Every finding on record at Greenspring Village

Based on observation, resident interview, staff interview, clinical record review and facility documentation review, the facility staff failed to implement interventions to prevent the development of a pressure ulcer for one resident, Resident #1 (R1) of 33 residents in the survey sample, which resulted in a facility acquired wound that was identified at the advanced stage 3, constituting harm. The findings included: According to the clinical record, R1 was admitted to the facility on [DATE]. Diagnoses for R1 included but are not limited to muscle weakness, osteoarthritis, venous insufficiency, dementia, and lack of coordination. R1's Significant Change Minimum Data Set (an assessment tool), dated 1/11/2025, coded R1 with severe cognitive impairment, limited range of motion to left side, impaired mobility, and urinary & fecal incontinence. This assessment also coded R1 as dependent for turning & repositioning, while coding that R1 required maximal assistance for transferring. Although this assessment identified the presence of a stage 3 wound, there were no diagnosis coded to identify the specific wound location or type. On 3/3/25 at 3:00 p.m., a tour of unit 300 was conducted. During the tour, R1 was observed reclining in bed watching her television, which was mounted on the opposite wall in her room. On 3/4/25 at approximately 1:45 p.m., an interview was conducted with R1. R1 was laying on her back in bed with her head elevated, watching television. During the interview, R1 said, I have a wound on my butt that hurts sometimes. R1 was not able to recall how long she has had this wound. R1 said, I stay in the bed too much. They say they will get me up but never do. On 3/5/25 at approximately 8:50 a.m., an interview was conducted with LPN#3 (LPN3). During the interview, LPN3 stated that skin assessments were completed twice weekly. LPN3 stated, When a pressure wound heals, the skin is tender, and we order a protective dressing to be used. LPN3 said, We turn and reposition the resident [R1] every two hours and use the preventive treatment dressing until we feel the skin is stronger. LPN3 stated that R1 sometimes refused to get out of bed and that R1 did not like being transferred using a Hoyer lift. There was no documentation in the nurses notes or care plan about R1 refusing to get out of the bed or not liking to be transferred with the Hoyer lift. On 3/5/25 at approximately 10:00 a.m., a clinical record review was conducted. A wound assessment dated [DATE], documented that R1 had a facility acquired, stage 2 pressure wound on the sacrum. On 9/11/24, a wound assessment was completed, which read in part, . wound bed not visible. Started on 3/20/24, a physician's order for optifoam dressing to the sacrum 3 times a week & as needed was documented as active until 11/13/24. On 9/20/24, a physician's order was written for a protective dressing which read, Clean sacrum wound with wound cleanser, pat dry, cover with opt-view transparent dressing with hydro-core. Change dressing every six days. On 10/9/24, a wound assessment noted the facility acquired sacral wound was healed. On 11/21/24 a wound assessment read in part, .acquired since admission . coccyx -reopened wound . stage 3. The documented measurements were 1.0 cm length x 0.8 cm width x 2.0 cm depth, with 2.0 cm depth tunneling between 12 and 3 o'clock. The assessment also noted that the wound bed had moderate serous-sanguineous (thin, yellow fluid with a pink or red tinge) drainage and a mild odor. A review of R1's Treatment Administration Record (TAR) revealed that the optifoam dressing 3 times a week, which started on 3/20/24, was documented as completed until 11/13/25. The TAR also revealed that the optiview dressing treatment every 6 days to the healed sacral area was also documented weekly since 10/9/24. R1's care plan interventions included an alternating pressure mattress and gel cushion to wheelchair, but there were no new preventative measures implemented from 10/9/24, when the sacral wound healed, despite R1 being documented as high risk for skin breakdown, nor was there any change in the treatment in response to the new coccyx wound that was identified on 11/21/24. On 3/5/25 at approximately 11:45 a.m., an observation was conducted of the treatment to R1's stage 3 coccyx wound. R1 was observed reclining on her back watching television and required total assistance of two nursing staff to turn her onto her side for the wound care. R1 was not able to assist with this repositioning and appeared ridged throughout, with arms clenched at her sides, but tolerated it well. A licensed practical nurse, LPN#4 (LPN4), was observed performing the wound care for R1. Once exposed, R1's coccyx wound was a full thickness, with obvious depth, and pink, beefy tissue, but no foul odor was noted. The wound also had rolled edges, and lateral space underneath the skin, into which gauze dressing had been packed. The old dressing and wound packing were saturated with drainage. Also visible was healed scar tissue on the sacral area. On 3/5/25 at 4:30 p.m., R1 was again observed reclining on her back, in bed, watching television. On 3/5/25 at approximately 5:00 p.m., an end of day meeting was conducted with the director of nursing, administrator, the unit manager and assistant director of nursing. The surveyor discussed the concerns of R1's stage 2 sacral wound that was documented as having healed on 10/9/2024, and then on 11/21/24 a new wound was identified to the coccyx at a stage 3, instead of the acceptable stage 1. The facility was asked to provide any documentation regarding R1's pressure wounds, to include preventative measures and interventions. On 3/6/25 at 8:50 a.m., an observation was made of R1 laying on her back, with the head of the bed elevated, sleeping. On 3/6/25 at approximately 11:00 a.m., the facility provided a copy of an email from the registered dietician, dated 3/6/25, which appeared to be excerpts from the dietician's progress notes regarding R1. The email read in part, 9/29/24, follow-up d/t [due to] skin status . Seen during wound rounds for healing stage 2 sacral wound 0.5x0.5cm . The email also included the dietician's note, dated 11/14/24, which read in part, stage 2 sacral wound which is improving, but the nurses' clinical notes previously reviewed documented that the stage 2 sacral wound had healed on 10/9/24. A review of the email included the dietician's documentation dated 11/20/24 - 12/16/24, 11/28/24, and 11/29/24, but there was no mention of the stage 3 coccyx wound, which had first been identified on 11/21/24. Also included in this email was a dietician's note dated 12/19/24, which read in part, Skin: seen by wound team 12/17/24 for sacral stage 3 wound 4cmx4cmx3.5cm, tunneling: 9-12pm 3 cm, 12-3pm 2.5cm, Oval shaped . Left buttock stage 2: 0.5cmx0.8cm, Oval shaped . recommend Juven twice daily and active liquid protein 30 ml twice daily . for wound healing. No documentation, including skin assessments, treatments, or physician orders, was provided that addressed the stage 2 wound to the left buttock. On 3/6/25 at approximately 11:15 a.m., the facility provided skin assessments for review. The skin assessments completed on 11/8/24 indicated no skin impairments. The next skin assessment wasn't completed until 11/25/24 and had a circle on the sacral area, without any labeling or description of a wound. On 11/28/24, the skin assessment was completed and had an arrow pointing to the coccyx area with only pressure wound and treatment in progress noted on the assessment. On 3/6/25 at approximately 11:45 a.m., an interview was conducted with the administrator and the director of nursing. The director of nursing (DON) stated that she had a QAPI action plan that she wanted me to review. The plan was developed on 1/10/25, almost two months after R1 acquired the coccyx wound on 11/21/24. The listed interventions included staff education on pressure injury prevention, a skin sweep to all SNF [skilled nursing facility] residents, and audits. The action completed date was blank, and the Action Completed date was blank. The surveyor informed the DON and administrator that the survey team would review the information and that there was potential for harm. On 3/6/25 at approximately 11:55 a.m., a review of the facility policy titled, Skin Integrity Program, and it read in part, .prevention and management of alterations in skin integrity, including pressure injuries is a priority for the community. The approach to the management of pressure injuries and prevention will be consistent with professional standards of practice to promote healing, prevent infection, and prevent new ulcers/injury from developing. This policy also defined an avoidable wound as . resident developed a pressure ulcer/injury and that the facility did not do one or more of the following: evaluate the resident's clinical condition and risk factors, define and implement interventions that are consistent with the resident's needs, resident goals, and professional standards of practice, and evaluate the impact of the interventions or revise the interventions as appropriate. No additional information was provided prior to exit conference.

Based on staff interview, clinical record review and facility documentation review the facility staff failed to respond to medication reviews in a timely manner for three residents Resident #6 (R6), Resident #9 (R9) and Resident #31 (R31) out of a survey sample of 33 residents. The findings included: 1. The facility staff failed to review and respond to pharmacy consults in a timely manner. R6 was admitted to the facility on [DATE]. Diagnoses for R6 included but are not limited to unspecified psychosis, bipolar disorder and anxiety disorder. R6's Quarterly Minimum Data Set (an assessment protocol) with an Assessment Reference Date of 1/11/2025 coded R6 with no cognitive impairment. On 3/5/25 at approximately at 9:00 a.m. an interview was conducted with the registered nurse, RN#1 (RN1). RN1 stated that the pharmacy consult information is month to month and should be reviewed within 10 days of the review from the pharmacy. RN1 stated that the nurse practitioners and physicians was in the facility several times weekly. On 3/5/25 at approximately at 10:00 a.m. an interview was conducted with the director of nursing (DON). The DON stated that the pharmacy regimen reviews was supposed to be completed within 30 days of the date of the review. The DON stated that the unit managers were responsible to review the pharmacy regimen after the physician and to make sure the review was completed On 3/5/25 at approximately at 11:30 a.m. a clinical record review was conducted. On 3/14/24 a pharmacy consultation was not signed by the physician or by the DON for a gradual dose reduction of four central nervous system active medications. On 6/18/24 a pharmacy consultation for two of R6's inhalers was not dated by the physician or signed by the DON. On 6/18/24 a pharmacy consultation for a gradual dose reduction for Buspar, Xanax and Depakote were recommended and, was not addressed until 10/8/24 by the physician. On 11/12/24 a pharmacy consultation was completed to monitor R6's orthostatic hypotension due to her antipsychotic medication and this recommendation was not addressed by the physician until 12/23/24, and no rationale was given for the decline. 2. The facility staff failed to review and respond to pharmacy consults in a timely manner. R31 was admitted to the facility on [DATE]. Diagnoses for R31 included but are not limited to unspecified dementia, major depressive disorder and delusional disorders. R31's Annual Minimum Data Set (an assessment protocol) with an Assessment Reference Date of 12/20/24 coded R31 with severe cognitive impairment. On 3/5/25 at approximately at 9:00 a.m. an interview was conducted with the registered nurse, RN#1 (RN1). RN1 stated that the pharmacy consult information is month to month and should be reviewed within 10 days of the review from the pharmacy. RN1 stated that the nurse practitioners and physicians was in the facility several times weekly. On 3/5/25 at approximately at 10:00 a.m. an interview was conducted with the director of nursing (DON). The DON stated that the pharmacy regimen reviews was supposed to be completed within 30 days of the date of the review. The DON stated that the unit managers were responsible to review the pharmacy regimen after the physician and to make sure the review was completed. On 3/5/25 at approximately at 11:30 a.m. a clinical record review was conducted. On 1/23/25 a gradual dose reduction (GDR) was recommended for R6 trazodone and sertraline. The pharmacy consultation report was addressed on 3/4/25 and had no rationale for why the GDR was not being completed. On 6/18/24 a recommendation from the pharmacy was to taper Seroquel to 12.5 mg every other day for 14 days then discontinuing on a trial basis and the physician declined and recommended, psych to evaluate, on 10/8/24. On 3/6/25 a review of facility documentation was conducted. The facility document titled, Timeliness of Medication Regimen Review (MRR) Reports, and read in part, .the attending physician is expected to review and sign the residents individual MRR and document that he/she has reviewed the pharmacist's identified irregularities prior to the pharmacy consultants next scheduled visit/typically within 30 days. On 3/5/25 at approximately at 5:00 p.m. an end of day meeting was conducted with the director of nursing, the administrator, the assistant administrator and assistant director of nursing. The above concerns were discussed. No additional information was provided prior to exit conference. 41449 3. For Resident #9 (R9), the facility staff failed to respond to a medication regime review (MRR) and recommendation from the pharmacist in a timely manner and failed to give rationale for the decisions selected. On 3/5/25 at 9 a.m., a clinical record review was conducted of R9's chart. This review revealed one MRR dated 12/20/24. This review noted that R9 was on an opioid Tramadol Hydrochloride in combination with a medication that may increase adverse effects, Quetiapine Fumarate. Recommendation: Please consider avoiding or minimizing concomitant use, perhaps tapering Quetiapine. The physician noted, I decline the recommendation(s) above and do not wish to implement any changes due to the reasons below. Rationale: which was blank and gave no rationale. On 3/5/25, the surveyor requested a copy of R9's MRR's and was provided MRR's dated 11/22/24, 1/23/25, and 2/20/25, which were not in the resident's clinical record. Review of these MRR's revealed that on 11/22/24, the pharmacist noted that R9 had a diagnosis of diabetes and made the recommendation to monitor A1C [lab work]. The doctor declined this recommendation on 3/5/25 and noted HBA1C [hemoglobin A1C] was done on 2/5/25. R9 had two MRRs dated 1/23/25. Each signed by different providers, but the printed name remained as one provider with no correction. One MRR was signed 3/4/25 and the other was dated 3/5/25. Both providers declined the recommendations. On 3/5/25 at 2:45 p.m., an interview was conducted with the unit manager, who was a registered nurse (RN #2). When asked about the medication regime reviews, and the delay in getting them addressed, she stated, I don't know why it took her so long to come in and sign it, I know they have been requesting for her to come and sign it. When asked why the printed physician name was not changed, when a different provider was addressing the recommendation, RN #2 said, Normally when I get it, I will cross out the printed doctor name and put [Psychiatric nurse practitioner's name redacted] name on it. On 3/5/25 at 4:13 p.m., the surveyor conducted a phone interview with the psychiatric nurse practitioner that had declined the gradual dose reduction recommendation. The provider was asked why it took so long for her to respond to the pharmacy recommendation and she stated she had just received the document. On 3/5/25, the facility administration was asked to provide their policy regarding MRR's. The facility provided a policy titled, 9.1 Medication Regimen Review, with a review date of 6/1/24. The document read in part, 1. The consultant pharmacist will conduct MRRs if required under a Pharmacy Consultant Agreement and will make recommendations based on the information made available in the residents' health record . 8. The consultant pharmacist will provide the resident's MRRs to facility identified personnel who will ensure that the attending physician, medical director, director of nursing and other necessary facility staff receive the recommendations . 9. Facility should encourage physician/prescriber or other responsible parties receiving MRR and the director of nursing to act upon the recommendations contained in the MRR. 9.1 For those issues that require physician/prescriber intervention, facility should encourage physician/prescriber to either accept and act upon the recommendations contained within the MRR or reject all or some of the recommendations contained in the MRR and provide an explanation as to why the recommendation was rejected, as outlined in the State Operations Manual Appendix PP [regulation set] . 12. If an irregularity is not time-sensitive but should be addressed before the consultant pharmacist's next monthly MRR, the facility staff and the consultant pharmacist will confer on the timeliness of attending physician/prescriber responses to identified irregularities based on the specific resident's clinical condition . On 3/5/25 at approximately 5:15 p.m., during an end of day meeting, the facility administrator and director of nursing, along with other management level staff, were made aware of the above findings. No additional information was provided.

Based on staff interview and facility documentation review, the facility staff failed to implement their abuse policy with regards to the pre-screening of employees for 12 of 25 (Staff C, E, G, H, I, K, M, P, S, U, W, and X) employee/staff records reviewed. The findings included: 1. For Staff U, the facility staff permitted the employee to work 20 months without knowing the status of their criminal background check and if they had been convicted of any barrier crimes. On [DATE], a sample of 25 staff records was selected for review for pre-screening requirements. Staff U's file was provided, which indicated she was a certified nursing assistant (CNA) and was hired [DATE]. The facility provided evidence that a criminal record check was requested on [DATE], but no evidence that the criminal record check was received was provided. On [DATE] at 09:35 a.m., an interview was conducted with the Senior Human Resources manager, (other employee #10- OE #10). OE #10 stated, It is a state regulation for us to pull a criminal background check, they are pulled by our recruiter after an offer is made. We have two recruiters. When asked why they would want to see someone's criminal background when hiring someone, OE #10 said, It is an [company name redacted] policy, most of my career has been in corporate human resources, I've been here about ten years in facilities. All of them I have worked for have a policy for pulling a criminal background check. In Virginia, they require us to pull from the Virginia state police. On [DATE] at 10:09 a.m., an interview was conducted with the human resources coordinator (Other Employee #11- OE #11). When asked about the process and purpose of a criminal background check, OE #11 said, The criminal background check is with the pre-hire process . once the pre-screening is done and an offer is made and accepted, we do a criminal background check with Va State police, they get sworn statement and consent form via docu sign. The sterling process does federal background and with the Va state police, if nothing is pending it comes back immediately, if they have something, they mail it, and it could take 15 days. We need to make sure they don't have a barrier crime and are not a sex offender that would prevent them from providing care for our residents. On [DATE] at 10:10 a.m., following the above interview, OE #10 and OE #11, were down the employee file of Staff #U. When asked about the criminal background check, they stated, We know it was ran but when we went through her packet, we didn't see the results page attached. The facility's policy titled, Abuse Prevention was received and reviewed. According to the abuse policy, it read in part, . Procedure: 1. Employees will have criminal background checks completed and licensing/certification verified for good standing . On [DATE] at 4:38 p.m., the facility administrator and director of nursing were made aware of the above findings. They confirmed that Staff U is employed as a PRN (as needed) staff member and last worked [DATE]. Staff U was not scheduled to work again until [DATE]. On [DATE] at 8 a.m., the facility provided evidence that a criminal background check had been obtained for Staff U on [DATE] at 6:26 p.m. No additional information was provided. 2. For ten employees (Staff C, E, H, I, K, M, P, S, W and X), the facility staff permitted the employees to work, providing direct resident care, without having verified they held an active and unincumbered license to practice in that position, performing assigned duties. On [DATE], the survey team selected a sample of 25 employee records to review and requested the records of the employees. On [DATE], the employee records were reviewed. The findings were as follows: I. Staff C was hired [DATE] as a licensed practical nurse (LPN). Staff C was permitted to work as an LPN and provide direct resident care. The facility staff failed to verify that Staff #C held an active and unencumbered license to practice in that role until [DATE]. II. Staff E was hired on [DATE] as a licensed practical nurse (LPN). The facility staff verified on [DATE], that Staff E had an active license with no disciplinary action. However, it was three months before Staff E started working for the facility, at which time they didn't confirm that Staff E's license had remained active with no adverse actions. III. Staff H was hired [DATE] as a certified nursing assistant (CNA). The facility staff permitted the employee to work in this role without knowing if the employee held an active license without any disciplinary action, until [DATE], when they verified the license. IV. Staff I was hired [DATE] as an occupational therapist. Staff I was permitted to work directly with residents, providing care, and the facility did not verify the license until [DATE]. V. Staff K was hired [DATE] as a CNA and permitted to provide direct resident care for an entire year before the facility verified the employee's professional license to determine that they held an active and unincumbered license on [DATE]. VI. Employee M, who was an occupational therapist, was hired [DATE]. The facility did not have any evidence that the professional license of Employee M was verified to ensure it was current and unencumbered until [DATE]. VII. On [DATE], the facility staff verified that Staff P held an active certification from the department of health professions to work as a certified nursing assistant. Staff P was hired [DATE] and had been permitted to work as a certified nursing assistant and provide direct resident care for 10 months before the facility verified the certification was current without any disciplinary actions. VIII. Staff S, who was a speech language pathologist (SLP), was hired [DATE]. The facility permitted Staff S to work in the capacity of a SLP and didn't verify the license to do so was active until [DATE]. IX. For Staff W, who was hired as an LPN on [DATE]. The facility staff did not verify Staff W's license to work as an LPN until [DATE]. X. Staff X was hired [DATE], as a certified nursing assistant. On [DATE], the facility staff verified that Staff X held a current and unencumbered certification to practice as a CNA. On [DATE] at 09:35 a.m., an interview was conducted with the Senior Human Resources manager, (other employee #10- OE #10). OE #10 stated, On [DATE] at 10:09 a.m., an interview was conducted with the human resources coordinator (Other Employee #11- OE #11). The facility's policy titled, Abuse Prevention was received and reviewed. According to the abuse policy, it read in part, . Procedure: 1. Employees will have criminal background checks completed and licensing/certification verified for good standing . The facility policy titled, Health Services License and Certification Tracking, was reviewed. It read in part, .1. Upon hire, each continuing care employee will have a license and/or certification added into the HCM [Human Capital Management system] under Certifications based on job requirements. This is collected during onboarding by Human Resources. 2. Human Resources team will track license/certification within HCM based on expiration date. Employees are ultimately responsible for maintaining their individual licenses and certification as required based on their position, however, it is important that each community monitor adherence to these requirements . Any employee without an active license must be removed from the schedule until an updated license is provided. This does include employee without an active care associate . On [DATE], the above findings were discussed with the facility administrator and senior human resources manager. 3. For Staff #G, the facility staff permitted the employee to work as a certified nursing assistant, whose certification had expired, without knowing if they had renewed their license from the department of health professions to work in such capacity. On [DATE], a sample of 25 employee records were reviewed, which included Staff #G. The facility staff indicated that Staff #G was hired on [DATE] as a certified nursing assistant. According to Staff #G's personnel file, the license verification was conducted on [DATE], which indicated Staff #G's certification as a nurse aide expired [DATE]. The facility staff permitted Staff #G to work as a certified nursing assistance without having evidence that they verified the employee renewed their license to work as a certified nursing assistant. On [DATE], the above findings were discussed with the facility administrator and senior human resources manager. As requested, the facility's policy titled, Abuse Prevention was received and reviewed. According to the abuse policy, it read in part, . Procedure: 1. Employees will have criminal background checks completed and licensing/certification verified for good standing No additional information was provided.

3. For Resident #9 (R9), who was receiving multiple psychotropic medications, the facility staff failed to perform gradual dose reductions and ensure the resident was free from unnecessary psychotropic medications. On 3/4/25 and 3/5/25, R9 was observed attending group activities and eating meals in the dining room. R9 was noted to be calm, engaged and no behaviors noted. On 3/5/25, a clinical record review was conducted. This review revealed that R9 was admitted to the facility on [DATE] from assisted living, where her spouse was also a resident. R9's diagnosis included, but were not limited to: unspecified dementia, unspecified severity, without behaviors/psych/mood/anxiety; bipolar disorder, unspecified; psychotic disorder with delusions due to known physiological condition; unspecified dementia with behavioral disturbance; major depressive disorder, recurrent, mild; major depressive disorder, single episode, unspecified; dementia in other disorder classified elsewhere, severe, with other behavioral disturbance; and delusions disorders. Upon admission, R9 was ordered to receive multiple psychotropic medications to include an antipsychotic medication of Seroquel. The physician orders dated 11/18/2024, included the following psychotropic medications: Bupropion HCL SR [also known as Wellbutrin] 200 mg tablet, 12 hour sustained-release, 1 tablet every 12 hours starting 11/18/2024, indication: depression; Buspirone 30 mg tablet [also known as Buspar], one tablet two times daily starting 11/19/24, indication: major depressive disorder; Trazodone 50 mg tablet, 2.5 mg at hour of sleep, starting 11/18/2024, indication: depression and insomnia; Lexapro 20 mg tablet, 1 tablet every day starting 11/18/24, indication: depression; Seroquel 50 mg tablet, every day starting 11/18/24, and Seroquel 100 mg tablet, at bedtime starting 11/27/2024, indication: dementia and dementia with behavioral disturbances. According to R9's medication administration records (MAR), all the psychotropic medications to include Bupropion HCL SR, Buspirone, Trazodone, Lexapro, and Seroquel were administered as ordered daily from admission through 3/5/25, at the time of surveyor review. There had been no changes in dosage and no indication that gradual dose reductions had been attempted. According to R9's care plan, the only mention that the resident was on/receiving psychotropic medications was in section 10. Medications that read in part, . I am taking anti-psychotics: yes. These are the 'actions/expressions' I exhibit/exhibited to support use of anti-psychotic: yelling at staff and trying to hit, Prior to beginning and/or administering antipsychotic medications please try the following approaches: calm quiet surroundings . The care plan did identify that R9 has increased anxiety when it's time for me to change my clothes ., I become extremely anxious when I am incontinent ., I may wander the hallways at times ., I am confused to my own situation and to place. My move to this neighborhood has been confusing and I have begun to leave the neighborhood to explore ., This is how I exhibit or express anxiety: Frantic packing of items, wanting to contact her husband and asking questions . According to R9's nursing notes, since admission, the only noted behavior was wandering on and off the unit. She had one instance of refusing a shower but did accept a bed bath. The notes indicated R9 attended various activities, ate meals in the dining room, etc. According to the physician progress notes, R9 was seen by the medical provider on 12/17/24, which noted, .Patient is seen sitting in her room and appears comfortable . Dementia is stable, speech is fluent . On 1/14/25, the medical nurse practitioner saw her again and noted, . She is doing well in long-term care unit no new change in her status . dementia is persist and ongoing getting worse with time, need frequent reminders. Having episodes of anxiety, agitation, and delusion, well-controlled with Seroquel, Lexapro and Wellbutrin [sic] . On 2/3/25, 2/10/25, and 2/18/25, R9 was seen by the medical provider who noted no changes in behavior. A Psychiatric-Mental Health Nurse Practitioner (PMHNP), saw R9 on 12/3/24. Within the progress note from the PMHNP, it read in part, .The patient is alert and oriented to self only. Patient has been moved to long term care. The patient was observed with a calm demeanor . Patient is currently stable on the current medication regimen . Patient will remain on the current medication and have a follow-up in 6 weeks .GDR: Patient is currently on Seroquel for symptoms management. Medication benefit outweigh the risks at this time . On 12/16/24, R9 was seen again by the PMHNP. Within the progress note, it read in part, . assessed for follow up. Patient presents with a calm demeanor and some confusion. Patient move to long term care and is slowly adjusting to the new environment. Patient appetite is decent at this time. Patient sleep is ok. Patient present with some delusion. Patient is currently on Seroquel 50 mg in am and 50 mg at bedtime for symptoms management . This was not the dose of Seroquel R9 was receiving, R9 received 100 mg at bedtime daily and 50 mg in the morning. According to another note by the PMHNP dated 2/5/25, it noted no behavioral changes or indication why a gradual dose reduction was contraindicated other than noting, . Patient is stable on the current medication regimen . R9 had two MRRs dated 1/23/25. Each signed by different providers, but the printed name remained as one provider with no correction. One MRR was signed 3/4/25 and the other was dated 3/5/25. Both providers declined the recommendations. One recommendation, which was signed by the PMHNP noted that R9 receives Escitalopram Oxalate, a medication known to increase the risk of QT prolongation, and 1 or more medications with possible risk of QT prolongation, Tramadol Hydrochloride. Recommendation: Please reevaluate continued use of these medications. Rationale for Recommendation: Use of concomitant medications with known and possible QT prolongation risk should generally be avoided and may be contraindicated due to the additive risk of potentially life-threatening arrhythmias, including Torsade's de Pointes (TdP) The PMHNP noted, I decline the recommendation above and do not which to implement any changes due to the reasons below. Medication benefit outweigh risk family disagree with GDR [sic]. The recommendation dated 2/20/25, recommended a gradual dose reduction of the Seroquel. It read in part, Rational for Recommendation: CMS requires that antipsychotics, being used to treat expressions or indications of distress related to dementia, be evaluated at least quarterly with documentation regarding continued clinical appropriateness. Dose reductions should occur in modest increments over adequate periods of time to minimize withdrawal symptoms and to monitor symptom recurrence . The provider signed this recommendation on 3/4/25 and declined the recommendation with read, I decline the recommendation(s) above because GDR is Clinically Contraindicated for this individual. The resident's targeted symptoms returned or worsened after the most recent GDR attempt within the facility and a GDR attempt at this time is likely to impair the individuals' function or increase distressed behavior as documented below. Please provide CMS required patient-specific rationale describing why a GDR attempt is likely to impair function or increase behavior in this individual: Patient medication benefit out weight the risk. On 3/5/25 at 2:45 p.m., an interview was conducted with the unit manager, who was a registered nurse (RN #2). RN #2 was asked what the process is when a resident is admitted on psychotropic mediations. RN #2 said, It is my understanding we document and let the providers know and let the psychiatric provider know. We have a UR [utilization review] and high-risk meetings with the psych NP [nurse practitioner] to go through psychotropic meds to see who can do a gradual dose reduction (GDR). When I came here, we have a lot of residents on it. When asked about the purpose of GDR, RN #2 said, first of all we want to make sure the meds they are on are actually beneficial for them and because they need it. The side effects for psych meds are greater than if they don't need it or the minimal amount. A lot of residents when on higher doses are not as responsive, we want them to have more quality of life and want the medication to benefit them. On 3/5/25 at 4:13 p.m., an interview was conducted with the PMHNP. It was discussed that the resident had not had any GDRs of her psychotropic medications and the clinical record didn't clearly indicate the reason why a GDR would be contraindicated. The PMHNP repeated multiple times that a GDR had been attempted previously and was not successful and her family is adamant about not doing a GDR. It was explained that the clinical record did not reflect that a GDR had been attempted at any point in the resident's stay, or prior to admission and why it failed. The PMHNP was also asked if the family had been educated about the use of psychotropic medications, side effects and requirements to attempt GDR, the PMHNP just kept saying she had attempted a GDR previously, when R9 was in a different level of care. On 3/5/25 at 4:15 p.m., the Director of nursing confirmed that R9 did not have any GDR attempts while a resident of this facility. The surveyor shared that there was not documentation from the medical providers why a GDR was contraindicated within R9's clinical record. Review of the facility policy titled; Psychoactive Medications was conducted. The policy read in part, .1. All psychoactive medication orders will contain supporting documentation to define specific goals of treatment. The minimum documentation required includes a specific diagnosis or condition, if known, OR a specific target behavior. Any medication used to manage behavior will include provider documentation of target symptoms or behaviors in the clinical record and the documentation will be sufficient to demonstrate the said behaviors are a. [NAME] or dangerous to self or others; or b. extremely disturbing to the resident or other staff; c. Interfere significantly with care delivery causing adverse outcomes. 2. Antipsychotics: . c. Delirium and behaviors associated with dementia and other cognitive disorders may require medications as part of a comprehensive treatment plan. 1. which have been quantitatively and objectively documented; and 2. Which are present; and 3. Which are not caused by preventable reasons; and 4. Not amendable to redirection, changes in environment, and 5. Not felt to be due to other medications . Drug Reduction: 1. Residents on antipsychotic medications will receive gradual dose reductions (GDR) and behavioral interventions as clinically indicated in an effort to discontinue these medications. 2. When a drug reduction program has been implemented, such information shall be entered on the resident's plan of care to ensure that such reduction is closely monitored by the staff . 4. The continuing care medication reduction program consists of tapering the resident's daily dose to determine if the resident's symptoms can be controlled by a lower dose or to determine if the medication can be discontinued . On 3/5/25, during an end of day meeting, the above information to include the lack of a GDR and lack of documentation to indicate R9's psychotropic medications to include an antipsychotic were necessary was not present was discussed with the facility administrator, director of nursing and other management staff. No additional information was provided. Based on staff interview, clinical record review and facility documentation review the facility staff failed to ensure residents are free from unnecessary psychotropic medications for three residents Resident #6 (R6), Resident #9 (R9) and Resident #31 (R31) out of a survey sample of 33 residents. The findings included: 1. The facility staff failed to respond to a pharmacy consultation for a gradual dose reduction of a medication in a timely manner. R6 was admitted to the facility on [DATE]. Diagnoses for R6 included but are not limited to unspecified psychosis, bipolar disorder and anxiety disorder. R6's Quarterly Minimum Data Set (an assessment protocol) with an Assessment Reference Date of 1/11/2025 coded R6 with no cognitive impairment. On 3/5/25 at approximately at 9:00 a.m. an interview was conducted with the registered nurse, RN#1 (RN1). RN1 stated that the pharmacy consult information is month to month and should be reviewed within 10 days of the review from the pharmacy. RN1 stated that the nurse practitioners and physicians were in the facility several times weekly. On 3/5/25 at approximately at 10:00 a.m. an interview was conducted with the director of nursing (DON). The DON stated that the pharmacy regimen reviews was supposed to be completed within 30 days of the date of the review. The DON stated that the unit managers were responsible to review the pharmacy regimen after the physician and to make sure the review was completed. On 3/5/25 at approximately at 11:30 a.m. a clinical record review was conducted. On 3/14/24 a pharmacy consultation was not signed by the physician or by the DON for a gradual dose reduction of four central nervous system active medications. On 6/18/24 a pharmacy consultation for a gradual dose reduction for Buspar, Xanax and Depakote were recommended and was not addressed until 10/8/24 by the physician. On 11/12/24 a pharmacy consultation was completed to monitor R6's orthostatic hypotension due to her antipsychotic medication and this recommendation was not addressed by the physician until 12/23/24, and no rationale was given for the decline. 2. The facility staff failed to respond to pharmacy consultation for a gradual dose reduction of a medication in a timely manner. R31 was admitted to the facility on [DATE]. Diagnoses for R31 included but are not limited to unspecified dementia, major depressive disorder and delusional disorders. R31's Annual Minimum Data Set (an assessment protocol) with an Assessment Reference Date of 12/20/24 coded R31 with severe cognitive impairment. On 3/5/25 at approximately at 9:00 a.m. an interview was conducted with the registered nurse, RN#1 (RN1). RN1 stated that the pharmacy consult information is month to month and should be reviewed within 10 days of the review from the pharmacy. RN1 stated that the nurse practitioners and physicians was in the facility several times weekly. On 3/5/25 at approximately at 10:00 a.m. an interview was conducted with the director of nursing (DON). The DON stated that the pharmacy regimen reviews was supposed to be completed within 30 days of the date of the review. The DON stated that the unit managers were responsible to review the pharmacy regimen after the physician and to make sure the review was completed. On 3/5/25 at approximately at 11:30 a.m. a clinical record review was conducted. On 1/23/25 a gradual dose reduction (GDR) was recommended for R6 trazodone and sertraline. The pharmacy consultation report was addressed on 3/4/25 and had no rationale for why the GDR was not being completed. On 6/18/24 a recommendation from the pharmacy was to taper Seroquel to 12.5 mg every other day for 14 days then discontinuing on a trial basis and the physician declined and recommended, psych to evaluate, on 10/8/24. On 3/6/25 a review of facility documentation was conducted. The facility document titled, Timeliness of Medication Regimen Review (MRR) Reports, and read in part, .the attending physician is expected to review and sign the residents individual MRR and document that he/she has reviewed the pharmacist's identified irregularities prior to the pharmacy consultants next scheduled visit/typically within 30 days. On 3/5/25 at approximately at 5:00 p.m. an end of day meeting was conducted with the director of nursing, the administrator, the assistant administrator and assistant director of nursing. The above concerns were discussed. No additional information was provided prior to exit conference.

Based on resident interview, staff interview and facility documentation review, the facility staff failed to ensure that five residents, (Resident #4 (R4), Resident #8 (R8), Resident #22 (R22), Resident #30 (R30), and Resident #309 (R309)), had the information on how to file a complaint with the state licensure office and state survey agency in a survey sample of 33 residents. The findings included: The facility failed to make sure all residents was aware of how to file a complaint with the state licensure office and state survey agency. On 3/3/25 at 2:00 p.m., a resident council meeting was conducted. The five residents stated that they were not aware of where the postings were located with the information on how to contact the state licensure office and state survey agency if they needed to file a complaint. The surveyor observed the postings on each nursing unit that contained the state licensure office and state survey agency contact information. On 3/4/25 at 5:08 p.m., an end of day meeting was conducted with the administrator, assistant administrator, director of nursing, assistant director of nursing, and unit managers. The above concerns were discussed with the facility staff. The staff was made aware that the residents were not aware of how to file complaints with the state licensure office or the state survey agency. On 3/5/25 at 10:00 a.m. an interview was conducted with the assistant administrator. The assistant administrator stated that the complaint education for the residents was in the, Residence and Care Agreement, in the admission packet. The assistant administrator stated that information was in the packet on how to contact the state licensure and state surveyor's offices. On 3/5/25, a review of the facility admission packet was conducted. The state licensure office and the state surveyor agency information were not in the admission packet. On 3/6/25 9:30 a.m., a meeting with the administrator and assistant administrator was conducted. They were informed of the above concerns and that the state licensure office and state surveyor agency information were not in the admission packet. The assistant administrator looked at the admission packet and stated that she did not see the information. No additional information was provided prior to exit conference.

Based on observation, resident interviews, staff interviews and facility documentation, the facility staff failed to ensure that five residents,( Resident #4 (R4), Resident #8 (R8), Resident #22 (R22), Resident #30 (R30) and Resident #309 (R309), had the information on how to file a grievance out of a survey of 33 residents. The findings included: The facility staff failed to provide the information to the residents on how to file a grievance, where grievance forms are located, and who the grievance officer was for the healthcare residents on Unit 200 and 300. On 3/3/25 at 2:00 p.m. a resident council meeting was conducted, which was attended by R4, R8, R22, R30, and R309. The five residents stated that they were not aware of what a grievance form was or how to file a grievance. When asked who the grievance officer was, none of the residents able to. The surveyor was able to give a copy of a grievance form to each resident in the meeting and all five of the residents stated that they had never been told about this form. R30 said, We haven't had a social worker since [name redacted] left on my floor and didn't get another one. This is the kind of thing a social worker would take care of for me. On 3/4/25 at 5:08 p.m., an end of day meeting was conducted with the administrator, assistant administrator, director of nursing, assistant director of nursing, and unit managers. The above concerns were discussed with the facility staff. The staff was made aware that the residents was not aware of how to file a grievance, where to get the grievance form, or who the grievance officer was for the healthcare residents on unit 200 and 300. On 3/5/25 at 10:00 a.m., an interview was conducted with the assistant administrator. The assistant administrator stated that the grievance education for the residents was in the, Residence and Care Agreement, in the admission packet. On 3/5/25, a review of the facility admission packet was conducted. During the review, the surveyor was unable to find grievance education for the residents in the admission packet. On 3/6/25 9:30 a.m., a meeting with the administrator and assistant administrator was conducted. They were informed of the above concerns and that grievance education for the residents were not in the admission packet. The assistant administrator looked at the admission packet and stated that she did not see the information. No additional information was provided prior to exit conference.

Based on observation, staff interview and facility document review, the facility staff failed to prepare food in a sanitary manner in the main kitchen. The findings include: A scoop was observed stored in the bulk flour supply. Stainless serving pans were stored nested and wet. On 3/3/25 at 2:18 p.m., an initial inspection of the kitchen was conducted accompanied by the executive chef (other staff #1), certified dietary manager (other staff #2) and assistant general dietary manager (other staff #3). During this inspection, a scoop was observed stored inside the bulk flour bin, resting in the flour. The executive chef stated at this time that the scoop was not supposed to be positioned in the flour and that the scoop was to be removed from inside the flour bin and cleaned after each use. A rack of ready-to-use serving pans were inspected. Eight large stainless serving pans were nested with water droplets noted along the rims of the pans. The certified dietary manager stated the pans were supposed to be air dried prior to stacking/nesting. A dry rack was observed available for pan storage. The facility's policy titled SOP (Standard Operating Procedure) Food/Non-Food Storage (revised 4/24) documented, .Food is stored in compliance with applicable federal, state and local regulations regarding sanitary storage conditions .Dry, bulk foods, such as flour, sugar, and rice will be labeled and stored in metal or plastic containers with tight fitting lids. Scoops for dispensing these items will be stored separately in a holder . The facility's policy titled Dishwashing Operation (revised 4/24) documented, .Proper infection control techniques will be followed when washing dishes, utensils and other food service equipment .All items will be air dried (no towel dried equipment or utensils) to prevent wet nesting or contamination . These findings were reviewed with the administrator, director of nursing and assistant administrators during a meeting on 3/4/25 at 5:15 p.m. with no further information presented prior to the end of the survey.

Based on observation, staff interviews and clinical record review, the facility's quality assessment and assurance program failed to implement appropriate plans of action to correct identified quality deficiencies previously cited, having the potential to affect residents on two of the two nursing units. The findings included: The facility's quality assessment and assurance program failed to implement appropriate plans of action to correct quality deficiencies previously identified by the state survey agency and remained out of compliance during a revisit survey. During a survey conducted 3/3/25-3/6/25, the facility was identified and cited for several quality deficiencies which included, development and implementation of comprehensive resident centered care plans, failure to review and revise care plans, timely completion of drug regime reviews, unnecessary psychotropic medications, food storage, and COVID-19 immunizations. Following the survey, the facility submitted an approved plan of corrective action that included they would complete audits to identify other residents affected by the deficient practice and make corrective actions to bring the facility into compliance with the regulatory requirements. The facility alleged they would be completed with their approved plan of correction and be in regulatory compliance by 4/20/25. During this re-visit survey conducted 5/13/25-5/15/25, the survey team identified that the facility's quality assurance program had failed to implement a plan of correction to sustain ongoing compliance as continued deficient practice was identified in the same areas noted above. On 5/13/25, the facility staff failed to implement the comprehensive care plan and provide nutritional interventions for Resident #101, who had experienced a significant weight loss of 7.58 % in less than two months. The facility staff also had in the comprehensive care plan that the level of assistance needed with eating, Activity did not occur. According to the quality assessment and assurance committee's plan of correction developed it read, DON [director of nursing] or designee will audit 100% of SN [skilled nursing] residents care plan to ensure care plan has person-centered, comprehensive approaches with measurable, objectives and timeframes. Any discrepancies will be corrected promptly. SDC [staff development coordinator] or designee will educate all SN nurses and interdisciplinary team (IDT) on the facility policy for person-centered and accurate comprehensive care plan approaches for all residents. The DON or designee will review all new admissions to ensure baseline care plans are comprehensive, have specific measurable goals and outcomes and appropriate prevention strategies. These audits will occur weekly for one (1) month and monthly for two (2) months. Audit findings will be reported to the QAPI committee monthly for review, additional audits and education may be determined based on findings On 5/14/25, the survey team identified the facility remained out of compliance involving residents #101 (R101) and resident #106 (R106), the facility staff failed to review and revise the care plans to reflect the resident's current needs. R101 had developed blanchable redness to the sacral area that they had implemented a preventative treatment for and implemented an air mattress that was not reflected in the care plan. R101 had a change in condition that required the order and implementation of oxygen continuously, which the care plan did not include. For R106, who had cognitive impairments and several falls, the facility staff failed to review and revise the care plan with interventions to prevent reoccurrence. According to the facility's submitted and approved corrective action plan indicated they were going to audit 100% of all residents' care plans, provide staff education and conduct audits to ensure ongoing compliance. They were going to conduct weekly audits for one month, then monthly for two months and be reported to the quality assurance committee. For resident #111 (R111) a medication regime review (MRR) was completed 3/13/25, by the pharmacist. The pharmacist made recommendations to the provider to conduct gradual dose reductions of two psychotropic medications that the resident had been on for nine and ten months with no attempted reductions. The recommendation was not responded to until 5/2/25, at which time the provider signed agreeing to the recommendation to conduct dose reductions of the two psychotropic medications but only wrote orders for one reduction. The delayed response to the recommendation resulted in R111 receiving psychotropics without the required gradual dose reductions or documentation of why it was contraindicated, which constituted unnecessary psychotropic medications. During the previous survey, the facility had been identified to have been out of compliance for the same regulations of not responding timely to medication regime reviews and unnecessary psychotropic medications. The facility implemented a plan of correction that included a review of 100% of the MRR's completed to ensure they were addressed timely. Education was provided to the medical providers and clinical managers. To ensure ongoing compliance audits were going to be conducted weekly for one month, then monthly for two months and findings would be reported to the quality assurance and performance improvement committee. During the survey conducted in March 2025, the tour of the kitchen revealed scoops being stored in bulk food items and pans wet nesting. During the kitchen tour conducted on 5/13/25, the same observations were again noted. According to the action plan that the facility submitted and indicated would be completed by 4/20/25, they indicated: The general manager (GM) has removed the scoop from the flour dispenser and discarded the remaining flour. The GM has also removed and re-sanitized the wet pans, then allowed them to air dry prior to storage. The GM will complete a 100% audit of all dry bulk food storage containers ensure areas of non-compliance are adequately addressed. The GM or designee will audit 100% of the ready-to-use serving pans to ensure proper storage. Any concerns will be addressed promptly. The GM will provide education to all SN Dining staff regarding proper storage of food and proper sanitation and storage of materials. The GM or designee will perform audits of the dry storage and pan storage areas to ensure items are stored and dried appropriately. These audits will occur weekly for one (1) month and monthly for two (2) months. Audit findings will be reported to the QAPI committee monthly for review, additional audits and education may be determined based on findings. During the annual recertification survey conducted March 2025, the facility was identified to have not offered a resident the COVID-19 vaccine. As their plan of correction, they indicated they an audit was conducted of all residents to ensure if they were not up to date, they were offered vaccines, and it was appropriately documented in the clinical record. On 5/14/25, the survey team identified that that Resident #106 had declined the vaccine but was given the vaccine despite the declination. The facility had alleged they were going to conduct audits to maintain ongoing compliance. When the facility administration was made aware of this by the survey team, they conducted an internal investigation and had not identified this concern prior. On 5/15/25 at 9:18 a.m., during a meeting with the Regional Director of Clinical Operations (RDCO), she explained that following the notification by the survey team of the findings on the evening of 5/14/25, they had implemented quality assurance and performance improvement plans for each of the area's identified and initiated staff education. The RDCO explained that everything we did we put a QAPI plan in place to make sure we are monitoring to sustain and solve this. That's the most important thing, is that we sustain the correction. The RDCO explained that the role of QAPI is, When we identify a problem we come together as a team and plan action steps and develop a goal of intent of what we are doing. We evaluate the outcome, meet weekly or monthly to review audits and determine if the action items are working or not. When asked what the failure was in the previous plan for them to have not maintained compliance for so many areas identified deficient in less than a month after they alleged, they were in compliance, the RDCO gave no clear explanation. The RDCO did provide the survey team with copies of Quality Care Action/Performance Improvement plans following the survey team's findings being shared on 5/14/25. The plans provided had Plan Development Date of 5/14/25 and 5/15/25. On 5/15/25 at 10:18 a.m., a meeting was held with the facility administrator and the quality assurance program was reviewed. The administrator indicated that the QA committee meets monthly and reviews the data from the prior month. The administrator explained that in the March 2025 QA meeting, data from February was reviewed. With regards to the survey conducted in March 2025 and the findings of the inspection the administrator said we discussed it outside of QAPI, in April when we submitted it [the plan of correction] they were involved in that during the April 29th meeting. We discussed the citations, what plan we were implementing, etc. During the above meeting the surveyor explained that in reviewing the facility's audits conducted, it identified on-going compliance concerns, and that correction had not been sustained. When the administrator was asked if the audits had been reviewed with the QA committee, she indicated they would be reviewed during the meeting held at the end of May. When asked if anyone is reviewing the audits and had identified that they had not achieved ongoing compliance, the administrator stated again that this will be reviewed in our May QAPI, but we do a daily meeting involving the administrator, Director of nursing, clinical members and discuss this daily. She went on to state that they had not identified the ongoing non-compliance. The administrator was then shown some of the audits that indicated ongoing compliance issues. The administrator was also shown some of the medication regime reviews conducted 3/14/25, that the provider signed and dated as being reviewed prior to it being conducted on 3/7/25, but the orders were not noted until 4/29/25. The audits for unnecessary psychotropic medications were conducted prior to their date of completion and there was no evidence of any monitoring following 4/20/25. The facility's Quality Assurance Performance Improvement (QA/PI) Plan policy with a version date of 04/025 [sic], was reviewed. The policy read in part, The community will develop, implement and maintain an effective, comprehensive and data-driven QAPI program focused on outcomes of care and quality of life. The community will establish and maintain a QAPI Committee to oversee the QAPI process . How the QAPI Plan Will Address Key Issues: Departments in the Continuing Care will be involved in the development and execution of Quality Assurance Performance Improvement activities. The QAPI process will: . Develop and execute correction action or performance improvement activities . The above findings were discussed with the facility administrator on 5/15/25. No additional information was provided.

Based on observation, staff interviews and clinical record review, the facility's quality assessment and assurance program failed to implement appropriate plans of action to correct identified quality deficiencies previously cited, having the potential to affect residents on two of the two nursing units. The findings included: The facility's quality assessment and assurance program failed to implement appropriate plans of action to correct quality deficiencies previously identified by the state survey agency and remained out of compliance during a revisit survey. During a survey conducted 3/3/25-3/6/25, the facility was identified and cited for several quality deficiencies which included, development and implementation of comprehensive resident centered care plans, failure to review and revise care plans, timely completion of drug regime reviews, unnecessary psychotropic medications, food storage, and COVID-19 immunizations. Following the survey, the facility submitted an approved plan of corrective action that included they would complete audits to identify other residents affected by the deficient practice and make corrective actions to bring the facility into compliance with the regulatory requirements. The facility alleged they would be completed with their approved plan of correction and be in regulatory compliance by 4/20/25. During this re-visit survey conducted 5/13/25-5/15/25, the survey team identified that the facility's quality assurance program had failed to implement a plan of correction to sustain ongoing compliance as continued deficient practice was identified in the same areas noted above. On 5/13/25, the facility staff failed to implement the comprehensive care plan and provide nutritional interventions for Resident #101, who had experienced a significant weight loss of 7.58 % in less than two months. The facility staff also had in the comprehensive care plan that the level of assistance needed with eating, Activity did not occur. According to the quality assessment and assurance committee's plan of correction developed it read, DON [director of nursing] or designee will audit 100% of SN [skilled nursing] residents care plan to ensure care plan has person-centered, comprehensive approaches with measurable, objectives and timeframes. Any discrepancies will be corrected promptly. SDC [staff development coordinator] or designee will educate all SN nurses and interdisciplinary team (IDT) on the facility policy for person-centered and accurate comprehensive care plan approaches for all residents. The DON or designee will review all new admissions to ensure baseline care plans are comprehensive, have specific measurable goals and outcomes and appropriate prevention strategies. These audits will occur weekly for one (1) month and monthly for two (2) months. Audit findings will be reported to the QAPI committee monthly for review, additional audits and education may be determined based on findings On 5/14/25, the survey team identified the facility remained out of compliance involving residents #101 (R101) and resident #106 (R106), the facility staff failed to review and revise the care plans to reflect the resident's current needs. R101 had developed blanchable redness to the sacral area that they had implemented a preventative treatment for and implemented an air mattress that was not reflected in the care plan. R101 had a change in condition that required the order and implementation of oxygen continuously, which the care plan did not include. For R106, who had cognitive impairments and several falls, the facility staff failed to review and revise the care plan with interventions to prevent reoccurrence. According to the facility's submitted and approved corrective action plan indicated they were going to audit 100% of all residents' care plans, provide staff education and conduct audits to ensure ongoing compliance. They were going to conduct weekly audits for one month, then monthly for two months and be reported to the quality assurance committee. For resident #111 (R111) a medication regime review (MRR) was completed 3/13/25, by the pharmacist. The pharmacist made recommendations to the provider to conduct gradual dose reductions of two psychotropic medications that the resident had been on for nine and ten months with no attempted reductions. The recommendation was not responded to until 5/2/25, at which time the provider signed agreeing to the recommendation to conduct dose reductions of the two psychotropic medications but only wrote orders for one reduction. The delayed response to the recommendation resulted in R111 receiving psychotropics without the required gradual dose reductions or documentation of why it was contraindicated, which constituted unnecessary psychotropic medications. During the previous survey, the facility had been identified to have been out of compliance for the same regulations of not responding timely to medication regime reviews and unnecessary psychotropic medications. The facility implemented a plan of correction that included a review of 100% of the MRR's completed to ensure they were addressed timely. Education was provided to the medical providers and clinical managers. To ensure ongoing compliance audits were going to be conducted weekly for one month, then monthly for two months and findings would be reported to the quality assurance and performance improvement committee. During the survey conducted in March 2025, the tour of the kitchen revealed scoops being stored in bulk food items and pans wet nesting. During the kitchen tour conducted on 5/13/25, the same observations were again noted. According to the action plan that the facility submitted and indicated would be completed by 4/20/25, they indicated: The general manager (GM) has removed the scoop from the flour dispenser and discarded the remaining flour. The GM has also removed and re-sanitized the wet pans, then allowed them to air dry prior to storage. The GM will complete a 100% audit of all dry bulk food storage containers ensure areas of non-compliance are adequately addressed. The GM or designee will audit 100% of the ready-to-use serving pans to ensure proper storage. Any concerns will be addressed promptly. The GM will provide education to all SN Dining staff regarding proper storage of food and proper sanitation and storage of materials. The GM or designee will perform audits of the dry storage and pan storage areas to ensure items are stored and dried appropriately. These audits will occur weekly for one (1) month and monthly for two (2) months. Audit findings will be reported to the QAPI committee monthly for review, additional audits and education may be determined based on findings. During the annual recertification survey conducted March 2025, the facility was identified to have not offered a resident the COVID-19 vaccine. As their plan of correction, they indicated they an audit was conducted of all residents to ensure if they were not up to date, they were offered vaccines, and it was appropriately documented in the clinical record. On 5/14/25, the survey team identified that that Resident #106 had declined the vaccine but was given the vaccine despite the declination. The facility had alleged they were going to conduct audits to maintain ongoing compliance. When the facility administration was made aware of this by the survey team, they conducted an internal investigation and had not identified this concern prior. On 5/15/25 at 9:18 a.m., during a meeting with the Regional Director of Clinical Operations (RDCO), she explained that following the notification by the survey team of the findings on the evening of 5/14/25, they had implemented quality assurance and performance improvement plans for each of the area's identified and initiated staff education. The RDCO explained that everything we did we put a QAPI plan in place to make sure we are monitoring to sustain and solve this. That's the most important thing, is that we sustain the correction. The RDCO explained that the role of QAPI is, When we identify a problem we come together as a team and plan action steps and develop a goal of intent of what we are doing. We evaluate the outcome, meet weekly or monthly to review audits and determine if the action items are working or not. When asked what the failure was in the previous plan for them to have not maintained compliance for so many areas identified deficient in less than a month after they alleged, they were in compliance, the RDCO gave no clear explanation. The RDCO did provide the survey team with copies of Quality Care Action/Performance Improvement plans following the survey team's findings being shared on 5/14/25. The plans provided had Plan Development Date of 5/14/25 and 5/15/25. On 5/15/25 at 10:18 a.m., a meeting was held with the facility administrator and the quality assurance program was reviewed. The administrator indicated that the QA committee meets monthly and reviews the data from the prior month. The administrator explained that in the March 2025 QA meeting, data from February was reviewed. With regards to the survey conducted in March 2025 and the findings of the inspection the administrator said we discussed it outside of QAPI, in April when we submitted it [the plan of correction] they were involved in that during the April 29th meeting. We discussed the citations, what plan we were implementing, etc. During the above meeting the surveyor explained that in reviewing the facility's audits conducted, it identified on-going compliance concerns, and that correction had not been sustained. When the administrator was asked if the audits had been reviewed with the QA committee, she indicated they would be reviewed during the meeting held at the end of May. When asked if anyone is reviewing the audits and had identified that they had not achieved ongoing compliance, the administrator stated again that this will be reviewed in our May QAPI, but we do a daily meeting involving the administrator, Director of nursing, clinical members and discuss this daily. She went on to state that they had not identified the ongoing non-compliance. The administrator was then shown some of the audits that indicated ongoing compliance issues. The administrator was also shown some of the medication regime reviews conducted 3/14/25, that the provider signed and dated as being reviewed prior to it being conducted on 3/7/25, but the orders were not noted until 4/29/25. The audits for unnecessary psychotropic medications were conducted prior to their date of completion and there was no evidence of any monitoring following 4/20/25. The facility's Quality Assurance Performance Improvement (QA/PI) Plan policy with a version date of 04/025 [sic], was reviewed. The policy read in part, The community will develop, implement and maintain an effective, comprehensive and data-driven QAPI program focused on outcomes of care and quality of life. The community will establish and maintain a QAPI Committee to oversee the QAPI process . How the QAPI Plan Will Address Key Issues: Departments in the Continuing Care will be involved in the development and execution of Quality Assurance Performance Improvement activities. The QAPI process will: . Develop and execute correction action or performance improvement activities . The above findings were discussed with the facility administrator on 5/15/25. No additional information was provided.

Based on observation, staff interview and facility document review, the facility staff failed to maintain the walk-in freezer in proper working order. The seal on the freezer door was in disrepair and had been in this condition for over seven months. The findings include: On 3/3/25 at 2:29 p.m., accompanied by the certified dietary manager (other staff #2), assistant general dietary manager (other staff #3) and the executive chef (other staff #1), the walk-in freezer was inspected. There was heavy frozen condensation observed across the ceiling of the freezer. Frozen condensation was observed on the fan grates positioned along the ceiling on the right wall of the freezer. Fine ice shavings were noted in the freezer floor. There was no observed contamination of food/product packaging, and the freezer temperature was acceptable. The certified dietary manager and executive chef were interviewed at this time about the condensation. The certified dietary manager stated there had been an issue with condensation on and off for months and that kitchen staff scraped/removed the condensation at least weekly. The certified dietary manager stated that work orders were written, and maintenance worked on the freezer, but the condensation problem had not been resolved. The certified dietary manager stated the freezer was old and in need of repair. The executive chef stated the freezer door was difficult to latch and that staff were reminded to use effort to be sure the door was latched when close. The executive chef stated the condensation had been an ongoing problem for months. On 3/4/25 at 3:07 p.m., the maintenance supervisor (other staff #5) and maintenance mechanic (other staff #4) were interviewed about the freezer condensation. The maintenance mechanic stated the door seal on the freezer was bad. The maintenance mechanic stated an outside vendor assessed the condensation issue and determined the freezer door needed replacement. The maintenance supervisor stated the freezer door did not latch unless closed tightly with manual effort because the door seal was in disrepair. The maintenance supervisor stated the outside vendor provided a quote to fix the freezer door months ago, but the door had not yet been replaced. When asked when the door was expected to be repaired, the maintenance supervisor stated, That's above my pay grade. The maintenance supervisor presented an outside vendor quote regarding the freezer dated 7/31/24 stating, During our visit on 7/19/24, the technician found the walk-in door need to be replaced . This finding was reviewed with the administrator, director of nursing and assistant administrators during a meeting on 3/4/25 at 5:15 p.m.

Based on resident interview, staff interview, clinical record review and facility documentation review, the facility staff failed to follow professional standards of nursing practice for one resident, Resident #104 (R104), out of a survey sample of 11 residents. The findings included: The staff failed to notify the physician when a medication was not available. On 5/13/25 at 2:30 p.m., an interview was conducted with R104. During the tour of the nursing unit, R104 was interviewed by request. R104 stated that she was prescribed a prn (as needed) cough medicine that she could have every six hours if needed. R104 said, I got a dose of the cough medicine during the night but when I asked for a dose this morning, I was told by the nurse there was no more here; it would need to be ordered. R104 stated she asked the nurse to check in the stat (immediate) box and R104 said, The nurse was not even aware of a stat box where you can get medications from if needed. Reportedly, R104 was told that the medication was supposed to be here by 8:00 a.m., and then the time was changed to arrive at noon. R104 said, Here it is 2:30 p.m., and still no cough medicine. R104 stated she had called her pulmonologist (lung specialist) and said, My pulmonologist wants me to go out to the emergency room to get a CT scan and be treated for my cough, since the facility cannot treat me. R104 stated that she had called her pulmonologist, was waiting to be dressed, and then she was calling 911 (emergency number) herself. On 5/13/25 at 3:00 p.m., an interview was conducted with a licensed practical nurse, LPN#2. WHen questioned about the cough medicaine, LPN#2 said, [R104's name redacted] cough medicine was not here because the medicine ran out. LPN#2 stated the third shift nurse reported to her the cough medicine was out and had been ordered. LPN#2 said, I called the pharmacy, and it was supposed to be here by noon today, but it still is not here. LPN#2 stated that the physician was not notified of the cough medicine being unavailable because it was a PRN medicine. LPN#2 said, When out of a prn, I don't notify the doctor about that. R104's clinical record was reviewed. R104 had a prn order for `dextromethorphan-guaifenesin 10mg-100mg/5 ml oral liquid for cough as needed every six hours. On 5/13/25 at 8:32 p.m., a progress note was written by LPN#2, which read in part, The night nurse informed this writer that the resident's prn cough medication was out of stock. The writer contacted the pharmacy twice [pharmacy staff names redacted] both of whom confirmed that the order had been received and was being processed. LPN#2 had a progress note that documented that R104 was transferred to the hospital at 3:30 p.m. The medication administration record was reviewed, and no prn cough medicine had been administered prior to R104 going out to the emergency room. A review of facility documentation was conducted. The policy Medication Administration, Receipt, Storage and Disposal read in part, when a licensed nurse or CMA/CMT determines that an ordered medication is unavailable, the following steps are initiated: if medication has not been ordered, fax request immediately and ensure request has STAT written on the top. Call the pharmacy and let them know which medication is needed as soon as possible. I medication is not available in the Omnicell machine, provider is notified and EMR [electronic medical record] will reflect conversation with the provider. Provider may ask nurse for alternative medications available in the Omnicell and provide a one time for an alternative to cover until medication is received for skilled/long term care residents only. On 5/14/25 at 4:00 p.m., an end of the day meeting was conducted with the administrator and corporate staff, during which the above findings were discussed. No additional information was provided prior to the exit conference.

Based on staff interviews, clinical record review and facility documentation review, the facility staff failed to ensure residents were free from unnecessary psychotropic medications and perform gradual dose reductions for one resident, Resident #111 (R111), out of a survey sample of 11 residents. The findings included: A review of R111's clinical record revealed that a gradual dose reduction (GDR) was not completed for one of R111's antidepressant medications. On 5/14/25 at 9:03 a.m., an interview was conducted with a licensed practical nurse, LPN#1. LPN#1 was asked to explain the procedure for pharmacy recommendations. LPN#1 stated that pharmacy recommendations were given to the physician to review. LPN#1 said, Recommendations should be done right away, it needs to be taken care of. LPN#1 stated that the floor nurses and the clinical manager was responsible for notifying the physician of the pharmacy recommendations and making sure the recommendations were addressed. On 5/14/25 at 4:00 p.m., an end of day meeting was conducted with the administrator, director of nursing and the corporate staff. They were made aware of the above concerns. On 5/15/25 at 9:25 a.m., the regional of clinical operations presented additional information. The regional of clinical operations stated that when the provider was asked about the pharmacy recommendation for R111 that she only wanted to decrease the Lexapro and leave the Trazadone dose as ordered. The regional of clinical operations said, We did educations to the providers again yesterday. The regional clinical of operations acknowledged that she was aware that gradual dose reductions were required to be completed on psychotropic medications. Also present was the regional executive director, who nodded his head in agreement that the provider agreed with the drug reduction recommendations but only made changes to one medication. An additional clinical record review was conducted. R111's clinical record documented that Lexapro 10 mg (milligrams) was ordered on 6/19/24 and the first GDR was done on 5/2/25. R111's Trazodone 50 mg was ordered on 5/13/24 but no GDR had been attempted on this medication. R111 had a pharmacy recommendation on 3/13/25 that read in part, [ R111's name redacted] receives multiple antidepressants for depression concomitantly without documentation in the medical record of an inadequate response to monotherapy: Trazodone Hydrochloride, Escitalopram Oxalate. Please consider gradual dose reductions, with the end goal of discontinuation. The clinical record documented that the provider checked to accept the recommendations above, noting please implement as written but provided no written instructions on the pharmacy recommendation form. Also found was a telephone order that decreased the Lexapro 10 mg to 5 mg on 5/2/25. The medication order for Trazodone remained at the same dose. There was no reason given on the recommendation to why the Trazodone dose was not decreased by the provider. The clinical record also documented a provider's note dated 5/2/25, which read in part, .Lexapro was decreased to 5mg once daily for symptoms management. Also documented in the providers' note was a section that read, recommendations Decrease Lexapro to 5mg. The pharmacy recommendation for the Trazodone was not addressed in the provider's note. When provided, facility documents were also reviewed. The policy titled, Psychoactive Medications, read in part, .Gradual Dose Reduction Program: a structured approach aimed at systematically decreasing the dosage of certain medications to assess whether lower doses or complete discontinuation are feasible without adversely affecting a resident's well-being. The policy titled, Psychoactive Medication Management, read in part, .to ensure our guests/residents will not be chemically restrained during their stay. Guest/resident responds to their medical condition, their surrounding/environment and/or approach taken by others. No additional information was provided prior to the exit conference.

Based on staff interview, clinical record review, and facility document review, the facility staff failed to provide written notification of reasons for transfer or discharge to the resident and the resident's representative(s) for one of thirty-three sampled residents, (Resident #20). The findings include: For Resident #20, the facility staff failed to provide the resident and the resident's representative(s) written notice of the reason(s) for transfer/discharge to the hospital on [DATE], 1/21/25, and 2/24/25. Resident #20's diagnosis list indicated diagnoses that included, but were not limited to, Urinary Tract Infection (UTI), Acute Respiratory Failure with Hypoxia, Repeated Falls, Sepsis, Congestive Heart Failure, Chronic Kidney Disease-Stage 3, and Vascular Dementia. The most recent minimum data set (MDS) with an assessment reference date (ARD) of 2/3/25, assigned the resident a brief interview for mental status (BIMS) summary score of 3 out of 15 for cognitive abilities, indicating the resident was severely impaired in cognition. A review of the clinical record indicated Resident #20 was transferred to the hospital on [DATE], 1/21/25, and 2/24/25. No evidence of written notice of the reason for transfer/discharge being provided to the resident and the resident's representative could be located for any of the transfers/discharges. Surveyor requested evidence of written notifications for reason of transfer/discharge for Resident #20 and resident's representative for transfers/discharges that occurred on 12/20/24, 1/21/25, and 2/24/25. On 03/05/25 at 12:10 PM, administrative staff #2 (AS#2) informed surveyor no evidence of written notifications of reasons for transfer/discharge being provided to Resident #20 and resident's representative for the transfers/discharges that occurred on 12/20/24, 1/21/25, or 2/24/25 could be located. This concern was discussed at the end of day meeting on 3/5/25 at 5:05 PM with assistant administrator #2, administrator, director of nursing, assistant administrator #4, assistant director of nursing, and clinical manager. Surveyor requested and received a facility policy, titled, Skilled Nursing Initiated Transfer/Discharge with a Version date of 6/2021, that read in part, .If a resident is temporarily transferred on an emergency basis to an acute care facility (facility initiated transfer), the notice of transfer must be provided to the resident and resident representative as soon as possible both verbally and in writing . No further information regarding this concern was presented to the survey team prior to the exit on 3/6/25.

Based on observations, resident interview, staff interview, clinical record review, and facility documentation review, the facility staff failed to develop and implement a timely and adequate baseline care plan for one resident (Resident #49) in a survey sample of 33 residents, that includes the instructions needed to provide effective and person-centered care. On 3/4/25 at 9:50 am, Resident #49 (R49) was observed sitting in a wheelchair beside his bed, wearing a large black molded plastic boot that encased his left foot, from the toes to just below the knee. Also present was R49's significant other/POA. When asked about care satisfaction, R49 nodded his head and looked at his significant other who replied, Yes, I believe that they do a good job here, much better than where he's been before . but I know one thing that they could do better. They really need to make sure everyone knows how to fasten his boot properly. The staff mean well, but they really [NAME] those straps. Everyone does it differently. Even PT has exclaimed at finding the boot with the straps so messed up. Noting a printed paper sign on the wall that read Left boot to LLE [left lower extremity/leg] when OOB [out of bed], R49's significant other said, Yes, PT put that sign up, but I wrote out what the abbreviations meant in pen because some of the staff didn't know. When asked how the staff knows how to properly apply the orthotic, R49's significant other said, Well, they look at that care plan book over there. So, it's probably in there. When asked if he had received a copy of any of the care plans, R49 started to shake his head No, but looked again to his significant other, who responded, Nope. I just look at that one over there [indicating the care plan binder behind the door] from time to time, but the print is so tiny. Actually, when he was first admitted , he had to wear the boot all the time, even in bed, but his last ortho appt was good news. The fracture is healing so now he can bear weight when using the walker, but that's really only with PT. When asked if there had been a different sign on the wall then, R49's significant other replied, No, they put that sign up when he no longer had to keep the boot on all the time. R49's significant other joined this surveyor in review of the care plan, but no reference to the orthotic boot was found. A later review of the printed care plan kept in R49's room revealed that it had been initiated 1/20/25 and was dated 2/13/25, but none of the goals/interventions had individual dates that reflected when they had begun or when the review was due. A few pages had manual entries, but there were no entries or updates that reflected the use of an orthotic boot. Under the Skin Integrity section of this care plan, the only care concern listed was Infections of the foot, with general interventions that included Inspect pressure areas related to splints/brace/immobilizer/cast/ Prosthesis during routine care and report concerns. There was no specific guidance to staff on how the boot should be applied or the associated special care considerations associated with the use of the orthotic boot. On 3/5/25 930 am, an interview was conducted with the licensed practical nurse (LPN3) working on R49's hall. When questioned about the timeline for the baseline care plan, LPN3 replied, We have 24 hours to get that care plan in. We constantly add & update until the next care plan time, when all those handwritten updates are entered into the electronic care plan. Then we do everything together . notify the NP or doctor of a decline or special equipment needs. When asked how special equipment needs are handled, LPN3 replied, They are referred to therapy and then they say what equipment they can use. On 3/5/25 at 10:20am, certified nursing assistant #1 (CNA1) working on R49's hall was interviewed. When asked about the boot that R49 wears, CNA1 said, When he first came, he wore the boot all the time. Then, it changed to when he gets out of bed. When asked how changes in care are communicated, CNA1said, When something changes, its supposed to go on the care plan. We keep them in each room, behind the door. When asked if she had ever seen any instructions on the right way to secure R49's boot, CNA1 said, No, but there's a sign on the wall. When pointing out that the sign tells 'when,' not 'how', CNA1 agreed and replied, I was working when rehab came to do the initial eval. They called me down to show me how to put it on. When asked how that type of information would be shared, CNA1 replied that it goes on the care plan, but was unable to locate that care guidance had been updated on R49's care plan. Reviewing the Rehab section of R49's paper chart revealed a PT eval dated 1/16/25 which documented LLE [left lower extremity] NON-WB [non-weight bearing] but omitted any reference that R49 had been admitted wearing a boot or that provided specific care guidance for this special equipment. The 1/16/25 OT Eval notes that R49 . is unable to adhere to NWB restriction in LLE and requires assistance lifting foot off floor during t/f [transfer]. This non-weight bearing status, apparently active upon admission, was not reflected on the baseline/interim care plan. A review of R49's clinical record documented that R49 was admitted on [DATE], with diagnosis that included Fracture of left ankle, Parkinson's Disease, Muscle Weakness, UTI, hx Falls, metabolic encephalopathy, Dementia with severe agitation, Urine Retention, Neuromuscular bladder dysfunction. It was also revealed that the first documented evidence that a baseline care plan had been developed and implemented was dated 1/20/25, which exceeded the required baseline. No evidence was found that R49 and/or his significant other had been offered/provided a copy or summary of the baseline care plan. On 3/5/25 at 5:30am, during the end of day meeting, concerns were shared that R49's baseline care plan had not been completed timely, nor did it address the minimal guidance staff needed to address his unique care needs. On 3/6/25 at 940am, when questioned about the history of R49's orthotic boot, RN1 responded that R49 had been admitted with the boot for his fractured left ankle, initially wearing it all the time, then, only when out of bed, but is now weight bearing as tolerated. When asked to locate where that was noted in the care plan, RN1 indicated the one entry dated 2/26/25, reflecting that the boot was to be worn when out of bed. When questioned about care directives for the use of the boot prior to that date, guidance to staff on care considerations associated with the orthotics or how to secure the straps correctly, and the initial weight bearing status, RN1 confirmed that this information should've been included in the care plan. When comparing the care plan in the electronic health record and the copy kept in R49's room, RN1 was asked which version is most accurate and RN1 responded that the one kept in the room is a working version . which means its updated as his orders and needs change. Pointing out the lack of start dates or review dates since it was implemented, RN1 was asked how the goals are measurable or how the effectiveness of the interventions is determined, RN1 made no verbal response, while slowly nodding head up and down and gazing at the care plan. When asked how the Baseline care plan differs from the Comprehensive Care plan, the RN1 stated that they start with the baseline and just keep adding to it, which becomes the Comprehensive Care Plan. Identifying 1/20/25 as the date of the Baseline Care Plan, RN1 had no explanation for why the CP had not been done within the first 48 hours from admission, as required. A review of the facility policy, Care / Service Plans, revealed the following: .An interim care plan will be generated by a nurse within 8 hours of admission . will reflect resident's goal and include interventions that address his or her current needs in a language and format that the resident and/or representative, if applicable, understand . will include healthcare information necessary to care for a resident . an interim care plan will be provided to the resident and responsible party, if applicable . documentation that the interim care plan was provided to the resident and/or responsible party, if applicable, will be documented in the medical record. No additional information was provided prior to survey exit.

Based on observations, resident interview, staff interview, clinical record review, and facility documentation review, the facility staff failed to develop and implement an accurate comprehensive person-centered care plan for one resident (Resident R49) in a survey sample of 33 residents, that included measurable objectives and timeframes. On 3/4/25 at 9:50 am, resident was observed sitting in a wheelchair beside his bed, wearing a large black molded plastic boot that encased his left foot, from the toes to just below the knee. Also present was R49's significant other/POA. When asked about care satisfaction, R49 nodded his head and looked at his significant other who replied, Yes, I believe that they do a good job here, much better than where he's been before . but I know one thing that they could do better. They really need to make sure everyone knows how to fasten his boot properly. The staff mean well, but they really [NAME] those straps. Everyone does it differently. Even PT has exclaimed at finding the boot with the straps so messed up. Noting a printed paper sign on the wall that read Left boot to LLE [left lower extremity/leg] when OOB [out of bed], R49's significant other said, Yes, PT put that sign up, but I wrote out what the abbreviations meant in pen because some of the staff didn't know. When asked how the staff knows how to properly apply the orthotic, R49's significant other said, Well, they look at that care plan book over there. So, it's probably in there. When asked if he had received a copy of any of the care plan, R49 started to shake his head No, but looked again to his significant other, who responded, Nope. I just look at that one over there [indicating the care plan binder behind the door] from time to time, but the print is so tiny. Actually, when he was first admitted , he had to wear the boot all the time, but his last ortho appt was good news. The fracture is healing so now he can bear weight when using the walker, but that's really only with PT. When asked if there had been a different sign on the wall then, R's significant other replied, No, they put that sign up when he no longer had to keep the boot on all the time. R49's significant other joined this surveyor in review of the care plan, but no reference was found to the orthotic boot. A later review of the printed care plan kept in R's room revealed that it had been initiated 1/20/25 and was dated 2/13/25, but none of the goals had individual dates that reflected when they had begun or when the review was due. A few pages had manual entries, but there were no entries or updates that reflected the use of an orthotic boot. Under the Skin Integrity section of this care plan, the only care concern listed was Infections of the foot, with general interventions that included Inspect pressure areas related to splints/brace/immobilizer/cast/ Prosthesis during routine care and report concerns. There was no specific guidance to staff on how the boot should be applied or the associated special care considerations associated with the use of the orthotic boot. 3/5/25 930 am An interview was conducted with the licensed practical nurse (LPN3) working on R49's hall. When questioned about the timeline for the baseline care plan, LPN3 replied, We have 24 hours to get that care plan in. We constantly add & update until the next care plan time, when all those handwritten updates are entered into the electronic care plan. Then we do everything together . notify the NP or doctor of a decline or special equipment needs. When asked how special equipment needs are handled, LPN3 replied, They are referred to therapy and then they say what equipment they can use. LPN3 listed action taken after a resident fall as including . monitoring, like every 2-hour checks, taking them to activities, keeping an eye on them, anticipating needs, keeping items within reach, no clutter, fall mats. 3/5/25 10:20am certified nursing assistant #1 (CNA1) working on R49's hall. When asked about the boot that R49 wears, CNA1 said, When he first came, he wore the boot all the time. Then, it changed to when he gets out of bed. When asked how changes in care are communicated, CNA1said, When something changes, its supposed to go on the care plan. We keep them in each room, behind the door. When asked if she had ever seen any instructions on the right way to secure R49's boot, CNA1 said, No, but there's a sign on the wall. When pointing out that the sign tells 'when,' not how, CNA1 agreed and replied, I was working when rehab came to do the initial eval. They called me down to show me how to put it on. When asked how that type of information would be shared, CNA1 replied that it goes on the care plan, but was unable to locate that care guidance on the R49's care plan. 3/5/25 1130am After reviewing the care plan in R49's electronic chart but finding no reference to the boot, the care plan in R49's room was again accessed, but noted that a handwritten entry had been added, dated 2/26/25, which read Left boot to LLE when OOB. No other entries referencing the left boot were found. Review of Physician orders section of R49's paper chart revealed an ortho consult, dated 1/30/25, which recommended NWB[non-weight bearing] LLE[left lower extremity] - boot for comfort. Reviewing the Rehab section of the paper chart revealed PT eval dated 1/16/25 which documented LLE [left lower extremity] NON-WB [non-weight bearing] but omitted any reference that R49 had been admitted wearing a boot or that provided specific care guidance for this special equipment. Also found under the Rehab section of the paper chart was another ortho consult dated 2/24/25 to Start PT - WBAT with boot & walker. F/u in 1 mo. These progressive changes in weight bearing status were not noted in R49's care plan. Review of the clinical record revealed that R49 had fallen on 2/4/25 @ 7:25am, 2/8/25 02:00 am, and 2/8/25 @9:15am. Hand-written entries signed by the Unit Mgr (RN1) to the Falls section of the care plan kept in R49's room were dated 2/4/25, 2/8/25, and 2/11/25, but did not implement different fall strategies with each fall. Social Worker notes dated 1/21/25 8:23 PM documented . presents with a lot of confusion . inattention . disorganized thought process . observed to doze off during conversation as well as answer in a nonsensical way at times He is admitted as medically non-decisional per MD certification . The MDS (minimum data set) assessment dated [DATE] under Section C0500 coded R49 as being severly impaired cognitively, but the care plan noted R49 as being both Indep - decisions consistent/reasonable and Lethargic and Confused. Under the Medication section of the Care Plan, it was noted that I am not taking antipsychotics as a goal, but interventions included Because I take psychotropic drugs monitor me for sleepiness, drooling, insomnia. A review of Physician orders documented that quietiapine, a psychotropic medication, was started 1/27/25, with subsequent order changes noted 1/28/25, and 1/31/25, but no care plan updates identified targeted behaviors or non-pharmaceutical interventions The Acute Health Concerns section of R49's care plan did not have any updates to include R49's hospitalization , urinary tract infection, or suspected reoccurrence of pneumonia since R49's admission, niether were the care and immunization refusals included in this care plan. On 3/6/25 at 9:40 am, when questioned about the intervention implemented in response to R49's falls, RN1 said, Well, he has low bed and fall mats. When it was pointed out that those interventions were already in place before the falls, RN1 replied, Well basically the plan was to increase staff monitoring. We were just trying to keep an eye out for him a little more. When further questioned on specifically what was done differently each time R49 fell to decrease the risk of reoccurrence, RN1 seemed unsure of how to answer. When asked if any attempt to support R49's apparent preference to get out of the bed, by getting him up had been attempted or if diversional activities were offered outside of his room, RN1 replied, Oh, I see, you mean the interventions should change. When comparing the care plan in the electronic health record and the copy kept in R49's room, RN1 was asked which version is most accurate and RN1 responded that the one kept in the room is a working version . which means its updated as his orders and needs change. Pointing out the lack of start dates or review dates, RN1 was asked how the goals are measurable or how effectiveness of the interventions is determined, RN1 made no verbal response, while slowly nodding head up and down and gazing at the care plan. When asked how the Baseline care plan differs from the Comprehensive Care plan, the RN1 stated that they start with the baseline and just keep adding to it, which becomes the Comprehensive Care Plan. Identifying 1/20/25 as the date of the Baseline Care Plan, RN1 had no explanation for why the CP had not been done within the first 48 hours from admission, as required. On 3/5/25 at 5:30 pm, during the end of day meeting, concerns were shared that R49's comprehensive care plan had not been adequately developed/revised to fully address R49's initial and emerging care needs or formatted with measurable objectives and interventions. On 3/6/25 at 940 am, when questioned about the history of R49's orthotic boot, RN1 responded that R49 had been admitted with the boot for the fractured left ankle, initially wearing it all the time, then only when out of bed, but is now weight bearing as tolerated. When asked to locate where that was noted in the care plan, RN1 indicated the one entry dated 2/26/25 reflecting that the boot was to be worn when out of bed. When questioned about care directives for the use of the boot prior to that date, guidance to staff on care considerations associated with the orthotics or how to secure the straps correctly, the changes in the weight bearing status, or resident focused fall interventions, RN1 confirmed that this information should've been included in the care plan. A review of the facility policy, Care / Service Plans included A comprehensive person centered care plan wll be developed by the Interdisciplinary Team and be completed within 72 hours of admission and will include measurable objectives, preferences, goals . and will address the resident's medical, nursing, mental, and psychosocial needs as identified from the resident's comprehensive assessment . any changes identified in the comprehensive care plan in the resident's goals, physical, mental, or psychosocial functioning, that was not identified in the interim care plan, will be provided to the resident and/or responsible party, if applicable . Care plans will be reviewed, revised if applicable, on an ongoing basis by the interdisciplinary team with any change in condition and after each assessment, including both comprehensive and quarterly assessments. In addition, Post-Acute residents will have their care plan reviewed weekly . all interdisciplinary team members will document any updates on care plan copy in the guest/resident suite/apartment/designated accessible location and review update with designated care associate. No other information was provided prior to exit.

Based on observations, resident interview, staff interview, clinical record review, and facility documentation review, the facility staff failed to review and revise the care plan for three residents (Resident #5- R5, Resident #39-R39, and Resident #49-R49), in a survey sample of 33 residents. The findings included: 1. For R5, who was non-verbal and totally dependent upon facility staff for all activities of daily living, the facility staff failed to review and revise the care plan to accurately reflect the resident's needs for activity programing. On 3/3/25 in the afternoon, on 3/4/25 at 2:55 p.m., and 3/5/25 at 2:32 p.m., R5 was visited in her room. R5 was laying in her bed each of the days, was noted to be non-verbal, and didn't respond when spoken to. There was a sign in the room that indicated Keep the tv on channel 133 EWTN Religious channel. On 3/3/25 and 3/4/25, R5 was in bed without the tv on, no radio was on, and no indication of social, auditory, visual, or other sensory stimulation was observed. On 3/5/25, R5 was dressed, sitting in a wheelchair at the bedside with the television on a religious program. On 3/5/25 at 2:40 p.m., an interview was conducted with a certified nursing assistant, (CNA #1). CNA #1 reported that R5 rarely comes out of her room, but they cut her tv on for her and activities reads to her several times a week. On 3/5/25 at 3:07 p.m., an interview was conducted with the unit manager, who was a registered nurse (RN #2). RN #2 stated that R5 doesn't come out of her room much and is totally dependent on staff for all care needs to include being fed by staff. On 3/5/25 at 3:32 p.m., an interview was conducted with the activity's coordinator for the unit. The activities coordinator reported that she visits R5 almost daily. She went on to report, When the weather is nice, I take her out on the patio, I do sensory things with her, massage her hands, etc. She added that she is visited weekly on Fridays for religious prayers but is no longer able to partake in communion due to her diet. The activities coordinator confirmed that R5 is unable to pursue or initiate any leisure/stimulation programs independently. On 3/5/25, a review was conducted of R5's two most recent Minimum Data Set (MDS), (an assessment tool) with an assessment reference dates (ARD) of 1/13/25 and 10/20/24. According to both MDS assessments, it was noted that R5 had short and long-term memory impairments, severely impaired decision making, and altered level of consciousness. According to the 10/20/24 MDS, Section F indicated R5 preferred family or significant other involvement in care discussion and listening to music. According to R5's current care plan, section 12. titled, Engagement and Socialization read, I prefer to engage myself independently. I like to observe others while they are participating in activities daily. The care plan noted, I like small groups, to keep up with the news/read paper, to listen to music, to watch tv. It went on to state, Care plan Approaches: I would like to attend music programs. I would like staff to include me in small group to observe others and listen. I would like to go to Catholic Mass. On 3/6/25, the facility staff provided the surveyor with a revised copy of R5's care plan. This care plan had been revised, the revisions were initialed and dated 3/6/25. The revisions had crossed out I prefer to engage myself independently and had handwritten, I would like to be encouraged and escorted to group activities. 2. For R39, who had auditory and visual electronic monitoring within the room, the facility staff failed to revise the care plan to reflect the use of the camera. On 3/3/25, in the afternoon, while conducting a tour of the unit, the surveyor noted a sign on R39's room door that indicated electronic monitoring device is in use. On 3/4/25, a clinical record review was conducted. According to R39's care plan there was no mention of an electronic monitoring device being in use. According to an email communication within R39's clinical record, dated 1/25/25, between R39's guardian and power of attorney and the facility social worker, the family of R39 agreed that they would purchase, install and maintain the camera, the positioning of the camera as to not capture R39's care during changing [incontinence care] due to privacy concerns, and signage would be posted on the outside of the room of such monitoring. On 3/5/25 at 10:23 a.m., an interview was conducted with R39 and her private duty aide. When asked about the camera, R39 stated that she wasn't surprised to know there was a camera in the room. R39 did exhibit some confusion and was not clear on who could see the video footage from the camera or that her family had placed it in the room. R39 didn't express any concerns knowing the camera was present and in use. According to the private duty aide, the camera had video and auditory capability. The family could see the resident and talk to her through the camera device. The private duty aide went on to say that she provides R39's care such as toileting and changing clothes in the bathroom, where the camera cannot see, for privacy. The private duty aide reported that the family had put the camera in place about 2-3 weeks ago because they no longer provide a private duty aide overnight and are concerned about the resident getting up and falling. On 3/5/25 at 10:37 a.m., an interview was conducted with a certified nursing assistant (CNA #2). CNA #2 reported that the camera had been placed in the room by the family about a month ago. CNA #2 stated that the facility's administration was aware of it being present and the family was told it couldn't be positioned where it could see into the bathroom. 3. For Resident #49 (R49), facility staff failed to review and update the comprehensive care plan to reflect the use of an orthotic boot and omitted changes in weight bearing status. On 3/4/25 at 9:50 am, resident was observed sitting in a wheelchair beside his bed, wearing a large black molded plastic boot that encased his left foot, from the toes to just below the knee. Also present was R49's significant other/POA. When asked about care satisfaction, R49 nodded his head and looked at his significant other who replied, Yes, I believe that they do a good job here, much better than where he's been before . but I know one thing that they could do better. They really need to make sure everyone knows how to fasten his boot properly. The staff mean well, but they really [NAME] those straps. Everyone does it differently. Even PT has exclaimed at finding the boot with the straps so messed up. Noting a printed paper sign on the wall that read Left boot to LLE [left lower extremity/leg] when OOB [out of bed], R49's significant other said, Yes, PT put that sign up, but I wrote out what the abbreviations meant in pen because some of the staff didn't know. When asked how the staff knows how to properly apply the orthotic, R49's significant other said, Well, they look at that care plan book over there. So, it's probably in there. When asked if he had received a copy of any of the care plan, R49 started to shake his head No, but looked again to his significant other, who responded, Nope. I just look at that one over there [indicating the care plan binder behind the door] from time to time, but the print is so tiny. Actually, when he was first admitted , he had to wear the boot all the time, but his last ortho appt was good news. The fracture is healing so now he can bear weight when using the walker, but that's really only with PT. When asked if there had been a different sign on the wall then, R's significant other replied, No, they put that sign up when he no longer had to keep the boot on all the time. R49's significant other joined this surveyor in review of the care plan, but no reference was found to the orthotic boot. A later review of the printed care plan kept in R49's room revealed that it had been initiated 1/20/25 and was dated 2/13/25, but none of the goals had individual dates that reflected when they had begun or when the review was due. A few pages had manual entries, but there were no entries or updates that reflected the use of an orthotic boot. Under the Skin Integrity section of this care plan, the only care concern listed was Infections of the foot, with general interventions that included Inspect pressure areas related to splints/brace/immobilizer/cast/ Prosthesis during routine care and report concerns. There was no specific guidance to staff on how the boot should be applied or the special care considerations associated with the use of the orthotic boot. 3/5/25 930 am, an interview was conducted with the licensed practical nurse (LPN3) working on R49's hall. When questioned about care planning, LPN3 replied, We constantly add & update until the next care plan time, when all those handwritten updates are entered into the electronic care plan. Then we do everything together . notify the NP or doctor of a decline or special equipment needs. When asked how special equipment needs are handled, LPN3 replied, They are referred to therapy and then they say what equipment they can use. When asked how new orders or special care needs are communicated to staff, LPN3 stated, That happens during the Daily Huddle at the beginning of each shift. We give a report to the incoming staff of what happened on our shift. As requested, LPN3 retrieved the Huddle binder and pointed out that each person signs off that they attended. Observing that the most recent shift sheet was dated 2/4/25, LPN3 was questioned and confirmed that 2/4/25 was likely the last date the sheet was completed, as she stated that they had not signed a sheet that morning. When asked how staff coming in late or for a split shift would get the needed care report, as the topics listed on the sheet were only general and there was no resident specific information, LPN3 replied, I get a much better report here than the last place I worked. It's really good communication, but I hadn't thought about that. 3/5/25 10:20am certified nursing assistant #1 (CNA1) working on R49's hall. When asked about the boot that R49 wears, CNA1 said, When he first came, he wore the boot all the time. Then, it changed to when he gets out of bed. When asked how changes in care are communicated, CNA1said, When something changes, its supposed to go on the care plan. We keep them in each room, behind the door. When asked if she had ever seen any instructions on the right way to secure R49's boot, CNA1 said, No, but there's a sign on the wall. When pointing out that the sign tells 'when,' not 'how', CNA1 agreed and replied, I was working when rehab came to do the initial eval. They called me down to show me how to put it on. When asked how that type of information would be shared, CNA1 replied that it goes on the care plan, but was unable to locate any care guidance regarding the left boot on the R49's care plan. On 3/5/25 at 1130am, after reviewing the care plan in R49's electronic chart but finding no reference to the boot, the care plan in R49's room was again accessed, but noted that a handwritten entry had been added, dated 2/26/25, which read Left boot to LLE when OOB. No other entries referencing the left boot were found. Review of the Physician orders section of R49's paper chart revealed an ortho consult, dated 1/30/25, which recommended NWB[non-weight bearing] LLE [left lower extremity] - boot for comfort but this specialized care guidance was not reflected in the care plan. Reviewing the Rehab section of the paper chart revealed PT eval dated 1/16/25 which documented LLE [left lower extremity] NON-WB [non-weight bearing] but omitted any reference that R49 had been admitted wearing a boot or that provided specific care guidance for this special equipment. Also found under the Rehab section of the paper chart was another ortho consult dated 2/24/25 to Start PT - WBAT with boot & walker. F/u in 1 mo. These changes in weight-bearing status were also not reflected in R49's care plan. On 3/5/25 at 5:13 p.m., the facility's management team, to include but not limited to, the facility administrator and director of nursing were made aware of the above concerns regarding R5 and R29's care plans, not being reviewed and revised as noted above. The facility's staff was also informed of the findings that R49 was admitted wearing an orthotic boot, which had never been included in the care plan since admission, as well as other notable omissions. This has resulted in concerns that the comprehensive care plan had not been adequately developed/revised to fully address R49's initial and emerging care needs. On 3/6/25 at 8:42 a.m., an interview was conducted with a licensed practical nurse (LPN #3). LPN #3 explained that the care plan is . individualized about the care of a resident. Whatever they need should be in the care plan, it is what we follow to take care of them. On 3/6/25 at 8:47 a.m., an interview was conducted with the assistant director of nursing, who is a registered nurse (RN #2). RN #2 stated that the purpose of the care plan is to . provide individualized care for our residents. It should have everything the resident needs in the care plan, how often, etc. The care plan guides the staff of how to take care of the residents, that's why it is in the resident room, so they can look through it to see what type of assistance they need. When asked if she would expect electronic monitoring to be indicated in the care plan, RN #2 said, Yes, we want to make sure it is not positioned to see care, for privacy, and in the bathroom. It [the care plan] should say she has it. On 3/6/25 at 940 am, when questioned about the history of R49's orthotic boot, the unit manager (RN1) for that wing responded that R49 had been admitted with the boot for the fractured left ankle, initially wearing it all the time, then only when out of bed, but is now weight bearing as tolerated with PT. When asked to locate where that was noted in the care plan, RN1 indicated the one entry dated 2/26/25 that reflected that the boot was to be worn when out of bed. When questioned about care directives for the use of the boot prior to that date, guidance to staff on care considerations associated with the orthotics or how to secure the straps correctly, and the changes in the weight bearing status, RN1 confirmed that this information should've been included in the care plan. The facility policy titled; Care/Service Plans was reviewed. The policy read in part, . 3. A comprehensive person-centered care plan will be developed by the Interdisciplinary Team and be completed within 72 hours of admission and will include measurable objectives, preferences, goals, any specialized services as a result of the PASARR evaluation, resident's discharge plan and will address the resident's medical, nursing, mental and psychosocial needs as identified from the resident's comprehensive assessment. 4. Any changes identified in the comprehensive care plan in the resident's goal, physical, mental, or psychosocial functioning, that was not identified in the interim care plan, will be provided into the resident and/or responsible party, if applicable . 8. Care plans will be reviewed, revised if applicable, on an ongoing basis by the interdisciplinary team with any change in condition and after each assessment, including both comprehensive and quarterly review assessments . In addition, Post-Acute residents will have their care plan reviewed weekly . all interdisciplinary team members will document any updates on care plan copy in the guest/resident suite/apartment/designated accessible location and review update with designated care associate. No additional information was provided.

Based on resident interview, staff interview, clinical record review and facility documentation review, the facility staff failed to follow professional standards of nursing practice for one resident, Resident #104 (R104), out of a survey sample of 11 residents. The findings included: The staff failed to notify the physician when a medication was not available. On 5/13/25 at 2:30 p.m., an interview was conducted with R104. During the tour of the nursing unit, R104 was interviewed by request. R104 stated that she was prescribed a prn (as needed) cough medicine that she could have every six hours if needed. R104 said, I got a dose of the cough medicine during the night but when I asked for a dose this morning, I was told by the nurse there was no more here; it would need to be ordered. R104 stated she asked the nurse to check in the stat (immediate) box and R104 said, The nurse was not even aware of a stat box where you can get medications from if needed. Reportedly, R104 was told that the medication was supposed to be here by 8:00 a.m., and then the time was changed to arrive at noon. R104 said, Here it is 2:30 p.m., and still no cough medicine. R104 stated she had called her pulmonologist (lung specialist) and said, My pulmonologist wants me to go out to the emergency room to get a CT scan and be treated for my cough, since the facility cannot treat me. R104 stated that she had called her pulmonologist, was waiting to be dressed, and then she was calling 911 (emergency number) herself. On 5/13/25 at 3:00 p.m., an interview was conducted with a licensed practical nurse, LPN#2. WHen questioned about the cough medicaine, LPN#2 said, [R104's name redacted] cough medicine was not here because the medicine ran out. LPN#2 stated the third shift nurse reported to her the cough medicine was out and had been ordered. LPN#2 said, I called the pharmacy, and it was supposed to be here by noon today, but it still is not here. LPN#2 stated that the physician was not notified of the cough medicine being unavailable because it was a PRN medicine. LPN#2 said, When out of a prn, I don't notify the doctor about that. R104's clinical record was reviewed. R104 had a prn order for `dextromethorphan-guaifenesin 10mg-100mg/5 ml oral liquid for cough as needed every six hours. On 5/13/25 at 8:32 p.m., a progress note was written by LPN#2, which read in part, The night nurse informed this writer that the resident's prn cough medication was out of stock. The writer contacted the pharmacy twice [pharmacy staff names redacted] both of whom confirmed that the order had been received and was being processed. LPN#2 had a progress note that documented that R104 was transferred to the hospital at 3:30 p.m. The medication administration record was reviewed, and no prn cough medicine had been administered prior to R104 going out to the emergency room . A review of facility documentation was conducted. The policy Medication Administration, Receipt, Storage and Disposal read in part, when a licensed nurse or CMA/CMT determines that an ordered medication is unavailable, the following steps are initiated: if medication has not been ordered, fax request immediately and ensure request has STAT written on the top. Call the pharmacy and let them know which medication is needed as soon as possible. I medication is not available in the Omnicell machine, provider is notified and EMR [electronic medical record] will reflect conversation with the provider. Provider may ask nurse for alternative medications available in the Omnicell and provide a one time for an alternative to cover until medication is received for skilled/long term care residents only. On 5/14/25 at 4:00 p.m., an end of the day meeting was conducted with the administrator and corporate staff, during which the above findings were discussed. No additional information was provided prior to the exit conference.

Based on resident interviews, staff interviews, clinical record review and facility documentation review, the facility staff failed to assess resident, communicate with the provider, and ensure quality of care for one resident, R#104 (R104), out of a survey sample of 11 residents. The findings included: The staff failed to assess R104 prior to being sent out to the emergency room , failed to communicate with the physician before 911 was called by R104, and failed to review the emergency room report for new orders. On 5/13/25 at 2:30 p.m., R104 stated that she had called her pulmonologist (lung specialist) and said, My pulmonologist wants me to go out to the emergency room to get a CT scan and be treated for my cough, since the facility cannot treat me. R104 stated that she had called her pulmonologist and was waiting to be dressed and then she was calling 911 (emergency number) herself. The resident stated that her vital signs were not being checked, and no one had listened to her lung sounds. R104 said, When my oxygen levels are checked, I have to ask for it to be done. On 5/13/25 at 3:00 p.m., an interview was conducted with a licensed practical nurse, LPN#2. LPN#2 stated that she was aware that R104 had called her pulmonologist, and that she had given the number to R104. LPN#2 said, I didn't speak with the doctor. LPN#2 was aware that R104 was going to call 911 and that R104 stated to her that the pulmonologist I that she goes to the emergency room for evaluation. LPN#2 said, It was not the normal way for the residents to call the doctor or to call 911. I would call 911 if I felt she needed to go to the emergency room . LPN#2 stated that the physician was not notified of the cough medicine being unavailable because it was a PRN medicine. LPN#2 stated that R104 vital signs was obtained because she was going out to the emergency room . LPN#2 stated that R104's transfer packet was completed and given to the emergency medical staff. On 5/14/25 at 9:10 a.m., an interview was conducted with the clinical manager, registered nurse (RN#1). RN#1 stated the nurses should review the report from the emergency room and if anything was new or changes to notify the provider. LPN#2 showed the new order for cough medicine to RN#1 that was approved by the nurse practitioner (NP). RN#1 asked it the NP was going to order the prednisone and then she said, Never mind she will get me to call [R104's name redacted] pulmonologist about that. On 5/14/25 at 5:22 p.m., an interview was conducted with the NP. The NP stated, These instructions from the emergency room were not discharge orders. The emergency room s paperwork states to ask your doctor about these medications. When asked if she was R104's provider, the NP said, Umm hmm. The NP was asked if she was aware that R104 had called the pulmonologist and 911 herself and the NP replied, Umm hmm. On 5/14/25 at 6:30 p.m., an interview was conducted with LPN#2. When asked if the NP had seen R104 today, LPN#2 said, She did not see the resident today and only sees them if the nurse has a concern. When shown the emergency room report, LPN#2 stated these orders was new orders and that she was going to review the orders with the NP. Although the report from the hospital emergency room was placed in the miscellanous section of the resident's hard chart, but the staff was not aware of the new orders that were in the emergency room report. On 5/15/25 at 9:25 a.m., an interview was conducted with the regional director of clinical of operations, who stated that R104's lung sounds, skin assessment, medication review, coughing and shortness of breath were assessed last night by two nurses. The regional of clinical operations stated that the risk versus the benefits of the nasal cannula to be worn correctly was discussed with R104. The ADON reported having a clinical note in the chart about the assessments and about the education given to R104. The regional director of clinical of operations stated that the expectations of the staff were to assess prior to going out to the emergency room , staff were expected to speak to the doctor, and the provider was to physically see the resident within 24 hours of returning from the emergency room (ER) visit. The regional director of clinical operations said, The provider wouldn't write a note if she didn't see her and the provider is aware and knows the expectation of resident to be seen within 24 hours after an ER visit. The regional director of clinical operations was shown the provider's note where no physical exam was recorded. A clinical record review was conducted. R104 clinical notes had vital signs recorded the day she went out to the emergency room . When R104 returned from the emergency room no assessment was recorded for R104. On 5/14/25, a clinical note was written about R104 being on antibiotic and prednisone for upper respiratory infection but no vital signs were recorded in the note. A provider's note was reviewed during the clinical record review. The NP was in the facility and wrote a progress note addressing the ER (emergency room ) visit, which only had medical history, surgical history, hospitalization , family history, social history and a list of medication. There was no physical exam in the NP's note. On 5/14/25 at 4:00 p.m., an end of the day meeting was conducted with the administrator and corporate staff, during which the above findings were discussed. No additional information was provided prior to the exit conference.

Based on staff interview, facility document review, and clinical record review, the facility staff failed to protect a resident's right to be free from physical/verbal abuse by a private duty aide for one of thirty-three residents in the survey sample (Resident #252). The findings include: A clinical record review revealed that Resident #252 (R252) was admitted to the facility with diagnoses that included Parkinson's, post hip joint replacement, delusional disorder, anemia, dementia with behavioral disturbance, anxiety, vitamin deficiency and psychotic disorder. The minimum data set (MDS) assesment dated 3/8/23 coded R252 with short and long-term memory problems and severely impaired cognitive skills. A facility reported summary dated 3/15/23 documented that a housekeeper (other staff #15) reported on 3/15/23 at 12:45 p.m. that she witnessed R252's private duty aide (other staff #16) shove him back into his wheelchair and refer to the resident as crazy. The facility's investigation documented that the housekeeper stated she was cleaning R252's room when R252 was observed standing from his wheelchair. The investigation documented the housekeeper witnessed the private duty aide (other staff #16) harshly shove the resident back into the wheelchair. The investigation documented that when the housekeeper questioned the resident about the shoving incident, the private duty aide stated not to listen to the resident because he was crazy. The facility's synopsis documented that when questioned the private duty aide responded that she was attempting to keep the resident from falling and denied calling the resident crazy. The facility's synopsis revealed that the resident was pushed into the wheelchair with the private duty aide referring to the resident as crazy. The private duty aide was removed from the facility and not allowed to work for any residents in the facility. R252's clinical record documented a physical assessment on 3/15/23 in response to the incident, indicating no physical injuries from the incident. R252's clinical record documented assessment and follow up in the days following the incident with no changes in behavior/demeanor noted. R252 was discharged back to assisted living on 3/27/23. On 3/4/25 at 11:21 a.m., the assistant administrator (administration staff #2) was interviewed about R252. The assistant administrator stated the incident on 3/15/23 was reported to the state, adult protective services and the ombudsman. The assistant administrator stated the private duty aide was a companion and did not provide direct care to R252. The assistant administrator stated this private duty aide was removed from the facility at the time the incident was reported and had never provided care for any other residents in the facility. The assistant administrator stated that the private duty aide met prerequisites for sitters and was employed by the family through a local agency. On 3/4/25 at 2:42 p.m., the social worker (other staff #14) that investigated the reported incident on 3/15/23 was interviewed. The social worker stated the housekeeper (other staff #15) immediately reported the incident as required. The social worker stated the private duty aide was removed from the facility, was not allowed to care for any other residents, and had not been allowed to return. The social worker stated the private duty aide had cared for R252 in independent and assisted living prior to admission to the nursing facility and was familiar/known to the resident. The social worker stated the family reported no prior issues with the aide. The social worker stated the resident's family member did not want to terminate services with the private duty aide due to the incident but understood the actions taken by the facility in response to the incident were required. The social worker stated she interviewed the housekeeper and that the housekeeper reported she witnessed the private duty aide shove R252 back into his wheelchair. The social worker stated when the housekeeper asked about what was happening, the private duty aide said not to listen to the resident because he was crazy. The social worker stated private duty aides were not allowed to provide direct care to residents and were considered companions. The social worker stated the private duty aide denied calling the resident crazy, stated she was trying to prevent the resident from falling, and did not consider her actions rough. The social worker stated the private duty aide was removed from the facility with notifications made to the responsible party and provider. The social worker stated the incident was reported to the aide's employment agency and a self-report issued to the state agency, along with adult protective services and the ombudsman. The social worker stated nursing completed a skin assessment on R252 on 3/15/23 that revealed no injuries. The social worker stated R252 demonstrated no mood/behavior changes following the incident. The social worker stated the family hired a new companion following the incident and R252 had no concerns, reactions, or conflicts with the new companion. The social worker stated the resident discharged back to assisted living as planned on 3/27/23. On 3/4/25 at 2:52 p.m., the registered nurse unit manager (RN #3) that cared for R252 at the time of the incident was interviewed. RN #3 stated the private duty aide (other staff #16) had cared for the resident prior to admission to the facility. RN #3 stated that the housekeeper reported that she witnessed the private duty aide shove the resident back into his wheelchair and then refer to the resident as crazy when she questioned the incident. RN #3 stated private duty aides were considered companions and were not allowed to provide direct care. RN #3 stated the private duty aide had not reported any problems or concerns to nursing on 3/15/23 prior to the incident. RN #3 stated if R252 was standing repeatedly or demonstrating unsafe behaviors, the private duty aide should have notified a staff person. RN #3 stated private duty aides were supposed to get a staff member to intervene as needed with resident care concerns. On 3/5/25 at 10:15 a.m., the administrator and director of nursing (DON) were interviewed about R252's incident on 3/15/23. The DON stated the housekeeper reported the witnessed incident immediately as required and there was zero tolerance for abuse of any type. The DON stated that the private duty aide was removed from the facility, reported to her employment agency, and a facility summary was forwarded to the state agency. The housekeeper that reported the abuse incident with F252 was on leave and not available for interview. The facility's policy titled Abuse Prevention (revised 5/21) documented the nursing facility, .is committed to providing an environment where residents' rights are protected and residents remain free from abuse, neglect, exploitation, mistreatment .To this end, [the nursing facility] has adopted a standard of zero tolerance of resident abuse, neglect, exploitation, mistreatment, including injuries of unknown source or misappropriation of property in our communities, and will ensure that such allegations, are reported as required by federal, state and local laws and investigated promptly .This standard will include all community staff, other residents, consultants, volunteers, staff of other agencies serving the resident, family members, legal guardians, friends or other individuals . The facility's policy titled Private Duty Nurses-Aides in Continuing Care (revised 6/24) documented, .As defined in this policy, companionship includes the following duties: sitting with the resident to provide company and social engagement, bed making, and escort services .The PDN/A [private duty nurse/aide] will communicate relevant information regarding the resident to the Continuing Care staff member responsible for overseeing the care of the resident. Significant events and emergencies will be reported immediately . On 3/5/25 at 3:46 p.m., the administrator was interviewed about R252. The administrator stated the facility's analysis of the 3/15/23 revealed evidence of the events as witnessed/reported by the housekeeper. The administrator presented a summary of interventions/corrections that had been implemented in response to R252's abuse incident on 3/15/23. The administrator stated there had been no further allegations of abuse since 3/15/23. The facility's plan of correction included the following. 3/15/23 - Witnessed incident was immediately reported by the housekeeper to the housekeeping supervisor, social worker, and administrator. The private duty aide was removed from the facility and suspended. Notifications were made to the resident's family member, physician, state agency, adult protective services, and ombudsman. The private duty aide (other staff #16) was no longer permitted on the premises or allowed to sit for any other residents. Reviewed and determination made that the private duty aide (other staff #16) had provided care to no other residents in the facility. 3/15/23 - Initiated training with all nursing staff regarding abuse prevention policy, including reporting and investigation. 3/16/23 - Interviews and statements obtained from the housekeeper (other staff #15) and the private duty aide (other staff #16), and an attempted interview with R252. 3/22/23, 3/29/23 - Additional training for rest of the nursing staff on abuse prevention policy. 3/28/23 - In-service training conducted with department heads/leadership team regarding abuse reporting and investigation. Ongoing monitoring of facility reported incidents including abuse allegations. 4/21/23 - Incident reviewed/discussed in QAPI (quality assurance and performance improvement) meeting with facility leadership. Monthly QAPI meetings included ongoing review/discussion of all facility reported incidents including any abuse allegations. No further abuse allegations reported or identified. Date of correction was 4/21/23. Actions taken were reviewed. Education was documented as listed in the correction plan. A review of facility reported incidents for 1/1/24 through 3/5/25 revealed no allegations of abuse. Review of the QAPI program evidenced ongoing monitoring of all facility reported incidents including abuse allegations. Interviews with residents, families, and staff during the current survey revealed no concerns about abuse and/or mistreatment. This deficiency was cited as past non-compliance.

Based on staff interviews, clinical record review and facility documentation review, the facility staff failed to ensure residents were free from unnecessary psychotropic medications and perform gradual dose reductions for one resident, Resident #111 (R111), out of a survey sample of 11 residents. The findings included: A review of R111's clinical record revealed that a gradual dose reduction (GDR) was not completed for one of R111's antidepressant medications. On 5/14/25 at 9:03 a.m., an interview was conducted with a licensed practical nurse, LPN#1. LPN#1 was asked to explain the procedure for pharmacy recommendations. LPN#1 stated that pharmacy recommendations were given to the physician to review. LPN#1 said, Recommendations should be done right away, it needs to be taken care of. LPN#1 stated that the floor nurses and the clinical manager was responsible for notifying the physician of the pharmacy recommendations and making sure the recommendations were addressed. On 5/14/25 at 4:00 p.m., an end of day meeting was conducted with the administrator, director of nursing and the corporate staff. They were made aware of the above concerns. On 5/15/25 at 9:25 a.m., the regional of clinical operations presented additional information. The regional of clinical operations stated that when the provider was asked about the pharmacy recommendation for R111 that she only wanted to decrease the Lexapro and leave the Trazadone dose as ordered. The regional of clinical operations said, We did educations to the providers again yesterday. The regional clinical of operations acknowledged that she was aware that gradual dose reductions were required to be completed on psychotropic medications. Also present was the regional executive director, who nodded his head in agreement that the provider agreed with the drug reduction recommendations but only made changes to one medication. An additional clinical record review was conducted. R111's clinical record documented that Lexapro 10 mg (milligrams) was ordered on 6/19/24 and the first GDR was done on 5/2/25. R111's Trazodone 50 mg was ordered on 5/13/24 but no GDR had been attempted on this medication. R111 had a pharmacy recommendation on 3/13/25 that read in part, [ R111's name redacted] receives multiple antidepressants for depression concomitantly without documentation in the medical record of an inadequate response to monotherapy: Trazodone Hydrochloride, Escitalopram Oxalate. Please consider gradual dose reductions, with the end goal of discontinuation. The clinical record documented that the provider checked to accept the recommendations above, noting please implement as written but provided no written instructions on the pharmacy recommendation form. Also found was a telephone order that decreased the Lexapro 10 mg to 5 mg on 5/2/25. The medication order for Trazodone remained at the same dose. There was no reason given on the recommendation to why the Trazodone dose was not decreased by the provider. The clinical record also documented a provider's note dated 5/2/25, which read in part, .Lexapro was decreased to 5mg once daily for symptoms management. Also documented in the providers' note was a section that read, recommendations Decrease Lexapro to 5mg. The pharmacy recommendation for the Trazodone was not addressed in the provider's note. When provided, facility documents were also reviewed. The policy titled, Psychoactive Medications, read in part, .Gradual Dose Reduction Program: a structured approach aimed at systematically decreasing the dosage of certain medications to assess whether lower doses or complete discontinuation are feasible without adversely affecting a resident's well-being. The policy titled, Psychoactive Medication Management, read in part, .to ensure our guests/residents will not be chemically restrained during their stay. Guest/resident responds to their medical condition, their surrounding/environment and/or approach taken by others. No additional information was provided prior to the exit conference.

Based on observation, family interview, staff interview, facility document review, clinical record review and complaint investigation, the facility staff failed to provide care and supervision to ensure resident safety for three of 30 residents in the survey sample. In addition, the facility staff failed to implement a system to prevent accidents and promote safety for residents returning to the facility from a short-term leave basis. This resulted in potential harm and the identification of immediate jeopardy and substandard quality of care due to lack of a facility-wide accounting system of residents leaving and returning to the facility following short-term outings. 1. Resident #3 was left without care and/or supervision for approximately 3 hours after returning to the facility from a family outing. When found, Resident #3 was slumped and partially out of her wheelchair, glasses in the floor and without incontinence care. 2. Resident #429 was observed leaving Unit two with a family member on [DATE] at approximately 4:40 p.m. Resident #429's family member did not sign the resident out as being off the unit. Resident #429 was also observed leaving through the front door of the facility with the same family member at approximately 6:30 p.m. Resident #429 was not signed out on the unit or at the front desk of the facility as to her whereabouts. 3. The facility staff failed to ensure an appropriate method of supervision for leaves of absence for Resident # 93. Resident # 93 was leaving the facility with family via a sign out method, but there was no system in place to ensure the resident's return and/or that staff were aware of the resident's return or what to do in the event the resident was gone longer than expected. The facility administration was notified of the finding of Immediate Jeopardy on [DATE] at 6:10 p.m. Following the presentation and the acceptance of the Plan of Removal, the finding of Immediate Jeopardy was abated on [DATE] at 11:10 a.m. Subsequently, the deficiency was assigned a scope and severity of Level 2, widespread. The findings include: 1. Resident #3 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]., hypertension, Vitamin-D Deficiency, [MEDICAL CONDITION], and gastro-[MEDICAL CONDITION] reflux disease (GERD). The minimum data set ((MDS) dated [DATE] assessed Resident #3 with severely impaired cognitive skills. This MDS indicated that Resident #3 was always incontinent of bowel and bladder, and was totally dependent with one-person assistance for care, including incontinence care. A facility reported incident (FRI) dated [DATE] for the incident on [DATE] documented the following: on [DATE] the spouse of Resident #3 reported that at approximately 1 p.m., on the afternoon of [DATE], his daughter returned with the resident to her room. The daughter requested that staff clean her (Resident #3) up and then put her in bed for a nap, according to her afternoon routine. When the spouse arrived at approximately 4 p.m. to spend time with her (Resident #3), he allegedly found his wife (Resident #3) in her wheelchair, slumped over, almost falling out. Her eyeglasses were on the floor. The spouse stated he thought she had died . He reported, feeling there was no evidence that she (Resident #3) had been rounded on as she was still in her chair, not put in bed and he 'seriously doubts' whether or not she had been cleaned up since her return at 1 p.m. The facility's investigation of the incident included interviews with the staff providing care for Resident 3. The investigation reported the aide who routinely cared for Resident #3 stated she assisted Resident #3 on the morning of the incident and that her husband had taken her out. The report stated the aide said she had not seen Resident #3 the rest of the shift. The reports stated the said she stopped by the room during her normal rounds at approximately 12:45, and that the resident was not there. Both individuals assigned to the resident stated they were unaware of her return to the facility. The clinical record was reviewed on [DATE], to include the care plan. Resident #3's care plan under section 3f. documented Assistance in Bathroom-Functional Status/Continence documented the resident required total dependence with one person physical assist. Resident #3 required assistance to pull up or down my garments. To make sure I cleanse myself (perineal care). To manage protective garments and/or continence products. Resident #3's physician's orders [REDACTED]. Resident #3's clinical record documented nothing further about her leaving or returning to the facility on the date of the incident. On [DATE] at 10:50 a.m., the director of nursing (DON) and the assistant administrator were interviewed regarding the FRI which occurred on [DATE]. The DON and assistant administrator were asked if the facility had a sign in/out policy. The assistant administrator stated there was a sign out book at the front desk and they ask family and visitors to use the front desk book, however it doesn't always happen. The Assistant Administrator stated Resident #3 was not signed out at the front desk downstairs, and provided a copy of the front desk's arrival and departure log for [DATE]. The DON stated the family or resident representative (RR) will notify the staff when the resident leaves and returns to the facility. The DON and assistant administrator were asked about the expectation regarding the staff knowing the residents' location. They both stated the expectation was for staff to round on individuals to make sure they are capturing if the residents are on or off the unit. On [DATE] at 12:12 p.m., Resident #3's husband was interviewed and he stated he takes her out of the facility daily for dinner to the cafe located on the Independent Living (IL) side of the community property. Resident #3's husband stated his daughters brought his wife back to the facility around 1 p.m. He stated his daughters said they reported to someone on the floor that his wife was in her room and needed changing and then to lay her down for her afternoon nap. Resident #3's husband stated neither he, nor his daughters, knew the name of the person who was advised that Resident #3 had returned to her room. Resident #3's husband stated when he returned to the facility at approximately 4 p.m. he found Resident #3 in her room, sitting slumped over in her wheelchair, with her glasses on the floor beside her. He stated, I thought she had died . He said the room was very hot and the thermostat was on 90 degrees. He said he rubbed her back and started to talk to her and she seemed to go back to her usual self. He said, I took her out of there (room) and told someone about the room temperature. Resident #3's husband stated for a year and a half he has done daily visits with his wife, this is their routine to spend time together and they enjoy going to the IL cafe for dinner. He stated, When I arrived at 4 p.m. and found her in that condition, I knew there was no way they rounded on my wife or took care of her for those 3 hours. I feel she was just left there alone in that hot room. Resident #3's husband stated during the time she is with him he does not provide incontinent care. Resident #3's husband stated he normally arrives around 4 p.m. to pick up Resident #3 and she (Resident) remains with him for approximately two and half to three hours depending on how long it takes her to eat. He then returns Resident #3 to the facility where she remains for the evening and night. He stated he normally signs her out each time using the sign out book at the nurses' station. He stated there is no sign-in sheet, so when he returns he tells a staff member. He continued and said he notifies the aide or nurse who is assigned to Resident #3; however, he knows most of the staff so if her assigned person is not available then he will notify another staff member that he has brought her back. The certified nursing assistant (CNA) caring for Resident #3 on [DATE] was not available for interview. On [DATE] at 12:37 p.m., CNA #2, providing care for Resident #3 was interviewed about the sign in/out policy and rounding. CNA #2 stated they used a resident sign out sheet. CNA #2 presented a white 3 ring binder labeled as RC 4th Floor Resident Sign Out Sheet. CNA #2 stated the binder was kept at the nurses' station desk on the unit. The form titled Resident Monitoring Sheet had columns labeled as date/time, resident activities and initials. There was no column to sign-in listed on the sheet. CNA #2 stated this was their tracking system. CNA #2 was asked if the resident was not signed in/out and was noted not on the unit during rounds how they handle locating resident. CNA #2 stated she does walking rounds on the entire unit if she cannot locate a resident and if there is no knowledge of the resident signing in/out. CNA #2 stated she would check the resident's room, the entire unit and/or common areas to verify whether the resident has or has not returned. CNA #2 stated if it is at shift change, she passes the information on to the oncoming shift if the resident has not returned to the unit. A copy of the RC 4th Floor Resident Sign Out Sheet was provided and reviewed. There was no evidence showing Resident #3 had been signed out or back in to the facility on [DATE]. On [DATE] at 4:20 p.m., the team leader went to the administrator's office to obtain the facility policy regarding residents leaving the facility, signing in/out, etc. The assistant administrator presented a facility policy regarding Leave of Absence (LOA). She stated, This is the policy we have for extended leaves of absence, we haven't given this to you because we were looking to see if there are any other pieces. She was asked what constituted extended leave. She stated, Anything overnight or when the resident is going to be gone for an extended time, over the holidays .we ask to be given notice so we can get their medications together, we clear it with the doctor and the social worker is involved. She was asked if they had found any other pieces to the policy. She stated, No, this is what we have. She was asked what the policy was for residents leaving to go out to appointments, out to dinner with family, or to another area on campus. She stated, We don't have a policy for that, this is all we have. There are sign out sheets on the units and at the front desk. On [DATE] at 4:45 p.m. the licensed practical nurse (LPN) #3 on the fourth floor caring for Resident #3 was interviewed about the resident sign in/out procedure. LPN #3 stated we have a sign-out book on this floor. LPN #3 presented the same binder as CNA #2. LPN #3 stated some residents sign back in and some do not. LPN #3 stated we also have a sign in/out book downstairs at the front desk in the lobby. LPN #3 was asked if the family and/or resident would be stopped if they did not sign in/out downstairs. LPN #3 stated no, I don't think so, rather the front desk will call the unit to make sure it is ok for the resident to leave. LPN #3 stated if she noticed a resident has not returned and appears to be out longer than normal then she would call the family to check on the status of the resident's return. LPN #3 stated the staff communicates residents' locations during rounds and shift changes. On [DATE] at 4:58 p.m. the front desk staff was interviewed about family members signing resident's out. The staff stated That log book is for visitors coming in to the facility; it is not a sign out book for families to sign out the resident(s). On [DATE] at approximately 4:40 p.m., two residents, one on another unit and one in the lobby, were observed leaving the facility without signing out. At 5:30 p.m., the survey team inspected the other two units and found there was no use of facility-wide sign out/in book for residents leaving or returning to the facility. On [DATE] at 5:45 p.m., the state agency supervisors were notified the facility did not have a facility-wide system for tracking and accounting for residents who were on short-term leave of absence. On [DATE] at 6:10 p.m. the administrator and DON were informed of the finding of Immediate Jeopardy and Substandard Quality of Care due to the facility failed to have facility-wide system to account for residents leaving and returning to the facility following short-term outings. The administrator presented the survey team with the plan for abatement of the Immediate Jeopardy [DATE] at approximately 8:35 p.m. which included: 1. (Name of Resident #3) is currently being supervised and is in her room sitting in her chair watching television. ([DATE] @ 8:20 p.m.) 2. A security guard will be assigned to the entrance/exit until nursing staff is trained. A house wide audit was conducted. We have accounted for all residents on our current census. ([DATE] at 8:20 p.m.) 3. Administrator or designee are currently educating nursing staff in the building on Resident Leave of Absence (LOA) policy, specifically signing in and out in the log book on the neighborhood. We will complete the remaining nursing staff, health care sales staff, security and social work staff within the next 72 hours. ([DATE]) Resident and Families/Responsible Parties will be contacted to review the LOA process, specifically notifying staff and signing in and out in the log book on the neighborhood. Communication will be documented. ([DATE]) Each neighborhood will have a binder/notebook with Leave of Absence (LOA) log and the Leave of Absence-Off Campus forms. ([DATE]) 4. Administrator/designee will round every two hours to verify location of residents, LOA logs in place, and to conduct random staff interviews by neighborhood to validate knowledge of LOA policy. ([DATE]) Two-hour rounds will be conducted X (times) 72 hours. Random audits of log books and staff interviews will be conducted X 4 weeks, and every other X 2 months. Results of the audit will be reported to the QAPI committee to monitor for progress for improvement for 3 months. The survey team, reviewed the plan of correction and accepted the removal of the immediacy on [DATE] at 8:55 p.m., when security guards were put in place at the door. The survey team observed the following, accepted the plan of correction, and fully abated the IJ on [DATE] at 11:10 a.m.: 1. Resident #3 was observed on her unit eating breakfast and being supervised. 2. The security guards were observed at the front entrance and exit with clipboards signing residents in and out. A copy of the house wide audit was presented and reviewed documenting all residents were accounted for. 3. Staff were interviewed on each unit regarding the training for the short tern LOA policy and signing residents in and out of the logbook on each unit. Copies of the training logs were presented and reviewed that documented the training. A LOA logbook binder was observed on each unit's nurses' station. Residents and/or family members were observed being told about the LOA policy and sign in/out logbook as they were entering and exiting the building. 4. Copies of the Two-hour rounding sheets were presented and reviewed which documented each unit was completing 2-hour rounds on each resident on each unit. 2. Resident #429 was originally admitted to the facility on [DATE]. Her [DIAGNOSES REDACTED]. The admission MDS (minimum data set) with an ARD (assessment reference date of [DATE], assessed Resident #429 with a cognitive summary score of 06, indicating severe impairment in her cognitive status. On [DATE] at approximately 4:40 p.m., Resident #429 was observed in a wheelchair being pushed down the hallway of the 200 unit by a family member. Resident #429 was asked if she was going to the dining room, the family member responded, No, not yet. We are going to stroll around a little bit and get a change of scenery. She pushed the resident down the hallway and out of the unit door. CNA (Certified Nursing Assistant) #5 was observed standing in the hallway. She was asked if Resident #429 signed out when she left the unit. She stated, No, the residents or the family usually tell us when they are leaving .we don't have a sign out book. It's downstairs at the front door. CNA #5 was asked if the family member of Resident #429 had told her where they were going just now when they left. She stated, No, but they will be back for dinner. CNA #5 was asked how the residents were accounted for if there was an emergency and they had not left through the front door but were on another unit or another area of the facility campus. She stated, I try to tell the nurse's when the residents leave, if I see them going .I don't know what the nurse's do with the information. CNA #5 was asked if any of the nurse's were aware that Resident #429 had left the unit that evening. She stated, I don't know. There were no nurse's in the hallway, the nurse's station where clinical records were contained was a room with a locked door and no windows. LPN (licensed practical nurse) # 2 was in the nurse's station. She was asked if she was aware that Resident #429 had just left the unit. She stated, No. She was interviewed regarding the location of residents on the unit. She stated, If they have an appointment that is scheduled and they are leaving we write it on the 24 hour report. She was asked if there was a sign in/sign out book for when residents left the unit to go to dinner with a family member or friend or just out off the unit. She stated, No, we do not have a sign in or out book up here .there is a book downstairs at the front door .if the resident is cognitively intact and they are leaving we make sure they want to go .if they are not cognitively intact we check with the responsible party that is listed on the record to make sure it is okay .if they are going to be gone overnight we write it on the 24 hour report and send their medicine with them. At approximately 5:30 p.m., Resident #429 was observed in the dining room. Her family member was with her and was helping her with her meal. The family member was interviewed. She stated that Resident #429 normally lived in a different area of the facility in assisted living and that she was on this unit to get therapy. She stated, I'm only here visiting for a few days .Mom lived down on (name of unit) before coming up here .sometimes I push her back over there, or we go outside to get some fresh air .just a while ago we went down the long hall to the other side to get a change of scenery. She was asked if she spoke with anyone or had to sign her mother out before leaving the unit. She stated, No, I usually just wave to whoever is in the hallway to let them know we are leaving. At approximately 6:30 p.m., Resident #429 was observed leaving the front door of the facility with the same family member. The family member stated, We're going outside for some fresh air and to see how hot it is. The sign in/sign out book at the front desk was reviewed at that time. Resident #429 had not been signed out as leaving the building. The care plan was reviewed on [DATE] at approximately 8:30 a.m. The following was documented: My personal story: .I have always been a very social lady enjoying my time with friends and family, hosting events and gatherings. My entire life I have always been engaging and being out and about with others .The following actions, words, phrases, scents, etc. upset me? When I feel closed in or that I am missing out on something I want to do. I get confused and may need redirecting to get to a place at times. An area on the care plan: Activities and Socialization included the following information: I like interactive programs, I like to spend time with my neighbors in the living room of my neighborhood I enjoy: Everything on the calendar. I am out of my room all day going to different neighborhoods and participating in activities. Care plan approaches were: Staff will continue to encourage resident to attend activities of their interest. Under the section Safety and Exploring the following information was observed: I do not explore the neighborhood. At times I may forget exactly where my room is, but I am easily redirected. There were no other care plan approaches listed. The above information was discussed with the administrator and the DON (director of nursing) during a meeting on [DATE] at approximately 6:05 p.m. They were informed that the survey team had identified a system wide failure regarding the facility's ability to account for residents at all times. The facility staff did not know the whereabouts of residents when they were off the units or when they would be returning. This lead to the identification of Immediate Jeopardy and Widespread Substandard Quality of Care at 6:10 p.m. The immediacy was abated at 8:55 p.m. on [DATE]. No further information was obtained regarding Resident #429 prior to the exit conference on [DATE]. 3. Resident # 93 admitted to the facility on [DATE], with the most current readmission on [DATE]. [DIAGNOSES REDACTED]. The most recent MDS (minimum data set) was a quarterly assessment with an ARD (assessment reference date) of [DATE]. This MDS assessed the resident with a cognitive score of 14, indicating the resident was cognitively intact for daily decision making skills. This MDS assessed the resident as requiring extensive assistance with one person assist for most ADL's (activities of daily living). The resident's mode of mobility was documented as a walker and/or w/c (wheel chair). On [DATE] at approximately 4:30 p.m. the resident was observed with other females in the lobby, with one women pushing the resident in her w/c. The resident was asked if she was going out and the resident stated, Yes. At approximately 4:45 p.m., CNA (certified nursing assistant) # 8 was asked about how the process works when a resident leaves the facility for an outing. The CNA stated that when a resident goes out, the family or whoever (may not be family) is supposed to sign them (the resident) out in a book at the nurses station, they (the family) knows they are supposed to do that. The CNA stated that when they (a resident) come back they (the person returning the resident) will tell the nurse or whoever (other staff) or they see the resident and let them know that way that the resident is back. The CNA was asked if the resident is supposed to be signed back in by staff and/or family. The CNA stated, I don't know if they sign back in, for that part I don't know, for that part I am not sure. On [DATE] at 5:02 PM, OS (Other Staff) # 6, the unit 3 secretary, was asked if there was a sign out book/sheet for residents when they go out. OS # 6 stated, For what .appointments? OS# 6 was asked if there were any any types of sign out book/sheet for a resident leaving for anything, any type of appointment, or any type of leave from the unit and/or the building. OS # 6 stated that there is a sign out sheet on the resident's chart, under the miscellaneous tab and that not everyone (resident) has one in their chart because everyone doesn't go out. It is a leave of absence sheet located on the resident's chart. OS # 6 further stated that this (sign out sheet) is not part of the packet (admission packet) that we (staff) do when they (residents) are admitted . OS # 6 stated, We don't know who can go out until the family or whoever comes and tells us; then we have a sheet we put in the resident's chart, located in the back that they (family) sign out the resident. Resident # 93's chart was reviewed, including the sheet, titled Leave of Absence Log. The form had a date column, time column, name of resident column, print name of person accepting responsibility column, relationship column, expected time of return column, on campus or off campus, staff name, sign in date, sign in time, and staff name. OS # 6 explained that the family or other will fill out the form indicting if they are going to remain on campus or off campus, the person then puts their signature, along with the date, and enters an expected return time. The secretary stated, We will fill out the form sometimes that the resident is returned, but as you can see with this one (Resident # 93) that didn't happen. When asked if staff are supposed to sign the resident back in, OS # 6 stated that she didn't know and that maybe when they come back, they (the family) will just tell the nurse and they (staff) see them, so they (staff) don't sign them back in. OS # 6 was asked if there was any other areas or locations to log this information, OS # 6 stated that this form is where staff document when a resident leaves. On [DATE] at 11:17 AM, Resident # 93's leave of absence log was received, along with the resident's physician's orders [REDACTED]. The resident was signed out by her daughter on the evening of [DATE] at 4:30 p.m., the expected time of return was documented for 7:30 p.m., the off campus block was checked, but no other information was completed. The resident was signed out a total of seven times (since (MONTH) (YEAR)) and for each of the sign outs on the sheet, no documentation was found to regarding the resident's return, the time of the return, or the staff member receiving the resident from the return. The resident's physician's orders [REDACTED]. The resident's CCP (comprehensive care plan) was reviewed and documented the following, .safety and exploring .I like to sit outside but will need you to check on me frequently .I am not an elopement risk, I will need assistance from my care team to help me with mobility in my wheelchair inside and outside of my room .I will need assistance in and outside my neighborhood .Activities and Socialization .I enjoy visitation from my family .I vote at the polls .going to catholic mass, exercise and going outside when weather is good . No other information was found regarding Resident # 93 leaving the facility. The administrator and DON (director of nursing) were made aware of serious concerns in a meeting with the survey team on [DATE] at approximately 5:10 p.m. regarding the facility not having an adequate tracking system in place to ensure the whereabouts of all resident's at all times. This lead to the identification of Immediate Jeopardy and Widespread Substandard Quality of Care at 6:10 p.m. The immediacy was abated at 8:55 p.m. on [DATE]. No further information was obtained regarding Resident #93 prior to the exit conference on [DATE].

Based on observation, staff interview, resident interview, clinical record review, and facility document review, the facility staff failed to ensure two of 24 residents in the survey sample were provided adequate supervision and/or failed to implement safety interventions to prevent accidents for Resident's #'s 6 and 18. The facility staff failed to provide adequate supervision for Resident # 6, which resulted in a fall and subsequently a fracture to the left leg. The facility staff failed to ensure an implemented safety device (chair alarm) for Resident # 18 was turned on and functioning properly. Findings include: 1. Resident # 6 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The most current MDS 3.0 (minimum data set) was a annual assessment, dated 03/06/11. This MDS assessed Resident # 6 as having a cognitive score of "2", which indicated severe impairment. Resident # 6 was also assessed as requiring extensive assistance with transfers and toileting, which required 2 person's physical assistance. The resident also received a code of 8/8 for ambulation, which indicated that this activity did not occur. The previous MDS 3.0 dated 12/19/10, was a quarterly assessment and was used for comparison. This assessment coded Resident # 6 with a cognitive score of "3", which indicated severe impairment. Resident # 6 was also assessed as requiring extensive assistance from 1 person for: transfers, dressing, and toileting. The resident also received a score of 8/8 on this assessment for ambulation, which indicated that activity did not occur. In section G0300 (Balance during transitions and walking) it was documented: "A. Moving from seated to standing position=2 (Not steady, only able to stabilize with human assistance)...D. Moving on and off toilet=2 (Not steady, only able to stabilize with human assistance)..." During clinical record review on 03/09/11 at approximately 10:00 a.m., the following nursing notes were observed: ? 12/28/10 (5:03 p.m.): "Res. (resident) asleep in bed, yelling "Get me up now!" 1 person transfer to w/c (wheelchair)...Cont. (continue) on ABT (antibiotic) Rocephin 1g (gram) IM (intramuscular) for UTI (urinary tract infection)...Self propelling...in w/c...Frequent attempts to self toilet in her bathroom and hallways. Fall precautions inplaced (sic)..." ? 12/28/10 (11:18 p.m.): "...Found on the floor in the bathroom next to unit manager's office in the hallway. Resident lying on her (L) (left) side against the wall, wheelchair in front of her. C/O (complained of) shoulder and knee pain...knee is still hurting...new order, xray..." ? 12/28/10 (3:41 a.m.): "Tech to do repeat X-ray...Medial side of (L) knee slightly swollen, however pt (patient) is able to move (L) leg without complaints...(L) knee not bent d/t (due to) writer not sure if it has a fx (fracture)..." ? 12/29/10 (4:29 p.m.): "...L knee lab (sic) result shows no fracture, dislocation or effusion seen...Res. awake at 9am, yelling "I want to get up." Upon assessment...redness, warmth to BLE (bilateral lower extremities)...Able slightly to lift legs up/down and flex without any difficultly. Insisted on getting out of bed (attempting to stand). Unable to bear wt. (weight), 2 person transferred to w/c...New order noted for x-ray of the Lt. (left) pelvis, hip and thigh (fall/pain, r/o (rule out) fx..." ? 12/29/10 (11:36 p.m.): "...new order(s) add left tib-fib (tibia/fibula) to Xray; non wt bearing to LE (Left extremity); splint to tib.-fib for suspected fx..." A radiology report dated 12/29/10 and timed 5:25 a.m., documented: "...Exam: Knee...Left...No fracture or dislocation seen..." A radiology report dated 12/29/10 and timed 7:18 p.m., documented: "...Exam: Hips bilat (bilateral)/pelvis...No pelvic or hip fracture seen..." Another radiology report dated 12/29/10 and timed 7:18 p.m., had an addendum attached and documented: "...Exam: Tibia/Fibula Left...There is an acute fracture of the proximal fibula with slight displacement...A possible subtle depressed fracture of the medial tibial plateau is considered..." Resident # 6's care plan was then reviewed and documented that the resident was at risk for falls. The care plan interventions listed included: a hand written intervention (# 11.), which documented: "...Bed and chair alarm to alert staff of attempted..." Other interventions observed in the care plan included: "...Motion detector to be used for ALL days while in bed, while in chair...Fall Precautions...provide total assistance for transfers at times with two staff (12/19/10- extensive /2 person)...Provide total assistance with toileting as incontinence of bladder and bowel..." The care plan was dated 05/10/10 with a review date of 09/11/10 and 12/19/10, which documented: "Cont (continue) POC (plan of care)..." The most recent POS (physician's orders [REDACTED]...05/10/10 BED ALARM TO PREVENT SOLO AMBULATION-CHECK UNIT EVERY SHIFT FOR OPERATION, 05/10/10 CHAIR ALARM TO PREVENT SOLO AMBULATION-CHECK UNIT EVERY SHIFT FOR OPERATION..." The administrator and DON (director of nursing) were made aware on 03/09/11 at approximately 4:10 p.m., of concerns regarding Resident # 6's fall and the injury incurred. The investigation on this fall was requested for review. The investigation was reviewed briefly on the morning of 03/10/11. The investigation documented that Resident # 6 was found in the bathroom, (located)by the Unit Manager's office (also known as RN (Registered Nurse) # 1) lying in the floor after staff heard a loud noise. On 03/10/11 at approximately 10:45 a.m., the DON and the administrator were interviewed regarding the investigation and Resident # 6's fall. The DON stated that she (Resident # 6) had an alarm attached to her chair, when asked if the alarm was functioning and whether it sounded or not; the DON stated that RN # 1 transferred her (Resident # 6) to the toilet and that is why the alarm would not have been sounding. The DON and administrator were then asked if RN # 1 left Resident # 6 alone in the bathroom. The DON and administrator both verbalized, "yes" that the resident could pull the call bell and that RN # 1 left the resident for "privacy." The resident did not pull the call bell when she was finished and as a result, fell in the floor and incurred injury/fracture to the left leg. The DON and administrator were made aware that the information that they had just been shared with the survey team, was nowhere in the investigation, on the incident report or in the nurse's notes. After discussing Resident # 6's cognitive status and functional mobility, the survey team expressed concern that Resident # 6 was assisted to the toilet and then left alone by staff. The DON and administrator then voiced that the resident transferred herself to the toilet. Again, the question was asked-if the resident's chair was equipped with an alarm, why was it not sounding/alerting staff when the resident transferred. The DON or administrator did not provide a comment for the question. The DON and administrator then voiced that they would look to see if there was any additional information regarding this incident. This surveyor requested to interview RN # 1 at this time. On 03/10/11 at approximatley 11:25 a.m. RN # 1 met with the survey team for an interview regarding Resident # 6. RN # 1 stated that Resident # 6 was coming down the hall in her wheelchair toward RN # 1's office (there is a bathroom located next to this office). RN # 1 stated that, I (RN # 1) was coming out of my office and saw Resident # 6, she (Resident # 6) had asked to go to the bathroom. RN # 1 stated that she (RN # 1) assisted her (transferred) her to the toilet and then left her. RN # 1 voiced leaving the resident alone on the toilet and shutting the door to provide privacy. RN # 1 stated that Resident # 6 could call for assistance using the call bell system on the wall. RN # 1 was asked, given Resident # 6's cognitive status she was able to call for assistance? RN # 1 stated, "Yes, she is able to call...she may forget, but most times she does call." It was pointed out that Resident # 6 did not call for assistance and Resident # 6 fell , staff heard a loud noise, which prompted staff to check on the resident. RN # 1 voiced, ...went out, shut door for privacy, just heard a "bang." The DON and administrator were informed of the above on 03/10/11 at approximately 2:05 p.m. No further information or documentation was provided prior to the exit conference. 2. Resident # 18 was admitted to the facility 2/19/11 with [DIAGNOSES REDACTED]. The most recent MDS(minimum data set) was an admission assessment with an ARD(assessment reference date) of 2/26/11 and had the resident scored as being cognitively intact. The clinical record was reviewed 3/10/11 at approximately 10:00 a.m. The nursing notes documented the resident was found on the floor with no injury on 2/27/11 and was found sitting in front of her wheelchair 3/5/11, again without injury. Resident # 18 was able to tell facility staff how she fell , and the careplan was updated accordingly as well as an updated Fall Risk Assessment in which the resident was coded as a 15, indicating a high risk for falls. A physician order [REDACTED]." At approximately 10:55 a.m. 3/10/11 the surveyor went to Resident # 18's room to ensure the chair alarm was in place and functioning. Upon knocking and being invited into Resident # 18's room, the resident was sitting in the wheelchair reading. The surveyor noted the alarm to be placed on the wheelchair, and proceeded to pick the alarm up for closer inspection. Resident # 18 stated "It's not on. Watch this." Resident # 18 then placed her hands on the arms of the wheelchair, stood up momentarily and then sat back down stating "no one will come to see about me because that alarm isn't turned on." The surveyor checked the alarm controls and found the control to be in the "off" position. Resident # 18 went on to say " the alarm is supposed to make a beeper that my assigned CNA carries go off, but they haven't bothered to turn it on, so she isn't going to come and check on me. I understand why I have the alarm since I've had a couple of falls, but the pad the alarm is attached to is uncomfortable to sit on and if it's not even going to turned on I don't see why I have to put up with it!" The surveyor then went out to find the resident's assigned CNA. The charge nurse, LPN # 1, was in the hallway administering medications and the surveyor asked her if she was familiar with Resident # 18. LPN # 1 stated she was, and also paged the CNA. LPN # 1 was interviewed about the chair alarm. LPN # 1 stated she was aware of the alarm, and it was on the resident's wheelchair. The CNA, who shall be identified as CNA # 1 arrived at that time and was also interviewed about Resident # 18's chair alarm. CNA # 1 stated she was carrying the beeper device for the alarm. The surveyor then asked LPN # 1 and CNA # 1 if they knew whether the alarm was turned on for Resident # 18. Both stated the alarm was on. The surveyor then advised them that the alarm was in fact not turned on. CNA # 1 stated "it may have been turned off when she went to therapy this morning; they turn the alarms off so they won't go off while they're in therapy." The surveyor then asked CNA # 1 when Resident # 18 returned from therapy. CNA # 1 replied she did not know the resident was back. CNA # 1 was then asked when resident's assigned to her went out for any reason, did she then go to check they were back and in this case, ensure the alarm had been turned back on. CNA # 1 did not answer the surveyor. LPN # 1 then looked at a third staff member sitting at a desk and said "will you go and turn Resident # 18's alarm on please?" The surveyor then returned to Resident # 18's room. Resident # 18 smiled at the surveyor and stated "well, it's (the alarm) on now. Someone just came in and turned it on." The surveyor the asked Resident # 18 if the alarm had been turned off when she went to therapy that morning. Resident # 18 stated "I don't go to therapy today until 2:00 p.m." These findings were presented to the administrator and DON(director of nursing) 3/10/11 at approximately 2:15 p.m. during a meeting with facility staff.