Every finding on record at Fairfield Nursing & Rehabilitation Center

Based on medical record review and interview, it was determined the facility staff failed to follow consultant physician orders for residents. This was evident for 2 (Resident #2 and #7) of 7 residents reviewed during a complaint survey.The findings include:1.The facility staff failed to follow the Wound Doctor orders for Resident #2.Review of Resident #2's medical record on 3/19/26 revealed the Resident had returned from the hospital on 1/27/26 and was seen by the Wound Doctor on 1/28/26. On 1/28/26 the Wound Doctor assessed the Resident to have a non-pressure sacral wound, and ordered the Resident to have silver sulfadiazine and calcium alginate dressing daily.Further review of the medical record revealed the Wound Doctor assessed the Resident again on 2/3/26 and 2/10/26 and ordered the Resident to have silver sulfadiazine and calcium alginate daily.Review of Resident #2's January 2026 medication and treatment records revealed the Resident did not receive the sacral wound treatments of silver sulfadiazine and calcium alginate until 2/18/26, 21 days later.Interview with the Director of Nursing on 3/20/26 at 11:45 AM confirmed the facility staff failed to provide Resident #2's sacral wound treatments as ordered by the Wound Doctor from 1/28/26 until 2/18/26.2.The facility staff failed to follow the preop instructions for Resident #7.Review of Resident #7's medical record on 3/17/26 revealed the Resident was admitted to the facility on [DATE] from the hospital and was scheduled to have an outpatient vascular procedure on 12/12/25.Further review of Resident #7's medical record revealed on 12/10/25 the Vascular physician's office sent preop instructions to the facility for Resident #7's 12/12/25 outpatient procedure. The instructions included for the Resident to not have anything by mouth after midnight the night prior and to stop Eliquis 2 days prior to the procedure. Eliquis is a blood thinner medication. The instructions also included the Resident could take Aspirin, Metoprolol, Vimpat and Gabapentin the morning of surgery with a small sip of water.Further review of Resident #7's medical record revealed the Resident was given food and fluids after midnight on 12/12/25.Review of Resident #7's December 2025 Medication Administration Record revealed the facility staff failed to stop the Resident's Eliquis 2 days prior and did not administer the Resident's Aspirin, Metoprolol, Vimpat and Gabapentin on 12/12/25 the day of the scheduled procedure.Further review of Resident's medical record revealed the Resident's outpatient procedure was rescheduled for 12/23/25.Interview with the Director of Nursing on 3/17/26 at 12:45 PM confirmed the facility staff failed to follow Resident #7's preop instructions for 12/12/25.

Based on review of a complaint, observation of resident rooms, and interview, it was determined the facility staff failed to provide housekeeping and maintenance services necessary to maintain a sanitary, orderly and comfortable interior. This was evident for 1 (Resident #3) of 5 resident rooms observed during a complaint survey.The findings include: On 3/17/26 a review of complaint 2713635 from January 2026 alleged Resident #3's room had a fruit fly infestation. Observation of Resident #3's room on 3/17/26 at 12:24 PM revealed a few fruit flies flying around the Resident's room. The Surveyor observed behind the Resident's door on a bedside table a food tray with a tray ticket from 3/16/25 dinner. On the tray the Surveyor observed what appeared to be pasta and carrots, milk and ice cream containers. The Surveyor also observed behind the Resident's door a food tray with a tray ticket from 3/17/26 breakfast with food crumbs on it. Resident #3 was observed sitting in his/her chair with another bedside table in front of him/her. This bedside table was visibly dirty. Resident's drawers were also noted to be visibly dirty. Debris was noted on the floor by the Resident's window. Two peanut butter jars were observed on the Resident's shelves with peanut butter on the outside of the jars. The Resident's toilet was noted to be constantly running. During interview with Resident #3 at that time, the Resident was asked if he/she was willing to have housekeeping come in his/her room to clean up his/her room, remove the food trays and if the peanut butter jars could be placed in a sealed container. The Resident stated yes. The Surveyor returned to Resident #3's room on 3/17/26 at 12:33 PM with the Director of Nursing who confirmed the Surveyor's observations including a fruit fly flying in the room. The Surveyor returned to Resident #3's room on 3/18/26 at 8:45 AM. At that time the Surveyor counted 15 fruit flies in the Resident's bathroom, 2 fruit flies on the wall where the food trays were observed on 3/17/26 and one fruit fly on the sink. The Surveyor observed large cobwebs around both Resident's closet doors, dresser drawers remained dirty, peanut butter jars still had peanut butter on the outside of the jars and not in a sealed container, open ended pipe noted next to the toilet [NAME] out from the wall that doesn't appear to be in use, dry wall around sink with large cracks, old drill holes in wall under television. The Resident was again asked if he/she would be agreeable to a scheduled cleaning time. The Resident stated yes. The Surveyor returned to Resident #3's room on 3/18/26 at 9:00 AM with the Director of Nursing who confirmed the Surveyor's observations.

Based on medical record review and interview, it was determined the facility failed to obtain consent from a resident's representative for a change in treatment. This was evident for 1 (Resident #5) of 6 residents reviewed during a complaint survey. The findings include:Review of Resident #5's medical record on 3/19/26 revealed the Resident was admitted to the facility in October 2025 with a diagnosis to include dementia with psychotic disturbance.Further review of Resident #5's medical record revealed the Resident was assessed by facility staff on 10/29/25 to have a BIMS (Brief Interview for Mental Status) of 6 out of 15 indicating severe cognitive impairment.Review of Resident #5's physician orders revealed on 12/23/25 Staff #16 ordered the Resident to receive Seroquel 25 mg twice a day.Seroquel is an antipsychotic medication used in the treatment of schizophrenia, bipolar disorder and major depressive disorder.Review of a physician note (Staff #16) on 12/26/2025 revealed Staff #16 documented: Patient agitated and not tolerating nursing or therapy care. No clear triggering etiology identified at this time. Staff #16 documented under plan: Will start short course of Seroquel for mood stabilization.Review of Resident #5's paper and electronic medical record revealed no consent was obtained for the administration of Seroquel.Review of Resident #5's December 2025 and January 2026 Medication Administration Records revealed Resident #5 received Seroquel beginning 12/23/25 at 9:00 PM and then twice daily until 1/27/26 when it was placed on hold for 7 days. Review of Resident #5's February 2026 Medication Administration Record revealed the Resident's Seroquel 25 mg was restarted on 2/4/26 at 9:00 AM until 2/6/26 at 9:00 AM.Interview with Staff #16 on 3/20/26 at 12:44 PM confirmed the facility staff failed to obtain consent for the administration of Seroquel to Resident #5.Interview with the Director of Nursing on 3/23/26 at 12:30 PM confirmed the facility staff failed to obtain consent from Resident #5's representative for the administration of Seroquel.

Based on observations, interviews, and record review, it was determined that the facility failed to maintain medical records in accordance with acceptable professional standards and practices by keeping complete documentation. This was evident in 4 (Resident # 69, #10, #33 & #25) out of 33 residents reviewed during the survey. The findings included:1. During a record review on 11/18/2025 at 11:30 am, the surveyor found no physician notes were found for Resident #69 from the current admission. The Director of Nursing (DON) was asked to show the location of provider notes in the electronic medical record (EMR). She stated the surveyor was looking in the correct location, but the facility had not uploaded any physician notes from the current admission for Resident #69. The surveyor requested access to notes for Resident #69. The DON provided twenty provider notes that had been faxed to the facility that were not available in the EMR. The notes were dated from 9/4/2025 through 11/17/2025. The DON stated the notes were found in the Medical Records office and the facility had not yet uploaded to the EMR. On 11/18/2025 at 1:29 PM, the DON acknowledged the concern that the EMR does not include the provider's notes. The DON stated the nurses always read the plan and followed up when they received the notes, but acknowledged the back log was a concern and stated the facility was trying to catch up. 2. On 11/18/25 at 11:57AM, the surveyor reviewed Resident #10's medical record. The review revealed that Resident #10 had a past medical history that included, but not limited to, vascular dementia without behavioral disturbance, psychotic disturbance, mood disturbance, anxiety, emotional deficit following cerebral infarction and cognitive communication deficient. The surveyor next reviewed Resident #10's psychiatric note written by physician #25. The most recent progress note written was dated 1/13/25. The note stated that the resident should be follow up monthly. No additional notes were located in Resident #10's electronic medical record. Also, in Resident #10's electronic medical record was a psychological services progress note written on 1/4/25. The note stated the plan was to meet weekly to work on the resident's goals. The surveyor requested all 2025 psychiatric notes for Resident #10. On 11/19/25 at 11:32 AM, the surveyor reviewed additional psychiatric notes that were provided by the facility written by Staff #25. The notes were dated, 5/1/25, 6/30/25, 9/30/25 and 11/13/25. Two of these notes stated Resident #10 should be seen monthly, however the facility was only able to provide 5 notes from Staff #25 from January 2025- November of 2025. Additionally, psychological services progress note dated, 9/13/25, 10/11/25,10/18/25, and 10/25/25 were provided. No other notes were provided even though all notes stated that Resident should be seen 1-5 times per month. On 11/19/25 at 12:33 PM, the surveyor conducted an interview with the Unit Manager (UM) #6. During the interview UM #6 stated that these were the only records she could find. She further stated that some notes were found in the backlog of medical records that needed to be scanned, and other documents were requested by reaching out to the providers. At the time of exit the surveyor relayed the concern that Resident #10's medical record was not complete. 3. On 11/18/25 at 10:04 AM, the surveyor reviewed Resident #33's medical record. The review revealed that Resident #33 had a past medical history that included, but not limited to, schizophrenia, vascular dementia without behavioral disturbance, psychotic disturbance, mood disturbance, anxiety, obsessive-compulsive disorder, and bipolar. The surveyor next requested Resident #33's psychiatry note. There was only one note, dated 3/10/25, in Resident #33's electronic medical record. The surveyor requested all psychiatric notes from 2025. On 11/18/25 at 1:09 PM, the surveyor reviewed Resident #33's psychiatry notes provided. Physician #25 wrote a progress note on 9/10/25 and 10/01/2025. Both notes had a time stamp when the fax was sent at the top of the page. The time stamp on both notes were dated 11/18/25 at 1PM. Additionally psychological services noted dated, 9/13/25, 9/20/25, 9/27/25, 10/10/25, 10/17/25, 10/24/25 11/1/25, 11/7/25 and 11/8/25 were provided. Even though the plan documented in all of the notes to have Resident #33 seen 1-5 times per week no additional notes were provided for earlier months. On 11/19/25 at 12:33 PM, the surveyor conducted an interview with the Unit Manager (UM) #6. During the interview UM #6 stated that these were the only records she could find. She further stated that some notes were found in the backlog of medical records that needed to be scanned, and other documents were requested by reaching out to the providers. At the time of exit the surveyor relayed the concern that Resident #33's medical record was not complete. 4. On 11/18/25 at 1:09 PM, the surveyor reviewed Resident #25's medical record. The review revealed the last note written by a provider was September of 2025. The surveyor requested the last provider note for Resident #25. On 11/18/25 at 1:45 PM, the surveyor was provided with additional provider notes for Resident #25. The surveyor asked the Director of Nursing (DON) where the notes were located. The DON stated that the Assistant Director of Nursing (ADON) was able to obtain the physician progress notes but was not sure where she got them. On 11/18/25 at 2:11 PM the surveyor interviewed ADON. The ADON stated that she obtained the notes from medical records from the provider visits from 9/18/25 and 10/14/25. She stated that the documents were faxed over on 9/18/25 and 10/17/25 from the visit respectively. She further stated that both notes had not been scanned and placed into the resident's electronic medical record yet. On 11/19/25 at 8:14 AM, the surveyor reviewed the concern that Resident #25's medical records were not complete.

Based on observations and interviews with facility staff it was determined that the facility failed to store and prepare food in accordance with professional standards. This was evident of 2 of 3 kitchen observations and 1 of 2 unit refrigerator observations during the annual survey. The findings include:On 11/17/25 at 7:41 AM, the surveyor performed an initial tour of the facility's kitchen. On 11/17/25 at 7:44 AM, the surveyor viewed the walk-in refrigerator labeled #2. During the observation the surveyor noted a takeout container not labeled or dated with what appeared to have a chili like substance it in. [NAME] #26 stated that the container should not be in there and that she would discard it. On further observation of the refrigerator there a see-through container with a piece of cake (not labeled or dated), an opened jelly jar (not dated on open), a fastfood soft drink cup (ice in the cup), brown lunch bag dated 11/17/25 with a first name on it, and an additional lunch bag with what appeared to be a personal lunch inside (no name or date). Next the surveyor observed, a container of baked bean labeled 11/9/25 with no used by date, container of ziti labeled 11/8/25 with no used by date (both well over 7 days old) and sandwiches in baggies and no label to indicate type of sandwich or date to note the date they were made. Additionally next to the shelf was a cardboard box of ground beef packages. One package within the box was opened with cellophane over the opened end. The beef had an open date of 11/14/25 with no date written to discard and appeared to have the potential for juices to leak into the box. On 11/17/25 at 7:57 AM, the surveyor observed the walk-in freezer. During this observation it was noted that a box labeled onion rings was opened and contained three different food times. None of them were labeled and none appeared to be onion rings. Next to the box was a bag of what appeared to be chicken tenders on top of another box. The bag had no label. On exiting the freezer the surveyor noted that the afternoon freezer temperature checks were missing from the 13th and 14th and both morning and afternoon temperatures were missing on the 15th and 16th. On further observation in the room exterior to the freezer it was noted that a yellow container labeled eccolab was on a storage shelf. Within the same room where the shelf was there was also a tray that contained multiple bread bags. On 11/18/25 at 8:32 AM, the surveyor reviewed the concerns with the Certified Dietary Manager (CDM). The CDM confirmed that personal food items from employee should not be stored in the kitchen refrigerator and that the items were removed. The CDM stated that the food items that were over 3-5 days were discarded. He further stated that floor cleaner should not have been left in the room with bread. On 11/21/25 at 8:57 AM, the surveyor observed that the dishwashing sanitize log was not filled out on 11/20/25 for breakfast, lunch and dinner. The surveyor reviewed the findings at the time with the CDM. He stated that it is the responsibility of the dietary aides and they must have forgotten to document their findings. On 11/21/25 at 9:08 AM, the surveyor observed the nourishment refrigerator on the Atlantic unit. Within the refrigerator it was noted that a re-used Gatorade bottle contained a milky white substance. No label was on the container to indicate what it was the bottle was dated 11/20. Next the surveyor asked the Unit Manager (UM) #6 about the unlabeled reused container. UM #6 did not know what or why the substance was in the refrigerator or who it belonged to and took the bottle out. Both the UM and the surveyor reviewed the concern with the Director of Nursing (DON).

Based on observations and facility staff interviews it was determined that the facility failed to provide a safe, clean, comfortable, homelike environment for Residents. This finding was found to be evident in 6 out of 33 Resident rooms and common areas reviewed for safe/clean/comfortable/homelike environment.The findings include: 1. On 11/17/2025 at 7:45 AM during tour of the facility the surveyor observed items in Resident rooms that were not in good repair. The following rooms were observed with items that were not in good repair: room [ROOM NUMBER] – bedside dresser marred and chipped; room [ROOM NUMBER] – baseboard behind head of bed loose and not affixed to the wall, bedside dresser with two broken drawers not affixed to the dresser tracks; room [ROOM NUMBER] – severely marred and chipped wall behind the head of the bed, closet curtain not affixed on the curtain rod; room [ROOM NUMBER] – baseboard molding marred and paint chipped; room [ROOM NUMBER] – no window blinds, hole in wall behind door knob; shower room on long-term care (LTC) unit – marred and chipped door, gap towards the bottom half of door between the door and the door frame; long-term care (LTC) unit hallway – hole in wall above the baseboard by the hallway phone. In an interview with the Maintenance Assistant at 8:10 AM on 11/21/2025 the surveyor conveyed the areas of repair needed on the long-term care (LTC) unit in the 5 Resident rooms and common areas. The Maintenance Director acknowledged the surveyor and stated that he was aware of some of these items that needed repair and had already begun fixing these needed repairs. No additional information was provided by the facility by the time of survey exit. 2. On 11/17/2025 at 10:24 AM, surveyors observed Resident #69's room and noted drywall dust on the top of the headboard and significant scrapes in the paint and drywall behind the headboard of the bed. On 11/18/2025 at 9:16 AM, surveyors showed Maintenance Assistant #9 the wall behind the bed. He stated he was not aware of the damage and he would repair it with spackle and paint. When asked how he received reports of needed repairs, he stated that the nurses either call him or write in in the book at the nurses station. The Administrator acknowledged the concern about the wall on 11/21/2025 at 7:04 AM and stated that the facility would fix the damage behind the bed.

Based on observations and staff interviews, it was determined that the facility failed to adhere to professional standards of practice for medication disposition. This was found to be evident in 1 out of 2 carts reviewed for medicine storage.The findings include:On 11/20/2025 at 9:28 AM, during surveyor review of a medication storage cart with LPN #11 and found the following expired medications: gabapentin 100 mg, glimepiride 2 mg, carvedilol 6.25 mg, pantoprazole 40 mg, dexamethasone 2 mg and trazodone 100 mg. The expired medications were in blister packs, lodged between the locked medication box and a drawer divider. The surveyor also found expired therapeutic nutritional supplements, Suplena and Boost, on the cart. The Director of Nursing removed the expired medications and supplements from the cart on 11/20/2025 at 9:30 AM. She stated the pharmacy recently completed a review of the carts and stated the facility would need to perform further review.

Based on observations and interviews it was determined the facility failed to 1) ensure that the resident's call system was functioning properly and 2) failed to have a call light device accessible for a Resident to call for staff assistance. This was found to be evident for 1 (Resident #25) for call light function and 1 (Resident #42) out of 8 Residents reviewed for Resident call system accessibility. The findings include:1) On 11/17/25 at 10:24 AM, the surveyor asked Resident #25 to push his/her call button. On 11/17/25 at 10:25 AM, the surveyor observed Unit Manger #6 walk into Resident #25's room. On 11/17/25 at 10:25 AM, the surveyor asked UM #6 if Resident #25's call button was on. UM #6 stated that she had heard the call light on at the nurse's station but was not sure who's call light it was. She stated that no light was on in the hallway above Resident #25's room. The surveyor asked UM #6 to push the call button to see if the light would come on. UM #6 then pushed the call button. Again, no light came on in the hallway above Resident 25's room. Resident #25 stated that the call light doesn't work. On 11/1725 at 10:30 AM, the surveyor conducted an interview with the Nursing Home Administrator (NHA) and the Director of Nursing (DON) in the nurses' station. Both staff were at the call light monitor, which had a black screen display. The DON stated that the call light monitor would normally give the location of a call light request, however the system was being rebooted. The surveyor reviewed the concern that the call light was not lit up above Resident #25 hallway door and that the staff were unaware of which Resident was requesting help. 2) On tour of the long-term care (LTC) unit on 11/17/2025 at 7:45 AM the surveyor observed Resident #42 in bed in his/her room. Resident #42 was alert and oriented, in no distress. The call light device was observed lying on the floor next to Resident #42's bed. Resident #42 was unable to call for staff assistance because the call light device was on the floor next to Resident's bed, and Resident #42 was unable to reach the call light device. In an interview at 8:22 AM on 11/17/2025 with the RN Unit Manager, the surveyor conveyed that Resident #42 was unable to reach the call light device as the device was lying on the floor next to Resident's bed. The RN Unit Manager observed with the surveyor Resident #42's call light device lying on the floor in Resident's room next to the bed and acknowledged the surveyor. The surveyor asked the RN Unit Manager what the expectation was for Resident accessibility of call light devices, and the RN Unit Manager stated that the call light devices should be in reach for Residents to call for staff assistance. No additional information was provided by the facility at the time of survey exit.

Based on observations, staff interviews and record reviews it was determined that the facility failed to provide a safe, functional, sanitary and comfortable environment for a Resident and staff. This finding was found to be evident for 2 (Resident #24 & #33) out of 33 Residents reviewed for a safe, functional, sanitary and comfortable environment and in the laundry and parking lot area. The findings include: 1. The surveyor conducted an initial tour of the facility on 11/17/2025 at 7:45 AM. The surveyor observed Resident #24's room. The toilet in Resident #24's bathroom was observed as inoperable, specifically the toilet was not attached to the sewer hole/line, and the toilet was resting next to the sewer hole/line with a cloth stuck in the hole in the floor. Resident #24 was sitting in a wheelchair in the room and stated that the toilet had been broken since last week and maintenance was working on it. In an interview with the Director of Nursing (DON) and the RN Unit Manager at 9:45 AM on 11/17/2025 the surveyor conveyed that Resident #24 had a toilet in the bathroom that was inoperable. They acknowledged the surveyor and stated that maintenance was aware and were working on fixing the toilet. In an interview with the Licensed Nursing Home Administrator (LNHA) on 11/19/2025 at 7:15 AM the surveyor conveyed that the inoperable toilet was a concern as the bathroom toilet did not provide a safe, functional and sanitary environment for the Resident and staff that provided assistance to Resident #24. The nursing staff did not have an operable toilet in Resident room to dispose of urine and solid waste. The LNHA acknowledged the surveyor and stated that the Resident was incontinent, and that the toilet had been out of operation since last Wednesday (11/12/2025). The LNHA stated that the toilet was leaking from the base, and maintenance was unable to remove the pipe. The LNHA further stated that 2 outside vendors were contacted regarding the inoperable toilet and repair of the pipe. Additionally, the LNHA stated that Resident #24 was offered but refused to be transferred to another room temporarily. The surveyor conducted a review of Resident #24's medical record on 11/19/2025 at 8:30 AM. Review of the medical record revealed that Resident #24 was continent of bladder and bowel but experienced occasional bladder and bowel incontinence. Additionally, Resident #24 used a urinal at bedside. The LNHA on 11/19/2025 at 12:15 PM provided the surveyor with a timeline of the repair of Resident #24's toilet. The pipe was repaired, and the toilet was replaced, and the toilet was operable status as of 11/20/2025. 2. On 11/17/25 at 11:41 AM, the surveyor conducted an interview with Resident # #33 in his/ her room. During the interview the surveyor observed an electrical outlet in the wall that did not have an outlet cover it. On closer observation a silver object was noted in the lower right prong of the outlet. On 11/21/25 9:03 AM, the surveyor conducted an interview with maintenance assistant #9. During the interview Staff #9 stated he was not sure why the outlet was like that and would fix the concern. 3. During an observation of the laundry area on 11/18/2025 at 11:31 AM with the Director of Housekeeping, the surveyor identified a concern for bulging, stained ceiling tile over a washing machine as well as other stained and broken tiles in the surrounding area. The Director of Housekeeping stated the roof used to leak. The Maintenance Assistant stated the tile was dry but damaged from an old leak and he would fix it right away. On 11/18/2025 at 11:45 AM, the Nursing Home Administrator (NHA) was shown the ceiling tile concern. The Administrator stated it would be fixed and acknowledged that it was a concern. 4. On 11/21/2025 at 12:40 PM, the surveyors observed a large pothole in the parking lot measuring 70 inches long, 38 inches wide, and 2 inches deep. The NHA acknowledged the concern on 11/21/2025 at 1:16 PM, and stated he would look into having it repaired.

Based on interviews, and record review, it was determined that the facility failed to review and revise a Resident's care plan after a Resident's situation changed. This was found evident of 1 (Resident #10) out of 2 Residents reviewed for care planning during the survey.The findings include:On 11/18/25 at 11:57AM, the surveyor reviewed Resident #10's medical record. The review revealed that Resident #10 had a care plan that stated, Resident #10 has an Activities of Daily Living (ADL) self-care performance deficit related to muscle weakness, left sided weakness from a Cerebral Vascular Accident (CVA). It further stated that Resident #10 had left upper extremity contracture and required a left upper extremity splint. The care plan was initiated on 10/2/23 and last updated 10/30/25.On 11/19/25 at 1:39 PM, the surveyor interviewed the Director of Rehabilitation Staff #16. During the interview Staff #16 stated that Resident #10 refused Occupational Therapy (OT) services and the last time it was offered. Staff #16 confirmed that last time Resident #10 was seen by OT was in January of 2023. Staff #16 provided the OT discharge notes from January of 2023. The recommendations were to perform passive range of motion to left digits/writ prior to splint application. It further instructed that Resident #10 should wear resting hand splint up to 2 hours/daily and to monitor for redness/irritation. The surveyor next reviewed Resident #10's orders. An order was placed on 12/15/23 that stated, left hand splint to be worn for 6-8 hours and as tolerated for contracture management. Monitor for skin breakdown.On 11/21/25 at 12:30 PM, the surveyor interviewed Resident #10. During the interview resident #10 stated that he/she had the left hand splint in the room but had not worn it for the last year or two. Resident #10 stated the splint was too ridged and not comfortable.Following the interview with Resident #10 the surveyor conducted an interview with the Director of Nursing (DON). During the interview the surveyor reviewed the concerns that Resident's 10's care plan for the left upper extremity splint was not reflective of the actual recommendations or refusal by the Resident.

Based on observations, staff interviews and record reviews, it was determined that the facility failed to ensure that a Resident's environment was free from accident hazards related to the compatibility of a Resident's mattress and bed frame. This finding was found to be evident in 1 (Resident #12) out of 1 Resident reviewed for accident hazards and Resident beds.The findings include:On the initial tour of the nursing facility on 11/17/2025 at 7:45 AM the surveyor observed Resident #12 in bed in the Resident room in no distress. The surveyor observed that Resident #12 had a gap between the end of the mattress and the footboard of the bed frame. Additionally, the surveyor observed that there was a long blue pillow in the gap between the end of the mattress and the footboard of the bed.In an interview with the Director of Nursing (DON) on 11/17/2025 at 1:09 PM the surveyor conveyed that Resident #12 had a pillow between the end of the mattress and the footboard of Resident's bed and that this was a concern for Resident's safety. The DON acknowledged the surveyor and Resident #12's bed, mattress and the pillow were observed by the DON. Review of Resident #12's medical record on 11/18/2025 at 9:22 AM revealed that Resident was at risk for falls and had recent falls. Additionally, Resident's weight was 137 lbs. and height was 70 (5 feet 8 inches).On 11/18/2025 at 1:30 PM the surveyor observed a plastic foam cushion that was between the end of the mattress and the footboard for Resident #12's bed. The cushion filled the gap between the footboard and the end of the mattress, but the cushion was not secure and did not stay in place on the bed frame. The surveyor interviewed the Maintenance Assistant at 8:20 AM on 11/21/2025 and conveyed that Resident #12 had a mattress on the bed that did not fit the bed frame properly and the cushion was not secure and did not stay in place between the mattress and the footboard. The Maintenance Assistant observed Resident #12's bed and the cushion that was between the end of the mattress and the footboard of the bed. The Maintenance Assistance acknowledged the surveyor and stated that he was told by Nursing to change the bed for Resident #12. At 11:15 AM on 11/21/2025 the surveyor observed that Resident #12 had a new bed. The mattress and the bed frame were observed as compatible, and the mattress fit the bed frame properly. There was no cushion and no gap between the foot board and the end of the mattress.No additional information was provided by the facility by the time of survey exit.

Based on observation and interview, it was determined that the facility failed to perform hand hygiene between resident encounters. This was evident for 1 (Resident #72) out of 6 medication passes observed during the recertification survey.The findings include:During a med pass on 11/20/2025 at 8:32AM, the surveyor observed LPN #19 exit Resident #72's room and begin preparing medications for another resident without performing hand hygiene. When asked the facility policy for performing hand hygiene between residents LPN #19 stated, I am supposed to perform hand hygiene after each resident encounter. A bottle of hand sanitizer sat on the medication cart. The Director of Nursing acknowledged the concern of the missed opportunity for hand hygiene during an interview on 11/20/2025 at 9:30 AM.

Based on observation and interviews, it was determined that the facility failed to ensure that a resident was served a meal according to a predetermined menu. This was evident for 1 (#10) 2 residents reviewed for food during the survey.The findings include:On 11/21/25 at 12:30 PM, the surveyor reviewed the lunch that was provided to Resident #10 along with the meal ticket. The surveyor noted there was no nectar thickened tomato juice nor pureed fresh baked roll, which were both listed on the meal ticket. The surveyor asked Resident #10 if these items had come on the lunch tray. Resident #10 stated that they didn't and that if they were available, he/she would like these items.Next the Surveyor reviewed the scheduled lunch menu. The regular menu was breaded Fried fish, stewed tomatoes, fresh baked roll, cream pie and macaroni & cheese cup.On 11/21/25 at 12:37 PM, the surveyor interviewed the Certified Dietary Manager (CDM). During the interview the CDM confirmed that he did not have nectar thick tomato juice available. He further stated that the kitchen does not puree rolls. The surveyor reviewed the concern that the resident was not provided with the meal that was preplanned, and he/she desired.

Based on medical record review and interviews, it was determined that the facility failed to involve and inform a resident on treatment changes. This was found evident in 1 (Resident #39) out of 33 residents reviewed during the survey. The findings include: On 11/17/25 at 9:58 AM, the surveyor interviewed Resident #39. During the interview Resident #39 stated that he/she had requested the ointment that was prescribed to him/her and was told by the staff he/she could no longer have it. On 11/21/25 at 7:48 AM, the surveyor conducted an interview with the Director of Nursing (DON). During the interview the surveyor asked why Resident #39 could no longer have his/her ointment and if this was the situation why the resident was not informed on the decision to discontinue the ointment. The DON stated she would look into the matter. On 11/21/25 at 11:18 AM, the surveyor conducted a follow-up interview with the DON. The DON stated that Resident #39 went out to the hospital and when he/she returned were evaluated to not need the ointment. The surveyor asked if Resident #39 was involved and aware of the plan to discontinue the ointment. The DON stated she was not sure. On 11/21/25 at 11:38 AM, both the surveyor and DON interviewed Resident #39. During the interview the resident confirmed that he/she was not informed of the decision to discontinue the ointment and stated that he/she had used the ointment his/her whole life and did not understand why it was discontinued. The DON stated she would reach out to the provider to discuss reordering the ointment. Following the interview the surveyor discussed the concerns that the Resident was not involved or informed on regimen changes.

Based on observations and facility staff interviews, it was determined that the facility failed to ensure all corridors had firmly installed handrails on each side.The findings include:On 11/20/25 at 11:29 AM, the surveyor observed a resident in a wheelchair grasping with both hands the hall handrail adjacent to the kitchen hallway. Next the surveyor observed Human Resource Director Staff #17 assist the Resident off the handrail and wheeled him/her to the requested destination. The surveyor observed that there were no hallway handrails in the hallway of the front entrance nor back past the dining area towards the Atlantic units. The resident was observed between these two areas.On 11/21/25 at 7:20 AM, the surveyor reviewed the observations with the Nursing Home Administrator (NHA) and the Director of Nursing (DON). The NHA agreed that there were no handrails in the front lobby or hallway leading to the dining room areas and agreed that residents use these areas.

Based on observations, staff interviews and record reviews, it was determined that the facility failed to accurately document Minimum Data Set (MDS) assessments on Residents. This finding was found to be evident in 3 (Resident #4, #3 & # 33) out of 33 Residents reviewed for accuracy of MDS assessments.The findings include: 1. Fall mats are a safety cushion placed on the floor, typically next to a bed or in other high-risk areas, to reduce the risk of injury from a fall. They are made of high-density, shock-absorbing foam with non-slip backing and beveled edges to minimize tripping hazards and allow wheelchairs to roll over smoothly. These mats are used in hospitals, nursing homes, and homes to protect people at risk of falling, such as the elderly or those with cognitive impairments. On the initial tour of the facility on 11/17/2025 at 7:45 AM, the surveyor observed fall mats on the floor on each side of the bed in Resident #4's room. At 10:44 AM on 11/17/2025 Resident #4 stated to the surveyor that I have had 2 falls in the past, but it has been a while since I have fallen. The Minimum Data Set (MDS) assessment is a standardized assessment tool used to evaluate the health and functional capabilities of nursing home Residents. It is a federally mandated process for all Medicare and Medicaid certified nursing homes. MDS assessments are performed by trained clinicians at admission, discharge, and other intervals, such as quarterly or annually. The MDS gathers information on physical, psychological and psychosocial functioning, comorbidities, medical diagnoses, treatments, medications, and therapies. It also covers aging-related areas like cognitive status, geriatric syndromes, and life care wishes. MDS assessments help nursing home staff identify health issues and provide a valuable resource for studying disability and function in older adults. The Centers for Medicare and Medicaid Services (CMS) collect and make MDS data available. The surveyor conducted a record review of Resident #4's medical record on 11/19/12025 at 10:15 AM. Review of the medical record revealed that Resident #4 had a fracture of the right tibia and fibula (2 bones of the lower leg) on 7/6/2025. Further review of the medical record for Resident #4 revealed that the Discharge Minimum Data Set (MDS) assessment dated [DATE] Section J – Health Conditions – J1900. Number of Falls Since Admission/Entry or Reentry or Prior Assessment was coded 1 No injury. Additionally, Section I – Active Diagnoses – I8000. Additional active diagnoses did not list fractures of the right tibia and fibula. The Director of Nursing (DON) was notified on 11/19/2025 at 10:25 AM of the inaccurate coding on the MDS for Resident #4, reviewed the MDS and acknowledged the surveyor. In an interview with the LPN MDS Coordinator at 10:55 AM on 11/19/2025 the surveyor conveyed that Resident #4's Discharge MDS dated [DATE] was coded 1 No injury Section J1900. Number of Falls. Additionally, the surveyor conveyed that Section I8000. Additional active diagnoses did not list the fractures of the right tibia and fibula. The LPN MDS Coordinator reviewed Resident #4's Discharge MDS dated [DATE], acknowledged the surveyor, and stated that the diagnoses were an oversight and the fall should have been coded as Major injury because Resident had a fall in the facility with an x-ray report of acute right tibia and fibula fractures. The LPN MDS Coordinator stated that she would make the correction to the Discharge MDS. The LPN MDS Coordinator on 11/19/2025 completed a correction to Resident #4's Discharge MDS dated [DATE] which now was coded 1 Major injury under Section J1900. Number of Falls, and a copy was provided to the surveyor by the Director of Nursing (DON) at 3:40 PM on 11/19/2025. 2. On the initial tour of the facility on 11/17/2025 at 7:45 AM, the surveyor observed fall mats on the floor on each side of the bed in Resident #3's room. At 3:00 PM on 11/19/2025 the surveyor conducted a record review of Resident #3's medical record. Review of the medical record revealed that Resident #3 had documentation of falls on 5/29/2025 and 6/8/2025. Further review of the medical record for Resident #3 revealed that the Quarterly Minimum Data Set (MDS) assessment dated [DATE] Section J – Health Conditions – J1900. Number of Falls Since Admission/Entry or Reentry or Prior Assessment was coded 1 No injury. The Director of Nursing (DON) was notified of the inaccurate coding on the MDS for Resident #3 on 11/19/2025 at 3:45 PM, reviewed the MDS and acknowledged the surveyor. In an interview with the LPN MDS Coordinator on 11/21/2025 at 11:30 AM the surveyor conveyed that Resident #3 had falls on 5/29/2025 and 6/8/2025 and that the Quarterly MDS dated [DATE] Section J1900. Number of Falls was coded 1 No injury. The LPN MDS Coordinator reviewed Resident #3's falls and the Quarterly MDS dated [DATE], acknowledged the surveyor, and stated that the Quarterly MDS dated [DATE] was coded inaccurately as Resident #3 had falls on 5/29/2025 and 6/8/2025 and the Quarterly MDS dated [DATE] should have been coded 2 No injury. In a follow-up interview with the LPN MDS Coordinator at 11:50 AM on 11/21/2025, she stated to the surveyor that she was conducting a facility audit for falls and in the process of making modifications and corrections to the Resident MDS assessments as indicated. No additional information was provided by the facility at the time of survey exit. 3. On 11/18/25 at 10:04 AM, the surveyor reviewed Resident #33's medical record. The review revealed that Resident #33 had a past medical history that included, but not limited to, schizophrenia, vascular dementia without behavioral disturbance, psychotic disturbance, mood disturbance, anxiety, obsessive-compulsive disorder, and bipolar. On further review the surveyor noted that the Minimum Data Set (MDS) assessment dated [DATE] did not include any psychiatric/mood disorders in section I (Active Diagnoses). On 11/18/25 12:51 PM, the surveyor conducted an interview with the MDS coordinator Staff #13. During the interview the surveyor showed the schizophrenia diagnoses located in Resident #33's medical record and asked if schizophrenia should have been coded in the active diagnosis section. Staff #13 stated that Resident #33 should have been coded and that the diagnosis was missed in error.

Based on surveyor observation, facility staff interview, and surveyor record review it was determined that the facility failed to follow appropriate respiratory care and services. This finding was found to be evident in 1 (Resident #42) out of 1 Resident reviewed for respiratory care and services.The findings include:On tour of the long-term care (LTC) unit on 11/17/2025 at 7:45 AM the surveyor observed Resident #42 in bed with an oxygen concentrator and an oxygen emergency tank in the room. Additionally, it was observed that the oxygen humidifier bottle was dated 9/16. There was no oxygen signage posted on Resident #42's room door upon entry to the room. Resident #42 stated that he/she had not used oxygen in a while.In an interview at 8:22 AM on 11/17/2025 with the RN Unit Manager, the surveyor conveyed that Resident #42 had an oxygen concentrator and an oxygen emergency tank in the room, however there was no oxygen signage on Resident #42's room door. The RN Unit Manager observed with the surveyor the oxygen concentrator, the oxygen emergency tank, the oxygen humidifier bottle, and no oxygen signage on the door and stated that Resident #42 had a PRN (as needed) order for oxygen usage. The surveyor asked the RN Unit Manager what the expectation was for the posting of oxygen signage on Resident room doors, and the RN Unit Manager stated that the oxygen sign should be posted on Resident room doors when oxygen was in Resident rooms.The surveyor conducted a record review of Resident #42's medical record at 11:50 AM on 11/20/2025. Review of the medical record revealed that Resident #42 had a current physician order dated 10/27/2025 for oxygen via nasal cannula at 2 liters/minute as needed for shortness of breath.No additional information was provided by the facility at the time of survey exit.

Based on record review and interviews, it was determined that the facility failed to attempt a gradual dose reduction or have documented contraindication rationale for a resident receiving a psychotropic medication. This was found evident in 2 (Resident #10 & #33) out of 5 residents reviewed for unnecessary medications. The findings include: Psychotropic medications are used to treat mental health disorders and are considered any drug that affects behavior, mood, thoughts, or perception. There are five main types of psychotropic medications, and each type has its own specific uses, benefits, and side effects. The five main types are: antidepressants, anti-anxiety, stimulants, antipsychotics and mood stabilizers. Quetiapine (also known as Seroquel) - an atypical antipsychotic medication used to treat mental health conditions like schizophrenia, bipolar disorder, and major depressive disorder. Gradual Dose Reduction (GDR) refers to the stepwise tapering of a dose to determine if symptoms, conditions, or risks can be managed by a lower dose or if the dose or medication can be discontinued. 1. On 11/18/25 at 11:57AM, the surveyor reviewed Resident #10's medical record. The review revealed that Resident #10 had a past medical history that included, but not limited to, vascular dementia without behavioral disturbance, psychotic disturbance, mood disturbance, anxiety, emotional deficit following cerebral infarction and cognitive communication deficient. On further review it was noted that Resident #10 was prescribed Seroquel. The surveyor next reviewed Resident #10's psychiatric note written by physician #25. The note was dated 1/13/25 and documented Staff #25 recommendation Resident #10 start Seroquel for mood and agitation. It further stated that the resident should be followed up monthly. No additional psychiatric notes were located in Resident #10's electronic medical record. The surveyor requested all 2025 psychiatry notes for Resident #10. On 11/19/25 at 11:32 AM, the surveyor reviewed additional psychiatric notes provided by the facility from Staff #25. A note written on 5/1/25 that stated that no Gradual Dose Reduction (GDR) was recommended, however there was no rationale as to why. On 6/30/25 Staff #25 wrote, continue on Seroquel for mood and agitation. On 9/30/25 Staff #25 wrote, no need for gradual dose reduction, stable on current regiment, followed by, Resident #10 needs reassurance to take medications. The note did not give the rationale as to why Resident #10 was clinical contraindication for a GDR. On 11/13/25 Staff #25 wrote, Resident # 10 was being followed monthly for cognitive impairment, depressed mood, and generalized anxiety and appeared to be doing well on current medication. The plan was documented to continue current medication and psychotherapy. Next the surveyor reviewed the Minimum Data Set (MDS) assessment for Resident # 10 with the Assessment Reference Date of 10/31/25. In section N it is documented that Resident #10 regularly takes an antipsychotic. In this section it is also documented that no GDR was attempted. If further is documented there was no documentation that the GDR was clinically contraindicated. On 11/20/25 at 7:45 AM, the surveyor reviewed the concerns with the Director of Nursing (DON). At the time of exit no additional documents were provided. 2. On 11/18/25 at 10:04 AM, the surveyor reviewed Resident #33's medical record. The review revealed that Resident #33 had a past medical history that included, but not limited to, schizophrenia, vascular dementia without behavioral disturbance, psychotic disturbance, mood disturbance, anxiety, obsessive compulsive disorder, and bipolar. On further review it was noted that Resident #33 was prescribed Mirtazapine (antidepressant) and Risperdal (antipsychotic). The surveyor next requested Resident 33's psychiatric notes. Only one note dated 3/10/25 was in Resident #33's electronic medical record. On 11/18/25 at 1:09 PM, the surveyor reviewed Resident #33's psychiatry notes provided. Physician #25 wrote a progress note on 3/10/25 that stated no changes in mediations. On 9/10/25 Staff #25 wrote, .wanting to have his/her medications discontinued, said that it's excessive. Staff #25 continued and documented Resident #33 was on minimal medications. No changes in mediations. On 9/10/25 Staff #25 wrote that the patient maintained that he/she had been sleeping excessively and wanted the medications reduced. Staff #25 documented that he informed Resident #33 that he/she was on the bare minimum amount of medication and GDR failed recently. The plan stated no need for GDR. On 10/01/2025 Staff #25 wrote Resident #33 appeared stable. He further stated that any further reduction will lead to change of symptoms and psychosis as it has in the past. Next the surveyor reviewed the Minimum Data Set (MDS) assessment for Resident # 33 dated 9/4/25. In section N it is documented that Resident #33 regularly takes an antipsychotic. In this section it is also documented that no GDR was attempted. Below it documented that the date the physician documented it was clinically contraindicated 3/10/2025, however there was no documentation to when the last GDR was attempted and failed. The surveyor requested documentation to demonstrate that Resident #33 had a gradual dose reduction attempt to support the documentation.At the time of exit no additional documentation was provided.

Based on observation, staff interviews and record review it was determined that the facility failed to display the current posted nurse staffing information in a timely manner. This finding was found to be evident in review of sufficient and competent nurse staffing.The findings include:Nursing facilities are required to post daily nurse staffing information, including the facility name, current date, Resident census, and the total number and actual hours worked per shift for licensed and unlicensed nursing staff responsible for Resident care. This includes Registered Nurses (RN), Licensed Practical Nurses (LPN), Certified Nurse Aides (CNA), Geriatric Nurse Aides (GNA) and Certified Medication Aides (CMA). The information should be easily accessible and clearly displayed for Residents and visitors. Facilities should also retain nurse staffing data for review by the surveyors for a minimum of 18 months.On the initial tour of the facility when the survey team entered the facility at 7:00 AM on 11/17/2025 it was observed that the posted nurse staffing information sheet was not the current date. The date was 11/14/2025 on the daily staff posting sheet that was displayed on the receptionist desk in the facility lobby.The surveyor interviewed the Director of Nursing (DON) at 12:45 PM on 11/20/22025 and asked what the expectation was for posted nurse staffing information. The DON stated that it was the responsibility of the Nursing Supervisor to post the nurse staffing sheet daily, including the weekend. The DON was made aware that when the surveyors entered the facility at 7:00 AM on Monday 11/17/2025, the posted nurse staffing information sheet was dated 11/14/2025 which was displayed on the receptionist desk in the facility lobby. The DON acknowledged the surveyor and stated that the current nurse staffing sheet should have been posted by the Nursing Supervisor. No additional information was provided by the facility at the time of survey exit.

Based on complaint, interview, and medical record review, it was determined the facility failed to follow professional standards of practice when administering medications. This was evident for 4 (#14, #8, #17, #20) of 25 residents reviewed during a complaint survey.The findings include:The 6 rights of medication administration are the right patient, the right drug, the right does, the right route of administration, the right time, and the correct documentation. Administering medications at a time that was intended by the prescriber. Certain drugs have specific intervals or window periods during which another dose should be given to maintain a therapeutic effect or level. Nurses should not deviate from the time by more than 1 hour to avoid consequences. Nurses must sign off that medications were given immediately after the medication was given to prevent double dosing and ensuring accuracy.1.On 9/12/25 at 11:37 AM a review of complaint 323366 alleged that Resident #14 was given Metformin (diabetic medication) after he was instructed to not take the medication for 2 days after a procedure. It was alleged that Resident #14 grabbed the pill out of the medication cup and put it aside. The complaint alleged that the nurse handed the resident the medication cup with the Metformin in it and walked out of the room without watching the resident take the medication.On 9/15/25 at 11:50 AM an interview was conducted with Resident #14 who showed the surveyor pictures of medications that were left in his/her room during the medication pass. Resident #14 also stated the nurse left an insulin pen in his/her room, and it was the name of another resident. Resident #14 stated that Staff #10 makes medication mistakes and that she gave him/her the Metformin when she was supposed to hold it. Resident #14 stated, I looked in the cup and pulled the pill out. I then went and showed them that she was giving me a medication that was supposed to be held. They will leave the medications in my room. Staff #14 also complained that medications were not passed out timely and were often late.On 9/15/25 at 1:37 PM a review of an employee corrective action form dated 10/25/25 documented that Staff #10 was written up for attempting to administer Metformin that was not scheduled to be given and failing to follow a physician's order. A second corrective action form for Staff #10 documented that on 4/19/25 Staff #10 failed to follow the 5 rights of medication administration by administering a different patient's insulin to another resident, which was Resident #14. 2. Review of residents' medication administration records (MARs) revealed a pattern of charting late when medications were given. It was not known if the medication was given late or if the nurses signed of later in the shift that the medication was given.a. On 9/10/25 at 9:37 AM a review of Resident #8's medical record revealed the following:The medication Gabapentin for neuropathy was ordered to be administered every 12 hours at 9 AM and 9 PM. Review of the June 2025 MAR documented on 6/20/25 the 9 AM dose was signed off at 3:03 PM, the 6/22/25 at 9 AM dose was signed off at 11:26 AM.The medication Hydralazine 25 mg (blood pressure and heart failure medication) was to be administered at 9 AM, 2 PM, and 9 PM. Review of the June 2025 MAR documented the 6/20/25 at 9 AM dose was signed off at 3:03 PM and the 2:00 PM dose was signed off at 3:07 PM. On 6/21/25 the 9 AM dose signed off at 11:11 AM and the 9:00 PM signed off at 10:34 PM. The 6/22/25 at 9 AM dose was signed off at 11:26 AM.b. Resident #17's medical record was reviewed and revealed Acetaminophen was to be given at 6 AM, 2 PM, and 9 PM. On 8/9/25 the 2:00 PM dose was signed off at 6:34 PM, the 8/19/25 at 6 AM dose was signed off at 7:50 AM, and the 9/1/25 at 2 PM dose was signed off at 6:02 PM.The medication Aspirin that was to be administered at 9 AM, on 8/1/25 and 8/25/25 was signed off at 12:44 PM and the 8/26/25 at 9 AM was signed off at 11:09 AM. In September 2025, the 9 AM dose was signed off at 12:04 PM on 9/1/25, on 9/7/25 at 12:42 PM, and on 9/10/25 at 1:53 PM.The medication Eliquis (blood thinner) was to be administered at 9 AM and 9 PM. On 8/1/25 and 8/25/25 the Eliquis signed off at 12:44 PM and the 8/26/25 at 9 AM dose signed off at 11:09 AM. In September 2025, the 9 AM dose was signed off at 12:05 PM on 9/1/25, on 9/7/25 at 12:42 PM, and on 9/10/25 at 1:54 PM.The medication phenytoin (anti-seizure) medication was to be administered at 6 AM, 2 PM, and 9 PM. The 2 PM dose signed off at 6:34 PM and the 6 AM dose signed off at 7:50 AM. In September 2025 the 9/1 at 2 PM signed off at 6:05 PM.c. Resident #20's medical record was reviewed and revealed the medication Amlodipine (blood pressure) was to be given at 9 AM every day. The 9 AM dose was signed off on 9/1 at 12:22 PM, 9/3 at 11:58 AM, 9/7 at 12:31 PM, 9/10 at 4:13 PM, and 9/15 at 11:32 AM.The prescription mouthwash chlorhexidine gluconate was to be administered 3 times a day at 9 AM, 2 PM, and 9 PM. The 9/1 at 9AM dose was signed off at 12:16 PM, the 2 PM dose at 7:51 PM, the 9/3 at 9 AM dose at 12:11 PM, the 9/7 at 9 AM dose at 12:31 PM, the 9/10 at 9 AM dose at 3:56 PM and the 2 PM dose at 3:19 PM, and the 9/15 at 9 AM dose at 11:32 AM.The medication Eliquis (blood thinner) was to be administered twice per day. The 9/1 at 9 AM dose was signed off at 12:16 PM, the 9/3 at 9 AM at 11:59 AM, the 9/7 at 9 AM dose at 12:31 PM, the 9/10 at 9 AM dose at 3:56 PM and the 9/15 at 9 AM dose at 11:32 AM. The medication Gabapentin (anticonvulsant and nerve pain) was to be administered 3 times a day at 9 AM, 2 PM, and 9 PM. The 9/1 at 9 AM dose was signed off at 12:18 PM, the 2 PM dose at 7:52 PM, the 9/3 at 9 AM dose at 11:59 AM, the 9/7 at 9 AM dose at 12:31 PM, the 9/10 at 9 AM dose at 3:57 PM and the 9/15 at 9 AM dose at 11:33 AM. The medication Humalog Kwik Pen Insulin (insulin lispro), sliding scale was to be administered at 6:30 AM, 11:30 AM, and 4:30 PM. The 9/1 at 4:30 PM signed off at 7:53 PM, 9/3 at 4:30 signed off at 7:52 PM, and the 9/7 at 4:30 PM signed off at 6:10 PM. The above examples were just a sampling of medications that were signed off late. On 9/15/25 at 12:36 PM an interview was conducted with Staff #11 (LPN). The surveyor asked Staff #11 to explain what late administration meant when looking at the MAR. Staff #11 stated it was either the nurses signing off after the medications were administered later in the shift or it was medications that were given past the one-hour window of timely administration. Staff #11 stated, we try to give out timely. It depends on the workload. There are times you come on the floor and don't have a medicine aide working with you; therefore, you have to make sure the medications are given out timely and then you sign off later. When there is no medicine aide that means the nurse has more than 18 patients to give medications to and some of the patients will get medications when they should and other times they won't. On 9/15/25 at 2:00 PM an interview was conducted with the Assistant Director of Nursing (ADON) and Staff #26-unit manager, and medication administration concerns were discussed. They agreed with the surveyor that it was a concern.

Based on medical record review and interview, it was determined that the facility failed to protect a resident from abuse from another resident known for wandering. This resulted in harm to Resident #18 who required hospitalization with rib fractures. This was evident for 1 (Resident #18) of 8 residents reviewed for abuse. The findings include: Review on 1/24/24 at 10:28 AM of a complaint and facility report revealed that, on 10/18/23 at around 5:00 AM, an altercation occurred between Resident #24 and Resident #18 resulting in Resident #18 needing to be hospitalized and surgical intervention. Review of the medical record for Resident #18 on 1/24/24 at 10:36 AM revealed a quarterly minimum data set completed on 8/12/23 documented that s/he has a brief interview for mental status (BIMS-an assessment to monitor cognition ranges from 0-15) score of 15, meaning that s/he is cognitively intact. The medical record for Resident #24 revealed diagnoses including vascular dementia, psychotic disturbance, generalized anxiety disorder and cognitive communication deficit. The admission MDS completed on 7/14/23 for Resident #24 was unable to complete the BIMS assessment secondary to the resident ' s cognitive abilities. During the review of Resident #24 ' s record on 1/24/24, an incident was found which documented an occurrence on 9/13/23. According to the nurse progress notes dated 9/13/23, Resident #24 9/13/23 was having aggressive behavior and started on monthly injections of Haldol for aggression. In addition, nursing notes on 9/13/23 stated that Resident #24 was having problems staying in [his/her] room or Unit. At 6 PM Pt. (patient/resident) was observed pacing the halls and entering other Residents' rooms on [his/her] units, [s/he] attempts to elope, and [his/her] alarm triggered, and code Yellow is announced .Pt got very aggressive with staff as they redirected [resident] back to [resident] unit. Staff reported that Resident #24 had raised his/her fists at them so the facility psychiatric doctor was notified and ordered Haldol for the identified behaviors. Review of the psychiatric doctor's notes on 1/24/24 at 11:00 AM revealed notes completed on 9/13/23 and 9/15/23 that documented record review and review of nursing staff reports. Notes revealed that the patient has been uncooperative, combative, disoriented, resistive to care, verbally hostile and agitated. The psychiatric specialty examination documented severe cognitive impairment, vascular dementia of unspecified severity with behavioral disturbances, psychiatric disturbances, and mood and anxiety disorders. Secondary to these findings and concerns, the psychiatric doctor started Resident #24 on Haldol intramuscular every 4 weeks for dementia and psychosis with agitation. With the start of the Haldol on 9/14/23, behavioral monitoring continued on the residents' medication/treatment administration record (MAR/TAR) for agitation and dementia. Review of the behavior monitoring documentation for 9/1/23-9/13/23 prior to starting Haldol noted that, of 38 opportunities (1 for each shift), there were 13 incidents (34 % of the time) when staff had to intervene with Resident #24 due to behaviors. After the Haldol was administered, of 49 opportunities, there were 19 incidents ( 20% of the time) staff documented occurrences where interventions were required for the month of September. However, Resident #24 ' s behavior care plan, initiated on admission, noted wandering, but failed to address the residents individualized needs and accelerating behaviors. The concern that Resident #24 was previously identified as having the potential for wandering in resident rooms, and having aggressive behaviors that were not identified in the care plans, however were documented in the nursing and physician notes was reviewed with the facility DON and Administrator on 1/24/24 at 11:30 AM. A review of the medical records on 1/30/24 at 8:30 AM failed to show any documentation that the nursing staff had any further interventions in place for Resident #24 after the incident on 9/13/23 after the documented increase in aggression when there were attempts at redirecting him/her. Through October staff were documenting a statistical increase in his/her wandering tendencies and need for interventions, even after the initiation of the Haldol, however, there was no other change or new intervention in place. Continued review of the medical record for Resident #24 on 1/24/24 at 12:45 PM revealed another occurrence on 10/18/24, involving another Resident, #18. Further review of the facility investigation did not reveal documentation of Resident #24 ' s whereabouts throughout the night shift on 10/17/23 into 10/18/23 or further interviews of staff regarding the resident's whereabouts. There was only 1 statement that s/he was not observed in Resident #18 ' s room, however, Resident #24 was noted walking down that hallway. According to Resident #24 ' s medication administration record, his/her wander guard bracelet was not signed off as having been checked by staff, and neither was the 2 hour checks on the resident for turning and repositioning on the 11 PM-7 AM shift of 10/17/23 into 10/18/23. Further review of this facility reported incident revealed that, on 10/18/23, Resident #24 entered Resident #18 ' s room while Resident #18 was in bed. S/he stood at the foot of the bed and, after multiple requests from Resident #18 for Resident #24 to leave, Resident #18 shoved Resident #24. In retaliation, Resident #18 pulled on the sheets and Resident #18, ended up on the floor. Resident #24 was immediately identified by Resident #18 as the aggressor at around 5:00 AM on 10/18/23 when s/he yelled for help. According to facility documentation, Resident #24 was placed on 1:1 observation from 6:00 AM until his/her discharge on 10/28/23. A care plan was implemented on 10/18/23 for behavior management, going into resident rooms, and being physically aggressive with other residents. However, the approaches failed to identify the 1:1 and the Haldol; they only stated to redirect, set firm limits, and make sure physical needs are met. Per the investigation, staff heard Resident #18 yelling for help and went to his/her room and found him/her on the floor. Staff did not find any apparent injury, however secondary to complaints of pain, Resident #18 was transferred to the hospital. The admission hospital report was reviewed on 1/25/24 at 7:20 AM. It documented that there was a right sided pneumothorax and fifth through seventh right rib fractures. The emergency room physicians placed a chest tube and drained 800 milliliters (ml) of blood. Thoracic surgery was then consulted. A chest tube was later placed and drained an estimated 1650 ml of blood and serosanguineous (yellowish fluid with a mix of blood) fluid. After the incident Resident #24 was placed on 1:1 monitoring, a care plan for behavior was implemented and a ' Stop ' sign was placed at Resident #18 ' s door as a trigger to remind Resident #24 not to enter. On 1/25/24 at 8:39 AM, Resident #18 was interviewed regarding the incident. S/he stated that Resident #24 was coming to his/her room frequently and that 10/18/23 was not the first time. S/he was asked if staff were aware and if they ever reported it. S/he stated ' yes, I told them and they were aware. ' S/he further stated when asked how this situation made them feel, that s/he was frustrated that it kept happening. Staff LPN #11, who was present as a staff nurse and one of the first to respond on 10/18/23, was interviewed on 1/26/24 at 7:48 AM. When asked about Resident #24 and any interventions that staff implemented with his/her behaviors, she stated that s/he was a frequent wanderer and they had to watch and monitor him/her. At first when asked Resident #24 went into rooms she stated yes, then stated ' no ' they only wandered the halls. Staff LPN #11 reviewed her note from 10/18/23. It stated, staff witnessed Resident [#18] calling for help, [s/he] reported that [s/he] was attacked by another resident a wanderer [#24], [s/he] said the Resident [#24] pulled [him/her] out of bed and threw [him/her] onto the floor [s/he] complained of pain on the affected side and requested [his/her] pain medication. According to the note Resident #18 then called his/her daughter to call 911 that s/he wanted the police because s/he needs a police report. The police arrived, took the report, then the resident was transferred to the emergency room for further evaluation and treatment. On 1/26/24 at 12:55 PM these concerns were reviewed with the facility Nursing Home Administrator and Director of Nursing. The facility Medical Director met with the survey team on 1/30/24 at 7:42 AM in the presence of the Director of Nursing and the Nursing Home Administrator. He stated that the resident was not technically aggressive and that the roommate started it. He further stated that they had an intervention in place with the Haldol, that they financially cannot provide 1:1 to all residents who are identified as wanderers.

Based on observation, interview, and review of medical records and other documentation on 12/8/2015, it was determined that the facility failed to maintain a safe environment for residents at risk for elopement and maintain a safe walk-way in the courtyard area. Resident #211 resided on a unit where 4 exit doors were not visible from the nursing station, were left unlocked, were not armed with WanderGuard sensors, and 1 of 4 doors on the same unit had a non functioning door alarm. The facility had no elopement policy in place and staff did not follow any clear process to check alarms that did sound. The only intervention in place to protect Resident #211 from elopement through the door with the broken alarm was a sign draped across the door that said stop and was held up by Velcro. These related concerns were evident for 1 Resident (Resident #211) selected for review during an annual survey. Therefore, an Immediate Jeopardy for health and safety was called at 5:00 PM on 12/08/2015 by the Office of Health Care Quality. The findings include: 1. On 12/8/15 at 10:40 AM, 2 surveyors observed the 2 exit doors, (E and H) on the long term care hallway on the North side. Velcro stop signs were draped across each door but neither door was locked and neither door was visible from the nursing station. The other Surveyor and this Surveyor both independently opened doors E and H on the North side at 10:42 AM. These alarms did not sound for 4 seconds. Nurse (#3) walked down the hall but turned around without checking either door. She then returned after a few seconds. The nurse then entered a resident's room for a few seconds and then returned back up the hall towards the nurse's station without checking the doors at the end of the hall. The other Surveyor then opened door E again, which exits the facility and leads to a steep embankment. After 4 seconds the alarm sounded. Staff did not arrive to check this door so the surveyor opened the door a second time. Staff arrived at 10:46 AM to check the door that alarmed, 4 minutes after the door first alarmed. These findings were discussed with the Administrator on 12/8/15 at 10:46 AM. The Administrator stated that the only failure was that Nurse #3 should have responded more quickly to the alarm and checked the doors. At 12:21 PM on 12/8/15, the administration team was asked how they determine if someone is a wanderer. The Director of Nursing (DON) stated that on admission staff screens every resident. Review of the elopement risk screening assessment tool revealed that it provided no objective measures to determine the actual level of risk for elopement for any given resident. There was no scale to indicate if a resident was a high or low risk on the assessment. The DON was asked again, how they determine if someone is a wanderer since the assessment tool is not a clear determinant. The DON stated that a visual and physical assessment is also used to help determine if a resident is a wanderer. Review of the facility policy on 12/8/15, entitled Missing Resident, revealed that the facility performs quarterly mock drills. No other elopement policy was available and the Administrator of record stated that the Corporate was working on a draft ' elopement policy,' but they did not have a policy in place. During the interview at 12:21 PM on 12/8/15, the administration team was questioned regarding any identified wanderers in the building. Currently there was 1 identified, Resident #211, who resided on the south side of the long term care unit. Review of the comprehensive MDS (Minimum Data Set) assessment with reference date of 9/12/15, revealed that during the week of 9/6/15 through 9/12/15 Resident #211 was observed with wandering behaviors 4 - 6 days during the 7 day window. The MDS assessment documented that the wandering behavior placed the resident, at significant risk of getting into potentially dangerous places. The most recent quarterly MDS assessment revealed that the wandering behavior was still evident during the quarterly assessment window of 11/21/15 through 11/27/15. The Minimum Data Set (MDS) is a comprehensive assessment of the resident completed by the facility staff. Information on the MDS should reflect the seven days up to and including the Assessment Reference Date (ARD). Resident #211 was observed by multiple surveyors during the survey independently walking around the long term care unit without any assistance from staff and walking up and down the North and South hallways in addition to the activities room and the dining room. In interview on 12/8/15, the DON stated that Resident #211 had a WanderGuard bracelet placed as an intervention to protect him/her from risks associated with elopement. Record review and direct observation of the resident by the surveyor corroborated that the WanderGuard was in place as an intervention for Resident #211. However, the WanderGuard system requires both bracelet placement on the resident, and alarming sensors placed at exit locations. In interview, the Administrator stated that the WanderGuard alarms were located at doors C and D, identified as the 2 doors that lead to the front parking lot. Door D was the front entrance of the facility and door C was an exit from the rehab side of the building. Surveyors confirmed that there were no WanderGuard alarms on the doors (F and G) that lead out of the facility from the long term care side where Resident #211 resided. Although no WanderGuard sensors were present on Resident #211's unit, the Administrator stated there were door alarms that sounded when the doors opened. Resident #211 resided on the south hall of the LTC unit and exit doors (Doors F, and G) from this unit were observed by the surveyor. These doors were not visible from the nursing station and although labeled with Velcro stop, signs, these four doors were not locked. The survey team then tested the door alarms. On 12/8/15 at 4:27 PM, the F Door (South side exit door facing the woods) was tested and the F door alarm did not sound, and the alarm did not register at the nursing station panel to alert staff about which door alarm had activated. This door led outside and just outside the door, a steep embankment (downhill slope) was observed. Therefore, staff were completely unaware as to which of the 4 doors could be alarming. The Administrator, the Director of Nursing, the Interim Administrator, the Interim Maintenance Director and the Surveyors were present when this door alarm was tested . The Interim Maintenance Director stated, 'I knew it (referring to the panel) wasn't working. ' Subsequently door G was tested , and it was also noted that it did not register at the nursing station. Regarding door maintenance, in interview, the current maintenance manager stated that weekly tests are done on the WanderGuard doors and monthly tests are completed on all the doors. Review of the documentation for these various checks revealed that on 8/10/15, the previous maintenance manager documented that the old system needs to be replaced. I have a number of times oiled the ball which sticks and alarm will not work. The documentation also revealed that the next audit was not completed on 10/1/15. Interview with the Administrator on 12/8/15 after the immediate jeopardy was called revealed that the door that did not alarm, failed to alarm because the, 'ball was stuck and did not re-engage.' In addition, he was unaware that any of the bulbs on the panel were not functioning. The Administrator stated that he was not aware of the August maintenance audit and the concerns identified then, or of any improvements that were completed or to which door the August audit documentation was referencing. During an interview on 12/9/15 at 10:53 AM with the Regional Maintenance Director, he revealed that he too was not aware of the audit completed in August, or of any improvements that had occurred to any doors in the facility. He stated that any improvements would need to go through the Administrator. The interrelated failures to have a safe physical environment, an effective elopement policy, and a care plan with effective strategies or interventions left Resident #211 at very high risk for very serious harm and possible death. Therefore an immediate jeopardy was called by the Office of Health Care Quality on December 8, 2015 at 5:00 PM. A plan of action was given to the survey team and the Office of Health Care Quality for review on December 8, 2015 at 7:50 PM by the facility and was accepted. The action plan included: The facility had staff present at the malfunctioning door for the next 12 hours. During the time period of 12/9/15 from 9:00 AM to 4:00 PM the door would be tested hourly. The tests would repeat on 12/10/15 and 12/11/15 at 9:00 AM and at 9:00 PM. Regarding the enunciator panel, staff were in-serviced to ignore the panel and go to their respective assigned doors to check the doors. If there were any malfunctions noted during the testing, staff would be assigned to those specific doors again and new plan developed. The immediate jeopardy was removed at 7:57 PM on December 8, 2015 after the survey team validated that the plan to address the immediate safety concern was implemented. The facility also contacted a door vendor and the facility alarm vendor. A contract was presented to the Survey team on 12/11/15 for the placement of locks on the 4 doors that lead to the outside of the building from the long term care side and the bulbs were being replaced in the enunciator panel. 2. On 12/11/15 at 8:37 AM the courtyard walkway between the North and West units was observed and toured. The cement area was noted to be damaged resulting in loose gravel. In another area of the courtyard a cement slab had shifted forming a six inch drop from one section of the walk-way to the next; located adjacent to a large tree. Upon observation of this tripping hazard the Administrator stated that they would come up with a plan to address it. At 8:41 AM further observation of the courtyard revealed that at the patio area near the far left, elevated garden, the cement had come loose causing a tripping hazard for residents walking and for wheelchairs mobilizing. This observation included one approximately 12 inches x 24 inch area and another approximately 18 inch x 8 inch area. On 12/11/15 at 11:35 AM surveyor observed yellow caution tape had been placed near the tripping hazard on the walkway. On 12/14/15 at 12:45 PM the concerns regarding the hazardous courtyard walk-way and patio areas were discussed with the Interim Administrator and the Director of Nursing.

Based on observation, medical record review and staff and family interview, it was determined the facility staff failed to: 1) appropriately treat and manage a resident ' s pain as directed by physician orders, and 2) follow physician orders. This was evident in 2 of 31 residents (#252 and #253) in the stage two survey sample.The findings include:1. On 12/9/15 at 9:20 AM surveyor observed Resident #252 crying as therapy rolled the resident past the nursing station with the family member following. Surveyor asked the therapist what was wrong with the resident and before the therapist could respond the family member reported that the facility staff was to medicate the resident 30 minutes before therapy and the resident did not receive any pain medication. Review of the medical records on 12/9/15 at 9:20 AM revealed that the resident was admitted to the facility in November 2015 for rehabilitation and with [DIAGNOSES REDACTED]. Further review of the medical records revealed a physician order [REDACTED].[MEDICATION NAME] is a brand name for the combination prescription drug [MEDICATION NAME]/[MEDICATION NAME]. It's used to treat moderate to severe pain.While in the resident ' s room on 12/9/15 at 9:30 AM, the surveyor observed Resident #252 moaning and rocking back and forth while the resident's family member was trying to sooth him/her. Staff nurse #3 entered the room and tried to assess the resident for pain but the resident continued to moan and then Resident #252 was medicated for pain after he/she returned from therapy.During an interview with staff nurse #3 on 12/9/15 at 9:40 AM, she acknowledged that the resident did not get her/his scheduled pain medication before therapy due to therapy not informing the nurse that the resident was leaving. The surveyor asked the nurse if she was aware that the resident was to get scheduled pain medication before therapy. The nurse replied yes, and the surveyor asked if she checked to see what time the resident would be going to therapy. The staff nurse #3 acknowledged that she was not aware of what time the resident was scheduled for therapy.During an interview with the unit manager on 12/9/15 at 10:00 AM, she revealed that therapy gives the nursing unit a daily therapy schedule to inform staff of the scheduled times for resident ' s therapy. The surveyor asked the staff for a copy of the therapy schedule. The unit manager was unable to locate the therapy schedule and she stated, we must not have gotten one. The unit manager also revealed that it is the responsibility of the nurse assigned to the resident to find out what time the resident is scheduled for therapy, so if pain medication is ordered before therapy staff will medicate the resident per the order.On 12/9/15 at 10:20 AM during an interview with the Rehabilitation manager, the surveyor asked how physician orders [REDACTED]. He replied that each morning a meeting is held with the therapy department to discuss each resident ' s needs such as medication before therapy or if the resident wants to come later in the day. Surveyor asked if the resident was discussed in morning report. He stated he would investigate and let the surveyor know.On 12/9/15 at 12:34 PM the Rehabilitation manager and the compliance officer met with the surveyors to discuss the concerns regarding Resident #252's pain management as it related to therapy. The Rehabilitation manager stated that the facility discusses in morning meetings any orders or issues with resident care. He indicated that they try to schedule individualized treatments and expect that therapy staff meet with the nurses prior to residents going to therapy. Surveyor asked if the therapist spoke with Resident #252's nurse before she took the resident to therapy. The therapist reported that she did not speak with Resident #252's nurse prior to taking the resident to therapy. During an interview with the therapist, the rehabilitation manager and the compliance officer on 12/9/15 at 2:20 PM the therapist revealed she was not aware of the order to medicate the resident for pain before therapy. The therapist also revealed that she went in to see the resident and she spoke with the daughter prior to therapy. The therapist assumed that the resident ' s daughter would have said something regarding the pain medication. Surveyor inquired about how it is communicated to therapy that a resident is to receive pain medication. The therapist replied it is relayed to therapy in the morning meeting. The compliance officer reported that it is the normal policy for therapist to let the nurses know that the resident is leaving.Further review of the medical records revealed that the resident also did not receive the scheduled pain medication due at bedtime on 12/8/15, which was the evening prior to her/his morning physical therapy session.In summary, Resident #252 experienced unnecessary pain secondary to a systems breakdown in communication and coordination between the facility's physical therapy staff and the nursing staff regarding Resident #252's pain management.2. On 12/11/15 at 9:50 AM medication administration pass was completed on Resident #253. On 12/14/15 medical records were reviewed for medication reconciliation and medication administration records.During medication reconciliation the resident's medication packet that was delivered by pharmacy was compared to the physician orders, and other medications not included in the packet were documented by the surveyor as the medication was prepared for the resident and checked against the orders.Review of the medical records revealed an order written [REDACTED]. On 12/10/15 [MEDICATION NAME] was increased to 60 milligram every day. [MEDICATION NAME] is a medication used treat depression. Review of the medication packet that was delivered by the pharmacy failed to have the medication [MEDICATION NAME] 60 milligram included in the packet. Review of the medication administration records revealed that on 12/11/15 the facility staff signed the medication off, indicating that the medication was administered at 9:00 AM. Review of the surveyor medication pass worksheet failed to reveal the medication [MEDICATION NAME].During an interview with the Director of Nursing on 12/14/15 1:30 PM the surveyor asked for a pharmacy manifest to reconcile the medication with the physician order [REDACTED]. These concerns were also discussed with the nursing home administrator on 12/14/15 at 3:30 PM.On 12/14/15 the order status details was reviewed. This review revealed the medications that was ordered for the resident and what date it was delivered to the facility. Further review revealed that on 12/12/15 [MEDICATION NAME] 30 milligram 2 tablets and [MEDICATION NAME] 60 milligram was sent to the facility to be administered on 12/13/15. Review of the pharmacy order details failed to reveal that [MEDICATION NAME] had been delivered to the facility before 12/12/15, therefore the resident could not have received the [MEDICATION NAME] if it was not delivered to the facility.During an interview with the DON the surveyor asked for any documentation showing that the pharmacy had delivered the [MEDICATION NAME] from the original order on 12/4/15. As of 12/14/15 3:00 PM no additional information was available to the surveyor.On 12/15/15 at 9:15 AM during an interview with the DON and while reviewing the medication administration records, the surveyor showed the DON all the 0 indicating that staff was administering the [MEDICATION NAME]. In addition the surveyor revealed that during medication pass observation the resident's blood pressure was low so the blood pressure medication was not administered. Surveyor informed the DON that during medication pass observation staff nurse #17 did not administer the medication but discarded the pill. Review of the MAR indicated [REDACTED].On 12/15/15 at 9:30 AM the surveyor again requested any documentation indicating that the [MEDICATION NAME] had been delivered to the facility. At exit the facility failed to provide any additional information.

Based on medical record review and interviews, it was determined the physician and nursing staff failed to discontinue the administration of a calcium supplement when a resident had an elevated calcium level and failed to treat an elevated creatinine level. This was evident for 1 (Resident #89) of 31 residents reviewed in Stage 2. The findings included: Resident #89 was admitted to the hospital with [REDACTED]. Resident #89 is alert and oriented. Review of the medical record revealed that on 10/06/14 the nursing staff notified the physician that the resident was confused. The physician ordered the following lab tests on 10/06/14 to determine the cause of her confusion: UA C&S, TSH, Vitamin B and calcium level. UA C&S is a urine culture and sensitivity that identifies the bacteria that is causing a urinary infection and identifies which antibiotics are effective in treating the infection. TSH ([MEDICAL CONDITION] Stimulating Hormone) is a blood test that monitors [MEDICAL CONDITION] function. Vitamin B is essential for normal cell function and metabolism. Calcium is essential for bone formation, muscle contraction and nerve and brain function. Further review of the medical record revealed the following elevated blood levels on 10/06/14: calcium level of 15.4 (normal range is 8.5-10.1) creatinine level of 3.0 (normal range is 0.6-1.3) The medical record revealed that the nursing staff notified the physician of the abnormal lab results on 10/06/14. Review of the medical record revealed that a repeat calcium level was done on 10/07/14. The calcium level continued to be elevated at 15.0 (normal range is 8.5-10.1). Nursing staff notified the physician of the 15.0 calcium level on 10/07/14. To determine the cause of the elevated calcium, the physician ordered a [MEDICAL CONDITION] hormone level, a Vitamin D level and an endocrinology consult. [MEDICAL CONDITION] hormone (PTH) is a major element in regulating calcium in the body. Vitamin D hormone acts with [MEDICAL CONDITION] hormone to regulate calcium levels in the blood and to supply appropriate amounts of calcium to all cells. Endocrinologists are doctors who specialize in hormone diseases, such as diabetes, metabolic disorders, [MEDICAL CONDITION] diseases and hypertension. Review of the medical record revealed that the resident was receiving 500mg of calcium supplement three times a day. The physician did not discontinue the administration of the calcium supplement in light of the elevated calcium levels and confusion. Review of the October 2014 Medication Administration Record [REDACTED]. Review of the MAR indicated [REDACTED]. Further review of the medical record revealed no plan of treatment by the physician or nursing staff for the elevated creatinine level of 3.0 (normal range is 0.6-1.3) on 10/06/14. Creatinine is a chemical waste molecule that is generated from muscle metabolism. A physician's orders [REDACTED]. Interview with the Director of Nursing at 1:00 PM on 10/09/14 revealed that the resident had been admitted to the hospital with [REDACTED]. Review of the Emergency Department Provider Notes dated 10/08/14 revealed that the resident "appears distressed, agitated, disoriented and anxious with disordered thought content and abnormal recent memory". Review of the blood tests done in the emergency room revealed an elevated creatinine level of 3.7 (normal range is 0.5-1.5) and an elevated calcium of greater than 16 (normal range is 8.1-10.2).

Based on medical record review, observations and interviews, it was determined the nursing staff failed to notify the physician of the ineffectiveness of treatments used for ongoing complaints of itching in 2 (Residents #89 and #92) of 31 residents reviewed in Stage 2. This failure to notify the physician resulted in the physician not having the opportunity to assess the situation and to make changes to the plan of care leaving these residents with unrelieved intense itching (pruritus). Pruritus or itch is defined as an unpleasant sensation of the skin that provokes the urge to scratch. Itching can be intractable (unrelieved) and incapacitating (unable to function in a usual way). The findings included: 1. Resident #89 is alert and oriented and makes her own decisions. Review of the medical record revealed that this resident had an ongoing pruritic (itchy) rash that was evaluated and being treated by a dermatologist. Review of the medical record revealed that the resident was seen by the dermatologist on 09/04/14 and the treatment was changed. Review of the physician orders [REDACTED]. Further review of the medical record revealed the following nurses' notes: 10/04/14 6:53 AM: "(resident) continues to scratch all over body while rash persists prescribed cream applied but resident later refused saying it does not do any good. [MEDICATION NAME] (medication used to relieve itching) also given po (orally) per PRN (as needed) order with little effect." 10/05/14 3:33 PM: "this morning resident requested to go to the hospital that she could not stand the itching any more. Dr (name) called and order obtained to send for evaluation via private ambulance left around 9 AM and returned around 1:30 PM." Review of the physician orders [REDACTED]." The medical record revealed no notification of the physician of the continued pruritic rash that was unrelieved by the current oral and topical treatments. Interview with the Director of Nursing at 1:00 PM on 10/09/14 verified that the physician had not been notified of the ineffectiveness of the topical and oral treatments for itching on 10/04/14 and 10/05/14 until the resident requested to go to the hospital on [DATE] because "she could not stand the itching anymore". 2. Resident #92 is alert and oriented. Review of the medical record revealed that this resident had an ongoing pruritic rash that was evaluated and being treated by a dermatologist. Review of the medical record revealed that the dermatologist had made changes to the treatment of [REDACTED]. The medical record revealed that the resident was last seen by the dermatologist on 09/10/14. Review of the medical record revealed the following nurses' notes: 09/21/14 10:18 AM: "(resident) continues to itch, generalize skin rash getting worse, no improvement, continue to apply cream as ordered. [MEDICATION NAME] given for itching, continue on ABT (antibiotic) for [MEDICAL CONDITION], will continue to monitor." 09/21/14 at 8:46 PM: "generalized rash appearing worse, resident still is itching, treatment to rash done, continued on ABT [MEDICATION NAME] for [MEDICAL CONDITION]" 09/22/14 6:58AM: "resident continues to yell at intervals for itching, [MEDICATION NAME] given per PRN order with little effect prescribed lotion applied slept for a short while and started yelling again will let 7-3 charge nurse follow up with MD (physician)." 09/26/14 7:10 AM: "alert and verbally responsive able to make needs known, continues to yell out at intervals for itching to rash all over the body prescribed cream applied and [MEDICATION NAME] given po per PRN order with little effect as resident still scream for anti-itch..." 09/28/14 at 9:47 PM: "continues on ABT for [MEDICAL CONDITION], general skin condition is red and he complains of itching, cream applied as per the current order." 09/29/14 4:56 AM: "general skin condition is red and he complains of itching, cream applied as per the current order." Review of the medical record revealed no notification of the physician of the continued pruritic rash that was unrelieved by the current oral and topical treatments. Interview with the Director of Nursing at 1:00 PM on 10/09/14 verified that the physician had not been notified of the ineffectiveness of the topical and oral treatments for itching despite the resident's continued complaints, including yelling out about the itching. Observation of the resident at 6:45 AM on 10/07/14 revealed the resident to be constantly scratching his arms and abdomen. Resident stated that he has "an itchy rash that is being treated but that it still itches."