Every finding on record at Frostburg Rehab Center

Based on medical record reviews, interviews, and review of facility investigation documents, it was determined that the facility failed to ensure residents were free from accidents as evidenced by the resident sustaining an injury while being assisted by staff in transferring. This was evident for 1 (Resident #104) of 12 residents reviewed for accidents. The deficient practice resulted in actual harm to resident # 104.The findings include:A review of Resident #104’s medical records on 8/7/25 at 11:40 AM, revealed a comprehensive assessment with a reference date of 1/7/25 that indicated the resident had severely impaired cognition and was dependent on staff for transfers and mobility. The review also revealed the resident’s care plan with interventions that include a) dependent bed mobility, b) Full lift for all transfers. A review of the intake information on 7/31/25 at 12:10 PM, related to incident 358487 and complaint 358486 indicated that Resident #104 sustained a fracture of the left leg on 2/20/25. The investigation packet related to incident 358487 was reviewed on 8/6/25 at 2:27 PM. The investigation indicated that Resident #104 was being treated for passive range of motion on 2/20/25 at 10:15 AM by Physical Therapy Assistant (Staff #34), when she noticed a change in the appearance of the resident’s left leg. This was reported to the Licensed Practical Nurse (LPN #35) assigned to the resident at that time. LPN #35 assessed the resident and noted swelling and bruising on the resident’s left lower leg and reported it to the attending physician, who ordered imaging to be taken. The attending physician then ordered for the resident to be sent to the emergency department (ED) for further evaluation and treatment for possible fracture. The ED then confirmed the resident had a broken left lower leg. Simultaneously in the facility, the incident was reported to the Director of Nursing (DON) who initiated an investigation. The DON took statements from all the staff assigned to Resident #104 at that time. The Geriatric Nursing Assistant (GNA #36) wrote on her statement that on 2/20/25 at 7:10 AM, she was transferring the resident to the wheelchair and the resident’s leg got twisted as she was sitting the resident down. An interview was documented by the DON with GNA #36 dated the same day at 4 PM. During the interview, GNA #36 confirmed that the resident’s transfer status was a 2 person assist but failed to seek another staff to help in transferring the resident. Further review of the investigation documents revealed that GNA #36 was suspended while the investigation took place. When the facility concluded that Resident #104’s fracture was the result of improper transfer, the facility’s corrective action was to educate the GNA on transfer status with return demonstration. However, documentation in the investigation packet revealed that GNA #36 was terminated on 2/27/25 and reported to the Board of Nursing on 3/3/25. No other corrective action was documented in the investigation packet. On 8/7/25 at 1:04 AM, GNA #18 was interviewed about her process when a resident needs assistance with transfers. She reported that resident information regarding required assistance for transfers are found in the Kardex (Kardex is the computer system that GNA’s use to document the tasks/care they had provided to the residents) or assignment sheet (assignment sheet is the paper document that GNA’s typically write on when they are getting reports during change of shift). GNA #18 showed the surveyor her assignment sheet which had a column titled “Transfers”. This column indicated the assistance required for residents to safely complete a transfer. She also showed the surveyor the Kardex which also indicated the required assistance for transfers, noting that she checks to verify that the information from the two matched. Resident #104’s information was reviewed with GNA #18. She reported that the resident was a full lift for all transfers and indicated that it meant she would need to use a mechanical lift to perform the transfer and required two staff members to complete the task. On 8/7/25 at 3:53 PM, the DON was interviewed about the incident. He confirmed that per his investigation, GNA #36 failed to secure assistance from another staff to safely transfer a dependent resident. He reported that the facility’s initial plan was to bring GNA #36 back for education about transfers but when the incident was forwarded and reviewed by corporate staff, they instructed the facility to terminate GNA #36. He also reported that the facility did a whole house education but did not include it in the investigation documents. He stated, “I keep a soft file in my office” and indicated that he would provide the surveyor with evidence that all clinical staff were educated on transfers. On 8/7/25 at 4:34 PM, the DON provided the surveyor with the attendance sheets for the employee education that included transfers as one of the topics, dated 2/25/25. A review of the attendance sheets was conducted on 8/8/25 at 12:15 PM. The review revealed that not all clinical staff attended the education. A subsequent interview with the DON was conducted on 8/8/25 at 12:53 PM. During the interview, the DON reported again that all clinical staff attended the education. He added, “if they failed to attend, they would have been written up.” The finding that not all clinical staff attended the education was discussed and the DON was asked if he had a list of staff who failed to attend. He indicated Human Resource (Staff #9) can give him that information. On 8/11/25 at 9:23 AM, Staff #9 printed a list of staff who failed to attend the education regarding transfers. The list consisted of 7 nurses and 4 GNA’s. Staff #9 was asked if staff on the list were written up for not attending and she answered, “No.” A review of GNA #36’s employee record was conducted on 8/11/25 at 12:13 PM. The review revealed the last education regarding transfer was done on 1/13/21 and last performance evaluation was dated 9/5/22. There was no other documentation found to indicate a performance evaluation was conducted in the last 2 years. On 8/13/25 at 8:43 AM, the findings were reviewed with the Nursing Home Administrator (NHA) and the DON, and the concern was discussed that GNA #36 had failed to follow the appropriate transfer status of a resident resulting in harm as evidenced by Resident #104’s lower leg fracture. Also, there was no evidence to indicate that all clinical staff were educated on transfers after the 2/20/25 incident with Resident #104. Both staff acknowledged the concern.

Based on review of pertinent documentation and interviews it was determined that the facility failed to ensure a registered nurse was working for at least 8 consecutive hours every day. This was found to be evident for 3 out of 16 weekends of staffing reviewed during the survey but has the potential to affect all residents.The findings include: On 8/11/25 surveyor reviewed the staffing sheets for the weekends during January, February and March of 2025, as well as the staffing sheets for 7/15 -7/30/25 for the presence of a registered nurse (RN). These schedules reflected 24 hour periods that started and ended at 7:00 AM. The nurses usually worked 12 hour shifts, either day shift 7:00 AM to 7:00 PM or night 7:00 PM to 7:00 AM.Review of the Friday 1/10/25 staffing sheet failed to reveal an RN on duty for the night shift.Review of the Saturday 1/11/25 staffing sheet failed to reveal an RN on duty for the day or night shift.Review of the Sunday 1/12/25 staffing sheet failed to reveal an RN on duty for the day or night shift.This represents a continuous 60 hours without an RN working in the building.Review of the 7/25/25 staffing sheet failed to reveal an RN on duty for the day or night shift.Review of the 7/26/25 staffing sheet failed to reveal an RN on duty for the day or the night shift. A separate report provided by the facility for hours worked per patient day (PPD) included documentation to indicate the Director of Nursing (DON) had worked for 4 hours on 7/26/25. An interview with the DON on 8/11/25 at 3:01 PM revealed that he has worked on the floor a couple of times and indicated that he recently had worked from 11:00 AM to 3:00 PM to cover the medication cart. When DON was told this was in regard to Saturday 7/26, the DON responded that he probably came in to help out on the weekend. On 8/11/25 at 3:32 PM surveyor reviewed with the Nursing Home Administrator the above findings for July 25 and 26, and January 11 and 12. On 8/12/25 surveyor requested the staffing sheets for 8/9 and 8/10/25.Review of the Saturday 8/9/25 staffing sheet failed to reveal an RN on duty for the day or night shift.Review of the Saturday 8/10/25 staffing sheet failed to reveal an RN on duty for the day shift.On 8/12/25 at 11:28 AM the Human Resources Director confirmed that this past weekend there was no RN coverage from Saturday 8/9 at 7 AM until Sunday 8/10 at 7:00 PM.This represents a 36 hour period with no RN in the facility.On 8/13/25 at 8:40 AM surveyor informed the NHA of the concern regarding multiple days when the facility failed to ensure an RN was working for 8 consecutive hours, including this past weekend.

Based on review of pertinent documentation and interviews it was determinted that the facility failed to ensure annual evaluations were being completed for geriatric nursing assistants (GNA). This was found to be evident for three (GNA #48, #18 and #49) out of three GNAs who were selected for review of annual training.The findings include: Review of a list of employees with their hire dates revealed GNA #48 was hired in March of 2023; GNA #18 was hired in June of 2004; and GNA #49 was hired in March of 2021. On 8/7/25 surveyor requested from the Human Resource Director documentation of the the annual evaluations for these three GNAs.On 8/11/25 review of the documentation provided failed to reveal documentation to indicate an annual review had been completed for GNA #48. The most recent Annual Performance Appraisal for GNA #18 was dated 8/13/22. The most recent Annual Performance Appraisal for GNA #49 was dated May 2023.On 8/11/25 at 11:55 AM the Human Resource Director reported she generates a list of who suppose to get an evaluation and sends it to nursing and then it is nursing's responsibility to complete them. She confirmed that GNA #48 has not had an evaluation; and that the most recent evaluations for GNA #18 and #49 were completed prior to 2024.On 8/13/25 at approximately 8:45 AM surveyor review the concern with the Nursing Home Administrator and the Director of Nursing regarding the failure to ensure evaluations are being completed annually for GNAs.Cross reference to F 689

Based on review of the facility assessment, medical records and contracts, and interviews it was determined that the facility failed to ensure the facility assessment addressed all of the required components of this regulation. This deficient practice has the potential to affect all residents.The findings include: Review of the Facility Assessment, which was provided for review at the beginning of the survey, revealed it was most recently updated on 2/24/25, however it failed to reflect the actual current name of the facility. The name found in the assessment was [name of previous corporate ownership] at Frostburg Village.Review of the section of the facility assessment addressing resident needs and staffing failed to include an assessment of the acuity levels of residents for the determination of staffing needs.On 8/12/25 at 10:55 AM during an interview with the Nursing Home Administrator (NHA) regarding staffing and the development of the facility assessment. The NHA referenced a grid in the facility assessment with the goal number of GNAs and nurses per shift. When asked how these numbers were obtained, NHA reported they were just trying to maintain their 3.0 PPD (Hour per patient day). State regulations require a minimum of 3.0 HPPD. When asked if she felt the nursing department was currently staffed appropriately to meet the needs of the residents, the NHA responded: can never have enough staff, would fight for another GNA and then she referenced a fair amount of hoyer lifts. Hoyer lifts are a mechanical device used to transfer a resident from bed to chair, chair to bed, or even off the floor in the case of a fall. Two staff are usually required to operate a hoyer lift.Further review of the facility assessment failed to reveal documentation to indicate how many, or what percentage of the residents require hoyer lifts, or more than one staff member to assist with transfers. Mechanical lifts are included in the list of physical equipment but fail to include the number or lifts owned/utilized by the facility.During the 8/12/25 at 10:55 AM interview, the NHA was asked if they determined how many full-time nurses and GNAs were needed in order to be fully staffed. The NHA reported they do have that information and confirmed that they assessed acuity in order to determine those levels. Surveyor reviewed the concern that no mention of this information is found in the facility assessment.At approximately 11:15 AM on 8/12/25 the NHA provided documentation of an 8/11/25 staffing review which included the number of current open positions for RNs, LPNs, CMA (certified medicine aides) and GNAs. It also included documentation of recent recruitment activity but failed to include documentation of an assessment of resident acuity levels that were used to determine these numbers.Review of the Facility Assessment section listing the type of staff that the facility provides included RNs, LPNs and GNAs. This section included the following statement: The departments are staffed appropriately to meet the needs of the residents. No documentation was found in the Facility Assessment to indicate a goal number of RN, LPN and GNA employees that would be required to fully staff the facility.Further review of the daily staffing grid, found in the facility assessment, revealed it listed Nurses but failed to identify the need for RNs specifically.Cross reference to F 727.Additionally, review of the section titled Staffing Plan included the following: Call-outs and open shifts are replaced as needed via the center staff. Review of weekend staffing sheets from January and February 2025, prior to the most recent revision of the Facility Assessment, revealed frequent usage of agencies to staff both for nurses and GNAs. For example, for the night shift on 2/14/25 all four of the LPNs on duty and three out of the five GNAs were from various staffing agencies. Review of staffing sheets for Sunday 8/10/25 revealed three out of the five day shift nurses were from agencies as well as five out of the eleven day shift GNAs.Interview with the Human Resource Director on 8/11/25 at 11:55 AM revealed that they do currently utilize agency staff for both nurses and GNAs. She confirmed that the agencies were responsible for skills assessment and trainings. Further review of the Facility Assessment failed to reveal documentation that addressed the need for, or use of, agency nursing staff.Cross reference to F 726

Based on a review of pertinent documents, observations and interviews, the facility failed to have a place to ensure residents were provided with water and other fluids to support their hydration and preferences. This was evident in two out of three units reviewed for dining during the survey.The Findings include:On 8/06/25 at 2:30 PM, a review of resident council minutes revealed that residents reported they were not receiving ice or water between the hours of 11:00 PM and 7:00 AM In addition review of complaint #358470 8/11/25 revealed a concern that the residents were not provided water. On 8/07/25 at 5:32 AM, a nighttime observation was conducted from 4:00 AM to 5:15 AM. The observation revealed that GNA Staff #19 and Hospitality Aide (Staff #21) were in the process of delivering water to residents. Staff #19 reported typically beginning water delivery around 5:00 AM.On 8/07/25 at 4:28 AM, an observation in Resident #92's room revealed an empty cup of water with the date 8/6 written on the top rim.On 8/07/25 at 4:29 AM, an observation in Resident #73's room revealed a cup with a small amount of water remaining and no date written on the top.On 8/07/25 at 4:38 AM, the above observations were confirmed by GNA Staff #4.On 8/07/25 at 4:49 AM, an observation in Resident #129's room revealed an empty cup on the bedside table. Continued observation failed to reveal any additional water containers in the room.On 8/07/25 at 4:52 AM, an observation in Resident #49's room revealed a cup on the bedside table containing a small amount of brown liquid.At 4:52 AM, a brief interview was conducted with Resident #49, who was noted to have no documented cognitive decline. The resident reported that the cup had contained Pepsi from the previous day and that no water had been provided on 8/06/25.On 8/07/25 at 4:54 AM, an observation in Resident #83's room revealed a single cup with a very small amount of water and the date 8/5 written on the top.On 8/07/25 at 4:56 AM, the observations for Residents #49 and #83 were confirmed by GNA Staff #3.On 8/07/25 at 7:44 AM, an interview was conducted with the Administrator and the Director of Nursing (DON). Both reported recent experience working the night shift and familiarity with the 11:00 PM - 7:00 AM water distribution process. The DON stated an understanding that new water cups were dated and distributed around 5:00 AM to ensure residents had water for the morning pass. The Administrator stated an understanding that new cups were distributed at the beginning of the night shift to ensure residents had access to water throughout the night. Both confirmed there was no consistent procedure in place to ensure residents received water to support hydration.

Based on review of medical records and other pertinent documentation, and interviews it was determined that the facility failed to ensure staff had adequate training. This was evident for one geriatric nursing assistant (GNA #25) out of two GNAs reviewed for mechanical lift training.The findings include: A review of Resident #45's clinical record revealed that they were admitted to the facility in 2022 and they required assistance to transfer from bed to wheelchair.A review of the facility's mechanical lift policy titled Lifting Machine, Using a Mechanical, revealed the statement that read, in part, that when lowering the resident, care should be taken ensure the sling bar did not hit the resident. On 8/06/2025 at 3:28 PM a record review of Resident #45's medical record revealed a progress note written on 7/10/25 by Licensed Practical Nurse (Staff #23) which described an incident when the resident developed a forehead hematoma (bruise) when they were hit on the forehead by the mechanical lift while being transferred into the wheelchair. The note explained that 2 Geriatric Nursing Assistants (GNA) assisted the resident with the transfer.On 8/07/2025 at 11:10 AM an interview was conducted with the unit manager Staff #2 to review the incident. When asked about the incident she said that GNAs were trained to use the mechanical lift but that she herself did not provide the training. She was asked to provide evidence of training for the two GNAs (Staff #24, Staff #25) who assisted the resident during the incident,.On 8/07/2025 at 11:57 AM Staff #2 brought training documents for Staff #24 and Staff #25. A review of Staff #25's training competency checklist revealed that it was a self-evaluation. There was no evidence that Staff #25 had received training in the use of a mechanical lift or that she had been deemed competent to perform a transfer with a mechanical lift.On 8/07/2025 at 12:03 PM an interview with Human Resources Director, Staff #9 was conducted to review the GNA training records for Staff #25. Staff #9 reviewed the document and concurred that the documents did not show evidence of training or competency. When asked for further evidence, Staff #9 replied that Staff #25 was an agency GNA and that there were no other training documents available.On 8/07/2025 at 12:43 PM the Director of Nursing confirmed that documentation in the resident's medical record confirmed that the mechanical lift bar hit the resident in the head and resulted in a bruise, and he also confirmed that there was no evidence that Staff #25 was competent to use the mechanical lift.

Based on pertinent document review, observation and interview, it was determined that the facility failed to provide a nutritional snack to Residents when meals were scheduled more than 14 hours apart. This was evident in one unit out of four unit reviewed for Dining during a survey.The findings include:7/31/25 at 11:13 AM during an interview, Resident #3, a long-term resident of the facility, reported that s/he had not received snacks at night. 7/31/25 review of the facility meal schedule revealed that the New Horizons Unit Hall (400 hall) had dinner scheduled at 5:00 PM, that breakfast was served at 7:35 AM, which is more than 14 hours apart. On 8/04/25 at 11:55 AM, the kitchen manager provided the food committee meeting minutes for the following months: July, April, and May of 2025. A review of food council revealed that residents reported not receiving evening snacks. In addition, review on 8/11/24 of the most recent Resident Council minutes, held on 8/6/25, revealed that residents reported they were not being offered evening snacks. On 8/04/2025, the surveyor observed evening snacks being delivered along with the dinner trays to the New Horizons Unit (400 Hall) at 5:22 PM. Upon closer observation, there were eight individual snacks, each labeled with a resident's name.On 8/4/25 at 6:27 PM an observation was made of the refrigerator and freezer on the New Horizon Unit. The observation failed to reveal any additional snacks other than the eight individual snacks, each labeled with a resident's name.On 8/4/25 at 6:28 PM Geriatric Nursing Assistant (GNA) (Staff #16) reported to the surveyor that the only snacks available to residents on the New Horizons Unit were individual snacks, each labeled with a resident's name. The GNA and the surveyor conducted an observation of the room that the GNA identified as the location where snacks were kept. The observation revealed a few saltine crackers; There were not enough snacks available for all the residents on the unit to receive a evening time snack.On 8/4/25 at 7:00 PM during a brief interview with the nighttime cook (Staff #17), she reported that all the snacks were delivered to the New Horizons Unit with the evening meal cart. She confirmed that all the snacks that had been delivered to the New Horizons Unit were individually labeled with residents' name, and no other snacks are to be delivered tonight. On 8/5/25 observation of the breakfast in New Horizon Unit revealed that the breakfast trays were still being distributed at 8:15 AM. On 8/6/25 The GNA documentation (TASKS) under HS snack was reviewed. The review revealed that 16 residents received snacks in the evening of 8/4/25. However, only 8 snacks were brought up by the kitchen and no other generic snacks were available on the unit.HS snack is a snack specifically to be given at bedtime or before going to sleep.On 8/6/2025 3:14 PM a phone interview with conducted with GNA Staff #18. She reported that she did provide snacks to the residents on the Horizons Unit the evening of 8/4/25. She reported that she provided snacks to the residents that did not receive the induvial snacks from the kitchen with their names on them. GNA #Staff 18 stated that sometimes the facility does not have snacks available for residents that are not ordered individual snacks, so she brings in her own snacks for the residents. She reported that she did provide some of her own snacks to the resident on the evening of 8/4/25. On 8/6/25 during an interview the administrator reported the staff have been educated not to provide snacks brought from home to the residents but use the snack provided by the facility. She reported that her expectation is that the residents HS snacks be provided by the facility. On 8/11/2025 at 12:55 PM Speech Therapist (Staff #37) was interviewed. During the interview, she reported that residents' diets are designed for the specific nutritional and safety needs, (resident ability to swallow) of the resident. She reported she had not approved of any snacks being brought in from outside to be served to the residents. Her expectation was that all snacks being served to the residents by the facility be approved by the kitchen, physician or speech therapy. The exception was food broughy in by the residents or family.

Based on record review and interview, it was determined that the facility failed to thoroughly investigate allegations of abuse and injuries of unknown origin. This was evident for 2 residents (Resident #23 and Resident #53) reviewed during review of the grievance log and one facility reported incident (#358482) of sixteen facility reported incidents reviewed during the recertification survey.The findings include:1) During a review of the facility’s grievances/concerns binder on 8/6/2025, it was noted that Resident #23’s roommate had filed a grievance regarding Resident #23. The grievance indicated that on the night of 3/2/25 into 3/3/25, a GNA (geriatric nurse aid) had answered Resident #23’s call light and said to him/her, “Now listen, I’m not coming in here on and off all night, is everything out of you? Because I am not coming back.” Then staff proceeded to give Resident #23 incontinence care by wiping him/her with a “paper towel”. According to the report, Resident #23 began to cry because the staff was “hurting her”. A continued review noted an additional complaint dated 3/13/25 from Resident #23’s roommate regarding the same staff member, stating that he used a paper towel again to wipe Resident #23, and the soiled brief was not changed. The report indicated Resident #23 was crying again. The roommate also reported that previous concerns had been raised without resolution. Both concerns were reported to the Director of Nursing (DON), who also serves as the facility’s Abuse Coordinator. However, the review failed to show that the facility completed a thorough investigation of both allegations including a head to toe assessment of Resident #23, statements from the staff involved, interview and/or assessment of other residents who had been in the care of the staff involved to ensure no one else had similar complaints and interview of other staff who may have known about the incident. In an interview on 8/6/2025 at 1:40 PM, the DON indicated that when he received the first concern, he cautioned the staff involved on how he spoke to residents. The DON also noted that the second concern was merely a repetition of the first, so no new intervention was required. However, it was another occurrence on a different date, and there was no evidence of a thorough investigation of the complaint. 2) A review of the facility’s grievances/concerns binder included a concern for Resident #53 dated 4/24/25 that stated that a GNA “was rough” and “touched [Resident #53] in a way [s/he] did not like” during care. The DON and Nursing Home Administrator (NHA) were notified of Resident #53’s concern. However, the review did not show that the facility thoroughly investigated the allegation. There was no evidence of a head-to-toe assessment of Resident #53, no interviews with other residents cared for by the same staff, and no statements from staff, including the one involved in the incident. During an interview on 8/7/2025 at 10:17 AM, the Nursing Home Administrator verbalized understanding of not thoroughly investigating allegations of abuse. 3), A review of the facility reported incident (FRI) #358482 revealed that Resident #107 was found on the floor in the hallway on 1/25/25 and was injured. The resident was sent to the emergency room where it was determined that he/she had a fractured tibia. The report further stated that there were no witnesses, no perpetrator was identified, that both the resident and the resident’s roommate were deemed incapable, and that staff who were on duty the day the injury was identified were interviewed and none had knowledge of the injury. A review of the facility’s investigation file revealed a witness statement written 1/25/25 at 2:00 pm by Staff #38 which indicated that she was the nurse who cared for the resident that day and that the resident refused to get out of bed, was assessed in the morning with no abnormal findings, but around noon/lunch time the resident complained of pain, the doctor was notified, an x-ray was ordered, and pain medication was administered. Further review of the facility’s investigation file failed to reveal any other staff witness statements from that day. The file lacked evidence that other residents were interviewed or assessed. There were no staff assignment sheets or resident census documents to identify staff and residents who were present on that day. There was no documentation of Resident #107’s physical assessment other than the staff witness statement. On 8/11/25 at 3:45 PM in an interview with the Director of Nursing (DON), he provided an explanation for how the resident’s injury occurred but acknowledged that this information was not included in the investigation file nor in the resident’s medical records. He confirmed the deficiency that the facility’s investigation was incomplete.

Based on record review and interview, it was determined that the facility failed to report injuries of unknown origin. This was evident for one facility reported incident (#358490) of sixteen facility reported incidents and 1 of 1 grievance binder reviewed during the recertification survey.The findings include:1) A review of the facility’s grievances/concerns binder on 8/6/2025 revealed a resident concern form dated 3/3/25 for Resident #23. The form indicated that on the night of 3/2/25 into 3/3/25, Resident #23’s roommate observed that a GNA (Geriatric nurse aid) had answered Resident #23’s call light. When he entered the room, he said to Resident #23, Now listen, I’m not coming in here on and off all night, is everything out of you? Because I am not coming back.” The GNA proceeded to wipe Resident #23’s peri area with a paper towel and according to the report, Resident #23 began to cry because the staff was “hurting her”. A continued review revealed another grievance dated 3/13/25 reported by Resident #23’s roommate that the same GNA had “used paper towel once again to wipe [Resident #23] and did not change [his/her] soiled brief”. The grievance report indicated that Resident #23 was “crying again”. The report also stated, “I reported this before, but nothing has been done about it”. Further review revealed that both concerns were reported to the Director of Nursing (DON), who also serves as the facility’s Abuse Coordinator. However, the review failed to show that the facility immediately reported the allegation of abuse to the state office. In an interview, Staff #6, the Social Services Director, stated that after receiving the concern dated 3/13/25, she and the Activity Director visited Resident #23’s roommate, who confirmed the concerns. Staff also added that they did notice paper towels and used gloves in Resident #23’s trash can. In an interview on 8/6/2025 at 1:40 PM, the DON indicated that when he received the first concern, he cautioned the staff on how he spoke to residents. The DON also added that the second concern was only a repetition of the first, so there was no new intervention to implement. However, earlier record review noted that it was another occurrence on a different date, and the facility failed to report the allegations of abuse to the state office immediately. 2) A review of the facility’s grievances/concerns binder included a concern for Resident #53 dated 4/24/25. The form indicated that the Resident #53 voiced concern that a GNA “was rough” and “touched [him/her] in a way [s/he] did not like” during care. Further review showed that the DON and the Nursing Home Administrator were notified of Resident #53’s concern. However, the review failed to show that the facility immediately reported the allegation of abuse to the state office. In an interview on 8/7/2025 at 9:44 AM, the social service director indicated that what had initially been told to the DON, then to her regarding Resident #53, seemed like an abuse allegation. That was why both she and the DON went to speak to Resident #53. However, the interview failed to show that the concern was immediately reported to the state office. During an interview on 8/7/2025 at 10:17 AM, the Nursing Home Administrator stated that she had signed off on the concern form, indicating she was aware of the issue, but did not view it as an abuse allegation before the surveyor’s intervention. 3) A review of the facility reported incident #358490 revealed that on 4/08/25 Resident #87 was observed on the floor next to his/her bed and with a laceration to the head. The report included a statement that indicated that no witnesses were able to verify the alleged incident. The resident was transferred to a local hospital emergency room for sutures. Further review revealed that staff became aware of the resident’s injury on 4/08/25 at 11:30 PM, and that the Director of Nursing (DON) was notified on 4/08/25 at 11:35 PM. Further review of the initial report revealed that the report of the injury of unknown origin was submitted to the Office of Health Care Quality (OHCQ) on 4/10/25 at 11:00 AM. On 8/12/25 at 10:34 AM in an interview with the Director of Nursing (DON), he was asked about the initial report timeframe, which was two days after the incident. He said he was not sure why he did not report it sooner and acknowledged that it was reported later than the regulation required. No further evidence was provided prior to the end of the survey.

Based on record reviews and interviews, it was determined that the facility failed to ensure Minimum Data Set (MDS) assessments were accurately coded. This was evident for 1 (Resident #25) of 1 resident reviewed for hospice care and 1 (Resident #5) of 12 residents reviewed for accidents.The findings include:The MDS is a federally-mandated assessment tool used by nursing home staff to gather information on each resident's strengths and needs. Information collected drives resident care planning decisions. MDS assessments need to be accurate to ensure each resident receives the care they need. 1) Resident #25 had been a resident of the facility since 2018. A review of the facility matrix indicated that the resident was under hospice care. On 8/1/25 at 12:05 PM, a subsequent review of Resident #25’s medical record revealed an MDS assessment for a significant change with an assessment reference date (ARD) of 3/17/25 coded the resident as receiving hospice care. The next MDS assessment was a quarterly assessment with an ARD of 6/17/25 that coded the resident as not receiving hospice care. A review of Resident #25’s medical orders was conducted on 8/6/25 at 9:29 AM. The review revealed the following orders pertaining to hospice care:a) Refer to UPMC WM Hospice-End of Life Care -dated 3/4/25b) UPMC Hospice admitted -dated 3/7/25 The MDS nurse coordinator (Staff #14) was interviewed on 8/6/25 at 9:50 AM. During the interview, Staff #14 reported that Resident #25 was currently receiving hospice care. She also reported that the significant change assessment done on 3/17/25 was due to the resident going under hospice care. A review of the quarterly assessment with an ARD of 6/17/25 was conducted with Staff #14, particularly section O where Resident #25 was assessed if s/he was receiving hospice care. Staff #14 confirmed that the resident was coded wrong and stated, “That should have been a yes” and indicated that she would fix it. The Nursing Home Administrator and Director of Nursing was interviewed on 8/13/25 at 8:43 AM. During the interview the concern was discussed that Resident #25 was inaccurately coded for hospice care on the 6/17/25 quarterly assessment. Both staff also confirmed that Resident #25 was currently receiving hospice care and acknowledged the concern. 2) A care plan addresses the unique needs of each resident. It is used to plan, assess, and evaluate the effectiveness of the resident's care. Bi-level positive airway pressure (BiPAP) is a non-invasive ventilation machine used to assist in the work of breathing- both inspiration and exhalation. On 8/6/25 a record review revealed Resident #5 had a diagnosis of Chronic Respiratory Failure with hypoxia, Congestive Heart Failure (CHF), and Chronic Pulmonary Obstructive Disease (COPD). On 8/7/25 at 5:53 AM, a record review of the Care Plan identified BiPAP therapy and a record review of physician orders revealed BiPAP settings 15/5 with 5L oxygen continuous at 5L NC every shift for Respiratory Failure. On 8/7/25 at 6:52 AM, a record review of the MDS Annual assessment dated 4/2025, Section O reflected that Resident #5 did not use BiPAP therapy. In an interview on 8/7/2025 at 8:33 AM, the MDS nurse Coordinator (Staff #14) confirmed that she is responsible for completing section O on the MDS. Staff #14 verified that BiPAP therapy was not reflected on the MDS and confirmed that there was an order for BiPAP as of 3/31/25. She acknowledged the MDS was coded inaccurately.

Based on record review and interview, it was determined that the facility failed to protect residents from abuse. This was evident for 2 (#358494 and #358463) out of 16 facility reported incidents reviewed during the recertification survey.The findings include:1.) Resident #91 was admitted to the facility in 2022, was cognitively intact, and their own spokesperson/decision maker. On 6/08/25 Resident #91 and Resident #76 were involved in a verbal and physical altercation. A review of the facility reported incident (FRI #358494) revealed that the facility reported on 6/25/25 that Resident #91 complained that on 6/08/25 Staff #27 threatened to kick him/her out of the facility. The report further stated that the facility investigated the incident and determined that Staff #27 verbally and emotionally abused Resident #91. The report also included statements that due to the confirmation of abuse, the facility terminated Staff #27’s employment and reported Staff #27 to the state board of nursing. On 8/12/25 at 8:21 AM the Nursing Home Administrator was interviewed regarding the incident. She said that Staff #27 was on call on 6/08/25 at the time of the resident-to-resident incident and Staff #27 came in to take care of the allegation. The NHA said that on 6/25/25 Resident #91 came to talk with her and told her that on 6/08/25 Staff #27 had told the resident that he/she would have to leave the building if something were to happen again. The NHA further described that Resident #91 was crying and upset and that the resident’s behavior had changed in the two weeks since the incident on 6/08/25. The resident stayed in their room and did not participate in activities as was usual. The NHA said this was how the facility determined abuse had occurred. The NHA went on to explain that she reassured the resident that when residents were asked to leave the facility, the process involved multiple steps and written notification. The NHA said that she apologized to the resident. On 8/12/25 at 10:44 AM in an interview with the Director of Nursing (DON), he confirmed that the abuse was substantiated by the facility, and he provided copies of the facility’s report to the board of nursing for Staff #27. On 8/13/25 at 8:52 AM an interview was conducted with the DON and the NHA to review the concern that the facility substantiated that Resident #91 was verbally and emotionally abused. 2)Review of Resident #119’s medical record revealed the resident was admitted to the facility in late March 2023 with a diagnosis of dementia. Review of the April Medication Administration Record (MAR) revealed that on 4/1/23 the resident had orders for Ativan (an antianxiety medication) to be given every 8 hours as needed for anxiety/agitation for 14 days. The Ativan was documented as administered on 4/4/23. The resident also had orders for an Buspirone 5 mg (an antianxiety medication) to be administered two times a day, and Seroquel (an antipsychotic medication) to be administered at bedtime. Review of a nursing note, written by Nurse #28 and dated 4/4/23 at 5:59 PM, revealed the resident was showing increased agitation and aggressiveness to other residents. “Tries to grab other residents to ‘come work for [him/her]’ and if they do not go [her/his] way, the resident becomes aggressive and not able to be redirected. After getting prn [as needed] Ativan at 1130, resident settled some and rested in bed.” Review of the 4/5/23 psychiatric evaluation and consultation note, written by Staff #29, revealed that the resident was seen for initial evaluation and medication management for anxiety and behavioral disturbance. No documentation was found in this note about the Ativan order. Further review of the note revealed that the nursing staff was reporting that the resident tries to control other residents and gets frustrated when they are not doing what [s/he] wants them to do. The recommendations included to increase the resident’s Buspirone to three times a day and continue the resident’s antipsychotic medication in the evening. Review of the April MAR revealed the as needed Ativan was administered on 4/7/23 at 8:43 AM. Review of a nursing note, written by Nurse #28 and dated 4/7/23 at 3:00 PM, revealed the resident became agitated while receiving care, charged at staff and punched the staff in the face. The physician and family were made aware. The Ativan dose was changed to regularly scheduled at 9 am and 9 pm and a prn dose available at 2 pm only. “Will continue to monitor”. A review of the April MAR revealed the previous Ativan prn order was discontinued on 4/7/23. A new order, dated 4/7/23, was found for Ativan to be given every 6 hours as needed for agitation/anxiety for 14 days, Can be given at 3 pm only. This prn medication was administered on 4/7 and again on 4/9. There was also an order on 4/7 for Ativan to be given two times a day for 14 days, this order was discontinued on 4/9. Review of a facility reported incident (358460) revealed that on 4/7/23 Resident #119 was observed in Resident #120’s room. Resident #119 was observed punching Resident #120 on the side of the face, Resident #120 swung back and punched Resident #119 on the shoulder. Resident #119 then ran a wheelchair into Resident #120. Staff de-escalated the situation and separated the residents. Review of the medical records revealed Resident #119 and Resident #120 were not roommates on 4/7/23. Review of a nursing note, written by Nurse #28 and dated 4/7/23 at 6:07 PM, revealed the information found in the facility reported incident. It also included that a second aid went in to help and the resident grabbed the nurse’s arm and swung [his/her] fist into nurse’s hand. Review of a nursing note, written by Nurse #28 and dated 4/8/23 at 6:45 PM, revealed the resident combative with care, can not be redirected, grabs wheelchairs, when staff try to redirect the resident swings at staff. Review of a nursing note, written by Nurse #32 and dated 4/9/23 at 6:56 PM, revealed: “Resident was in the door way of another resident room with a chair in front of [him/her] and GNA tried to redirect [him/her] [s/he] started to swing at her so she tried to hold [his/her] arms back and [s/he] head butted her [GNA] full force. Supervisor on call aware.” Review of the Resident #119’s care plan revealed that on 4/10/23 a care plan addressing the resident’s physically and verbally aggressive behavior. The plan acknowledged that a resident to resident incident had occurred and that these behaviors were related to dementia, Alzheimer’s disease, confusion, agitation and being difficult to redirect at time. All of the interventions were initiated on 4/10/23. Further review of the April MAR revealed the dosage of the three times a day Buspirone was increased to 10 mg on 4/10/23. Review of a nursing note, written by Nurse #30 and dated 4/11/23 at 11:27 AM, revealed the Ativan order was clarified with the nurse practitioner. Ativan was ordered qid [four times a day] as needed and only at 3 pm. Order was changed to two times a day. Review of the April MAR revealed that on 4/11 a new order was put in place for Ativan every 12 hours as needed for anxiety. Review of a nursing note, written by Nurse #28 and dated 4/12/23 at 6:53 PM, revealed: “Resident continues to try to push other residents in their wheelchairs, and when staff tries to redirect, resident hits at staff.” Review of the psychiatric note, dated 4/13/23, revealed that the resident has continued to exhibit anxiety symptoms. The note addressed the current prn [as needed] Ativan order and that the buspirone dosage was increased by the primary care provider. The recommendations included to start regularly scheduled Ativan two times a day, to continue the buspirone three times a day and the antipsychotic at bedtime. Review of the April MAR revealed the prn Ativan was discontinued on 4/14/23. A new order was put in place on 4/14 for Ativan two times a day. This order remained in place and was documented as administered as ordered until the resident was discharged from the facility. No further prn Ativan orders were found for this resident’s admission. Review of a nursing note, written by Nurse #31 and dated 4/14/23 at 7:56 PM, revealed the resident continued to wander the unit and at times had increased agitation but was able to be redirected. Review of a nursing note, written by Nurse #32 and dated 4/16/23 at 9:08 PM, revealed: “…res at change of shift observed wondering into room at end of hall this writer responded immediately running to see res in room stating ‘get out.’ This writer attempted to redirect with 1:1 res began hitting this writer on side of ribs/back which did not cause harm to writer (res slightly drowsy and weak), this writer able to back res out of room by walking sideways towards res with arm up to prevent being hit inface, other staff responded and able to help redirect res once away from environment.” Review of a nursing note, written by Nurse #28 and dated 4/17/23 at 3:04 PM, revealed: “…Resident has been wandering into others rooms, and when staff tries to redirect [him/her], [s/he] swings at staff. Will continue to monitor.” Review of the 4/20/23 psychiatric note revealed that the nursing staff reported that the resident continues to experience anxiety and irritability, especially during care. During the visit the resident wandered into another resident’s room and sat on the bed, the resident resisted leaving the room and after several attempts the resident finally complied and was rolled out of the room in [his/her] wheelchair. Recommendations included to continue the Ativan two times a day, the Buspirone three times a day and the antipsychotic at bedtime; as well as “supportive care and encourage interaction with peers and participate in activities in the facility as tolerated. Redirect as needed.” Review of a nursing note, written by Nurse #28 and dated 4/21/23 at 6:49 PM revealed resident was aggressive and hard to redirect. Review of a nursing note, written by Nurse #28 and dated 4/22/23 at 3:04 PM, revealed the Resident continued to get physical with staff when providing daily care or when redirecting. Also that the resident had been “inappropriate with hands as well as kissing on staff and other residents. Will continue to monitor.” Review of a nursing note, written by Nurse #28 and dated 4/22/23 at 5:10 PM revealed: “Resident became aggressive when tried to redirect away from another resident [who] was trying to eat. This resident would not let [him/her] eat [his/her] dinner. Resident hit staff as well as grabbing them and swinging at other staff. This resident is not able to be redirected. Stormed off down the hall into other residents rooms.” Further review of the medical record revealed the resident was sent to the hospital on 4/22/23 for aggressive behaviors. Review of the hospital emergency department notes revealed documentation that the nurse at the facility reported the “patient was hitting staff and other residents and difficult to control.” Further review of the hospital records revealed the resident was administered the regularly scheduled oral antipsychotic; as well as injections of two different antipsychotic medications: Haldol and Zyprexa. The hospital medically cleared the resident to return to the facility during the early morning hours of 4/23/23. Further review of the medical record failed to reveal documentation to indicate any changes in the residents medications, or orders for increase in supervision upon return from the hospital on 4/23/23. Further review of the care plan addressing the resident’s aggressive behavior failed to reveal it was updated or that new interventions were added after the resident returned from the hospital on 4/23/23. Review of a nursing note, written by Nurse #28 and dated 4/23/23 at 6:36 PM revealed : “This resident was pushing other resident's around in their wheel chair and when tried to redirect resident [s/he] starting to swing and hit staff. Resident then tried to hit other resident. Staff intervened and tried to redirect this resident, when this resident hit this nurse in the jaw and kicked another aide in the knee. Resident was placed into a chair, where [s/he] would not stay seated and continued to try to go after other residents near by.” Further review of the medical record failed to reveal documentation to indicate that these behaviors of hitting staff and attempting to hit other residents was reported to either the primary care or the psychiatric provider on 4/23/23. Review of a nursing note, written by Nurse #33 and dated 4/24/23 at 4:38 AM revealed the resident was up at the beginning of the shift wandering throughout the unit and required some redirection out of other residents’ rooms. Review of a nursing note, written by Nurse #31 and dated 4/24/23 at 2:39 PM revealed the resident was requiring 1:1 to redirect to sit in wheelchair. Further review of the medical record failed to reveal documentation to indicate the physician was made aware that the resident was requiring 1:1 supervision; no order was found for 1:1 supervision, or other documentation to indicate 1:1 supervision was implemented as an ongoing intervention for Resident #119. Review of a nursing note, written by Nurse #31 and dated 4/25/23 at 4:35 PM revealed that in the morning, the nurse heard another resident yell for “help”, nurse observed Resident #119 attempting to talk to the other resident and push into the room, Resident #119 thought the other resident was their spouse and was going to assist the other resident to bed. “1:1 given able to redirect res long enough to remove other res from area… this writer managed to assist res to w/c. res at that time grabbed this writers hand attempting bite. res swinging at staff, res charged this writer nearly falling. res redirected and toileted. res making statements I'm going to kill you. Give me a gun because I am going to shoot you. res appears drowsy, res unable to ambulate in hallway knees buckling, staff assisted res to bed res unable at that time to amb on own. res cont to punch staff in stomach and several attempts to hold hand to bite….” The note went on to state that the resident then slept until 3:00 PM, was given medications at that time and was at the time of the note sitting calmly in a wheelchair. No documentation was found to indicate the primary care physician, or the psychiatric provider were made aware on 4/25/23 of the resident’s attempts to bite staff or the threatening statements made by the resident. Further review of the medical record revealed the resident was seen by the psychiatric provider on 4/26/23. Review of the corresponding note revealed that the nursing staff reported that the resident had been experiencing increased agitation and was refusing oral medications. The note revealed nurses reported resident being combative, hit a female staff in the face, had been wandering into other resident’s rooms and resists when redirected. The note addressed the visit to the ER. During the visit the resident was observed pacing the hallway in the wheelchair. The recommendation was to discontinue the evening antipsychotic for ineffectiveness and to start Depakote sprinkles twice a day for agitation. No changes were made to the two regularly scheduled anxiety medications already ordered; or to the behavioral interventions (Supportive care and encourage interaction with peers and participate in activities in the facility as tolerated. Redirect as needed.). No documentation was found to indicate the psychiatric provider was aware of the attempts to bite staff, or the verbal threats. Review of a nursing note, written by Nurse #28 and dated 4/27/23 at 4:14 PM revealed the resident was up wandering into other resident’s room and when staff tried to redirect, resident draws fist back and tries to hit people. Staff are not able to redirect the resident at times and other residents have to be moved away. Review of the facility reported incident 358463 revealed that on 4/29/23 staff heard Resident #95 yelling “get out of my room”. When staff entered Resident #95’s room Resident #119 was observed with [his/her] right arm around resident #95’s neck. With assistance of 3 staff members residents were separated and Resident #119 was escorted from the room. Resident #119 was sent to the hospital via 911. On 4/29/23 Resident #95 and Resident #119 were not roommates. Review of Resident #95’s medical record revealed the resident has a diagnosis of dementia and a need for assistance with personal care. On 4/29/23 Resident #95 sustained a small scratch 0.4 cm in diameter on the left side of the neck from Resident #119. On 8/8/25 at 12:15 PM an interview was conducted with the unit nurse manager (Nurse #2) about aggressive residents. When asked if there was an aggressive resident who was sent to the emergency room but then returned with no change in treatment, would they do anything different? Nurse #2 responded that they would look at doing every 15-minute checks or a 1:1. She went on to report a recent incident in which a resident pushed another resident down and they were going to implement a 1:1. On 8/8/25 at 1:19 PM surveyor reviewed the concern with the Director of Nursing (DON) that the resident was having aggressive behaviors and no documentation to indicate an increase in supervision, even after the resident was sent to the hospital for these behaviors. DON indicated he would check if there was documentation to indicate an increase in supervision after the hospitalization. The DON went on to report they have a hard time with the locale hospital just giving Haldol and then sending the residents back rather than admitting to psychiatric unit. He reported a recent incident of this occurring and they had a 1:1 until the resident was transferred out. On 8/13/25 at 8:40 AM the surveyor reviewed the concern regarding the facility's failure to protect resident to resident abuse in regard to the incident involving Resident #119 and #95. As of time of survey exit on 8/13/25 at 11:30 AM no additional documentation was provided to indicate additional supervision of Resident #119 was ordered or provided.

Based on record reviews and interviews, it was determined that the facility failed to ensure appropriate information was communicated to the receiving healthcare institution. This was evident for 2 (Resident #110, #25) of resident reviewed for hospitalization.The findings include:1) Resident #110 was admitted into the facility in mid-2025. The medical record indicated that the resident was hospitalized on [DATE]. A review of the transfer form dated 6/29/25 was conducted on 8/5/25 at 10:28 AM. The review revealed section H, item 2 that read, (Skilled Nursing Facility) SNF to (Emergency Department) ED TRANSFER CHECKLIST: Print the following documents and include with this transfer form in the order listed. Send entire packet with the patient to the hospital. The documents listed had a boxed space before each number to mark with a check to indicate that it was printed. Numbers 1, 2, and 4 were checked. The following documents were listed as:1. MOLST2. Facesheet3. X-Rays4. Medication list5. Lab Results6. SBAR7. Other InfoThe Nurse unit manager (Staff #2) was interviewed on 8/5/25 at 1:22 PM. During the interview, Staff #2 explained the process when a resident is transferred to the hospital including the documents that the facility prepares to be given to the receiving healthcare institution. She reported that on weekdays, between her, the other unit manager, or most commonly the unit clerk would print the documents. On weekends, a float nurse could help out in printing the documents while the nurse on duty prepares the resident for the transfer. She also reported that if she was the nurse, she would add printing capacity form, dietary orders, and her progress notes related to the concern why a resident is being sent out.Resident #110's medical record was reviewed with Staff #2 on 8/5/25 at 1:32 PM. She confirmed that the resident was sent to the ED on 6/29/25 and confirmed that the transfer form indicated the 3 items checked as printed and provided to the hospital. Staff #2 also reviewed the nurse's progress note to see if she indicated the documents that she sent with the resident upon transfer and reported that the nurse did not indicate which documents were printed and sent. Staff #2 was asked if they send care plan goals and advanced directive information since she had not mentioned it as part of the things they would print when a resident is ordered to be sent to the ED. She stated, typically I don't send that and reported that she was not aware that they were required to send them. A review of the federal regulation indicating at a minimum, the items/information that needed to be sent to the receiving healthcare institution was conducted with Staff #2. She verbalized understanding and acknowledged the concern.On 8/5/25 at 1:50 PM, the concern was discussed with the Director of Nursing (DON) that the receiving healthcare institution did not receive the minimum required information when Resident #110 was sent out on 6/29/25. The DON acknowledged the concern.2) Resident #25 had been a resident of the facility since 2018. Medical records indicate that the resident was hospitalized on [DATE]A review of the transfer form dated 2/28/25 was conducted on 8/5/25 at 10:05 AM. The review revealed section H, item 2 that read, SNF to ED TRANSFER CHECKLIST: Print the following documents and include with this transfer form in the order listed. Send entire packet with the patient to the hospital. The documents listed had a boxed space before each number to mark with a check to indicate that it was printed. Numbers 1, 2, and 4 were checked. The following documents were listed as:1. MOLST2. Facesheet3. X-Ray4. Medication List5. Lab Results6. SBAR7. Other InfoOn 8/6/25 at 9:46 AM, the Nurse Unit Managers (Staff #1 and #2) were interviewed about Resident #25's hospitalization on 2/28/25. They were asked if there was evidence that the resident's care plan goals and advanced directive information was sent to the hospital and both staff indicated that they would review the resident's medical record and report back to the surveyor.On 8/6/25 at 9:56 AM, Staff #2 reported that the nurse on duty when Resident #25 was hospitalized did not indicate in her progress notes the documents that she sent with the resident. Also, she confirmed that the checklist in the transfer form only indicated that the MOLST, facesheet, and medication list were printed and sent to the hospital with the resident.The concern was discussed with the Nursing Home Administrator (NHA) and the Director of Nursing (DON) on 8/13/25 at 8:43 AM, that the information sent to the receiving healthcare institution, when a resident was sent to the ED did not meet the minimum requirement of the federal regulation. Both staff acknowledged the concern.

Based on record review and interview, it was determined that the facility failed to ensure that Beneficiary Protection Notifications were issued at least two days before the end of a Medicare-covered Part A stay to Residents discharged from Medicare Part A services but had benefit days remaining and intended to stay at the nursing facility receiving non-skilled care. This was evident for 2 (#43, #76) of 3 residents reviewed for Skilled Nursing Facility Beneficiary Protection Notification.The findings include:Residents with Medicare Part A have rights and protections regarding financial liability and the appeals process. Providers provide specific notices to residents who are discharged from Medicare services and still have benefit days remaining. These notices communicate financial liability, appeal rights, and protections.The notices include:Notice of Medicare Non-Coverage (NOMNC): This must be issued at least two calendar days before the last day of Medicare coverage. The NOMNC informs the beneficiary of his/her right to an expedited review of the services termination. The resident and/or their representative must receive a copy of the notice in enough time to appeal the decision to terminate the paid coverage. The facility must indicate that the notice was sent/and/or given within the specified time.Skilled Nursing Facility Advance Beneficiary Notice (SNFABN): This notice must be issued far enough before delivering potentially non-covered services to allow sufficient time for the beneficiary to consider all available options.1) Record review on 8/6/2025 at 2:48 PM of the Beneficiary Notification checklist completed and provided by the facility to the survey team showed that Resident #43's Medicare A services in the facility started on 4/3/25 and ended on 5/2/25. The resident continued to reside in the facility after the last day of his/her Medicare coverage.The review contained a NOMNC and SNFABN for Resident #43, both of which were signed on 5/6/25 by the resident's representative. These were signed four days after Medicare services ended for Resident #43.The SNFABN issued to Resident #43 did not give all the necessary information for deciding about non-covered services. The D column was blank (care or services the facility believes Medicare may not pay for). The E column was blank (reason Medicare may not pay). The F column was blank (estimated cost for services in D).In an interview on 8/6/2025 at 4:26 PM, staff #5, a medical record personnel, stated that the NOMNC and SNFABN should have been issued two days before the end of Medicare services. However, she issued them late because she was on vacation.2) A review was completed of Resident #76's Beneficiary Notification checklist, which the facility completed. It showed that Resident #76's Medicare Part A services began on 3/4/25 and ended on 4/30/25.The continued review noted that the facility initiated Resident #76's discharge from Medicare Part A services before benefit days were exhausted. This was due to a notice from therapy stating that ongoing assessment of the patient's rehab needs was no longer required. Resident #76 remained in the facility. The review also showed that Resident #76's NOMNC and SNFABN were signed on 4/29/25, a day before Medicare services ended for the resident. SNFABN issued to Resident #76 did not provide all the needed information for deciding about non-covered services. The D column was blank (care or services the facility believes Medicare may not pay for). The E column was blank (reason Medicare may not pay). The F column was blank (estimated cost for services in D).In an interview on 8/7/2025 at 4:30 PM, staff #5 confirmed that Resident #76's NOMNC was issued late on 4/29/25, possibly due to her being on vacation. It was only issued upon her return. Staff also stated that she had not been trained on how to complete the SNFABN before providing it to residents or their representatives.

Based on medical record review and interview it was determined that the facility failed to ensure staff informed the physician or nurse practitioner when a resident exhibited violent and aggressive behaviors. This was found to be evident for one (Resient #119) out of 15 residents reviewed for abuse during the survey.The findings include: Review of Resident #119's medical record revealed the resident was admitted to the facility in late March 2023 with a diagnosis of dementia. Review of the medical record revealed the resident had a multiple instances of aggressive behavior both with other residents and with staff. The resident was seen on multiple occasions in April 2023 by a psychiatric provider. On 4/22/23 the resident's psychotropic medications included Ativan 0.5 mg twice a day for anxiety, Buspirone 10 mg three times a day for anxiety, and a dose of Seroquel (an antipsychotic) at bedtime. No orders were found for as needed medications to be administered for increased anxiety or agitation.Further review of the medical record revealed the resident was sent to the hospital on 4/22/23 for aggressive behaviors. Review of the hospital emergency department notes revealed documentation that the nurse at the facility reported the patient was hitting staff and other residents and difficult to control.Further review of the hospital records revealed the resident was administered the regularly scheduled oral antipsychotic; as well as injections of two different antipsychotic medications: Haldol and Zyprexa. The hospital medically cleared the resident to return to the facility during the early morning hours of 4/23/23.Further review of the medical record failed to reveal documentation to indicate any changes in the residents medications, or orders for increase in supervision upon return from the hospital on 4/23/23.Review of a nursing note, written by Nurse #28 and dated 4/23/23 at 6:36 PM revealed : This resident was pushing other resident's around in their wheel chair and when tried to redirect resident [s/he] starting to swing and hit staff. Resident then tried to hit other residents. Staff intervened and tried to redirect this resident, when this resident hit this nurse in the jaw and kicked another aide in the knee. The Resident was placed into a chair, where [s/he] would not stay seated and continued to try to go after other residents near by.Further review of the medical record failed to reveal documentation to indicate that these behaviors of hitting staff and attempting to hit other residents was reported to either the primary care or the psychiatric provider on 4/23/23.On 8/8/25 at 12:15 PM the unit nurse manager (Nurse #2) confirmed each incident of resident being aggressive should be reported to provider.Review of a nursing note, written by Nurse #33 and dated 4/24/23 at 4:38 AM revealed the resident was up at the beginning of the shift wandering throughout the unit and required some redirection out of other residents' rooms.Review of a nursing note, written by Nurse #31 and dated 4/24/23 at 2:39 PM revealed the resident was requiring 1:1 to redirect to sit in wheelchair.Further review of the medical record failed to reveal documentation to indicate the physician was made aware that the resident was requiring 1:1 supervision; no order was found for 1:1 supervision, or other documentation to indicate 1:1 supervision was implemented as an ongoing intervention for Resident #119.Review of a nursing note, written by Nurse #31 and dated 4/25/23 at 4:35 PM revealed that in the morning, the nurse heard another resident yell for help, nurse observed Resident #119 attempting to talk to the other resident and push into the room, Resident #119 thought the other resident was their spouse and was going to assist the other resident to bed. 1:1 given able to redirect res long enough to remove other res from area. this writer managed to assist res to w/c. res at that time grabbed this writers hand attempting bite. res swinging at staff, res charged this writer nearly falling. res redirected and toileted. res making statements I'm going to kill you. Give me a gun because I am going to shoot you. res appears drowsy, res unable to ambulate in hallway knees buckling, staff assisted res to bed res unable at that time to amb [ambulate - walk] on own. res cont [continue] to punch staff in stomach and several attempts to hold hand to bite. The note went on to state that the resident then slept until 3:00 PM, was given medications at that time and was at the time of the note sitting calmly in a wheelchair.No documentation was found to indicate the primary care physician, or the psychiatric provider were made aware on 4/25/23 of the resident's attempts to bite staff or the threatening statements made by the resident.Further review of the medical record revealed the resident was seen by the psychiatric provider on 4/26/23. Review of the corresponding note failed to reveal documentation to indicate the psychiatric provider was aware of the attempts to bite staff, or the verbal threats.On 8/08/25 at 1:19 PM surveyor reviewed the concern with the Director of Nursing of multiple documentation of incidents of the resident being aggressive with staff and residents but no indication that MD was notified on day of occurrences. As of time of survey exit on 8/13/25 at 11:30 AM no additional documentation was provided regarding notifications.Cross reference to F 600

Based on medical record review, interview and observations it was determined that the facility failed to ensure care was provided in accordance with professional standards of practice. This was evident for 3 (Resident # 114, #4, and #5) out of the 78 residents included in the sample. The findings include: 1) Review of Resident #114's medical record revealed the resident was admitted to the facility in 2023 with diagnosis that included, but not limited to, dementia and high blood pressure. Further review of the medical record revealed a Change in Condition note, with an effective date of 3/22/25 at 7:36 AM that was complete by a Licensed Practical Nurse (Nurse #39). This note revealed that the resident sustained a fall on 3/22/25 at 12:25 AM. The nurse documented that the resident was observed on the floor next to the bed sitting on his/her bottom and the resident had no explanation; the physician was notified at 3:00 AM. No documentation was found to indicate the nurse had completed a set of vital signs (heart rate, pulse, respirations, temperature) at the time of the initial assessment after the resident was found on the floor or prior to the notification of the physician at 3:00 AM. On 8/8/25 at 12:00 noon Licensed Practical Nurse (Nurse #41) reported that if a resident falls she completes an assessment which would include neuro checks and vital signs. Further review of the 3/22/25 Change in Condition note revealed in Section C Background (Evaluation) the nurse documented yes to the question: Are these the most recent vital signs taken after the change in condition occurred. The documentation indicated the blood pressure and heart rate measurements were from 3/21/25 at 9:08 AM, the respiration rate, temperature and oxygen saturation rate were from 3/16/25, and the blood glucose reading was from 2024. Further review of the medical record revealed an additional nursing note, written by Nurse #39 with an effective date of 3/22/25 at 8:00 AM that includes a statement that “full assessment completed upon observation of resident on the floor” but failed to mention that vital signs were obtained as part of that assessment. This note was entered as a Late entry and was created on 4/5/25. On 8/8/25 at 2:16 PM the Director of Nursing (DON) reported his expectation after a fall was that staff complete a full assessment before the resident was moved and confirmed this assessment would include vital signs. The Surveyor then reviewed the concern that the medical record failed to reveal documentation that a set of vital signs was completed at the time of the fall and that the Change in Condition form referenced vital signs from before the fall occurred. The Surveyor then reviewed the electronic health record with the DON; the first documentation of blood pressure and heart rate post fall was found for 3/22/25 at 10:53 AM. The 3/22/25 at 10:53 AM blood pressure was recorded by Nurse #42 and was included in the documentation for the administration of a medication to be given for high blood pressure that was scheduled to be given at 9:00 AM. On 8/13/25 at 8:40 AM the surveyor reviewed the concern with the Nursing Home Administrator regarding the failure to ensure a thorough assessment after a fall. As of time of survey exit, on 8/13/25 at 12 noon, no additional documentation was provided to indicate a set of vital signs was completed at the time of the initial assessment after the fall. 2) On 7/31/25 Registered Nurse (RN #15) was observed entering Resident #4’s room. From the hall, the surveyor heard RN #15 ask the resident, “where do you want your insulin?” The reply, “in my arm.” On 7/31/25 at approximately 9:30 AM, the Surveyor and RN #15 entered Resident #102’s room. RN #15 administered insulin into the resident’s right upper arm after the resident stated that s/he preferred to have the insulin injected into his/her belly. On 8/4/25 at 3:59 PM in an interview, the Licensed Practical Nurse (LPN #12) indicated the insulin administration sites were “usually” rotated and documented in the Medication Administration Record (MAR) of the electronic health record. A record review of Resident #4’s MAR revealed that insulin was administered in the same location without rotating sites on 7/30/25, 7/28/25, 7/27/25, and 7/25/25. And Resident #102’s MAR revealed insulin was administered in the same location on 7/31/25, 7/27/25, 7/26/25, 7/24/25 and 7/23/25. On 8/5/25 at 3:14 PM in an interview with Unit Managers (UM) LPN #1 and LPN #2, they acknowledged that the facility does not adhere to any standard of care or practice for administering insulin and rotating sites. A review of DIABETES CARE, VOLUME 27, SUPPLEMENT 1, JANUARY 2004, pg. S109 revealed the standard of care for rotating sites: Rotation of the injection site is important to prevent lipohypertrophy or lipoatrophy. Rotating within one area is recommended (e.g., rotating injections systematically within the abdomen) rather than rotating to a different area with each injection. In a follow-up interview at 3:30 PM the Nursing Home Administrator confirmed that the facility does not adhere to a standard of care when administering insulin and in particular rotating sites. “It would make sense for us to do it here.” 3) On 8/6/25 at 11:00 AM this surveyor observed Resident #5 lying in bed with an alternating low air mattress set at 290 pounds per square inch (psi) and alternating every 20 minutes. Resident #5 stated, “I used to weigh over 300 pounds about a year ago.” On 8/7/25 at 5:53 AM a record review of the Care Plan revealed use of a pressure reducing mattress. Alternating pressure mattress. Nurse to check functioning and settings. On 8/7/25 at 7:11 AM this surveyor observed Resident #5 asleep on alternating low air mattress with settings at 290 psi and alternating flow every 20 minutes. On 8/7/25 at 7:45 AM in an interview, LPN #12 confirmed Resident #5’s low air mattress was set at 290 psi and alternating every 20 minutes. On 8/7/25 a record review of Resident #5’s monthly weights from January to August revealed 195.4, 198.8, 191.1, 191.8, 189.0, 187.0, 189, 186.6, respectively. On 8/7/25 at 8:00 AM the Maintenance Director, Staff #13 provided the Operation Manual for the Protekt Aire 8000 model. On 8/7/25 at 9:54 AM in an interview, LPN #12 indicated that the mattress settings are determined by the resident's weight. It was confirmed in the electronic medical record that Resident #5 currently weighed 186.6. On 8/7/25 at 10:09 AM, LPN #12 acknowledged that the mattress was set for a weight interval of 220-290 and that she had adjusted the weight interval to 150-220 after surveyor intervention.

Based on observations, record review and staff interviews, it was determined that the facility failed to administer oxygen as ordered by the physician. This was evident for 1 resident (Resident #5) reviewed as a complaint, #358479, during this survey.The findings include: Oxygen therapy is the administration of oxygen at concentrations greater than that in room air with the intent of treating or preventing hypoxia- low oxygen level in the blood.On 8/6/25 at 11:00 AM this surveyor observed Resident #5 lying in bed with oxygen (O2) via nasal canula (NC) at 4 liters (L). In an interview, Licensed Practical Nurse (LPN #10) confirmed O2 NC at 4L. On 8/7/25 5:49 AM a record review of Resident #5's Treatment Administration Record (TAR) revealed: Respiratory: Oxygen - Continuous at 5L NC every shift for Respiratory Failure. On 8/7/25 at 5:53 AM A record review of physician orders revealed 5Liters (L) oxygen (O2) continuous via nasal cannula (NC) every shift for Respiratory Failure.On 8/7/25 at 7:11 AM this surveyor observed Resident #5 asleep with 4L O2 NC. On 8/7/25 at 7:45 AM in an interview, LPN #12 confirmed Resident #5's oxygen was O2 NC at 4L. LPN #12 acknowledged the oxygen order was 5L NC.On 8/7/25 at 8:07 AM a second surveyor confirmed O2 at 4L NC.

Based on observation, staff interviews, and record review, it was determined that the facility failed to establish systems to accurately reconcile controlled medications using acceptable standards of practice. This was evident for 2 of 4 narcotic books reviewed during the medication administration task during this survey. The findings include:Reconciliation refers to a system of recordkeeping that ensures an accurate inventory of controlled medications by identifying loss or potential diversion of controlled medications. Controlled Medications are substances that have an accepted medical use, have potential for abuse, ranging from low to high, and may also lead to physical or psychological dependence. These medications fall under US Drug Enforcement Agency (DEA) Schedules II-V.Standard practice for narcotic reconciliation is conducted at the end-of-shift. Two licensed personnel, the on-coming licensed personnel and the out-going licensed personnel, count all controlled medications verifying the count accuracy and documenting their initials in the narcotic book. On 7/31/25 at 8:51 AM a review of the narcotic reconciliation book on the 200-hall unit revealed an unsigned sheet for a controlled medication, Lorazepam. In an interview, Licensed Practical Nurse (LPN #12) verbalized that the facility's process for narcotic reconciliation was conducted by two licensed nurses who count and sign the narcotic book. LPN #12 acknowledged the unsigned sheet.At 9:00 AM in an interview, Unit Managers (UM), LPN #1 and LPN #2 reviewed the unsigned narcotic sheet and acknowledged that it was incomplete. At 9:05 AM, LPN #12 and LPN #1 corrected the narcotic sheet after surveyor intervention.A review of the policy for Accepting Delivery of Medications and Controlled Substance revealed the Nurse coming on duty and nurse going off duty must count together and must sign designated controlled substance record. On 7/31/25 at approximately 10:00 AM, a review of the narcotic book on the 100-hall unit revealed a Lorazepam narcotic sheet dated 6/15/25 was signed by only one nurse. Further observation and an interview with RN #15 revealed inaccurate reconciliation and documentation of 1 of 3 bottles of liquid morphine. The surveyor asked, how do you know which sheet goes to which bottle, RN #15 replied, I have no clue.In an interview, UM, LPN #1 acknowledged that the narcotic sheets and corresponding bottles of morphine failed to be accurately reconciled and documented. LPN #1 also indicated the liquid morphine and accompanying narcotic sheets should not be on this cart because the resident was discharged from the facility last Friday. She stated, when a resident is discharged , it is the UM's responsibility to pull the narcotics and accompanying sheets and give them to the Director Of Nursing (DON). On 7/31/25 at 12:57 PM in an interview, the DON was made aware of the inaccuracies in narcotic reconciliation. He stated, narcotics don't have to be pulled from a medication cart according to a timeline as long as they are doubled locked.On 8/5/25 at 4:14 PM a review of the policy for Discarding and Destroying Medications, item #6, letter c stated, Disposal of controlled substances must take place immediately (no longer than three days) after discontinuation of use by the resident. DON aware.

Based on record reviews and interviews, it was determined that the facility failed to have an effective system in place to ensure a) pharmacy recommendations were addressed by the attending physician in a timely manner, b) the attending physician documents his rationale for no action taken to a pharmacy recommendation, and c)the facility's medication regimen review (MRR) policy did not specify the timeframe for the steps in the MRR process. This was evident for 2 (Resident #9, #14) of 5 residents reviewed for unnecessary medications.The findings include:1) Resident #9 had been a resident of the facility since early 2017 with diagnoses that include muscle weakness and difficulty in walking.On 8/4/25 at 10:58 AM, a review of Resident #9's medical record was conducted. The review revealed a MRR was conducted for the resident dated 6/18/25 and indicated that irregularities were identified with instructions to see report. However, the resident's medical record did not contain the report.The Nurse Unit Manger (Staff #2) was interviewed on 8/4/25 at 12:40 PM. during the interview, Staff #2 reported that when the monthly MRR is done by the consultant pharmacist, and a recommendation or irregularity is identified, she or the other nurse unit manager prints the report and refers it to the attending physician to address the concern. She then writes a progress note to document what the attending physician's response was to the recommendation. Resident #9's medical record was reviewed with Staff #2, and she confirmed that the report for the 6/18/25 MRR was not in the resident's medical record. Staff #2 then indicated that she would ask the Director of Nursing (DON) if he has the report because the MRR was requested from the consultant due to a fall and was not the usual monthly MRR.On 8/4/25 at 12:56 PM, Staff #2 provided the surveyor with the reports from the 6/18/25 MRR. The reports had 3 drug therapy problems identified, however there was no indication that these concerns had been addressed by the attending physician. Staff #2 reported that she would let the DON explain.The DON was interviewed on 8/4/25 at 12:59 PM. He confirmed that the 6/18/25 MRR for Resident #9 was requested outside of the monthly review of the consultant pharmacist due to a fall. The DON reported that when a MRR is requested outside the monthly review, the report goes to a different portal and that he is the only one who accesses it. He also reported that the MRR report was put in the attending physician's box so that he could address it but did not get a response. The DON confirmed that since the drug therapy problems had been identified, there had been no change in the resident's medication orders. The DON verbalized understanding that the attending physician had failed to respond to a pharmacy recommendation and acknowledged the concern.2) The medical management of dementia focuses on slowing disease progression, managing symptoms, and supporting overall well-being. Treatment often involves medications to address cognitive symptoms and behavioral issues. Treatment plans should be individualized based on the specific type and stage of dementia, as well as the individual's overall health and preferences. Ongoing monitoring and adjustments to the treatment plan are necessary as the disease progresses. Gradual Dose Reduction (GDR) is a strategy used in dementia care to systematically reduce or discontinue medications, especially in older adults. GDR in dementia treatment aims to achieve the lowest effective dose of medication, or ideally, to discontinue unnecessary drugs altogether. GDR decisions should be individualized, considering the patient's condition, goals, and potential risks and benefits. Detailed documentation of the rationale for medication changes and the patient's response are essential. GDR may not be suitable in all cases, such as for patients with chronic psychotic disorders or those who pose a risk to themselves or others. Effective GDR relies on collaboration among the healthcare team, patient, and caregivers. Resident #14 was admitted into the facility in late 2024 with a diagnosis of dementia. On 8/4/25 at 9:40 AM, a review of the resident's medical record indicated that MRR had been conducted monthly since admission, however the last one documented was done on 3/23/25. On 8/4/25 at 10:27 AM, the Director of Nursing (DON) was interviewed about the facility's process with MRR. He indicated that the 2 unit managers (UM) send him a notification that the monthly reviews are done. When an irregularity is identified by the pharmacist, the UM's print the report for the attending physician and once addressed, it gets scanned in the resident's electronic medical record.The DON was asked about Resident #14's monthly MRR after March of 2025. The DON indicated that he would ask the UM's about it and would also provide a copy of the facility's MRR policy to the surveyor.On 8/4/25 at 10:45 AM, the DON returned to the surveyor with one of the nurse unit managers (Staff #1). Staff #1 indicated that after March of 2025, the pharmacist had identified irregularities with Resident #14's MRR. She provided the surveyor with a copy of the reports for months April, May, June and July. Staff #1 reported that the reports had not yet been scanned to the resident's electronic medical record. A review of the reports provided by Staff #1 was conducted on 8/4/25 at 11:28 AM. The review revealed recommendations from the pharmacist noting a GDR was recommended for 2 medications. (Clonazepam dated 5/26/25 and Lexapro dated 5/28/25) The attending physician response for both medications indicated no change in the current order or dose reduction was contraindicated, however, the space where the attending physician was supposed to put his reason for not changing the order was left blank.Further review of Resident #14's medical record failed to reveal documentation from the attending physician for not changing the resident's current dose of Clonazepam and Lexapro against the recommendation from the consultant pharmacist.On 8/4/25 at 12:24 PM, a review of the MRR policy provided by the DON was conducted. The policy stated, Prescriber provides an explanation for disagreeing to recommendation. Further review of the policy failed to indicate a timeframe for all the steps in the MRR process. A subsequent interview was conducted with the DON on 8/4/25 at 2:43 PM. During the interview, the concern was discussed that the attending physician failed to document his reason/explanation why he disagreed with the pharmacy recommendation on 5/26/25 and 5/28/25. Also, after reviewing the policy for MRR, it failed to specify the timeframe for all the steps in the process. The DON confirmed the findings, verbalized understanding and acknowledged the concerns.

Based on medical record review and interview it was determined that the facility failed to ensure residents were free from significant medication errors. This was found to be evident for one (Resident #114) of 15 residents reviewed for potential abuse.The findings include: Review of Resident #114's medical record revealed the resident was admitted to the facility in 2023 with diagnosis that included, but not limited to, dementia and high blood pressure. The resident had an order for Metoprolol extended release 25 mg give one tablet one time a day related to hypertension (high blood pressure) and to Hold if the pulse (heart rate) was less than 60 or if the SBP(systolic blood pressure - the top number of a blood pressure reading) was less than 130. This order was in effect from 9/26/24 until it was discontinued on 3/28/25.Review of the March 2025 Medication Administration Record (MAR) revealed the metoprolol was administered on the following dates when the blood pressure and or heart rate were within the parameters to hold the medication:3/1 SBP was 1263/6 SBP was 121; HR: 553/10 SBP was1263/15 SBP was 1263/16: SBP 1263/22: SBP was 124 On 8/8/25 at 2:16 PM the Director of Nursing reported that he expects staff to follow the parameters that are included in orders for a medication. Surveyor reviewed the concern the metoprolol was administered on 6 occasions in March when, based on the ordered parameters, the medication should of been held. On 8/13/25 at 8:40 AM surveyor reviewed the concern regarding the failure to keep the resident free from a significant medication error with the Nursing Home Administrator.

Based on record reviews and interviews, it was determined that the facility failed to develop and complete a baseline care plan within 48 hours of a resident's admission. This was evident for 1 (Resident #96) of 12 residents reviewed for accidents.The findings include:Resident #96 was a newly admitted resident of the facility. Admitting diagnosis includes generalized muscle weakness and difficulty in walking.On 8/1/25 at 11:51 AM, a review of Resident #96's medical record revealed a fall risk assessment conducted on 7/22/25 by Licensed Practical Nurse (LPN #50), where the resident had a fall risk score of 9 (score of 10 and above indicated as high risk of falls).A subsequent review of Resident #96's medical record was conducted on 8/8/25 at 11:40 AM. The review revealed the following:a) Discharge summary from the hospital prior to the admission to the nursing facility indicated that the resident had generalized weakness with ambulatory dysfunction.b) Baseline care plan with sections A to M was initiated on 7/22/25. However, the only sections that had documentation were section J for social services, section K for therapy, and section M for signatures: signed by Rehab Director (Staff #45) on 7/22/25, Social Services Director (Staff #6) on 7/29/25, and Resident #96 on 7/29/25.c) Lift/Transfer/Reposition assessment indicated that the resident needed one person assist for repositioning in bed. However, the last section of the assessment had spaces to be marked as yes or no to indicate if care plan was developed with interventions was left blank. This assessment was signed by LPN #50 and dated 7/22/25.d) Clinical admission assessment was created by LPN #50 dated 7/22/25. However, the status indicated the assessment was still in progress.On 8/11/25 at 12:16 PM a copy of the medical records reviewed above was requested from medical records personnel (Staff #5). She printed and provided the surveyor the documents requested except for the clinical admission dated 7/22/25 and stated, I can't print it because it is still in progress indicating that it needed to be completed first for her to have the option to print the document.Further review of Resident #96's medical record on 8/11/25 at 1:50 PM revealed a progress note from LPN #50 with an effective date of 7/22/25 at 6:34 PM. in the progress note, she documented that the resident was admitted to the facility, used a wheeled walker and noted that the resident had a balance issue when ambulating.The Nurse Unit Manager (Staff #1) was interviewed on 8/11/25 at 2:07 PM. During the interview, she reported that the admitting nurse was responsible for initiating the baseline care plan and completing most of its sections. Resident #96's medical records were reviewed with Staff #1 on 8/11/25 at 2:20 PM. The review consisted of the resident's baseline care plan that was initiated 7/22/25 at 4:33 PM, where Staff #1 indicated that it was not a good example because all the nurse's parts were left blank and that the only staff members who documented on it were the rehab department and social services, The fall risk evaluation with an effective date of 7/22/25 at 5:55 PM conducted by LPN #50 was also reviewed with Staff #1. She confirmed that Resident #96 had a fall risk score of 9 and indicated that it meant a moderate risk for falls. Staff #1 reported that interventions should have been initiated in the baseline care plan for the resident's risk for falls.The concern that Resident #96's baseline care plan was not completed within 48 hours from admission was discussed with Staff #1. She verbalized understanding and acknowledged the concern.

Based on medical record review and staff and resident representative interview, the facility failed to 1) execute a safe and effective process to ensure that newly admitted resident records were reviewed to ensure that the correct resident's admission orders [REDACTED]. As a result, a resident received the wrong medications that included cardiovascular medication, [MEDICAL CONDITION] medication and [MEDICAL CONDITION] medication for 19 days and 2) failed to timely obtain and administer a Stat (immediate) pain medication and 2) failed to timely administer pain medication. This was evident for 2 (#5, #3) of 11 residents reviewed during a complaint survey. As a result, a condition of Immediate Jeopardy was declared on 6/5/19 at 11:33 AM. On 6/6/19 at 9:56 AM, the Immediate Jeopardy was lifted after an acceptable plan was put in place to correct process issues. The findings include: 1) On 6/4/19 at 9:00 AM, Resident #5's closed paper medical record and electronic medical record were reviewed. The medical record review revealed that Resident #5 was admitted to the facility on [DATE] following an acute hospital stay and was transferred to another skilled nursing facility (SNF) on 3/21/19. Review of Resident #5's After Visit Summary (hospital discharge summary), labeled with Resident #5's name, revealed a printed date of 3/1/19 at 12:23 PM, and fax received date of 3/1/19 at 1:24 PM. The summary included a list of medications that Resident #5 was to receive following his/her discharge from the hospital. Resident #5's (MONTH) 2019 MAR (medication administration record) was compared to the orders on the resident's hospital discharge summary and the medications on the MAR did not match the medications listed on Resident #5's discharge summary. Resident #5's (MONTH) 2019 MAR documented that Resident #5 received the following medications by mouth at least every day for 19 days: [MEDICATION NAME] ([MEDICATION NAME]) (hypertension (HTN) 5 mg (milligram) once a day Aspirin 81 mg twice a day Exemestane ([MEDICAL CONDITION] drug) every day [MEDICATION NAME] ([MEDICATION NAME]) (diuretic) every day [MEDICATION NAME] ([MEDICAL CONDITION]) once a day Potassium ChlorideER on ce a day, Carvedilol ([MEDICATION NAME]) (HTN) two times a day [MEDICATION NAME] ([MEDICATION NAME]) (anti-convulsant; treats nerve pain) three times a day [MEDICATION NAME] (HTN) three times a day and [MEDICATION NAME] AD ([MEDICATION NAME]) twice daily Supplements, multi-vitamins, Vitamin B, Calcium with Vitamin D and Vitamin C Resident #5's discharge summary medication list revealed that Resident #5 was to receive the following medications by mouth: [MEDICATION NAME] 2.5 mg once a day Aspirin 81 mg once a day, [MEDICATION NAME] (Vitamin D3) twice a day [MEDICATION NAME] ([MEDICATION NAME]) (platelet inhibitor) (prevents blood clots) once a day [MEDICATION NAME] ([MEDICATION NAME]) (antidepressant) every evening [MEDICATION NAME] (Normodyne) (HTN) twice daily [MEDICATION NAME] ([MEDICATION NAME]) (HTN) and [MEDICATION NAME] (antidiarrheal) twice daily. The medication list on Resident #5's hospital discharge summary did not match the medications that were documented as given on Resident #5's (MONTH) 2019 MAR. Further comparison of Resident #5's (MONTH) 2019 MAR and Resident #5's discharge summary medication list revealed that Resident #5 received cardiovascular, [MEDICAL CONDITIONS] and anti-convulsant medications that he/she had not been on prior to his/her admission to the facility. The resident's (MONTH) 2019 MAR revealed documentation that Resident #5 received [MEDICATION NAME], Aspirin and Vitamin D at different doses than what was listed on the discharge medication list and Resident #5 had not received his/her [MEDICATION NAME] and [MEDICATION NAME] as per his/her discharge medication list. Continued review of Resident #5's medical record reveal, on 3/2/19, in a History and Physical note, the physician indicated that Resident #5's medications were reviewed and documented that Resident #5's [DIAGNOSES REDACTED]. Continued review of the medical record failed to reveal evidence that Resident #5 had a history of [REDACTED].#5 had a history of [REDACTED]. Further comparison of Resident #5's (MONTH) 2019 MAR and Resident #5's discharge summary medication list revealed that Resident #5 received cardiovascular, [MEDICAL CONDITION] and [MEDICAL CONDITION] medications that he/she had not been prescribed prior to his/her admission to the facility. The resident's (MONTH) 2019 MAR documented that Resident #5 received [MEDICATION NAME], Aspirin and Vitamin D at different doses than what was listed on the discharge medication list and Resident #5 had not received his/her [MEDICATION NAME] and [MEDICATION NAME] as per his/her discharge medication list. On 6/4/19 at 11:50 AM, the Director of Nurses (DON) was made aware that the medications listed on Resident #5's (MONTH) 2019 MAR did not match the orders listed on Resident #5's hospital discharge After-Visit Summary. He/she was also made aware that there was no documentation in the medical record that addressed the discrepancy of the medications listed on Resident #5's (MONTH) 2019 MAR and the resident's hospital discharge medication list. On 6/4/19 at 12:00 PM, when asked what the process was for obtaining medication orders for newly admitted residents and the facility's admission orders [REDACTED]. The nurse reviews the resident's medications listed on the transfer summary with the physician, obtains the orders and puts the orders in the electronic medical record (EMR). This was done prior to the resident's arrival to the facility. The next day, the management team compares the transfer summary with the orders in the EMR. On 6/4/19 at 12:30 PM, continued review of Resident #5's paper medical record revealed a fax cover sheet with another person's name on it and a faxed hospital After Visit Summary (that included a list of medications) that had another's person's name on it. Review of the other person's medication list revealed that the medications listed on the hospital summary were the same as the medications, doses and frequency as the medications documented as administered on Resident #5's (MONTH) 2019 MAR. This indicated that Resident #5 had received the other person's medications. The other person's After Visit Summary was labeled with the other person's name, printed at 3/1/19 at 12:13 PM, and received by the facility on 3/1/19 on 1:15 PM. The summary had a medication list which indicated that the other person should take the following medication by mouth: [MEDICATION NAME] 5 mg once a day, Aspirin 81 mg twice daily, Carvedilol twice a day, Exemestane once a day, [MEDICATION NAME] once a day, [MEDICATION NAME] three times a day, [MEDICATION NAME] three times a day, [MEDICATION NAME] once a day, Potassium Chloride once a day and supplements (multi-vitamin, [MEDICATION NAME] with [MEDICATION NAME], Calcium and Vitamin D) once a day. The medication orders on Resident #5's (MONTH) 2019 MAR were compared against the other person's medications listed on the other person's summary and revealed that the medications listed on the other person's summary were the same medications listed on Resident #5's (MONTH) 2019 MAR. On 6/4/19 at 1:00 PM, the Director of Nurses and Administrator were made aware of the above findings and confirmed the findings at that time. On 6/4/19 at 1:30 PM, during an interview with the DON and ADON (assistant director of nurses) present, Staff #4 (LPN unit manager) stated that when the facility is notified that a new admission will be transferred that day, the nurse puts in batch standing orders (basic standard nursing orders) and puts in the discharge summary orders once they receive them via fax from the transferring facility. When the resident arrives to the facility and is admitted , the resident is assessed, the physician is called and the discharge orders from the transferring facility are reviewed. If the physician does not agree with the orders, the orders are amended to what the physician prescribes. On 6/4/19 at 1:58 PM, during an interview, Resident #5's representative (RP #1) stated that Resident #5 received the wrong medications the entire time the resident was at the first facility. RP #1 stated that they found this out when Resident #5 was admitted to the new facility and the staff at the new facility reviewed the medications with Resident #5 and the resident's other representative (RP #2). RP #1 stated that he/she did not know how this happened because when Resident #5 was discharged from the hospital, RP #1 and RP #2 transported the resident to the first facility and RP #2 hand carried Resident #5's hospital discharge paperwork, which included the correct medications that Resident #5 should have been on, and gave the paperwork to the receiving nurse at the first facility. RP #1 stated one of the things they were concerned about was, at the first facility, Resident #5 received [MEDICAL CONDITION] medication and did not have a [MEDICAL CONDITION] problem and Resident #5 received a [MEDICAL CONDITION] drug and he/she did not have [MEDICAL CONDITION]. On 6/4/19 at 2:55 PM, during an interview, Staff #4 stated when a resident is admitted to the facility, whoever receives the resident's hospital discharge paperwork packet that comes with the resident, should open it. Staff #4 stated if there is duplicate information, he/she shreds it and keeps the best copy. Medical records will thin what is not needed and place it in an envelope. If the facility is getting a resident from the local hospital, the hospital automatically faxes over the medication list. If the resident is coming from another hospital, he/she asks the hospital staff to fax over the resident's medications when they call report and the nurse will call the doctor before the resident gets here to go over the meds. . We call the doctor before the resident gets here, go over the meds. Staff #4 was asked if he/she normally goes through the hospital paperwork and the response was, it depends on how busy you are. I may peek through it, should check it but it depends on how many admissions that day. There are some days when we get 5 or 6 admissions, usually on a Friday. I did the admission assessment. The DON put the meds in the computer before the resident came. The packet went to the floor nurse. I just did the assessment. Someone comes after me; they should have opened the packet and checked, the second shift, 7 PM to 7 AM. The hospital packet was probably shoved in the back of the chart or not put in until later. I personally did not look at the hospital paperwork. On 6/4/19 at 3:00 PM, during an interview, the medical record staff stated that he/she looks at the name, glances here and there and stated do I look at every piece of paper, no, I have caught things before but in this case I didn't. Knowing now what could happen, I would have to look at each page when I put the medical records together. He/she stated the chart is thinned after 10-15 days, after MDS looks through it; he/she takes out the hospital paperwork, puts it in an envelope and leaves the discharge summary, med list and transfer summary on the chart. On 6/4/19 at 3:16 PM, during an interview, the DON stated that they compare what is faxed; the hospital discharge paperwork packet is compared to the faxed hospital transfer packet summary that was sent over initially. The next day management does a review. The DON stated that someone handed the papers to him/her from the fax machine and he/she started entering the meds in the computer. In the morning they checked the meds, PPD, pneumonia and flu consent, and all assessment were done. On 6/4/19 at 3:39 PM, the DON stated that the chart check was done by the DON and the ADON. Floor nurses aren't looking at the transfer summary. They are doing assessments and he/she did not feel that the original got to the chart. On 6/4/19 at 4:47 PM, during a phone interview, the physician stated that when a patient comes into the facility the nursing admission staff do the processing of the resident. When the physician sees the resident in the facility, he/she reviews all the hospital paperwork, plan of care and signs off on the medications in the resident's electronic record. When asked if he/she was aware of the concerns related to Resident #5's admission medication orders not matching Resident #5's hospital transfer summary, the physician stated he/she found out today, 6/4/19, and that there was some confusion with what was written in the resident's chart but he/she did not know the details It was also noted that on 3/2/19, in the History and Physical exam, the physician indicated that Resident #5's medications were reviewed. On 6/4/19 at 4:55 PM, during an interview, RP #2 stated that Resident #5 had been at the facility for about a week, when he/she told RP #2 that he/she was getting too many medications. RP #2 stated he/she asked a nurse about the resident's medications and was told the resident got vitamins and medication for dehydration, so it didn't bother him/her too much. RP #2 stated that when the resident continued to complain, he/she asked a nurse for a medication list, but never received one. RP #2 stated that the family and resident decided to transfer to another facility, so on 3/20/19, the resident was transferred from the first facility to a different long-term care facility. RP #2 stated that when the physician from the new facility came in and reviewed Resident #5's medications with the resident and the family, they realized Resident #5 had received the wrong medications at the previous facility. The transferring facility sent the list of medications the resident received at the first facility along with physician's orders [REDACTED]. A condition of Immediate Jeopardy was verbally declared on 6/5/19 at 11:33 AM and the Immediate Jeopardy Template was provided to the facility on [DATE] at 3:55 PM. The Immediate Jeopardy was lifted on 6/6/19 at 9:56 AM, after an acceptable plan was put in place to correct process issues. The facility's abatement plan included the following: The facility changed their process for receiving admission paper work for new residents. The facility put processes in place to ensure the accuracy of a resident's admission orders [REDACTED]. The facility audited resident's transfer summaries for reconciliation of the resident's name on the chart and the hospital discharge summary. A New Admission/Readmission Check Off List form and a New Admission Chart Audit form was developed. All nurses, department heads and physicians were in-serviced on the admission process and reconciling the hospital discharge summary to the resident's chart to verify the name of the resident. The facility staff would conduct random monthly audits of resident charts to ensure that the new admissions process is in compliant. The Quality Assurance and Performance Improvement Committee would review the results of the resident chart audits. 2) Review of the medical record for Resident #3 on 6/4/19 revealed a nursing progress note dated 3/30/19 at 5:45 PM which documented, new orders received: [MEDICATION NAME] solution 100/5 ml. Give 0.25 ml PO (by mouth) BID (twice per day) PRN (when necessary) for pain x (times) 2 days. Resident is not very active and has open areas on buttocks. [MEDICATION NAME] is observed to be ineffective for pain management at this time. Resident keeps moving arms and legs and appears in distress. Family expressed concern for patient's pain management being effective and being a priority at this time. The nursing note continued, (name of family member) made aware of [MEDICATION NAME] order. Orders for [MEDICATION NAME] received by (physician) at this time. On 3/30/19 at 7:25 PM a nursing note documented, discontinue [MEDICATION NAME] as [MEDICATION NAME] is in place, per physician. On 3/31/19 at 1:58 AM a nursing note documented, resident did not receive his/her [MEDICATION NAME] this shift. Resident was assessed for pain and was not comfortable, was given Tylenol as ordered. On 3/31/19 at 9:22 AM Staff #10 documented in the (MONTH) 2019 Medication Administration Record (MAR) that the [MEDICATION NAME] was not available. It was documented that the [MEDICATION NAME] was given at 3:06 PM on 3/31/19, which was 22 hours after the order was received by the physician. An interview was conducted with Resident #3's family member on 6/4/19 at 9:47 AM. The family member stated, they didn't give him/her the [MEDICATION NAME] and my sister-in-law came in on Sunday and said she didn't have the [MEDICATION NAME] and that Staff #9 stated that he/she tried to call the pharmacy and deal with the script for the [MEDICATION NAME] 3 times and gave up. Staff #8 stated on 6/4/19 at 10:40 AM, I wrote the concurrent review on 3/30/19 because I was trying to help out because I knew the son would escalate if not handled promptly. (name) was working but he didn't go to him/her, he came to me. It was a very complex situation because you must get the narcotic script and the physician must sign it and it needs to be either faxed back here or to the pharmacy. I had to call the pharmacy to get an authorization to get it out of the Pixis (locked medication drawer). It was complex because the doctor did not want to give 0.5 ml because he/she thought it was too strong and he/she went back and forth with the pharmacy. I left at the end of my shift and I told the oncoming nurse, Staff #9, that he/she had to follow up. It was a lot of miscommunication back and forth between the physician and the pharmacy. The nurse the next day, Staff #10, was new and a PRN nurse and not as aggressive and thorough. I got involved when I saw the resident had not received the medication. We were back and forth on the phone with the physician. Also, the medical director at the time was handling the issue and it wasn't the resident's regular physician. Staff #8 continued, we do have problems with the pharmacy, they don't send medications in a timely manner. Staff #10 stated on 6/4/19, when I arrived, I didn't receive in report from Staff #9 that he/she had a new [MEDICATION NAME] order. I relieved Staff #9 and I looked at the MAR and realized the [MEDICATION NAME] wasn't in the cart and I marked it not available. I assumed the night shift would have taken care of it. Staff #10 continued, Staff #8 was upset because it had not been taken care of. Staff #8 sat down with me and we called the doctor. The order was called in the day before as a STAT order and on Sunday it still took a little while and the pharmacy argued with us. On 6/4/19 at 11:56 AM the Director of Nursing (DON) was interviewed and stated he/she was aware of the situation and there was an issue between the physician and the pharmacy with the dosage. The DON was asked if he/she considered it a delay in treatment and the response was, yes. On 6/4/19 at 4:55 PM Staff #9 was interviewed and stated, they told me they got the order and the script was faxed. When it didn't come at midnight, I called the pharmacy and asked if he/she got the script and when I asked if I could get an authorization number to give the med the pharmacist said no because he/she didn't have a valid script. Staff #9 continued, I had just switched from daylight to evening and I was at a loss of what to do and wasn't sure on night shift what to do, if I should call the doctor in the middle of the night. Review of Staff #9's employee file revealed a Disciplinary Action Form for date of 3/31/19 for failure to follow policy by not following procedure in obtaining medication timely. It was a written warning from the DON and signed by Staff #9 on 4/1/19. This was not the first disciplinary action for Staff #9 as a second disciplinary action form dated 8/30/18 was noted in the employee's personnel file for administering a pain pill 2 1/2 hours after a resident had requested a pill for pain.

Based on review of the medical record, staff interview, and facility documents, it was determined that the facility staff failed to maintain adequate hydration for a resident known to be at risk for dehydration. This was evident for 1 of 2 (#172) residents reviewed for death. The findings include: Resident #172 was an [AGE] year old male admitted to an acute care facility for altered mental status on [DATE]. He was treated for [REDACTED]. His admitting [DIAGNOSES REDACTED]. According to his admission history and physical found in the medical record, and dated [DATE], his prognosis was fair and he had fair rehabilitation potential. Resident #172 had an admitting physician order [REDACTED]. He had a physician's orders [REDACTED]. His [DATE] admission orders [REDACTED]. On [DATE], the day his physician saw him and did a physical, he wrote an order for [REDACTED]. Weight and electrolyte monitoring aid in the assessment of ones hydration status. Resident #172 weighed 121 pounds on admission, according to his Admission / Readmission Data Collection form, dated [DATE], and found in the medical record. A Nutrition / Hydration care plan was implemented on [DATE]. Resident #172's next weight taken was documented on the Vital Signs & Weight Record on [DATE], and was 117.4 pounds. This showed a weight loss of 3.6 pounds in 4 days. The facility staff failed to follow the resident's physician's orders [REDACTED]. Interview of the NHA (Nursing Home Administrator) on [DATE] at 2:12 PM revealed there were no other weights for [DATE] or [DATE]. This weight loss of [DATE], was addressed and new physician's orders [REDACTED].@ B (breakfast) Fortified potatoes L&D (lunch and dinner)." The next weight was taken on [DATE], and showed that the resident weighed 105 pounds on that day. A reweigh was done on the same day, and confirmed the 105 pound weight. This is a 16 pound weight loss since admission. Resident #172 experienced a significant weight loss of 13.2% in 10 days. Interview of GNA #1 (Geriatric Nursing Assistant), on [DATE] at 2:45 PM, revealed that she was given a list of residents whose weight required monitoring and after the weights were taken, she returned them to the unit manager the same day. Interview of Unit Manager #1 on [DATE] at 8:45 AM, confirmed this was the protocol for weights. Subsequently, UM #1 is to notify the physician regarding weight loss and a copy of the entire weight list is given to the dietary staff in the kitchen. Continued interview of Unit Manager #1 revealed that the physician was not notified of resident #172's significant weight loss on [DATE]. She stated that the dietian would be notified if the physician requested notification. Interview of Dietian #1, on [DATE] at 9:20 AM, revealed that the weight list is placed in the dietary office in the kitchen and she reviews the list but was not sure if the list was there before she left for the day on [DATE]. She stated the next day that she worked was [DATE] and the weight loss was addressed at that time. The facility failed to notify the physician or the dietian of a significant weight loss in a timely manner for a resident at risk for dehydration. The facility failed to follow the care plan that was developed for Nutrition / Hydration which listed as an intervention to notify physician of weight fluctuation. Another intervention on the Nutrition / Hydration care plan was monitor and report signs and symptoms of dehydration to the physician. There was a list of signs and symptoms that included decreased urine output, concentrated urine, fatigue/weakness, recent/sudden weight loss. Resident #172 is described in Daily Skilled Nurse's Notes on [DATE] at 5 AM as pale, weak, inelastic skin and foley catheter draining dark yellow urine. The same day at 8 AM a nurse's note states "Foley catheter patent draining dark amber urine." On [DATE] at 5:10 AM and [DATE] at 3:10 AM Skilled Nurse's Notes written reveal again resident weak and foley catheter patent for dark concentrated urine. These signs and symptoms of dehydration were not reported to the physician as confirmed by the NHA on [DATE] at 2:35 PM. The care plan also stated to provide and serve supplements as ordered. Which for this resident consisted of the magic cup with meals and staff was to record the percentage consumed. Review of the Nurses Aide Records for this resident for [DATE] and [DATE] failed to reveal that the supplement was given 7 of 26 times and that the percentage consumed was not documented 8 of 26 times. There was no consistent documentation that resident #172 was consuming or was not eating the fortified cereal or potatoes that were ordered at meals. His meal consumption varied from refused to 25% to 75%. The same care plan also had a goal that the resident would "maintain acceptable nutritional parameters as evidenced by: Labs WNL"(within normal limits). The facility failed to follow physician orders [REDACTED]. No laboratory blood work was done for resident #172 until [DATE] at 10 AM. He was described in a daily skilled nurse's note on [DATE] at 4 AM as pale color, inelastic skin, foley catheter draining dark amber urine, shallow breathing at rest, short of breath with exertion and very weak. The physician was contacted at 9:45 AM and an order was written for a CBC and BMP stat which was collected at 10 AM. The laboratory blood work results returned on [DATE] after the resident expired at the facility. Resident #172 had a fluid deficit of 3.27 liters and a serum osmolality level of 341.33 milliosmoles per kilogram of water (Normal is 278 -300, high serum osmolality levels may be caused by too little water water in the body). Interview of Physician #1 on [DATE] at 10:10 AM revealed that he could not recall being notified of significant weight loss or any change in condition. He stated that if he had been notified he would have ordered IV (Intravenous) hydration. He stated his expectation was that the resident would improve and return to his assisted living facility. Cross reference F 157 & F 309.

Based on review of the medical record, staff interview and facility documents, it was determined that the facility staff failed to: 1) monitor,recognize changes and provide appropriate interventions for a resident at risk for dehydration. This was evident for 1 of 2 (#172) residents reviewed for death. 2) Assess the resident for pain in the right leg even though an x-ray was ordered to rule out fracture, failed to give pain medication when concurrent review stated "pain present", failed to follow the resident's care plan for pain, and failed to immediately notify the physician after receiving the x-ray results. This was evident for 1 of 41 (#193) residents reviewed during stage 2 of the survey. 3) Notify the physician of non-compliance, and failed to develop a plan of care for non-compliance. This was evident for 1 of 41 (#134) residents reviewed during stage 2 of the survey. The findings include: 1) Resident #172 was an [AGE] year old male admitted to the facility on [DATE]. His admitting [DIAGNOSES REDACTED]. He was to receive CPR (cardiopulmonary resuscitation) if needed, according to the admitting physician orders. Resident #172's Admission / Readmission Data Collection form, dated [DATE] at 2 PM, revealed that the resident was lethargic, oriented to name only, weighed 121 pounds, had moist lips, normal mucous membranes, no [MEDICAL CONDITION] , dusky color, clear breath sounds upper and lower with no cough. It also noted he had a foley catheter draining yellow urine and is dependent on staff for provision of fluid intake. According to his admission history and physical found in the medical record and dated [DATE], resident #172's prognosis was fair, and he had fair rehabilitation potential. The history and physical also noted the resident's chest was clear. Resident #172 had an admitting physician order [REDACTED]. He had a physician's orders [REDACTED]. His [DATE] admission orders [REDACTED]. On [DATE], the day his physician saw him and did a physical, he wrote an order for [REDACTED]. Weight and electrolyte monitoring aids in the assessment of ones hydration status. A Nutrition / Hydration care plan was implemented on [DATE]. Resident #172's next weight taken was documented on the Vital Signs & Weight Record on [DATE] and was 117.4 pounds. This shows a weight loss of 3.6 pounds in 4 days. The facility staff failed to follow the resident's physician's orders [REDACTED]. Interview of the NHA (Nursing Home Administrator) ,on [DATE] at 2:12 PM, revealed there were no other weights for [DATE] or [DATE]. This weight loss, [DATE], was addressed and new physician's orders [REDACTED].@ B (breakfast) Fortified potatoes L&D (lunch and dinner)." The next weight was taken on [DATE], and showed that the resident weighed 105 pounds on that day. A reweigh was done on the same day, and confirmed the 105 pound weight. This was a 16 pound weight loss since admission. Resident #172 experienced a significant weight loss of 13.2% in 10 days. Interview of GNA #1 (Geriatric Nursing Assistant), on [DATE] at 2:45 PM, revealed that she was given a list of residents who required weight monitoring, and when weighing was completed for those residents, the list of those residents was given to Unit Manager #1 the same day. Interview of Unit Manager #1, on [DATE] at 8:45 AM, confirmed the protocol for weights, and then physician notification is completed by UM #1 if there was a weight loss and a copy of the entire weight list is given to the dietary staff in the kitchen. Continued interview of Unit Manager #1 revealed that the physician was not notified of this significant weight loss on [DATE]. She continued stating that the dietian would be notified if the physician requested notification. Interview of Dietian #1, on [DATE] at 9:20 AM, revealed that the weight list is placed in the dietary office in the kitchen and she reviews the list, but was not sure if the list was there before she left for the day on [DATE]. She stated that the next day that she worked was [DATE], and the weight loss was addressed at that time. The facility failed to notify the physician or the dietian of a significant weight loss in a timely manner for a resident at risk for dehydration. The facility failed to follow the care plan that was developed for Nutrition / Hydration, which listed as an intervention to notify physician of weight fluctuation. Another intervention on the Nutrition / Hydration care plan was monitor and report signs and symptoms of dehydration to the physician. There was a list of signs and symptoms that included decreased urine output, concentrated urine, fatigue/weakness, recent/sudden weight loss. Resident #172 was described in Daily Skilled Nurse's Notes on [DATE] at 5 AM, as pale, weak, inelastic skin and foley catheter draining dark yellow urine, congested cough, lungs with ronchi (low pitched snore like sounds in the lungs) and wheezing. The same day at 8 AM a nurse's note stated "Foley catheter patent draining dark amber urine." The physician was not notified of these change in conditions. On [DATE] at 5:10 AM, and [DATE] at 3:10 AM, Skilled Nurse's Notes written revealed again resident weak and foley catheter patent for dark concentrated urine, exertional dyspnea. The physician was not notified of these change in conditions. The only Concurrent Review Clinical Evaluations, which are done when a resident has a change in condition, were done on [DATE] and [DATE]. The Concurrent Review form completed on [DATE] was for a skin tear and the one completed on [DATE] was for orders for constipation and to monitor for signs and symptoms of diabetes. The physician and family were notified for both change in conditions on [DATE]. Both Concurrent Review forms have a Nutrition/ Hydration checklist section which lists meal intakes, intake and output, and current weight. All areas listed have no change marked, even though the resident had a significant weight loss of 13.2% on [DATE]. On [DATE] at 7:15 PM, a nurse's note stated "ST (Speech Therapy) working with him only eating ,[DATE] bites per meal then refusing consistency pudding liquids due to over production of saliva that is thinning liquids down, to thin to swallow at times." Interview of Physician #1 on [DATE] at 10:10 AM revealed that he could not recall being notified of significant weight loss or any change in condition related to intake. He stated that if he had been notified, he would have ordered IV (Intravenous) hydration. Resident #172 also had a foley catheter making it easy to monitor urinary output. The care plan, as previously stated, had an intervention to report decreased urine output. Review of the medical record failed to reveal any change in urine output documented, other than color. The care plan also stated to provide and serve supplements as ordered, which for this resident consisted of a magic cup with meals, and staff was to record the percentage consumed. Review of the Nurses Aide Records for this resident for [DATE] and [DATE] failed to reveal that the supplement was given 7 of 26 times and that the percentage consumed was not documented 8 of 26 times. There was no consistent documentation that resident #172 was consuming, or was not eating the fortified cereal or potatoes that were ordered at meals. His meal consumption varied from refused to 25% to 75%. The same care plan also had a goal that the resident would "maintain acceptable nutritional parameters as evidenced by: Labs WNL"(within normal limits). The facility failed to follow physician orders [REDACTED]. No laboratory blood work was done for resident #172 until [DATE] at 10 AM. He was described in a daily skilled nurse's note on [DATE] at 4 AM as pale color, inelastic skin, foley catheter draining dark amber urine, shallow breathing at rest, short of breath with exertion and very weak. The physician was contacted at 9:45 AM and an order was written for a CBC and BMP stat, which was collected at 10 AM. Resident #172 was found pulseless at 12 noon, and cardiopulmonary resuscitation was initiated and 911 called. The resident expired at the facility. The laboratory blood work results returned on [DATE] after the resident expired at the facility. Resident #172 had a fluid deficit of 3.27 liters and a serum osmolality level of 341.33 milliosmoles per kilogram of water (Normal is 278 -300, high serum osmolality levels may be caused by too little water water in the body). Cross reference F 157 & F 327. 2) Review of the physician's orders [REDACTED]." There were 3 nursing notes found in the medical record related to the right leg. The first nursing note written on [DATE] at 4:00 PM stated "x-ray of right leg to r/o (rule out) fracture. Awaiting (company name). See concurrent review. The second nursing note, written on [DATE] at 9:00 PM, stated "this writer updated POA (Power of Attorney) on x-ray results." The third nursing note written on [DATE] at 3:00 PM stated "MD notified of x-ray results." Review of the Concurrent Review Clinical Evaluation form, dated [DATE], stated the following: Under reason for review/symptoms - the area was blank. Under the section for pain the "pain present" box was checked off with location to the right leg. Under the section for falls/injuries/incidents in the last 24 hours the box "no" is checked off. The accompanying note stated "x-ray of right leg to r/o fracture." Review of the [DATE] Medication Administration Record [REDACTED]. There is no documentation that pain medication was given, even though the [DATE] concurrent review stated "pain present." Review of the Pain Flow Sheet was blank from [DATE] to [DATE]. There was no further documentation found in the medical record related to pain of the right leg. 3) The facility staff failed to communicate to the physician the refusal of TED hose, which was ordered by the physician for [MEDICAL CONDITION], failed to document other interventions used to attempt to get the resident to wear the TEDs, and failed to develop a plan of care to address the refusals. Review of the medical record for Resident #134 revealed an order for [REDACTED].#134 sitting in her room in a wheelchair with red slipper socks on both feet. The resident was not wearing TED hose. TED hose are also known as compression stockings. A second observation was made, on [DATE] at 9:32 AM, of Resident #134 sitting in her room in a wheelchair with red slipper socks on and a third time on [DATE] at 4:40 PM. Again, the resident was not wearing TED hose. Review of the Geriatric Nursing Assistant (GNA) administration record for [DATE] showed documentation that the resident refused the TED hose for 20 days, and in [DATE], [DATE] and February 2015, the resident refused the TEDs every day. There was no documentation found in any of the nursing notes reflecting the refusals. There was no documentation found in the medical record that the physician was aware of the refusal. Review of the care plan failed to indicate that the resident was wearing TED hose for [MEDICAL CONDITION] (excess fluid) and failed to have a plan for the refusal, even though there is documentation found in physician notes stating the resident had [MEDICAL CONDITION] in the lower extremities. Documentation was also found in Occupational Therapy notes dated [DATE] stating " resident's LB (lower body) [MEDICAL CONDITION] resolved and tolerating TED hose daily. "

Based on review of the medical record and staff interview, it was determined that the facility staff failed to 1) notify a resident's physician, responsible party and dietitian in a timely manner when a resident experienced a significant weight loss and significant changes in their medical condition. This was evident for 1 of 2 (#172) residents reviewed for death. 2) Notify the resident's physician of a resident's refusal of treatment. This was evident for 1 of 41 (#134) residents reviewed during stage 2 of the survey. 3) Notify a residents physician of x-ray results in a timely manner. This was evident for 1 of 41 (#193) residents reviewed during stage 2 of the survey.The findings include : 1) Resident #172 was an [AGE] year old male admitted to the facility on [DATE]. His admitting [DIAGNOSES REDACTED]. He was to receive CPR (cardiopulmonary resuscitation) if needed according to the admitting physician orders. Resident #172's Admission / Readmission Data Collection form, dated [DATE] at 2 PM, revealed that the resident was lethargic, oriented to name only, weighed 121 pounds, had moist lips, normal mucous membranes, no [MEDICAL CONDITION] , dusky color, clear breath sounds upper and lower with no cough. It also notes he has a foley catheter draining yellow urine and is dependent on staff for provision of fluid intake. According to his admission history and physical found in the medical record, and dated [DATE], his prognosis was fair and he had fair rehabilitation potential. The history and physical also noted the resident's chest was clear. Resident #172 had an admitting physician order, dated [DATE], for a pureed diet with pudding thick fluids due to dysphagia (difficulty swallowing). On [DATE], the day his physician saw him and did a physical he wrote an order for [REDACTED]. On [DATE], new physician's orders [REDACTED].@ B (breakfast) Fortified potatoes L&D (lunch and dinner)." A weight was taken on [DATE] and showed that the resident weighed 105 pounds. A reweigh was done on the same day and confirmed the 105 pound weight. This was a 16 pound weight loss since admission. Resident #172 experienced a significant weight loss of 13.2% in 10 days. Interview of Unit Manager #1, on [DATE] at 8:45 AM, revealed that the physician was not notified of this significant weight loss on [DATE]. She continued stating that the dietitian would be notified if the physician requested notification. Interview of Dietitian #1, on [DATE] at 9:20 AM, revealed that the weight list was placed in the dietary office in the kitchen and she reviewed the list but was not sure if the list was there before she left for the day on [DATE]. She stated that the next day that she worked was [DATE], and the weight loss was addressed at that time. The facility failed to notify the physician, the dietitian, and responsible party of a significant weight loss in a timely manner for a resident at risk for dehydration. Interview of Physician #1, on [DATE] at 10:10 AM, revealed that he could not recall being notified of significant weight loss or any change in condition related to intake. He stated that if he had been notified, he would have ordered IV (Intravenous) hydration. The facility failed to follow the care plan that was developed for Nutrition / Hydration which listed as an intervention physician notification of weight fluctuation. Another intervention on the Nutrition / Hydration care plan was the monitoring and reporting signs and symptoms of dehydration to the physician. There was a list of signs and symptoms that included decreased urine output, concentrated urine, fatigue/weakness, recent/sudden weight loss. Resident #172 was described in Daily Skilled Nurse's Notes on [DATE] at 5 AM as pale, weak, inelastic skin and foley catheter draining dark yellow urine, congested cough, lungs with ronchi (low pitched snore like sounds in the lungs) and wheezing. The same day at 8 AM, a nurse's note stated "Foley catheter patent draining dark amber urine." Review of the medical record failed to reveal that the physician was made aware of these changes in the resident condition. On [DATE] at 5:10 AM, and [DATE] at 3:10 AM, Skilled Nurse's Notes written revealed resident to be weak and foley catheter patent for dark concentrated urine, exertional dyspnea. The only Concurrent Review Clinical Evaluations, which are done when a resident has a change in condition, were done on [DATE] and [DATE]. The Concurrent Review form completed on [DATE] was for a skin tear and the one completed on [DATE] was for orders for constipation and to monitor for signs and symptoms of diabetes. The physician and family were notified for both change in conditions on [DATE]. Both Concurrent Review forms had a Nutrition/ Hydration checklist section which listed meal intakes, intake and output, and current weight. All areas listed have no change marked. Even though the resident had a significant weight loss of 13.2% on [DATE]. On [DATE] at 7:15 PM, a nurse's note stated "ST (Speech Therapy) working with him only eating ,[DATE] bites per meal then refusing consistency pudding liquids due to over production of saliva that is thinning liquids down, to thin to swallow at times." Interview of Physician #1, on [DATE] at 10:10 AM, revealed that he could not recall being notified of significant weight loss or any change in condition related to intake. He stated that if he had been notified he would have ordered IV (Intravenous) hydration. The resident expired on [DATE]. Cross reference F 309 and F 327.This is a repeat deficiency from the annual survey of [DATE]. 2) Review of the medical record for Resident #134 revealed an order for [REDACTED].#134 sitting in her room in a wheelchair with red slipper socks on both feet. The resident was not wearing TED hose. TED hose are also known as compression stockings. A second observation was made, on [DATE] at 9:32 AM, of Resident #134 sitting in her room in a wheelchair with red slipper socks on, and a third time on [DATE] at 4:40 PM. Again, the resident was not wearing TED hose. Review of the Geriatric Nursing Assistant (GNA) administration record for [DATE] showed documentation that the resident refused the TED hose for 20 days, and in [DATE], [DATE] and February 2015, the resident refused the TED hose every day. There was no documentation found in any of the nursing notes reflecting the refusals. There was no documentation found in the nursing notes, or the physician notes, that the physician or the family were made aware of the refusal of Ted hose over the past 3 ,[DATE] months, even though it was documented in the Occupational Therapy Discharge Summary, dated [DATE], that the resident would tolerate daily wearing of TED hose 100% of the time due to [MEDICAL CONDITION]. 3) Review of the physician's orders [REDACTED]." There were 3 nursing notes found in the medical record related to the right leg. The first nursing note written on [DATE] at 4:00 PM stated "x-ray of right leg to r/o (rule out) fracture. Awaiting (company name). See concurrent review. The second nursing note written on [DATE] at 9:00 PM stated "this writer updated POA (Power of Attorney) on x-ray results." The third nursing note, written on [DATE] at 3:00 PM, stated "MD notified of x-ray results." The physician was notified 2 days later of the x-ray results. Physician notification of test results allows the resident's physician the opportunity to revise their treatment plan to promote optimal health. Cross Reference F309