mouth three times a day related to pain (round, white tablets) Oyster Calcium Oral Tablet 500 MG give 1 tablet by mouth two times a day related to deficiency of other vitamins (green tablets) Multivitamin Oral Tablet give 1 tablet by mouth one time a day related to deficiency of vitamins (red, round tablet)For Resident #5, she was admitted to the facility on [DATE] with diagnoses including but not limited to: hypertension, chronic pain syndrome, unspecified, psychosis not due to a substance or known physiological condition, unspecified mood disorder and overactive bladder. Resident #5's most recent MDS (Minimum Data Set Assessment) Quarterly Assessment with an ARD (Assessment Reference Date) of 8/15/25 coded Section C0500 as 99 indicating the resident was unable to complete the interview. This occurs when the resident is unwilling or unable to answer enough of the questions, making the BIMS result invalid. Section C1000. Cognitive Skills for Daily Decision Making was coded as moderately impaired.On 10/28/25 at 12:35PM during initial rounds, a medicine cup was observed on Resident #5's bedside table. The medicine cup contained 6 tablets - white, round tablets varying sizes and four (4) bottles of eye drops were also observed on the overbed table - 1 bottle was Artificial Tears, label on bottle indicated expired 3/2024,1 bottle was brimonidine, 1 bottle was dorzolamide and 1 bottle was prednisone. When asked her how long the pills had been on her overbed table she replied, I don't know. I don't take them anymore. Resident #5 unable to give any more details.A review of Resident #5's Medication Administration Record for October was completed which revealed that the resident had an order for, initialed by nurses as taking the medications and confirmed by nurse the following medications were in the med cart:Escitalopram 5mg 1 tablet every morning by mouthFurosemide 20mg 1 tablet every morning by mouth Metoprolol 25 mg 1 tablet every morning by mouth Norvasc 10mg1 tablet every morning by mouth Tylenol Extra Strength 500mg 2 tablets every morning by mouth Brimonidine eye drops twice daily - not in the medication cart Dorzolamide eye drops twice daily - not in the medication cart Prednisone eye drops twice daily - not in the medication cartFor Resident #6, she was admitted to the facility on [DATE] with diagnoses including but not limited to: restless leg syndrome, anemia, anxiety disorder, major depressive disorder, osteoarthritis Type 2 diabetes mellitus, hypertensive chronic kidney disease and morbid obesity. Resident #6's most recent MDS (Minimum Data Set Assessment) Quarterly Assessment with an ARD (Assessment Reference Date) of 10/22/25 coded BIMS (Brief Interview Mental Status 15 out of 15 as no cognitive impairment.On 10/28/25 at 12:45PM during initial rounds, a medicine cup was observed on Resident #6's overbed table. Resident was sitting in her wheelchair next to her bed and overbed table. The medicine cup contained many pills of different shapes and colors. An interview was initiated with Resident #6 regarding what was in the medicine cup, and she immediately picked up the medicine cup and put the pills in her mouth and drank a large amount of water. There were also a bottle of eye drops on the overbed table, but resident did not instill drops in her eyes in presence of the surveyor. According to Resident #6, the nurse had bought her pills earlier that day while she was eating her lunch and her medicines were often late. The nurse left the medicine cup, and eye drops on her overbed table for her to take after she finished her meal, but she had forgotten to take them.A review of Resident #6's Medication Administration Record for October was completed which revealed that the resident had an order for the following medications scheduled for 9:00AM and the medications were initialed by the nurse as taking them 10/28/25 prior to resident consuming the pills. Allegra Allergy Oral Tablet 180mg 1 tablet by mouth one time a day for allergy Aspirin 81 Oral Tablet Delayed Release 1 tablet by mouth one time a day for hypertension Lisinopril 4 mg 1 tablet by mouth every morning for hypertension Multi vitamin 1 tablet by mouth every morning for vitamin deficiency Norvasc 5mg 1 tablet (give 10 mg by mouth every day for hypertension Hydralazine 100mg by mouth three times a day for hypertension Prednisone 10mg (give 20mg) by mouth every morning for asthma Zoloft 100mg (give 150mg) by mouth every morning for depression Artificial tears twice daily 2 drops each eye (Refresh eye drops observed at bedside) Senna 8.6mg by mouth twice daily Clonidine 0.1mg by mouth twice daily for hypertension Famotidine 20mg by mouth twice daily for gastro-esophageal reflux disease without esophagitis Metoprolol 50mg by mouth twice daily for hypertension Cranberry tablet by mouth 1 tablet twice dailyOn 10/28/25, during end of the day meeting with the Administrator and Director of Nursing, the Director of Nursing was asked what her expectations were of nurses' responsibility when administering medications. She replied, to follow the 5 rights of medication administration. When asked if she expected the nurse to observe the resident taking the medication, she replied, Absolutely. A request was made for the facility's Medication Administration Policy.On 10/29/25 the Administrator provided a copy of the facility's Medication Administration Policy (from the facility's pharmacy provider) which indicated: Section 7.1 General Guidelines Medication Administration4. Medications are to be administered at the time they are prepared.5. The person who prepares the dose of the medication is the person who administers the dose.8. Check expiration date on package/container. No expired medication will be administered to a resident.15. Residents are allowed to self-administer medications when specifically authorized by the prescriber, the nursing care center's Interdisciplinary Team (IDT). And in accordance with procedures for self-administration of medications and state regulations.20. The resident is always observed after administration to ensure that the dose was completely ingested.Documentation1. The individual who administers the medication dose records the administration on the resident's MAR (Medication Administration Record) immediately following the medication being given.Section 7.3 Self-Administration by Resident1. 1. If the resident desires to self-administer medications, an assessment is conducted by the interdisciplinary team of the resident's cognitive, physical, and visual ability to carry out this responsibility, during the care planning process.2. 2. The interdisciplinary team determines the resident's ability to self-administer medications by means of a skill assessment conducted as part of the care plan process.4. If the resident demonstrates the ability to safely self-administer medications, a further assessment of safety of bedside medication storage is conducted.7.5 OralsProcedures10. Administer medication and remain with the resident while medication is swallowed. Do not leave a medication in a resident's room without orders to do so along with documentation of self-administration. Use caution with residents who have difficulty with swallowing.14. Chart medication administration on the Medication Administration Record immediately following each resident's medication administration.On 10/28/25 a review of clinical records for Residents #4, #5 and #6 was completed with no evidence that the residents had been assessed or care planned to self-administer medications.On 10/29/25 during the end of day meeting, the Administrator, Director of Nursing and Regional Nurse Consultant were made aware of concerns, and no further information was provided.

Based on Resident interview, staff interview, clinical record review, and facility document review, the facility staff failed to maintain an abuse/neglect free environment for 1 Resident (Resident #3) in a survey sample of 13 Residents.The findings included.Resident #3 Was admitted to the facility on [DATE] with diagnoses including stroke, anemia, gout, heart attack, diabetes, asthma, atrial fibrillation, and vertigo. The Resident required extensive assistance or was fully dependent on 1 to 2 staff members for all activities of daily living such as hygiene, and bed mobility. The Resident was her own responsible party and found to be alert and oriented to person, place, time, and situation. The Resident had no observable cognitive impairment. The Resident was conversational and appropriate in response to questioning and was a good historian. On 10/28/25 at 12:15 p.m. Resident #3 was interviewed in the Resident's Room. The Resident was sitting in bed dressed in hospital gown. CNA #6 (Certified Nursing Assistant #6) entered the room and Resident #3 asked is there any milk today? CNA #6 stated, I've told you, no milk at lunch (Resident's name). In a frustrated angry elevated voice, (the CNA had said this before to the Resident). The CNA was loud, curt, and dismissive. This caused the Resident to then whisper while talking to the surveyor out of fear of being overheard by the CNA, stating they have said before that we can't have milk at lunch. The Surveyor then asked the CNA, No milk at lunch is that a rule? CNA #6 replied they have tea and coffee at lunch, in a curt response. The Surveyor then asked, Even if she requested it? CNA #6 responded, Well, I guess if she asked dietary, they might get it. The CNA immediately exited the room and did not retrieve the milk for the Resident. Resident #3 then whispered, asking the surveyor I'm not going to get kicked out am I? The surveyor replied no, and asked does she always speak that way to you? The Resident replied, they all talk like that to us.On 10/28/25 at 12:30 p.m. an interview was conducted with the Dietary manager, who stated residents can request milk at lunch, but it is not routinely given out at lunch, however, it is with breakfast and dinner. She further stated that the Residents could have milk, and it was in the refrigerator on all of the units at the nursing station at all times, but the CNA's had to go and get it. The Refrigerator on the unit was examined and found to contain at least 12 cartons of 2% and whole milk options.CNA #6 willing (repeatedly) withheld readily available goods and services (neglect) from a Resident who requested them from her in the presence of a representative of the State Agency. This was done in an angry manner that resulted in the Resident experiencing fear of retaliation or reproach for asking for those goods and services (abuse). This action had been repeated by this CNA, and others.On 10-29-25 at 11:30 a.m. The Administrator, Corporate Registered Nurse (RN), and Director of Nursing (DON), were made aware of the incident, and stated that it had been reported to them. They had begun an investigation of abuse and notified the State Agency of such. CNA #6 was suspended (thus protecting the Resident) pending the result of their investigation.The facility policy on Abuse was reviewed and revealed their definitions of abuse supported this situation as being identified as an allegation of abuse. The policy steps were followed after the allegation of abuse was made.On 10-30-29 at the end of day debriefing the facility Administrator, DON, and Corporate RN were made aware of the deficient practice and they stated they had no further information to provide.

Based on observation, interview, and facility documentation the facility staff failed to ensure safe practice for infection prevention for one 5 staff memebers in the kitchen.For the facility, the facility staff failed to ensure that hair covering was worn by all staff entering the kitchen area.On 10/29/25 at approximately 12:15 PM LPN #1 was observed as she walked from hall past surveyor and went into the kitchen. There were no hairnets at this entrance. Surveyor was standing in doorway entrance awaiting staff to get hairnets. LPN #1 was observed going into the kitchen and walking out of the surveyors view to the other side of the kitchen. Surveyor spoke to dietary staff who alerted the dietary manager.LPN #1 walked to the other kitchen entrance where the hairnets are located exited to the hallway and then came to the surveyor and stated Oh! I had the hairnet in my hand and forgot to put it on.On 10/29/25 at approximately 12:25 p.m. an interview was conducted with the dietary Manager who stated anyone in the kitchen must have hair net.On 10/30/25 during the end of day meeting the Administrator was made aware of the concern and no further information was provided.

Based on observation, interview, clinical record review and facility documentation, the facility staff failed to ensure residents receive care to prevent the development of pressure ulcers for 1 Resident (Resident #1) in a survey sample of 13 Residents.The findings included: Resident #1, the facility staff failed to provide assessments, ordered treatments and supplements for the prevention and development of new pressure injuries.For Resident #1, the facility staff failed to provide assessments, ordered treatments and supplements for the prevention and development of new pressure injuries.Resident #1 was admitted to the facility on [DATE] from home with diagnoses including but not limited to hypertension, unstageable pressure injury sacrum, moisture associated skin damage to right buttocks, atrial fibrillation gastro-esophageal reflux disease with esophagitis, ventral hernia without obstruction, vitamin D deficiency, lymphedema, pain, sequelae of unspecified cerebrovascular disease, morbid obesity, hemiplegia and hemiparesis following cerebral infarction affecting right dominant side, chronic obstructive pulmonary disease, fusion of the spine, lumbar region, arthritis, chronic kidney disease Stage 3, heart failure, venous insufficiency, type 2 diabetes mellitus with diabetic neuropathy, nightmare disorder, peripheral vascular disease, atherosclerotic heart disease of native coronary artery without angina pectoris, specified disorders of the tendon left wrist and generalized anxiety.Resident #1's most recent MDS (Minimum Data Set) Quarterly Assessment with an ARD (Assessment Reference Date) of 5/14/25 coded the Resident as having a BIMS (Brief Interview of Mental Status) score of 15 out of a possible 15 indicating no cognitive impairment. Section GG coded the resident as requiring extensive assistance with turning/repositioning, lying to sitting, sit to stand, chair/bed to chair transfer, toileting, bathing and dressing. On 10/29/25, a review of the clinical record revealed that Resident #1 was admitted to the facility on [DATE] from her home accompanied by her daughter. According to the clinical record, the daughter reported the resident was alert and oriented, was able to voice her needs, was wheelchair bond, had several pre-existing wounds (bed sores per daughter's wording) to her buttocks and heels and was incontinent of bowel and bladder. Per clinical record review, Resident #1 was seen and evaluated by the facility's wound care provider {name redacted} Nurse Practitioner-C {name redacted} on 4/1/25. Head to toe evaluation revealed: Sacrum - unstageable full thickness 2.3 x1.5cm x unmeasurable - treatment initiated, reposition per facility protocol. Turn side to side every 1-2 hours if able; recommended debridement of necrosis (surgical removal of dead tissue) to aid in the healing process, the resident and daughter declined debridement. Right buttock - non-pressure wound, partial thickness 3.0 x 5.0 x 0.1cm - moisture associated skin damage - treatment initiated, reposition per facility protocol. Turn side to side every 1-2 hours if able Left scalp - non-pressure area 2.0 x 1.5cm x not measurable (due to presence of dried fibrinous exudate) treatment initiated Bilateral feet - hyperkeratosis and epidermal thickening - treatment initiatedAccording to the clinical record, on 4/2/25 Resident #1 assessed by the facility wound care nurse RN#1 for completion of the Braden Scale Assessment (a scale used to evaluate risk for development of pressure injuries). Resident #1 scored 14 indicating a Moderate Risk for pressure injury development (constantly moist, chairfast, very limited with mobility due to inability to make frequent or significant positional changes independently and potential problem in moving and sliding to some extent against sheets, chair and other devices.Per clinical record review of wound care provider's weekly assessments from 4/1/25 through 5/27/25, Resident #1's sacral pressure injury, right buttock moisture associated skin damage and scalp non pressure area continued to show improvement as evidenced by decreased surface area, depth and drainage until 5/27/25 where the sacral pressure injury showed deterioration as evidence of an increase in surface area and drainage at which time the Nurse Practitioner made changes to the treatment regimen. Per clinical record review, it was noted that Resident #1 did not have an assessment of wounds by either the facility's Wound Care provider Nurse Practitioner or the facility's wound nurse on 5/6/25 or 6/3/25.On 6/9/25, new areas of impaired skin integrity were identified by nurse, assessed by facility wound care nurse and treatment initiated; resident, daughter and nurse practitioner notified of new areas; -Left upper sacrum 2.0 x 2.0 x 0.1cm classified as Stage 2 Partial Thickness, Pressure Injury; -Right buttock 2.2 x 2.2 x 0.1cm, classified as Stage 2 Partial Thickness, Pressure Injury; -Left buttock 2.1 x 2.1 x 0.1cm, classified as Stage 2 Partial Thickness, Pressure InjuryOn 6/11/25, Resident #1 was seen and evaluated by the Wound Care provider Nurse Practitioner - sacrum Stage 3, Pressure Injury, RESOLVED; NEW Left buttock, reclassified as a Stage 3 Full Thickness Pressure Injury measuring 1.7 x 2.1 x 0.1cm, debrided by wound care nurse practitioner; NEW Right buttock, reclassified as a Stage 3 Full Thickness Pressure Injury measuring 3.2 x 2.7 x 0.1cm, debrided by wound care nurse practitioner; NEW upper Sacrum Stage 3 Full Thickness measuring 2.4 x 2.1 x 0.1cm, treatment initiatedOn 10/29/25, the Administrator produced service ticket for the delivery of an air mattress for Resident #1 on 4/4/2025, clinical record review could not produce any evidence that the air mattress was on Resident #1's bed or evidence that nurses were regularly checking placement and functionality. According to the Wound Care Provider Nurse Practitioner's recommendations, he recommended Turning and repositioning every 1-2 hours if able ; on Resident #1's care plan the intervention was noted as turn and reposition with ADLs (activities of daily living) and other servicesReview of Medication Administration Record (MAR) revealed holes/blanks in medication/supplement administration or coded as on order or not available:Prostat (a concentrated liquid protein supplement used to provide essential nutrients to aid in the promotion of wound healing) - coded on MARs as on order or not available for 9 days from 5/12-5/20/2025; MVI - holes/blanks noted on 5/3 and 5/5/25 and Zinc - holes/blanks noted on 5/1 and 5/16/25Review of Treatment Administration Record revealed holes/blanks in treatments: 4/5 and 4/6, 4/12 and 4/13/25 - sacrum 4/12/25 - right buttocks Moisture Associated Skin Damage 6/3 and 6/5/25 - bilateral legs 6/3/25 - scalp 6/3/25 - right buttocks 6/15/25 - left buttocks 6/15/2 - right buttocksReview of C.N.A documentation for Activities of Daily Living May, 2025 - on 5/17/25 numerous holes/blanks noted for evening shift; Turning and repositioning with ADL care and other services revealed coded as NA indicating not applicable on 5/14/25 and N indicating no turning on night shift for 5/31/25 June, 2025 - on 6/2 and 6/3/25 revealed numerous holes on day shiftOn 10/29/25 during end of day meeting with the Administrator, Director of Nursing and Regional Nurse Consultant, the Director of Nursing was asked why Resident #1 did not have Wound Care Provider {name redacted} notes for May as she had them for April and June, 2025, the Director of Nursing replied, They should be in her chart. According to the Administrator and the Regional Nurse Consultant they would get the copies of the assessments and have them available 10/30/25. A request was made to the Director of Nursing for the facility's policy on pressure injury assessment, prevention and management. On 10/30/25, the Wound care provider notes were reviewed revealing no assessment and evaluation of wounds for 5/6/25 and 6/3/25.A review of the facility's Policy and Procedure Skin Risk Assessment Policy - The Skin Risk Assessment will be completed weekly for consecutive four (4) weeks from admission. Procedure - 3. Initiate appropriate intervention to reduce risk. Procedure - 4. Document identified risk and intervention in the resident's Plan of Care.Prevention Minimal Risk - Assess condition of mattress Moderate Risk - all interventions for Minimal Risk, and Establish and record turning schedule, frequent position changes and avoid positioning on trochanter when inside lying positionOn 10/30/25 during the end of day exit meeting, the Administrator, Director of Nursing and Regional Nurse Consultant were made aware of concerns, and no further information was provided.

Based on observations and staff interviews, the facility staff failed to ensure resident rights to receive services in the facility with reasonable accommodation of resident needs and preferences for 5 residents in a survey sample of 13 Residents. (Residents #7, #8, #9, #10, #11).Findings include:For Residents #7, #8, #9, #10, #11, the facility staff failed to ensure residents had call bells within their reach to contact staff on 2 occasions on 10/28/25.On 10/28/25 at 12:05pm, initial rounds were conducted where Resident's #7, #8, #9 #10 and #11 were observed in their beds with their call bell on the floor behind the head of their bed.On 10/28/25 at 3:06pm, rounds were conducted to assess call bell placement. Resident's #7, #8, #9, #10 and #11's call bells were still observed on the floor behind the head of the bed.On 10/28/25 at approximately 4:00 pm, during the end of the day meeting with the Administrator, Director of Nursing and the Regional Nurse Consultant, the Director of Nursing was asked what her expectation was on staff's responsibility on ensuring residents had easy access to their call bell. She replied, staff should check and make sure that the call bell is placed within the residents' reach before they leave the residents' room. A request was made to the Director of Nursing and Administrator for a copy of the facility's policy on call bell placement.On 10/29/25 at approximately 3:30PM, an interview was conducted with Nurse RN #1 on her responsibility in call bell placement and she replied, it is my responsibility to always ensure my residents have access to their call bells so they can call us if they need usOn 10/29/25 at 11:50AM, an interview was conducted with Nurse LPN #5 on what her responsibility was in verifying call bell placement for residents and she responded, it is my responsibility to make sure they are within reach before I leave the room and make sure the C.N.A's have them clipped and placed where they can get to them easily.On 10/29/25 at 11:54AM, according to Nurse LPN #4 Unit Manager she stated, it is everyone's responsibility to make sure the residents always have they call bell within their reach, some of them have personal preferences on where they want them to be clipped or attached to the bed, but we need to make sure they can reach them.On 10/29/25 at approximately 11:55 AM, an interview was conducted with C.N.A # 7 who stated, When I am finished giving care to my residents, before I leave their room, I make sure to empty their trash and put their call bell close to them.On 10/29/25 during end of day meeting, when asked for the copy of the facility policy on call bell placement, the Regional Nurse Consultant responded, We do not have a policy addressing call bell placement. When asked what standards of professional practice the facility used, she replied, We use [NAME].According to [NAME], key principles of the [NAME] standards: PATIENT SAFETY: Make fall risk the sixth vital sign. [NAME] Barron [NAME] DNP, RN, [NAME] MSN, RN, DeaToasha D. [NAME] BSN-MHA, RN, [NAME] Berg RN, Nursing2011, April 2011, Volume 41 Number 4, Pages 62 - 64 The core standard, featured in [NAME]'s fall prevention resources, is that the call bell must always be placed within a resident's easy reach. This is especially crucial for individuals at high risk for falls, and staff should provide verbal and visual reminders to use it. Bedside accessibility: A call system must be available at each resident's bedside to summon staff assistance. Room environment checks: During regular patient rounding, nursing staff should ensure that the call light, along with other personal items like tissues and the phone, is within the resident's reach. This is part of a broader falls-prevention strategy. These guidelines align with federal regulations for long-term care facilities, which also mandate that a functioning call system be available at a resident's bedside and in their bathing areas.10/30/25 during the end of day exit, the Administrator, Director of Nursing and Regional Nurse Consultant were made aware of the concerns, and no further information was provided.

Based on observation, interview, clinical record review and facility documentation the facility staff failed to ensure Residents care plans were reviewed and revised for 1 Resident (#2) in a survey sample of 5 Residents. The findings included: For Resident #2 the facility staff failed to review and revise the care plan after the Resident exited the through a window in his room while on 1:1 supervision for exit seeking behavior. Resident #2 was admitted to the facility on [DATE] with diagnoses that included but were not limited to dementia, mood disorder and hypertension, paranoid personality, and anxiety. Resident #2's BIMS (Brief Interview of Mental Status) score on admission was 4/15 indicating severe cognitive impairment. Resident #2's most Minimum Data Set with an ARD (Assessment Reference Date) of 9/4/24 scored Resident #2 as having a BIMS of 1/15. The clinical record that Resident #2 was placed on 1:1 supervision for exiting seeking behaviors 5/28/24. On 7/12/24 at approximately 7 p.m. Resident #2 was able to manipulate the window in his room and crawl out of it while on 1:1 observation. On 10/1/24 an interview was conducted with the ADON who stated that care plans should be updated quarterly, annually and with changes in care and condition of the Resident. She also stated that she believed the care plan had been updated after the incident on 7/12/24. On 10/1/24 a review of the clinical record revealed the following items related to elopement and safety of the exit seeking Resident: FOCUS: I look for exits and am at risk for leaving the facility. Date Initiated: 05/28/2024 GOAL: I will not leave the facility unattended through my next care plan review. Date Initiated: 05/28/2024 Revision on: 09/11/2024 Target Date: 09/16/2024 INTERVENTIONS: Elopement Risk assessment per protocol. Date Initiated: 05/28/2024 Personal wander prevention device if necessary: check for placement each shift and check for proper function daily. Date Initiated: 05/28/2024 S Redirect resident from doors areas of exit. Date Initiated: 05/28/2024 FOCUS: At risk for elopement related to senile degeneration of the brain Date Initiated: 05/28/2024 GOAL: Patient will have no incidence of elopement Date Initiated: 05/28/2024 Revision on: 09/11/2024 Target Date: 09/16/2024 Will remain safe during placement at Living Center Date Initiated: 05/28/2024 Revision on: 09/11/2024 Target Date: 09/16/2024 INTERVENTIONS: 1:1 monitoring Date Initiated: 05/28/2024 Assess for risk of elopement per living center policy Date Initiated: 05/28/2024 Educate family/responsible party on talking positively about Living Center Placement Date Initiated: 05/28/2024 Encourage family to bring in personal possessions Date Initiated: 05/28/2024 Evaluate effect of cognitive impairment upon resident's ability to understand changes in surroundings Date Initiated: 05/28/2024 Introduce patient to other patients in the Living Center Date Initiated: 05/28/2024 Involve patient in preferred activities Date Initiated: 05/28/2024 Involve the patient in decision making regarding daily choices Date Initiated: 05/28/2024 Redirect patients from doors Date Initiated: 05/28/2024 Take picture of patient upon admission for identification for updating elopement book Date Initiated: 05/28/2024 Wander-guard intact as tolerated Date Initiated: 05/28/2024 On 10/1/24 during the end of day meeting the Administrator was made aware of the incident and no further information was provided.

Based on observation, interview, clinical record review and facility documentation the facility staff failed to ensure each Resident receives adequate supervision to prevent accidents, for 1 Resident (#2) in a survey sample of 5 Residents. The findings included: For Resident #2 the facility staff failed to ensure adequate supervision resulting in Resident #2 exiting through a window in his room while on 1:1 supervision. Resident #2 was admitted to the facility on [DATE] with diagnoses that included but were not limited to dementia, mood disorder and hypertension, paranoid personality, and anxiety. Resident #2's BIMS (Brief Interview of Mental Status) score on admission was 4/15 indicating severe cognitive impairment. Resident #2's most Minimum Data Set with an ARD (Assessment Reference Date) of 9/4/24 scored Resident #2 as having a BIMS of 1/15. The clinical record that Resident #2 was placed on 1:1 supervision for exiting seeking behaviors on 5/28/24. On 9/30/24 Resident #2 was observed walking briskly around the nurses station on A wing. Resident #2 was unable to be interviewed due to cognitive status. Resident #2 has no physical impairments to his limbs is able to ambulate without assistance of wheelchair, walker, can or physical assistance. On 9/30/24 during initial tour a random sample of 3 windows on each unit was selected and attempted to open. None of the windows on the units were able to open more than 5-6 inches. A review of the clinical record revealed the following progress notes: 7/12/24 7:18 p.m. - Situation: Background: Assessment: Resident did not have any signs or symptoms of any distress noted ROM [Range of Motion] WNL [Within Normal Limits] to all extremities, some agitation noted but easily redirected. Superficial scratches noted on neck area, face and left forearm. 7/12/24 8:18 p.m. Situation: Nurse from another unit alerted nurses that CNA for one-to-one monitoring stated the resident got out of his room window Background: Senile degeneration of brain, other frontotemporal neurocognitive disorder. Assessment: Nurses arrived at the residents room and note the window and window screen off of the window frame. The nurse looked out the window and noted resident outside of his window, resident was called to return to the window and was easily redirected by staff and assisted back into the resident room. Response: Supervisor, ADON and MD made aware. One to one caregiver was changed, and supervisor sat with the resident until the new CNA arrived. RP made aware. The following is an excerpt from the NP (Nurse Practitioner) note 7/16/24 10:41 a.m. - Asked to see patient for evaluation due to reports of restlessness and agitation. Staff reports that patient was noted to have recently manipulated the window in his room and attempted to exit the building via his window. Staff was sigh [sic] and intervened. There were no acute injuries. Patient is seen today of ambulating. He is a poor historian but appears in no acute distress, is not vocalizing any complaints to this provider. On 10/1/24 at approximately 11:00 AM an interview was conducted with the NP who stated that she was made aware of the incident that happened 7/12/24. She stated that she saw him after the incident and entered a note into the chart. She stated that the Resident had minor scratches. She stated that she was told the Resident had been within eyesight of the staff at all times. When asked if she was aware that the Resident was on 1:1 monitoring she stated that she was. She stated that the Resident was on Hospice and them (Hospice) had adjusted his medications since then and that Resident #2 has been much calmer and has had no more incidents like this one since July. The NP stated that he is now on Q15's (every 15 minute) checks instead of 1:1 since his behaviors have decreased. On 10/1/24 at 11:21 AM an interview with RN B was conducted, and she stated that the incident happened at change of shift (7p.m.) she stated she and the off going nurse were in the med room counting the cart, when staff alerted her that Resident #2 had gone out his room window. She stated that she went to the room with the off going nurse and they got Resident #2 inside safely. She stated that the attempts to ask the 1:1 CNA what happened were ineffectual due to language barrier. RN B stated she did not understand why he did not stop him from going out the window. When asked if the window was shattered or glass was broken, she stated that it was not. RN B stated that the Resident had taken the window off the track and busted out the screen. When asked if Resident #2 was injured she stated that he was not. When asked if she notified the MD and Responsible Party, she stated that she did but that it was a weekend, and she also notified the supervisor who notified the ADON. On 10/1/24 at approximately 12:45 an interview was conducted with Employee D, who was asked to demonstrate how the windows open. Employee D stated that the windows slide to the side to open, however they have stopper on them to prevent them being opened more than 5 inches. When asked why this is Employee D stated, This is a safety measure to prevent elopement or suicide. Employee D demonstrated how the windows operate. Employee D was asked if he has had any broken windows in the facilities in past 6 months, he stated that he has not. When asked has he had any windows that have come off track he stated that he did, and he indicated that in July there was one on A Wing that had to be put back on track. When asked about that he stated that Resident #2 is physically in good condition and was able to manipulate the window off track. He stated that once he had it off the track, he set it down without breaking it and was able to get out of the screen to the outside. The Resident's room is ground floor level, and he was able to climb out of the window without injury. Employee D stated that he was aware that this Resident was on a wanderguard and had 1:1 staff. Employee D stated that there have been no other incidents regarding windows since this happened in July. When asked if there had been any incidents involving windows with Residents other than Resident #2, he stated, There have not been any incidents that he can remember before this one and none since. Employee D state he has been working at this facility for 5 years. Employee D stated that unless you know what you are doing these windows are not easy to remove from the track. Employee D demonstrated the removal of the window from the track the window is estimated to weight 30-40 lbs. When asked why they would be removed other than to replace them he stated that is how they clean them. On 10/1/24 a review of the clinical record revealed that Resident #2 was a retired custodial / janitorial worker. This fact may explain why even with a BIMS score of 4 he was able to easily manipulate the window through the use of muscle memory. Three attempts to contact the CNA that was on duty the day of this incident were unsuccessful. A review of the incident reports revealed the following excerpts from the ADON's statement. I asked [CNA D name redacted] to give me a statement in detail as to what happened with [Resident #2 name redacted]. [CNA name redacted] said that [Resident #2 name redacted] started to become agitated so he wants to the doorway to yell for help and upon turning around [Resident #2 name redacted] had the window and screen off and went out the window. Resident was brought back in. He didn't get anywhere. I informed [CNA name redacted] that he was suspended pending investigation. A review of the investigation into the incident revealed the following Policy with regard to supervision: Policy: Resident safety checks can be initiated by physician or Clinical Nurse who deems a resident to be at risk to self or others. Procedure: 1. Initiate Resident Safety Checks form with intervals designated by physician or Clinical Nurse noting reason for form. 2. Check resident at required intervals. 3. Initial form indicating check was completed. 4. Form is filed in medical record. For residents exhibiting serious behaviors (not limited to aggression, physical aggression, sexual behaviors, and suicide ideation) Safety Checks in increments are not appropriate if these behaviors exist it is appropriate to initiate one to one until an appropriate intervention is implemented. (Psych consult, transfer out for mental health services, change in medication, seen by physician or other appropriate interventions.) After the event on 7/12/24 all staff were educated on de-escalation of behaviors. The following 1:1 education was provided to all nursing staff. The following educational requirement concerning 1:1 assignments 1) When assigned to 1:1 patient, you are to be t an arm's length at all times. 2) The caregiver (CNA) assigned is responsible for all documentation during their shift 3) The CNA assigned to resident must have relief during breaks (resident is never to be left unattended) 4) The CNA assigned to resident is responsible for all ADL care. On 10/1/24 during the end of day meeting the Administrator was made aware of the findings and no further information was provided.

Based on interview, clinical record review and facility documentation the facility staff failed to ensure Residents were free of significant medication errors for 2 Residents (#'s 1 & 3) in a survey sample of 5 Residents. The findings included: 1. For Resident #1 the facility staff failed to ensure insulin (both long-acting and short-acting) were administered per physician orders. On 10/1/24 a review of the clinical record revealed that Resident #1 had 2 orders for insulin. Resident #1 had orders for a long-acting insulin given twice a day and a short-acting insulin given prior to meals. The long- acting insulin orders were as follows: Insulin Glargine Solostar Subcutaneous Solution Pen-injector 100 Unit/ml [units per milliliter] Inject 37 unit subcutaneously two times a day related to Type 2 diabetes. Order Date-08/14/2024 This long-acting insulin was ordered for 9:00 a.m. and 9:00 p.m. A review of the MAR (Medication Administration Record) revealed the order times and the administration times. The following is a list of times that this order was not following in August and September of 2024. 8/24/24 9:00 a.m. given at 3:42 p.m. 9/14/24 9:00 a.m. given at 12:10 p.m. 9/28/24 9:00 a.m. given at 12:07 p.m. The short- acting insulin orders were as follows: Insulin Lispro Injection Solution 100 Unit/ml [units per milliliter]. Inject 35 unit subcutaneously before meals related to Type 2 Diabetes -Order Date- 08/15/2024 This short-acting insulin was ordered for 7:30 a.m. 11:30 a.m. and 4:30 p.m. A review of the MAR (Medication Administration Record) revealed the order times and the administration times. The following is a list of times that this order was not following in August and September of 2024. 8/04/24 4:30 p.m. given at 6:02 p.m. 8/19/24 7:30 a.m. given at 9:06 a.m. 8/24/24 7:30 a.m. given at 3:42 p.m. 8/29/24 7:30 a.m. given at 9:04 a.m. 9/01/24 7:30 a.m. given at 8:54 a.m. 9/02/24 7:30 a.m. given at 9:52 a.m. 9/02/24 11:30 a.m. given at 2:09 p.m. 9/02/24 4:30 p.m. given at 3:56 p.m. [**Note this is less than 2 hours from the prior dose] 9/03/24 7:30 given at 9:35 a.m. 9/05/24 11:30 09/05/24 3:51 p.m. 9/24/24 7:30 given at 9:40 a.m. 9/24/24 11:30 given at 12:52 p.m. 925/24 7:30 given at 10:49 a.m. 9/29/24 7:30 given at 10:21 a.m. 9/30/24 7:30 given at 9:07 a.m. On 10/1/24 at approximately 11:00 a.m. an interview with the Unit manager on B Wing was conducted who stated that nurses should always follow physician orders with regard to medication administration. She stated if there is a question they need to reach out to the practitioner for clarification. If a Resident refuses or there is an issue, they should notify the physician. When asked if there is a delay in a medication being given what should the nurse do, she stated Nurses should reach out to the provider when a medication is going to be late, especially one that is given multiple times a day. The physician may want to hold the next dose or change the schedule of doses depending on the medication. On 10/1/24 during the end of day meeting the Administrator was made aware of the findings and no further information was provided. 2. For Resident #1 the facility staff failed to ensure Trulicity (GLP 1 Receptor Agonist -Diabetes Medication) was administered per physician orders. On 10/1/24 a review of the clinical record revealed that Resident #3 had orders that read: Trulicity Subcutaneous Solution Pen injector 0.75 MG/0.5ML Inject 0.75 mg subcutaneously one time a day every Wed related to Diabetes Mellitus 08/20/2024 A review of the MAR (Medication Administration Record) revealed that Trulicity had been coded as #3 (See Nurses Note) upon looking in the progress notes 8/22/24 at 10:35 a.m. an entry was made into the progress notes that the medication was On order. On 9/4/24 once again the same information was entered. There were no notes indicating notification of physician or Resident. On 10/1/24 at approximately 11:00 a.m. an interview with the Unit manager on B Wing was conducted who stated that nurses should always follow physician orders with regard to medication administration. She stated if there is a question they need to reach out to the practitioner for clarification. If a Resident refuses or there is an issue, they should notify the physician. When asked if there is a delay in a medication being given what should the nurse do, she stated Nurses should reach out to the provider when a medication is going to be late, especially one that is given multiple times a day. The physician may want to hold the next dose or change the schedule of doses depending on the medication. On 10/1/24 during the end of day meeting the Administrator was made aware of the findings and no further information was provided.

Based on staff interviews and review of facility documents, the facility staff failed to verify through the Department of Health Professions certification of five of five newly hired (October 12, 2023) Certified Nursing Assistant (CNA), (CNA #11 through #15), in the survey sample. The findings included: A review was conducted on 1/24/24 of CNA #11 because the individual had been identified as rude to a resident and it was stated that the facility's staff failed to verify the employee's certification through the Department of Health Professions prior to hiring the individual. A review of the facility's abuse policy titled Abuse Policies and Elder Justice Guidance with a revision date of January 2023 read No employee may at any time commit an act of physical, psychological, or emotional abuse, neglect, mistreatment, and/or misappropriation of personal property against any resident. Violation of this standard will subject employees to disciplinary action, including dismissal, provided herein. Further review of CNAs hired at the same time as CNA #11 revealed that four other CNAs were hired at the same time as CNA #11. They were CNA 12, CNA 13, CNA 14 and CNA #15's and there was no evidence that their certification had been verified prior to each individual beginning to work in the facility. Also under the facility's Abuse policy were eight components of Abuse Prohibition. Competent A read, Screening - Persons applying for employment with the facility will be screened for a history of abuse, neglect or mistreating residents to include; references from a previous employer, criminal background check, an abuse check with appropriate licensing board and registries prior to hire, a sworn disclosure statement prior to hire and verify license or registration prior to hire. An interview was conducted with the Human Resources Director (HRD) on 1/29/24 at approximately 10:30 AM. The HRD stated for the hire date of 10/12/23 five CNAs were brought on as new employees and a sworn statement was obtained, as well as a criminal background search for crimes, references and verification of certification. The HRD stated she was out of work for a period after the new hires began working and upon organization of the HR files for the five individuals it was determined that the Department of Health Professions verifications were missing therefore new verifications were necessary to complete the five new hire files. The new verifications were retrieved from the Department of Health professions between 11/15/23 and 11/17/23 and no verification revealed that the five new hires were ineligible to work as a CNA. On 1/30/24 at approximately 5:40 PM, a final interview was conducted with the Administrator, Director of Nursing and [NAME] President of Operations. They had no further comments and voiced no concerns regarding the above information.

Based on staff interview, facility document review, and clinical record review, it was determined that the facility staff failed to administer CPR (cardio pulmonary resuscitation), per the resident's wishes, for one of one expired resident reviews, Resident #140 (R140). On [DATE], when the resident was found to be without respirations and pulse, the facility staff failed to administer CPR per the resident's wishes, as documented by the facility staff and the hospice nurse. This failure resulted in harm. The findings include: R140 was admitted to the facility on [DATE]. R140's admission assessment, dated [DATE], documented the resident's neurological status as alert and nonverbal. The resident expired in the facility on [DATE]. A review of R140's clinical record revealed the following, documented on a Doctor's Order Sheet: [DATE] Admit patient to [name of hospice company] under routine level of care for dementia. Patient is a full code. A review of R140's providers' orders throughout the four days of admission revealed no other order for code status. A review of R140's hospice progress notes revealed a note written by the hospice RN (registered nurse) on [DATE]. The note documented, in part: [AGE] year old .male admitted to hospice under routine level of care for dementia .Full Code per family wishes at this time. Hospice services and philosophy discussed. Family verbalizes understanding to call hospice with any changes or needs .POC (plan of care) coordination done with facility. A review of R140's facility progress notes revealed the following: [DATE] 11:21 a.m. Physician Note Late Entry: Note Text: NURSE PRACTITIONERS PROGRESS NOTE .DOS (date of service): [DATE] .CODE STATUS: FULL CODE. [DATE] 11:26 a.m. Physician Note Text: NURSE PRACTITIONERS PROGRESS NOTE .DOS: [DATE] .CODE STATUS: FULL CODE. [DATE] 20:50 (8:50 p.m.) General Note Text: Writer called into resident's room by assigned nurse for assessment. Complete assessment indicates no rising and falling of chest, no pulse, no respiration noted upon auscultation. Resident pronounced dead at this time. Hospice nurse .notified. [DATE] 20:50 (8:50 p.m.) General Note Text: Nurse was in Resident room for bed time medication, and observed Resident was lying in bed, but not breathing. No chest raise (sic), skin was dry and warm to touch. Unable to obtain vital signs. Co-worker RN nurse .was called into Resident room to verify Res. status. RP (responsible party) .NP (nurse practitioner) and .[name of hospice nurse] aware. Neither the hospice nurse nor the two facility nurses who wrote the [DATE] progress notes were available for interview. A review of R140's baseline care plan dated [DATE] at 1:15 a.m. revealed, in part: Code Status: DNR (do not resuscitate). The nurse who signed this care plan was not available for interview. On [DATE] at 12:28 p.m., ASM (administrative staff members) #3, regional director of clinical services, and ASM #4, regional vice president of operations, were asked to provide any plans of correction implemented at the facility since the middle of [DATE]. On [DATE] at 12:30 p.m., ASM #3 and ASM #4 provided an action plan related to the facility staff's failure to administer CPR to R140 on [DATE]. On [DATE] at 1:03 p.m., ASM #2, the director of nursing, ASM #3, and ASM #4 were interviewed. ASM #3 stated she discovered this failure when she was performing regular audit of nurses' notes. She stated she had experienced a similar scenario previously, and she frequently reviews progress notes around residents' deaths. ASM #3 stated it is always a good idea to check the code status for hospice patients, as a DNR status is not always a given. ASM #3 stated she would need some time to provide a date when the action plan had been completed. She stated the plan was completed prior to surveyor entrance on [DATE]. ASM #4 stated the completion date should have been when all the education was completed with staff. He stated the first step in the plan was to hold an ad hoc QAPI (quality and performance improvement) meeting on [DATE], when the error was discovered by ASM #3. ASM #3 stated the components of the plan included education to the staff on what should be done when a resident was discovered to be without pulse or respirations, an audit of code statuses and care plans to ensure accuracy, an audit of nursing CPR credentials, and mock code drills to assess staff understanding. ASM #2 stated if there is no order for code status for a resident, the nurse must go through the chart to attempt to locate a signed DNR/DDNR form. On [DATE] at 1:21 p.m., an interview was conducted with RN (registered nurse) #4, regarding what should be done if a resident is observed without a pulse or respirations. RN #4 stated she would check the resident's code status in the chart portion of the electronic medical record, and if the resident was a full code, then she would call for someone to get the code cart and begin CPR. RN #4 stated that if the electronic medical record did not document a code status then she would check the paper chart, ask the unit manager, contact the physician or nurse practitioner, then call the family. On [DATE] at 1:26 p.m., LPN (licensed practical nurse) #5 was interviewed. She stated if a resident had no pulse or respirations, she would assess the resident and call for help. She stated she would check for a DNR status by checking the resident's paper chart, or checking the computer, whichever is closest. She stated if the resident is not a DNR, she would start CPR immediately. She stated if there is not order for code status, she would perform CPR until help arrived by way of emergency medical services. She stated if there is a conflict between a provider's order in the computer, and the DNR that is in the paper chart, she would call the NP or physician to clarify. On [DATE] at 1:32 p.m., LPN #6 was interviewed. She stated if there were no pulse or respirations, she would check the resident's electronic medical record and paper chart for code status. She stated if there was no order for DNR, she would begin CPR. On [DATE] at 1:36 p.m., an interview was conducted with LPN #8 regarding what should be done if a resident is observed without a pulse or respirations. LPN #8 stated she would first check the paper chart for a DNR form and if she did not see one, she could also check the top portion of the electronic medical record for the resident's code status. LPN #8 stated that if the resident did not have a DNR form or a code status documented, then the resident should be considered a full code. A review of the facility policy, Advance Directive - Administration, revealed, in part: The facility will abide by resident advance directives if know, and if those directives are not in conflict with the facility's policies regarding the withholding or withdrawing of life support treatment .The Administrator must make certain the Admissions staff, Social Services, Medical staff, and Nursing staff are informed, aware, and trained to follow the company's policies and the resident's wishes regarding advance directives. A review of the facility policy, Cardiopulmonary Resuscitation, revealed, in part: Cardiopulmonary resuscitation is initiated on all residents except those with a no code order and appropriate documentation. On [DATE] at 2:24 p.m., ASM #2, ASM #3, and ASM #4 were informed that this failure would be cited at a level of harm, at past noncompliance. PAST NONCOMPLIANCE On [DATE] at 12:30 p.m., ASM #3 and ASM #4 provided an action plan related to the facility staff's failure to administer CPR to R140 on [DATE]. This plan included the following elements: 1. Ad Hoc (Self Identified Areas, Self Imposed IJ (immediate jeopardy) Meeting Minutes .Issues: Full code resident did not get CPR .Resolution: Education to licensed nurses on identifying code status .Code status order audit and care plan update .Audit CPR cards .Mock code drills weekly X 4 weeks. 2. Policy on CPR as documented above. 3. Self-Imposed IJ - Code Status .Resident Coded? No .Resident code status order on chart? No .Resident code status matches advance directives, Living Will or other documentation: No .Staff responded correctly to code blue? (per order) No .If resident was full code, staff started and continued CPR until 911 services arrived? No .Facility followed policy to NOT have identifiers for code status? Yes .Facility was prompt in actions? .No .Crash Cart brought immediately to code blue, stocked and ready? No .If nurse pronounced dead, was nurse within scope of practice in specific state to pronounce death? RN? Yes. 4. The facility provided credible evidence that education was provided to nursing staff, that code status order audits were performed for all residents, that licensed nursing staff CPR certifications were audited, and that mock codes were performed according to the action plan. 4. Summary Reports of Meetings .[DATE] . (Education) Meeting Notes .Resident observed without pulse and/or respirations. Immediately check chart for code status while another nurse gets crash cart. There were four sets of this document, and each one included signatures of facility staff in attendance at this education opportunity. No further information was provided prior to exit.

Based on staff interviews, clinical record review and facility staff record reviews the facility staff failed to recognize and implement the advance directives for one of 33 residents in the survey sample, Resident #3. Resident #3 had a physician order [REDACTED]. A Full Code is a physician directive to perform CPR (cardiopulmonary resuscitation) in the event her heart should stop beating and her breathing stopped. On the morning of [DATE] at 5:20 a.m., Resident #25 was found without a pulse or respirations (breathing), the staff did not initiate CPR as directed and did not call 911, Resident #25 expired. Cardiopulmonary resuscitation: [MEDICAL CONDITION] is characterized by an absence of pulse and respiration. If the nurse determines that a client has [MEDICAL CONDITION], cardiopulmonary resuscitation (CPR) must be initiated. CPR is a basic emergency procedure of artificial respiration and manual external cardiac massage . The purpose of CPR is to circulate [MEDICATION NAME] blood to the brain to prevent permanent tissue damage (AHA, 2001) Fundamentals of Nursing 6th edition, 2005; Patricia A. Potter and Anne Griffin Perry; Mosby, Inc; Page 1126. The findings include: Resident #25, a [AGE] year old female, was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The most recent MDS (minimum data set) assessment, an admission assessment, with an assessment reference date of [DATE], coded the resident as having no short or long term memory difficulties. In Section C1000 - Cognitive Skills for Daily Decision Making, Resident #25 was coded as being modified independence meaning she had some difficulty in new situations only. Resident #25 was coded as requiring extensive assistance of one to two staff members for moving in the bed and personal hygiene. The resident was coded as requiring limited assistance of one staff member for transfers, walking in the room, moving around the unit, dressing, and toileting. Resident #25 was coded in Section K - Swallowing/Nutritional Status as being 60 inches tall and weighing 92 pounds. In Section O - Special Treatments, Procedures and Programs, the resident was not coded as being on hospice care. The physician orders [REDACTED]. The admission orders [REDACTED]. The physician progress notes [REDACTED]. The comprehensive care plan dated, [DATE] documented, Focus: Patient has an Advanced Directive as evidenced by; Full Code. The DNR/DNI (do not resuscitate/do not intubate) form from the hospice was dated, [DATE]. The form documented, Full Code. Under this was a section, physician's orders [REDACTED]. The nurse's notes dated, [DATE] at 5:20 a.m. documented, Resident continues under Hospice care. Upon medication administration rounds, resident noted in bed eyes open and not responding to verbal or tactile stimulation. Resident notably alert, prior to med (medication) administration at 0445 (4:45 a.m.). Writer phone Hospice to inform of residents current status. Hospice nurse arrived to assess resident and inform family of residents change in status. Hospice stated they will remain in facility until family arrives and assist family with contacts and or final choices. A second nurse's note dated, [DATE] at 8:03 a.m. documented, Hospice nurse assessed resident and pronounced deceased at 0625 (6:25 a.m.). Informed writer of follow up with family. The comprehensive care plan dated, [DATE], documented, Focus: Patient has an advance directive as evidenced by: Full Code. The Interventions documented in part, CPR will be performed as ordered. Follow facility protocol for identification of code status. An interview was conducted with LPN (licensed practical nurse) #7, the nurse on duty at the time of the resident's death, on [DATE] at 2:43 p.m. When asked to explain what happened on the morning when Resident #25 expired, LPN #7 stated, I was the only nurse on the entire floor that night. The CNA (certified nursing assistant) came to me and said (Resident #25) doesn't have a pulse or respirations. I knew she was hospice and was preparing for the dying process. The supervisor came over. I called hospice to pronounce the resident. When asked if she initiated CPR, LPN #7 stated, No, I did not. When asked if she was aware that a resident can be on hospice and be a full code, LPN #7 stated, I didn't know that prior to this. When asked if she checked the chart for the code status, LPN #7 stated, It wasn't until I was on the phone with the hospice nurse that I was thumbing through the chart. I couldn't find a DNR sheet and then saw the order for the full code. LPN #7 was then asked if she initiated CPR at that time, LPN #7 stated, No, Ma'am. When asked how the facility staff identify a resident's code status, LPN #7 stated, We look for the DNR sheet, if there is no DNR sheet, they are ultimately a full code. When asked if there was any system in place at the facility to identify a resident's code status, LPN #7 stated, No. Attempts to contact the supervisor on duty at the time of the incident by phone were made on [DATE] at 12:45 p.m., 1:37 p.m. 2:00 p.m. and 2:18 p.m. No response or return call was received. An interview was conducted with administrative staff member (ASM) #2, the director of nursing services, on [DATE] at 4:22 p.m. When asked her knowledge of the death of Resident #25, ASM #2 stated, The resident was a full code. The staff did not perform CPR. I didn't find out about this until I got to work. I went to C wing and pulled the chart and looked, she was a full code. The hospice nurse had come in to pronounce. (Name of hospice nurse) was under the false assumption that she was a DNR. Everyone assumed she was a DNR. The niece wanted her to be a DNR. She (Resident #25) had just gotten out of a doctor's appointment on [DATE] and there wasn't anything they could do for her. The niece was in the process of getting the paperwork to be the POA (power of attorney). When asked the process at the facility for identifying the code status of a resident, ASM #2 stated, We look at the physician orders [REDACTED]. When asked if they used any kind of identifying systems, dots, symbols, ASM #2 stated, No, the staff have to check the chart for the code status. If they are a DNR they don't do anything, if they are a full code they are to initiate CPR. An interview was conducted with LPN #6, the hospice nurse who had been caring for Resident #25, on [DATE] at 4:08 p.m. When asked to explain what he knew of the resident's code status, LPN #6 stated, She wanted to be a full code. It took us two days to get all of her admission paperwork completed as she was very tired. She was estranged from her family until she took ill in November. Because of her increased confusion, her niece stepped up and was going through the paperwork to be her POA. The family was on board with the DNR. She (Resident #25) was explained the program of hospice. She didn't want any further aggressive treatment but couldn't make her mind up regarding CPR. I believe the mets (metastasis) had started to affect her thought processes. The family stepped up and was in the process of obtaining POA for her. When asked if the resident signed the DNR/DNI form that documented the resident's wishes to be a 'full code, as documented on the DNR/DNI form, LPN #6 stated, Yes, she signed the form of her wish to be a full code. When asked if a resident is on hospice care do they have to be a DNR, LPN #6 stated, No, it's not a requirement to be a DNR on Hospice. It's a matter of choice. An interview was conducted with LPN #5 on [DATE] at 4:34 p.m. When asked if a resident is found without a pulse and not breathing, what is the staff to do, LPN #5 stated, You first check the chart for full code or DNR. If no DNR form, you check the physician orders. If full code, you initiate a code. When asked if there was any kind of system in place at the facility to quickly identify the code status of a resident, LPN #5 stated, No, there is no system but I have asked for a system. The facility policy, Cardiopulmonary Resuscitation (CPR) Guideline documented, In the event a resident/patient experiences [MEDICAL CONDITION] (cessation of pulse and/or respirations), cardiopulmonary resuscitation (CPR) will be provide in the absence of a valid Advanced Directive or a Do Not Resuscitate (DNR) order directing otherwise. Once emergency medical services (EMS) arrive, EMS will take control of the resuscitative effort and direct all related activities until either the resuscitation effort is ceased or the resident/patient is transported to an emergency center. Guideline: If a patient/resident is found unresponsive, begin evaluation to determine presence or absence of pulse and/or respirations. In the absence of pulse and/or respirations do the following: 1. Remain calm. 2. Call out for help. Direct another staff member to announce the emergency per Living Center protocol and call Emergency Medical Services (EMS - 911). Direct another staff member to bring the emergency supplies and AED (automated external defibrillator) (1) to the scene. 3. A charge nurse will assume command of the scene and will direct other personnel in the effort. CPR certified personnel, when present in the facility, shall manage the physical efforts involved in resuscitation. 4. A staff member other than the one who is providing the resuscitation effort must promptly identify/validate current code status. While that step is undertaken, AED should be prepared and [MEDICATION NAME] placed. 5. If DNR status is validated, do not initiate CPR. If CPR/Code status is undetermined, CPR will be initiated and will continue until the arrival of EMS. The physician is responsible for directing medical treatment. Nurses are obligated to follow physician's orders [REDACTED]. Fundamentals of Nursing 6th edition, 2005; Patricia A. Potter and Anne Griffin Perry; Mosby, Inc; Page 419. ASM #1, the executive director, ASM #3, area vice president of operations, ASM #2, director of nursing services and ASM #4, the clinical consultant, were made aware of the concern for harm on [DATE] at 5:06 p.m. On [DATE] at 8:00 a.m., ASM #2 presented credible evidence that a five point plan of correction had been put into place following the above referenced incident. The credible evidence presented included the following: DATE: [DATE], Hospice resident was a full code, resident was observed not breathing, and CPR was not initiated. 1. The nurses involved in the situation were immediately in-serviced 2. 100% In-service to all nurses to ensure code status is checked to make sure CPR is immediately initiated on all full code residents. 3. Random education to nurses monthly x3 (times 3) and ongoing. Random mock code drills on all 3 shifts. 4. Random code drills monthly x 3 months. 5. [DATE] During the survey, three deceased resident charts, Residents #29, #30 and #31 were reviewed. All three residents expired after the date of compliance. All three residents had physician orders [REDACTED]. All three residents received CPR and 911 response was initiated. For all three of the residents, CPR was not successful. All three residents expired. PAST NON COMPLIANCE No further information was provided prior to exit. (1)An automated external defibrillator (AED) is a portable device that checks the heart rhythm and can send an electric shock to the heart to try to restore a normal rhythm. AEDs are used to treat sudden [MEDICAL CONDITION]. http://www.nhlbi.nih.gov/health/health-topics/topics/aed/