Every finding on record at Harbor Health & Rehab

Based on record review and interview, the facility failed to ensure Care Plans were updated with interventions for residents who had behaviors, falls, schizophrenia, and abuse care plans for 4 of 4 residents reviewed for care plans (Resident B, C, D, and E) Findings include:1. The record for Resident B was reviewed on 2/23/26 at 9:53 a.m. Diagnoses included, but were not limited to, Alzheimer's, psychotic disorder, hypertension (high blood pressure), depression, anemia (low iron), depression, and COPD.The Quarterly Minimum Data Set (MDS) assessment, dated 11/4/25, indicated Resident B was cognitively impaired for daily decision making.A facility reported incident, dated 12/11/25, indicated Resident B went to offer Resident D a piece of candy and Resident D had swatted at Resident B, which knocked the candy to the floor. A nurse had witnessed the incident, and no physical contact was made between the two residents and no injuries were noted. An investigation was initiated.A facility reported incident, dated 2/2/26, indicated staff had overheard a verbal altercation between Resident B and Resident C. Resident B was observed on the floor in the doorway. Resident B was assessed and had pain in his right leg and hip. All parties were notified and Resident B was sent to the hospital for further evaluation and Resident C was sent to the hospital for a psychiatric evaluation. An investigation was initiated.A Care Plan, dated 5/17/26 and revised on 2/3/26, indicated Resident B was an elopement risk and wandered. The interventions included, but were not limited to, providing distraction from wandering, 15-minute safety checks, and wearing a wander guard.The interventions for the elopement and wandering care plan were last revised on 6/10/25.A Care Plan, dated 5/22/24, indicated the resident was at risk for abuse/neglect. Interventions included, but were not limited to, report abuse per policy and assess for potential risk factors.Interventions for the abuse/neglect care plan were last revised on 5/22/24.A Care Plan, dated 5/17/24 and revised on 11/21/25, indicated the resident was at risk for falls related to antidepressant medication use, diagnosis of Alzheimer's dementia with poor safety awareness and wandering. Interventions included, but were not limited to, place call light within reach and PT (physical therapy) to evaluate and treat for gait and balance training.Interventions for the fall care plan were last updated on 7/17/25.During an interview on 2/25/26 at 1:37 p.m., the Director of Nursing, Nurse Consultant, and Administrator indicated the interventions should have been updated and they understood the concern. They had no additional information to provide. 2. The record for Resident C was reviewed on 2/24/26 at 2:47 p.m. Diagnoses included, but were not limited to, schizophrenia, dementia, dysphagia (difficulty swallowing), depression, anxiety, mild cognitive impairment, mild intellectual abilities, restlessness and agitation, HIV, and alcohol abuse.The Quarterly Minimum Data Set (MDS) assessment, dated 11/4/25, indicated Resident C was cognitively intact for daily decision making.A Nurse's Note, dated 12/23/25, indicated the resident was placed on 30 minutes checks for 72 hours. There were six behavior notes on 12/23/25 that indicated the resident was verbally aggressive toward staff and residents.A Nurse's Note, dated 12/24/25, indicated the resident was sent out to the hospital for evaluation.A Nurse's Note, dated 12/26/25 at 2:40 p.m., indicated the resident returned to the facility.A Nurse's Note, dated 12/27/25 at 8:45 a.m., indicated the resident was verbally aggressive to staff and was placed on 15-minute safety checks.A Nurse's Note, dated 12/27/25 at 12:18 p.m., indicated the resident was sent out to the hospital behavioral health unit for further evaluation.Nurse's Notes on 1/6, 1/13, 1/14, 1/17, 1/18, 1/19, 1/24, 1/25, 1/27, and 1/28/26 documented verbally aggressive behavior by the resident.A facility reported incident, dated 2/2/26, indicated staff had overheard a verbal altercation between Resident B and Resident C. Resident B was observed on the floor in the doorway. Resident B was assessed and had pain in his right leg and hip. All parties were notified and Resident B was sent to the hospital for further evaluation and Resident C was sent to the hospital for a psychiatric evaluation. An investigation was initiated.A Care Plan, dated 9/2/23 and revised on 2/3/26, indicated Resident C had a behavior problem. Interventions included, but were not limited to, praise progress/improvement in behavior, and intervene as necessary to protect the rights and safety of others and minimize potential for disruptive behaviors and placed on 15-minute safety checks.Interventions for the behavior care plan were last updated on 2/16/26 after the resident returned from a 15-day stay at the psychiatric hospital. The last intervention prior to the resident's 2/2/26 incident was 9/16/24.During an interview on 2/25/26 at 1:37 p.m., the Director of Nursing, Nurse Consultant, and Administrator indicated the interventions should have been updated after the resident returned from his second hospital stay on 12/27/26. 3. The record for Resident D was reviewed on 2/25/26 at 11:09 a.m. Diagnoses included, but were not limited to, suicidal ideations, dementia, anxiety, hypertension, major depressive disorder, and psychotic disorder.The Quarterly Minimum Data Set (MDS) assessment, dated 1/19/26, indicated Resident D was cognitively intact for daily decision making.A Facility reported incident, dated 12/11/25, indicated Resident B went to offer Resident D a piece of candy and Resident D had swatted at Resident B, which knocked the candy to the floor. A nurse had witnessed the incident, and no physical contact was made between the two residents and no injuries were noted. Investigation was initiated.A Care Plan, dated 8/2/24 and revised on 2/10/26, indicated the resident was at risk for abuse and neglect. Interventions included, but were not limited to, assuring the resident that they were in a safe environment, and reporting abuse per policy.The abuse/neglect care plan interventions were last revised on 8/2/24.A Care Plan, dated 9/5/24 and revised on 12/11/25, indicated the resident displayed socially inappropriate and maladaptive behavior. Interventions included, but were not limited to, exercising the resident at regular intervals, report behaviors to psych services, and use frequent reassuring phrases.The socially inappropriate/maladaptive behavior care plan interventions were last revised on 9/14/25.During an interview on 2/25/26 at 1:37 p.m., the Director of Nursing, Nurse Consultant, and Administrator indicated the interventions should have been updated and they understood the concern. They had no additional information to provide. 4. The record for Resident E was reviewed on 2/25/26 at 11:09 a.m. Diagnoses included, but were not limited to, hemiplegia (one side of the body has paralysis), hypotension (low blood pressure), paranoid schizophrenia, aphasia (difficulty talking), epilepsy, dysphagia (difficulty swallowing), and contracture of the right hand.A facility reported incident, dated 12/26/25, indicated Resident E had displayed aggressive behavior toward Resident D. Head to toe assessments were done on both resident's and no injuries were noted. The physician and the family were notified. Resident D was sent out to the hospital for evaluation.A Care Plan, dated 5/21/24 and revised on 12/28/25, indicated the resident was at risk for abuse/neglect. Interventions included, but were not limited to, assuring the resident knew they were safe, and reporting abuse per policy.The abuse/neglect care plan interventions were last revised on 5/21/24.A Care Plan, dated 5/7/24 and revised on 12/28/25, indicated the resident had paranoid schizophrenia. Interventions included but were not limited to, refer to psych services and observe for mood/behaviors related to paranoid schizophrenia and develop interventions for dealing with them as needed.The schizophrenia care plan interventions were last updated on 5/7/24.This citation relates to Intakes 2739564 and 2742394.3.1-35(a)

Based on record review and interview, the facility failed to ensure the resident's Responsible Party was notified of a roommate change for 1 of 3 residents reviewed for notification of change. (Resident B) Finding includes:The record for Resident B was reviewed on 2/23/26 at 9:53 a.m. Diagnoses included, but were not limited to, Alzheimer's, psychotic disorder, hypertension (high blood pressure), depression, anemia (low iron), depression, and COPD. The Quarterly Minimum Data Set (MDS) assessment, dated 11/4/25, indicated Resident B was cognitively impaired for daily decision making. A Nurse's Progress Note, dated 1/22/26 at 12:46 a.m., indicated the resident appeared to be adjusting well to his new roommate. There was no documentation of the resident's Responsible Party being notified of the new roommate. During an interview on 2/24/26 at 10:25 a.m., the Director of Nursing did not notify the Responsible Party of the roommate change, she was under the impression notification was only to be reported for a room change. She was now educating the staff to notify appropriate parties when a new roommate is brought in. This citation relates to Intake 2739564. 3.1-5(b)(1)

Based on record review and interview, the facility failed to ensure care plan meetings occurred for 1 of 3 residents reviewed for care planning. (Resident B)Finding includes:The record for Resident B was reviewed on 2/23/26 at 9:53 a.m. Diagnoses included, but were not limited to, Alzheimer's, psychotic disorder, hypertension (high blood pressure), depression, anemia (low iron), depression, and COPD.The Quarterly Minimum Data Set (MDS) assessment, dated 11/4/25, indicated Resident B was cognitively impaired for daily decision making.A Social Services Note, dated 9/23/25, indicated the Social Service Director (SSD) had called to schedule a care plan meeting with the resident's daughter. She had stated she was on her way to visit her father and could have the meeting when she arrived at the facility. The SSD indicated she was free to conduct the meeting when she arrived.The resident's last Care Plan Meeting was on 9/23/25.There was no documentation indicating a care plan meeting had occurred after 9/23/25.During an interview on 2/24/26 at 11:33 a.m., the Nurse Consultant indicated she had called the previous social worker to see if she could provide any input on why there was no documentation of a scheduled or rescheduled care plan meeting. At 4:11 p.m., the nurse consultant indicated the care meeting should have been documented as rescheduled if it was scheduled and cancelled.This citation relates to Intake 2739564. 3.1-35

Based on record review and interview, the facility failed to ensure a resident with behaviors received appropriate treatment and services to meet his needs, related to ongoing consistent behaviors without updated behavior interventions following an incident on 12/24/26 that resulted in 2 hospitalizations within 48 hours, and lacked 15-minute safety checks upon the resident's return for 1 of 4 residents reviewed for behaviors. (Resident C)Finding includes:The record for Resident C was reviewed on 2/24/26 at 2:47 p.m. Diagnoses included, but were not limited to, schizophrenia, dementia, dysphagia (difficulty swallowing), depression, anxiety, mild cognitive impairment, mild intellectual abilities, restlessness and agitation, HIV, and alcohol abuse.The Quarterly Minimum Data Set (MDS) assessment, dated 11/4/25, indicated Resident C was cognitively intact for daily decision making. Verbal behaviors were exhibited and the resident's current behavior was worse than the previous assessment.A Nurse's Note, dated 12/23/25, indicated the resident was placed on 30-minute safety checks for 72 hours.There were six behavior notes on 12/23/25 that indicated the resident was verbally aggressive toward staff and residents.A Nurse's Note, dated 12/24/25, indicated the resident was sent out to the hospital for evaluation.A Nurse's Note, dated 12/26/25 at 2:40 p.m., indicated the resident returned to the facility.A Physician's Order, dated 12/27/25, indicated to initiate 15-minute safety checks every shift and complete the safety log for monitoring. The order was discontinued when the resident was admitted to the hospital on [DATE].A Nurse's Note, dated 12/27/25 at 8:45 a.m., indicated the resident was verbally aggressive to staff and was placed on 15-minute safety checks.A Nurse's Note, dated 12/27/25 at 12:18 p.m., indicated the resident was sent out to the hospital's behavioral health unit for further evaluation.The record lacked 15-minute safety checks from 12/27/25- 2/2/26.Nurse's Note's on 1/6, 1/13, 1/14, 1/17, 1/18, 1/19, 1/24, 1/25, 1/27, and 1/28/26 documented verbally aggressive behavior by the resident.A Care Plan, dated 1/15/26, indicated the resident had aggression toward staff and residents related to mental illness. Interventions included, but were not limited to, administer medications as ordered, assess resident's coping skills, and assess resident's understanding of the situation.A Nurse's Note, dated 2/2/26 at 16:11 p.m., indicated that the resident was noted with verbal and physical aggression towards staff and another resident. The resident was isolated from all other residents for safety, resident was unable to be redirected with his behavior. The physician ordered the resident to be sent to the hospital for a psychological evaluation due to uncontrolled behavior. A Facility Reported Incident, dated 2/2/26, indicated staff had overheard a verbal altercation between Resident B and Resident C. Resident B was observed on the floor in the doorway of Resident C's room. Resident B was assessed and had pain in his right leg and hip. All parties were notified and an investigation was initiated. Resident B was sent to the hospital for further evaluation and Resident C was sent to the hospital for a psychiatric evaluation. An investigation was initiated.A Physician's Order, dated 2/2/26, indicated to initiate 15-minute safety checks for 72 hours.A Physician's Order, dated 2/2/26, indicated to send the resident to the hospital for a psychological evaluation.A Care Plan, dated 9/2/23 and revised on 2/3/26, indicated the resident had a history of a behavior problem evidenced by displaying verbal and physically aggressive behaviors towards peers related to schizophrenia. Interventions included, but were not limited to, praise progress/improvement in behavior, and intervene as necessary to protect the rights and safety of others and minimize potential for disruptive behaviors and placed on 15-minute safety checks.Interventions for the behavior care plan were last updated on 2/16/26 after the resident returned from a 15 day stay at the psychiatric hospital. The last intervention prior to the resident's recent 2/2/26 incident and the 12/24/25 and 12/27/25 hospital stay was on 9/16/24.A Physician's Order, dated 2/16/26, indicated to initiate 15-minute safety checks every shift for monitoring.During an interview on 2/24/26 at 10:35 a.m., the Assistant Director of Nursing indicated they had tried to identify a pattern or triggers for the resident's outburst but they were none, they were just random. She indicated the resident was recently in the behavioral unit in the hospital for a couple weeks and he was placed on 1:1 supervision for 72 hours when he returned and then placed on 15-minute checks.During an interview on 2/24/26 at 11:49 a.m., CNA 1 indicated the resident did not have a de-escalation technique that worked for him. Once [Resident C] gets started he doesn't stop until he is ready. She indicated he had hit their coworker recently right across the face, and he is verbally aggressive to residents with nothing triggering him.During an interview on 2/24/26 at 12:03 p.m., CNA 2 indicated Resident C had called her a b***h and slapped her across the face on 12/24/25. He was not provoked in any way. The facility called the police and the resident was taken to the behavioral hospital since she did not press charges.During an interview on 2/25/26 at 10:31 a.m., the Director of Nursing indicated the resident did not strike any residents prior to his 12/24/26 admission but he did slap a staff member. Resident C was not on 15-minute safety checks when he returned back from his two psychological evaluations at the hospital. She reported he did not get placed on them again until he returned from the behavioral hospital this last time on 2/12/26, he had 1:1 supervision for 72 hours and had been on 15-minutes safety checks since.This citation relates to Intakes 2739564 and 2742394.3.1-37(a)

Based on record review and interview, the facility failed to ensure clinical records were accurate and complete related to 15 minute safety checks for residents who had behaviors for 1 of 4 residents reviewed for abuse. (Resident C)Finding includes:The record for Resident C was reviewed on 2/24/26 at 2:47 p.m. Diagnoses included, but were not limited to, schizophrenia, dementia, dysphagia (difficulty swallowing), depression, anxiety, mild cognitive impairment, mild intellectual abilities, restlessness and agitation, HIV, and alcohol abuse.The Quarterly Minimum Data Set (MDS) assessment, dated 11/4/25, indicated Resident C was cognitively intact for daily decision making. Verbal behaviors were exhibited and the resident's current behavior was worse than the previous assessment.A Physician's Order, dated 2/16/26, indicated to initiate 15-minute safety checks every shift for monitoring.Safety logs were observed on the second floor and Resident C's 15-minute safety checks were not signed out from 3:00 p.m. to 4:00 p.m. on 2/24/26.During an interview on 2/24/26 at 4:15 p.m., LPN 2 indicated she should have charted the 15-minute checks after she performed them but she hadn't had a chance to do so.During an interview on 2/24/26 at 4:46 p.m., the Director of nursing indicated she would expect her nursing staff to complete the 15-minute safety checks on all the residents who had them on the unit and then sign off in their logs each time it was completed. She acknowledged the 15-minute safety checks should have been signed off for the previous hour.This citation relates to Intakes 2739564 and 2742394.3.1-50(a)(2)

Based on record review and interview, the facility failed to ensure the mandatory submission of staffing information, based on payroll data, was electronically submitted to iQIES. This had the potential to affect the 70 residents who resided in the facility. Finding includes: Nurse Staffing information was reviewed on 12/16/25 at 3:30 p.m. The CMS Payroll Based Journal (PBJ) Staffing Data report for FY Quarter 4 2025 indicated the facility failed to submit data.During an interview on 12/16/25 at 4:20 p.m., the [NAME] President (VP) of Operations indicated he was able to pull up the submission log of PBJ for the 4th quarter for the facility. The information from iQIES indicated there was a connection error and files failed to send. He indicated Nurse Consultant 1, the Human Resource (HR) Director Consultant, and himself all sit down quarterly and go over all the schedules before submitting to iQIES. During an interview on 12/17/25 at 9:15 a.m., Nurse Consultant 1 indicated she had called iQIES the previous day and they informed her it was the facility's responsibility to make sure the PBJ was transmitted and submitted. She indicated the HR Director, the VP of Operations and herself met on 11/11/25 to finalize the 4th quarter PBJ as it was due on 11/14/25. She did not check to ensure submission had gone through.

Based on observation, record review, and interview, the facility failed to ensure each resident's dignity was maintained related to not offering beverages to residents while participating in activities. The facility also failed to ensure personal care signs were not posted in resident rooms for 4 of 4 residents reviewed for dignity. (Residents 2, 20, 1, and 43)Findings include:1. During a random observation on 12/11/25 at 10:28 a.m., Resident 2 was observed in the Second Floor dining room participating in an activity. The resident received a cup of coffee from the activity aide and proceeded to attempt to pick up the coffee and drink from the cup. At 10:33 a.m., a staff member removed the resident's cup of coffee from the table due to it not being thickened. The resident was not given anything else to drink and the residents around him continued to drink their coffee. On 12/12/25 at 9:58 a.m., the resident was again seated in the Second Floor dining room. Activity staff were passing out cups of coffee to the residents, however, Resident 2 was not offered anything to drink. The record for Resident 2 was reviewed on 12/16/25 at 2:17 p.m. Diagnoses included, but were not limited to, dysphagia (difficulty swallowing) following stroke and vascular dementia. The Quarterly Minimum Data Set (MDS) assessment, dated 10/1/25, indicated the resident was cognitively impaired for daily decision making and he required supervision or touching assistance for eating. During an interview on 12/16/25 at 1:58 p.m., the Assistant Director of Nursing (ADON) indicated the resident should have been provided a drink that had been thickened after his coffee had been removed. 2. During a random observation on 12/15/25 at 10:30 a.m., five residents were observed in the Second Floor dining room. Resident 20 entered the dining room and asked the Activity Aide for a cup of coffee. The Activity Aide told the resident they didn't have any coffee, only juice. The resident proceeded to state, It's the coldest day of the year and we have no coffee? The Activity Aide again told the resident she only had juice to offer him. She did not make any attempts to call the kitchen to see if the resident could have a cup of coffee. During an interview on 12/16/25 at 2:00 p.m., the Director of Nursing indicated coffee was always available and the Activity Aide should have called the kitchen to get the resident a cup of coffee. 3. During random observations on 12/12/25 at 10:16 a.m. and 2:10 p.m., on 12/15/25 at 9:13 a.m. and 11:24 a.m., and on 12/16/25 at 8:29 a.m., 9:34 a.m., 11:15 a.m., and 1:30 p.m., there was a sign above Resident 1's bed that indicated Swallow Precautions. The record for Resident 1 was reviewed on 12/15/25 at 9:37 a.m. The resident was admitted to the facility on [DATE] and diagnoses included, but were not limited to, dysphagia (swallowing difficulties), stroke, and dementia. The 11/26/25 admission Minimum Data Set (MDS) assessment indicated the resident was moderately impaired for daily decision making. The resident had a loss of liquids from his mouth while eating and drinking and was observed holding food in his mouth/cheeks after meals. The resident was on a mechanically altered diet. There was no care plan the resident wished for his personal information to be posted on the wall above his bed. During an interview on 12/16/25 at 1:35 p.m., the Director of Nursing indicated she was unaware the swallowing signs were on the resident's wall in his room in plain sight. 4. During random observations on 12/12/25 at 10:35 a.m. and 1:57 p.m., 12/15/25 at 9:45 a.m., and 12/16/25 at 3:38 p.m., Resident 43 was observed resting in bed. A sign with swallowing instructions was posted above her bed. The resident's record was reviewed on 12/16/25 at 2:36 p.m. Diagnoses included, but were not limited to, vascular dementia and dysphagia (difficulty swallowing). The Annual Minimum Data Set (MDS) assessment, dated 11/13/25, indicated the resident had moderate cognitive impairment, was dependent in ADLs and transfers, and had difficulty swallowing. During an interview on 12/17/25 at 1:34 p.m., the DON indicated the signs should not be posted in plain view and speech therapy would be educated. 3.1-3(t)

Based on observation, record review and interview, the facility failed to ensure a resident's privacy was respected related to completing a room search of their personal belongings without permission for 1 of 1 resident reviewed for privacy. (Resident 4)Finding includes:On 12/12/25 at 2:02 p.m., Resident 4 was observed lying in his bed, staring at the divider curtain while a movie was playing on his laptop. He appeared visibly upset, and was slow to speak. At that time, he indicated staff made him go to the resident Christmas party on the previous afternoon. He indicated he watched everyone else exchange gifts while he got nothing. When staff returned the resident to his room, the Director of Nursing (DON) informed him staff went through his belongings looking for smoking materials. The resident indicated he was upset he was not informed the sweep was going to happen, and that he was not given the opportunity to be there. The record for Resident 4 was reviewed on 12/12/25 at 2:35 p.m. Diagnoses included, but were not limited to, quadriplegia, trauma, depression, and post-traumatic stress disorder (PTSD).The admission Minimum Data Set (MDS) assessment, dated 10/30/25, indicated the resident was cognitively intact for daily decision making, and was dependent in activities of daily living (ADLs) and transfers.A Nurse's Note, dated 12/11/25 indicated, . sweeps performed; resident is an active smoker. Positive findings. Writer educated resident of smoking policy and materials confiscated.An admission Contract, signed by the resident on 10/23/25, indicated, .Right To Privacy. Each resident shall have the right to retain, store securely, and use personal possessions (including some furnishings) and appropriate clothing, as space permits, unless to do so would infringe upon the rights of health and safety of the resident or of other residents -- in which case the facility shall explore alternatives through discussion with the resident, the Residents' Council or the Interdisciplinary Team and provide or assist in the arrangement of storage for possessions .A Smoking Consent, signed by the resident on 11/20/25, indicated, . I understand that my clothing, bags, and room can be searched for smoking materials . The consent did not indicate searches may be conducted without resident knowledge or presence.During an interview on 12/16/25 at 3:50 p.m., the DON indicated she was told the social worker was going to inform the residents that they were going to go through their belongings looking for smoking materials. When informed of the resident's concerns, the DON indicated it should not have happened that way. 3.1-3(s)

Based on observation, record review and interview, the facility failed to ensure proper medication storage related to pre-filled saline syringes used to flush implanted port devices stored in the resident's room for 1 of 6 residents observed during medication pass. (Resident 74)Finding includes:During a medication pass observation on 12/15/25 at 2:12 p.m., LPN 2 entered Resident 74's room with an Intravenous (IV) antibiotic medication and two pre-filled normal saline syringes to flush the resident's line before the IV administration. At that time, inside the resident's room, there was a pre-filled normal saline syringe laying on the resident's over bed table as well as two pre-filled normal saline syringes on top of the night stand. The LPN used the two pre-filled syringes she had brought into the room to flush the resident's port and then placed the other three syringes on top of the night stand before she left the room She informed the resident she would be back in one hour to take the IV down and disconnect the tubing. At 3:28 p.m. LPN 2 entered the resident's room with a pre-filled normal saline syringe to take the IV down, however, it was not completely infused. She left the pre-filled normal saline syringe on the over bed table and left the room. At 3:40 p.m., LPN 2 entered the resident's room again and the IV antibiotic had infused. She used the pre-filled syringe on top of the resident's over bed table, flushed the line and left the room. The other 3 pre-filled syringes of normal saline remained on the night stand. During an interview on 12/15/25 at 3:42 p.m., LPN 2 indicated she was unaware the normal saline syringes were left in the room and she would remove them. During an interview on 12/16/25 at 2:00 p.m., the Director of Nursing had no additional information to provide. The current 3/1/25 Medication Storage policy, provided by Nurse Consultant 1 on 12/16/25 at 4:15 p.m., indicated the facility should ensure medications and biologicals were stored in an orderly manner and locked in cabinets, drawers, carts, and refrigerators. 3.1-25(m)

Based on observation, record review, and interview, the facility failed to ensure adequate supervision was provided related to the serving of hot beverages and thickened liquids as well as a resident using a vape pen in their room for 2 of 3 residents reviewed for accidents. (Residents 2 and 63)Findings include: 1. During a random observation on 12/11/25 at 10:28 a.m., Resident 2 was observed in the Second Floor dining room participating in an activity. The resident received a cup of coffee from the activity aide that was not thickened. As she put the cup of coffee on the table, she told the resident to be careful because the coffee was hot. The resident proceeded to pick up the cup of coffee and it started to spill on the table and his hands due to his tremors. He waited a few seconds and attempted to pick up the cup again. The resident continued to shake but he was able to put the cup to his mouth and drink some of the coffee. There was no lid on the cup and he drank approximately a quarter of the coffee. At 10:33 a.m., a staff member came to the table and removed the resident's coffee. The record for Resident 2 was reviewed on 12/16/25 at 2:17 p.m. Diagnoses included, but were not limited to, dysphagia (difficulty swallowing) following stroke and vascular dementia. The Quarterly Minimum Data Set (MDS) assessment, dated 10/1/25, indicated the resident was cognitively impaired for daily decision making and he required supervision or touching assistance for eating. A Care Plan, dated 1/4/25 and reviewed on 10/1/25, indicated the resident had a swallowing problem related to the diagnosis of dysphagia. Interventions included, but were not limited to, diet to be followed as prescribed and resident is to eat only with supervision. A Physician's Order, dated 9/17/25, indicated the resident was to receive a pureed diet with nectar thickened liquids. During an interview on 12/16/25 at 1:58 p.m., the Assistant Director of Nursing (ADON) indicated the resident did have tremors and should have been assisted with the coffee and it should have been thickened. 2. During a random observation on 12/11/25 at 10:00 a.m., Resident 63 was observed sitting in her wheelchair in her room by the bed. At that time she was observed with a vape pen and was vaping inside her room. Restorative CNA 1 was observed sitting on the resident's bed watching the resident vape. The Housekeeping Director was also observed in the room and then walked out of the room. The resident's roommate was observed in her bed with her eyes closed while the resident was vaping. During an interview at that time, Restorative CNA 1 indicated the resident was allowed to vape in her room. She was informed by the Activity Director the resident could vape inside the facility. The record for Resident 63 was reviewed on 11/12/25 at 2:40 p.m. Diagnoses included, but were not limited to, chronic obstructive pulmonary disease (COPD), anxiety disorder, heart failure, and high blood pressure. The 9/26/25 Significant Change Minimum Data Set (MDS) assessment indicated the resident was moderately impaired for decision making. A Care Plan, dated 12/11/25, indicated the resident was a tobacco user. The approaches were for the resident to adhere to the smoking policy. A Smoking Risk Assessment, dated 11/21/25, indicated the resident did not currently smoke. A Smoking Risk Assessment, dated 12/11/25, indicated the resident actively smoked and was able to vape with one to one supervision. During an interview on 12/16/25 at 2:00 p.m., the Director of Nursing (DON) was unaware the resident was vaping in her room. During an interview on 12/17/25 at 10:50 a.m., the Activity Director indicated she was new to smoking facilities because she had not worked in one before. She indicated she did not vape and she did not know where a resident could vape, so she reached out to the DON and she told her the resident could vape in her room, Just pull the curtain back and she can do it. She indicated she was just doing what she was told to do. During an interview on 12/17/25 at 11:00 a.m., the Administrator indicated the DON told her it was a miscommunication with the Activity Director and her instructions on where the resident could vape. The current 9/2022 Resident Smoking policy, provided by the Administrator on 12/11/25, indicated smoking by residents and their visitors was permitted only in designated areas. Possessing, carrying, or holding materials used to smoke by residents who required supervision was prohibited inside the building. 3.1-45(a)(2)

Based on observation, record review, and interview, the facility failed to ensure indwelling Foley (urinary) catheter bags and tubing were kept off of the floor, nephrostomy tube equipment was changed and the site was monitored for 1 of 2 residents reviewed for Foley catheters and 1 of 1 resident reviewed for nephrostomy tubes. (Residents 1 and 6)Findings include:1. During random observations on 12/16/25 at 8:29 a.m., LPN 3 was observed preparing medications for the resident outside of Resident 1's door. The door was wide open and the resident was observed in bed. The resident told the nurse to come back later to give him his medications and to close the door. At that time, the resident's Foley catheter bag and tubing was observed on the floor next to his bed. LPN 3 closed the resident's door and did not pick up the Foley bag off of the floor. During random observations on 12/16/25 at 9:34 a.m. and 11:15 a.m., Resident 1 was observed in bed. At those times, his Foley catheter bag and tubing was observed on the floor next to his bed. During a random observation on 12/16/25 at 1:30 p.m., the resident was observed sitting in his in the wheelchair in his room. At that time, the Foley catheter bag and tubing was on the floor by the wheelchair. The record for Resident 1 was reviewed on 12/15/25 at 9:37 a.m. The resident was admitted to the facility on [DATE] and diagnoses included, but were not limited to, chronic kidney disease, stroke, anxiety disorder, schizophrenia, bipolar disorder, dementia, and neuromuscular dysfunction of the bladder. The 11/26/25 admission Minimum Data Set (MDS) assessment indicated the resident was moderately impaired for daily decision making. The resident was frequently incontinent of urine. A Care Plan, dated 12/14/25, indicated the resident had a Foley catheter. A Nurse's Note, dated 12/12/25 at 4:50 a.m., indicated a urine specimen was collected from the resident. The urine culture lab report, dated 12/14/25, indicated the resident had an urinary tract infection with greater than 100,000 colonies of Klebsiella-Extended-spectrum beta-lactamase (ESBL) A Physician's Order, dated 12/13/25, indicated the resident had a Foley catheter, size:18 French, balloon size, 30 milliliters (ml). Change as needed for dislodgement, leaking or blockage. A Physician's Order, dated 12/14/25, indicated Fosfomycin Tromethamine Oral Packet (an antibiotic), give 3 grams by mouth one time a day every 2 day(s) for ESBL in urine for 3 administrations. During an interview on 12/16/25 at 2:00 p.m., the Director of Nursing indicated the Foley catheter bag and tubing should not have been on the floor. The current 10/9/21 Urinary Catheter Care policy, provided by Nurse Consultant 2 on 12/17/25 at 9:00 a.m., indicated urinary drainage bags and tubing should be positioned to prevent touching the floor directly. 2. During an observation of nephrostomy (a tube inserted through the back to drain the kidney) care for Resident 6 on 12/16/25 at 1:31 p.m., the Wound Nurse removed the old dressing covering the insertion site. A StatLock (a medical securement device that adheres to the skin) was in place with the edges coming up. The tubing was connected to a collection bag. Neither the Statlock nor the collection bag were dated. At that time, the Wound Nurse indicated she did not normally perform the nephrostomy care, and was not sure if/when the Statlock or collection bags were changed. The resident's record was reviewed on 12/15/25 at 10:28 a.m. Diagnoses included, but were not limited to, urinary tract infection, stage 4 pressure ulcer of sacrum, and artificial opening of the urinary tract. The Quarterly Minimum Data Set (MDS) assessment, dated 11/30/25, indicated the resident was cognitively intact for daily decision making, and required substantial assistance with ADLs. A Physician's Order, dated 10/29/25, indicated to change the nephrostomy bag every Sunday night shift and as needed. The order was discontinued on 11/22/25. A Physician's Order, dated 11/26/25, indicated to monitor the right nephrostomy site and document output every shift. Notify the physician of any abnormalities. The record lacked documentation of changing the nephrostomy bag and instruction for use/change of the StatLock. The record lacked documentation of output from the nephrostomy on the following shifts: 11/29/25 first and second shifts, 11/30/25 first and second shifts, 12/4/25 first and second shifts, and 12/5/25 third shift. There was no documentation of the physician being notified of no urine output. A Care Plan, revised on 12/5/25, indicated the resident was at risk for complications due to the right nephrostomy tube. Interventions included monitoring, recording, and reporting to the physician for signs and symptoms of UTI, including no urine output. During an interview on 12/16/25 at 3:37 PM, the Director of Nursing (DON) was informed of the findings. She indicated the drainage bag was being changed every Sunday, and the order must have gotten left off when the resident went out and returned from the hospital. She indicated the output should have been measured three times a day, once each shift, and that she did not know anything about the Statlock that was in use, but would look into it. 3.1-41(a)(2)

Based on observation, record review, and interview, the facility failed to check for peg tube (a tube inserted directly into the stomach for nutrition) placement properly prior to medication administration for 1 of 1 resident observed for peg tube medication administration. (Resident 11)Finding includes:During a medication administration observation on 12/16/25 at 8:02 a.m., RN 1 poured and prepared medications for Resident 11 to be administered through his peg tube. She entered the resident's room and placed his enteral tube feeding on hold. The RN removed the connection device and hung it over the pole. She then removed the syringe and placed it into one of the two ports on the peg tube. She poured 30 cubic centimeters (cc) of water down the tube via gravity. She removed the syringe and placed the piston inside and pulled back (checking for residual) the stomach contents. She pulled back less than five cc of fluid from each port. At that time, she indicated she was supposed to be able to pull back 30 cc of residual so she was going to notify the physician. During an interview at that time, RN 1 indicated the new policy to check for peg tube placement was to pour 30 cc of water down the tube first and pull back the 30 cc of fluid. The record for Resident 11 was reviewed on 12/16/25 at 3:45 p.m. Diagnoses included, but were not limited to gastrostomy tube. A Physician's Order, dated 11/19/25, indicated enteral feed every shift and check enteral feeding tube placement by aspirating 30 milliliters (ml) and then return, if unable to verify via aspiration, hold feeding and notify the physician. During an interview on 12/16/25 at 9:52 a.m., Nurse Consultant 1 indicated the RN should have checked for residual by aspirating fluid first before flushing the tube with 30 cc of water. The current 11/19/25 Placement and Residual Volume Check of Enteral Feeding Tubes policy, provided by Nurse Consultant 1 on 12/16/25 at 9:50 a.m., indicated check placement and residual using the aspiration method. Attach a large 60 cc syringe, aspirate 30 cc of stomach content, replace aspirated stomach contents back. If acceptable placement and gastric residual volume is verified, flush feeding tube with 30 cc of water or as ordered by the physician. 3.1-44(a)(2)

Based on observation, record review, and interview, the facility failed to ensure an implanted port device was assessed and monitored for 1 of 1 resident reviewed for parental/IV fluids. (Resident 63) Finding includes:During a random observation on 12/12/25 at 2:00 p.m., Resident 63 was observed sitting in a wheelchair by the elevator. At that time, her shirt was falling off of her shoulder and an implanted port device was observed with a white bandage over it. The record for Resident 63 was reviewed on 12/12/25 at 2:40 p.m. Diagnoses included, but were not limited to, vulva cancer, adult failure to thrive, chronic obstructive pulmonary disease (COPD), anxiety disorder, heart failure, and high blood pressure. The 9/26/25 Significant Change Minimum Data Set (MDS) assessment indicated the resident was moderately impaired for decision making. A Care Plan, dated 12/14/25, indicated the resident had a right chest port-a-cath (PAC). The approaches were to monitor the port and report changes to the physician. An admission Assessment, dated 8/2/25, indicated the resident had a right upper chest PAC. Physician's Orders, dated 8/2/25 and 8/20/25, indicated to monitor the central venous access port to the right upper chest. Report any abnormalities to provider. The resident was admitted to the hospital on [DATE] and after her return there were no orders to monitor the PAC. A Physician's Order, dated 12/12/25, indicated to monitor the right chest port and report any swelling, drainage, or pain at the site to the physician. During an interview on 12/16/25 at 2:00 p.m., the Director of Nursing indicated the nurses should be monitoring the device, however, a new physician's order was not put into place after her most recent hospitalization. The current 9/1/22 Implanted Vascular device/Accessing, Blood draw, Maintenance (Port-a-Cath) policy, provided by Nurse Consultant 2 on 12/12/25 at 1:35 p.m., indicated ports must be flushed according to physician order (every four weeks if not in use). Document flushes in the medical record. The site must be assessed for signs of infection prior to each use. All procedures must be documented in the medical record. 3.1-47(a)(2)

Based on observation, record review, and interview, the facility failed to ensure dependent residents received assistance with activities of daily living (ADLs) related to having their hair washed for 1 of 3 residents reviewed for ADLs. (Resident 24)Finding includes:During an interview on 12/12/25 at 9:35 a.m., Resident 24 indicated she did not like to go into the shower room and preferred a bed bath. She indicated she did not remember the last time her hair was washed. At that time, the resident's hair was greasy with a large amount of dandruff flakes noted. During random observations on 12/15/25 at 10:55 a.m., on 12/16/25 at 1:14 p.m., and on 12/17/25 at 9:55 a.m., the resident was observed in bed and her hair was greasy with flakes of dandruff noted. The resident indicated her hair had not been washed. The record for Resident 24 was reviewed on 12/15/25 at 10:30 a.m. Diagnoses included, but were not limited to, major depressive disorder, anxiety, and osteoarthritis. The 8/31/25 Quarterly Minimum Data Set (MDS) assessment indicated the resident was cognitively intact for daily decision making and needed substantial to maximal assistance with bathing and showering. A Care Plan, revised on 12/11/25, indicated the resident required assistance with ADLs including bed mobility, transfers, and bathing. A Care Plan, revised on 12/11/25, indicated the resident was resistive to care related to ADL refusal. A Physician's Order, dated 8/17/23, indicated Selsun Blue Salon External Shampoo 1%, apply to hair topically every evening shift on Tuesday and Friday for dandruff. The 11/2025 Medication Administration Record (MAR) indicated the Selsun Blue shampoo was signed out as being applied to the resident's hair on 11/11, 11/14, 11/18, 11/21, 11/25, and 11/28/25. The 12/2025 MAR indicated the Selsun Blue shampoo was signed out as being applied on 12/2, 12/5, 12/9, and 12/12/25. The Skin Shower Sheets provided by the Assistant Director of Nursing indicated the resident received a complete bed bath on 11/25, 11/28, 12/2, 12/5, 12/9, and 12/14/25. There was no documentation the resident's hair was washed during those baths, nor was there any documentation the resident refused to have her hair washed. During an interview on 12/16/25 at 4:00 p.m., the Director of Nursing indicated there was no place to document the resident's hair being washed on the current shower sheets. 3.1-38(a)(3)(B)

Based on observation and interview, the facility failed to ensure food was served at a palatable temperature for one of one meal observation. (Residents 4, 24, and 42)Finding includes:During an interview on 12/11/25 at 11:16 am, Resident 4 indicated the facility's food was bad, and most of the time, he did not want to eat it. During an interview on 12/12/25 at 9:41 a.m., Resident 24 indicated the facility's food was often cold. During a resident council interview on 12/15/25 at 3:09 p.m., Resident 42 indicated food taste and temperature had been a concern brought up in resident council. He indicated the food was often cold when they received it. During a meal observation on 12/16/25 at 11:44 a.m., lunch trays were brought up on a non-insulated cart for the second floor dining room. On 12/16/2025 at 11:53 a.m., the test tray temperatures were checked by the Kitchen Manager as follows: chicken-104 degrees, rice-120 degrees, and black beans-120 degrees via a manual thermometer. The Kitchen Manager indicated she thought there was something wrong with the thermometer. She covered the food and went to get a digital thermometer. At 12:05 p.m., she returned, unable to find batteries for the digital thermometer. The food was tasted and was not hot. During an interview on 12/16/25 at 12:14 p.m., CNA 1 indicated she passed all of the room trays along with getting drinks for residents by herself. A policy titled, Food and Nutrition Services, received as current from Nurse Consultant 2 on 12/17/25 at 9:44 a.m. indicated, Each resident is provided with a nourishing, palatable, well-balanced diet that meets his or her daily nutritional and special dietary needs, taking into consideration the preferences of each resident . Food and nutrition services staff will inspect food trays to ensure the correct meal is provided to each resident, the food appears palatable and attractive, and it is served at a safe and appetizing temperature .3.1-21(a)(1)(2)

Based on record review and interview, the facility failed to ensure a resident received physical therapy as ordered by the physician for 1 of 1 resident reviewed for rehabilitation services. (Resident 10)Finding includes:During an interview on 12/11/25 at 11:16 a.m., Resident 10 indicated he did not receive therapy and sometimes went many days without it. The record for Resident 10 was reviewed on 12/15/25 at 1:20 p.m. The resident was admitted to the facility on [DATE]. Diagnoses included, but were not limited, chronic kidney disease and post surgical Thoracic 11 thru Lumbar 1 laminectomy (a procedure to remove pressure from the spinal cord). The admission Minimum Data Set (MDS) assessment, dated 11/5/25, indicated the resident was cognitively intact for daily decision making and received speech, occupational, and physical therapy. A Physician's Order, dated 11/1/25, indicated physical therapy was to see the resident for five times a week for 30 days for therapeutic exercises, activity tolerance training, gait training, bed mobility training and transfer training, one time a day five days on and two days off. A Physician's Order, dated 11/11/25, indicated to continue skilled physical therapy three times a week for four weeks addressing therapeutic exercise, activity, and gait training. A Physical Therapy certification and evaluation, dated 11/1/25, indicated the resident was to receive physical therapy for five times a week for 30 days. The resident was seen by physical therapy on 11/1, 11/5, 11/6 and 11/7/25. A Physical Therapy certification and evaluation dated 11/11/15, indicated the resident's payor source changed, therefore the therapy times and schedule changed as well. The new orders for physical therapy were three times a week for four weeks. The resident was seen on 11/11 and 11/12/25. Physical Therapy notes indicated the resident was unavailable on 11/14/25 (no reason was documented). The resident was seen on 11/19 and 11/21/25. Physical Therapy notes indicated the resident's session was canceled by another staff member on 11/20/25. The resident was not picked up for a third day of physical therapy for the above weeks. The resident was not seen three times a week as ordered by the physician. During an interview on 12/16/25 at 2:15 p.m., the Rehab Director indicated she was the only full time staff member due to census. She indicated the start of a therapy week began on a Saturday and ended on the following Friday. The resident was not seen five times a week the first week he was here and was only seen two times a week for the next two weeks. She indicated her staff were PRN (as needed) and were only in the building sometimes for three hours at a time as they would go to other sister facilities to work During an interview on 12/16/25 at 2:30 p.m., the Administrator indicated the residents should receive therapy as ordered by the physician. 3.1-23(a)(1)

Based on record review and interview, the facility failed to ensure the medical record was complete and accurate related to inaccurate tube feeding residual amounts and incorrect resident information in a record for 1 of 21 records reviewed. (Resident 11) Finding includes:The record for Resident 11 was reviewed on 12/16/25 at 1:56 p.m. Diagnoses included, but were not limited to, congestive heart failure (CHF), dysphagia (trouble swallowing), and gastrostomy (a feeding tube inserted through the abdomen). The Significant Change Minimum Data Set (MDS) assessment, dated 11/17/25, indicated the resident had moderate cognitive impairment, required substantial assist with activities of daily living (ADLs), and had an enteral (tube) feeding.A Physician's Order, dated 11/19/25, indicated to verify the enteral feeding residual every shift, if more than 100 milliliters (ml), hold the feeding and notify the physician.The December 2025 Medication Administration Record (MAR) indicated the following enteral tube feeding residual amounts: 12/1 1st shift-300, 12/4 2nd shift-300, 12/8 1st shift-300, 12/9 1st shift-250, 2nd shift-300, and 12/10/25 2nd shift-560. There were no narrative notes that indicated the resident had a residual over 100 ml, was not tolerating the feedings, or that the physician was notified. A Progress Note by NP 1, dated 12/16/25, included a full assessment and history for Resident 34. During an interview on 12/16/25 at 3:45 p.m., the Director of Nursing (DON) indicated the resident had never had a problem with tolerating feedings, and the nurses had documented incorrectly. The DON indicated NP 1 entered the wrong resident's information in Resident 11's record, and they would have to remove it. 3.1-50(a)(1)3.1-50(a)(2)

Based on record review and interview, the facility failed to promote antibiotic stewardship by ensuring the appropriate use of antibiotic therapy and a system of monitoring to improve resident outcomes and reduce antibiotic resistance related to a resident remaining on an antibiotic after the organism was determined to be resistant to the medication and prescribing antibiotics for not true infections based on the McGeer Criteria for 1 of 1 resident reviewed for urinary catheters. (Resident 8)Finding includes: During an interview on 12/12/25 at 10:23 a.m., Resident 8 indicated he was having issues with frequent urinary tract infections. The record for Resident 8 was reviewed on 12/16/25 at 10:37 a.m. Diagnoses included, but were not limited to, chronic kidney disease, renal dialysis, and obstructive and reflux uropathy (blockage of urine flow). The Quarterly Minimum Data Set (MDS) assessment, dated 9/10/25, indicated the resident was cognitively intact and had an indwelling catheter. A Care Plan, dated 3/28/24 and reviewed on 9/10/25, indicated the resident had a suprapubic catheter (a tube that drains urine from the bladder through a small opening in the lower abdomen) in place related to obstructive uropathy with urinary retention. Interventions included, but were not limited to, monitor and document for pain and discomfort due to catheter and monitor, record, and report to the physician signs and symptoms of a urinary tract infection (UTI). A Nurse's Note, dated 7/20/25 at 6:28 p.m., indicated the resident complained of pain when urinating. He stated he felt an aching and discomfort. The resident's suprapubic catheter was intact and patent with no signs of redness, swelling, or drainage noted. The physician was made aware and new orders were obtained for a urinalysis with culture and sensitivity. A Physician's Order, dated 7/21/25, indicated the resident was to receive Ciprofloxacin HCl (an antibiotic) 500 milligrams (mg) daily for five days for a UTI. A urine culture, dated 7/23/25, indicated the resident tested positive for 50-100,000 colonies of proteus mirabilis (a bacteria known for causing UTIs) and the bacteria was resistant to Ciprofloxacin. The resident received the full five days of Ciprofloxacin. There was no documentation in the resident's record indicating the physician had been notified of the culture results. During an interview on 12/17/25 at 11:25 a.m., the Director of Nursing indicated the resident should not have received the Cipro for his UTI since it was resistant and the physician should have been notified. 3.1-18(b)(1)

Based on observation, record review, and interview, the facility failed to ensure follow up documentation after a fall was completed for 1 of 1 resident reviewed for change in condition. The facility also failed to apply compression wraps as ordered for edema for 1 of 1 resident reviewed for edema. (Residents 19 and 1) Findings include: 1. The record for Resident 19 was reviewed on 12/12/25 at 2:00 p.m. Diagnoses included, but were not limited to, stroke, major depressive disorder, dementia, and high blood pressure. The 9/13/25 Quarterly Minimum Data Set (MDS) assessment indicated the resident was not cognitively intact for daily decision making and needed substantial to maximal assistance for transfers. The resident had no falls since the last assessment. A Care Plan, revised on 10/29/25, indicated the resident had a fall due to an unsteady gait. A Nurse's Note, dated 10/28/25 at 11:56 a.m., indicated the resident had a witnessed fall out of the wheelchair. A Post Fall Observation form, dated 10/28/25 at 1:25 p.m., indicated the resident had a fall that was witnessed by the staff nurse. The Fall Follow Up Assessment, dated 10/28/25 at 9:56 p.m., indicated the most recent vital signs were dated 10/29/25 at 8:43 a.m. The Fall Follow Up Assessments, dated 10/29/25 at 5:56 a.m. and 11:41 a.m., indicated the most recent vital signs were dated 10/29/25 at 8:43 a.m. The vital signs were only documented one time on 10/29/25 at 8:43 a.m. in the vital signs section in the clinical record. During an interview on 12/17/25 at 9:00 a.m., Nurse Consultant 2 indicated there was no fall follow up completed for the evening shift on 10/29/25 and the vital signs were incorrectly documented on 10/29/25. Nursing staff were to document every shift for 72 hours after a fall. 2. During an observation on 12/12/25 at 10:24 a.m., Resident 1 was observed in bed. At that time, both of his ankles were observed with edema (swelling) and he was wearing ankle socks to both of his feet. There were no compression socks or wraps on his legs. During random observations on 12/15/25 at 9:13 a.m. and 10:31 a.m., the resident was observed sitting in his wheelchair in the second floor dining room. At those times, he was wearing shoes and no socks. The backs of the shoes were folded down and his feet were not completely inside them. He was not wearing compression socks or ace wraps to his legs. At those times, his ankles were observed with edema. During random observations on 12/16/25 at 9:34 a.m., and 11:15 a.m., the resident was observed in bed and dressed in street clothes. He was not wearing any compression socks or ace wraps to his legs. At those times, his ankles were observed with edema. During an observation on 12/16/25 at 1:30 p.m., the resident was sitting in his wheelchair in his room. He was dressed in street clothes with shoes and plain socks on both feet. There were no ace wraps observed on his legs. The record for Resident 1 was reviewed on 12/15/25 at 9:37 a.m. The resident was admitted to the facility on [DATE] and diagnoses included, but were not limited to, chronic kidney disease, stroke, anxiety disorder, schizophrenia, bipolar disorder, dementia, and high blood pressure. The 11/26/25 admission Minimum Data Set (MDS) assessment indicated the resident was moderately impaired for daily decision making. A Care Plan, dated 12/9/25, indicated the resident was at risk for impaired circulation related to dependent edema. The approaches were to apply compression bandages for bilateral lower extremity edema, on in the morning and off at night. Weekly Skin Observations, dated 12/3/25, indicated the resident had edema to his bilateral lower extremities. A Skin Observation form, dated 12/10/25, indicated the resident had no edema. A Nurse's Note, dated 12/3/25 at 10:30 a.m., indicated the resident had pitting edema to his bilateral lower extremities. A Nurse's Note, dated 12/4/25 at 11:05 a.m., indicated a message was left for the the physician regarding the edema. A Physician's Order, dated 12/4/25, indicated compression bandages, apply to bilateral lower extremities daily for edema, on in the a.m. and off in the p.m. A Physician's Progress Note, dated 12/10/25, indicated the resident had bilateral lower extremity edema which was acute and unstable. During an interview on 12/16/25 at 2:00 p.m., the Director of Nursing had no additional information to provide. 3.1-37(a)

Based on observation, record review, and interview, the facility failed to ensure oxygen was set at the correct flow rate and signed out on the Medication Administration Record (MAR) for 1 of 3 residents reviewed for respiratory care. (Resident E) Finding includes: On 4/7/25 at 9:08 a.m., Resident E was observed lying in bed. The resident's nasal cannula tubing was sitting under her nose and the oxygen flow rate was set a little above 1.5 liters as the ball was under the 2 liter line. On 4/8/25 at 8:51 a.m., the resident was observed in bed eating breakfast. Resident E was wearing oxygen via nasal cannula and the flow rate was set little over 1.5 liter line. During and interview at the time, LPN 1 indicated the resident was on 2 liters of oxygen. When asked to verify the rate again, LPN 1 verified it was not at 2 liters and moved the ball to the middle line of the 2 liter line. The record for Resident E was reviewed on 4/8/24 at 9:11 a.m. Diagnoses included, but were not limited to, dementia, COPD, high blood pressure, heart failure and anxiety. The 3/3/25 Quarterly Minimum Data Set (MDS) assessment indicated the resident was moderately impaired for daily decision making. The resident required set/up and clean up assistance for eating and oral hygiene. The resident required dependent care with toileting, shower/bathing, upper and lower body dressing, putting on footwear and personal hygiene. A Care Plan, dated 3/3/25, indicated the resident required oxygen therapy as needed related to COPD and shortness of breath. Interventions were to, administer oxygen via nasal cannula as ordered by physician and administer, give medications as ordered and monitor for side effects and effectiveness. Physician's Orders, dated 3/23/25, indicated to administer oxygen at 2 liters via nasal cannula as needed for shortness of breath. During an interview on 4/8/25 at 1:32 p.m., the DON indicated the nurses were supposed to be checking oxygen flow rates and had been previously in-serviced about getting down to eye level to ensure the ball is on the correct liter flow. The oxygen rate should have been correct. 3.1-47(a)(6)

Based on record review and interview, the facility failed to ensure a dependent resident received adequate assistance and supervision to prevent accidents related to only one staff person assisting during a mechanical lift transfer for 1 of 2 residents reviewed for falls. (Resident 3) This deficient practice resulted in the resident falling and receiving a fracture to her leg. The deficient practice was corrected on 7/22/24, prior to the start of the survey, and was therefore past noncompliance. The facility identified the concern, completed a house wide sweep of the Hoyer lifts (a mechanical lift) and Hoyer slings, an inservice was held related to transfer techniques and two person staff assist while using the Hoyer lift, return demonstration by staff was observed, and audits related to the use of the Hoyer lift were being completed weekly. Finding includes: During an interview on 8/6/24 at 9:25 a.m., Resident 3 indicated she had fallen from the Hoyer lift about 3 weeks ago and she hurt her leg. She indicated she had been transferred by 1 staff person. The record for Resident 3 was reviewed on 8/6/24 at 3:17 p.m. Diagnoses included, but were not limited to, fracture of upper and lower end of right fibula, type 2 diabetes, chronic pain syndrome, and age-related osteoporosis. A Quarterly Minimum Data Set (MDS) assessment, dated 4/23/24, indicated the resident was cognitively intact, dependent on staff for bed mobility and transfers, and had no falls since the prior assessment. A Care Plan, dated 12/4/23, indicated the resident was at risk for falls secondary to: ADL and mobility dysfunction, lack of coordination, neuromuscular weakness, gait abnormality, osteoporosis, CVA, emphysema/COPD, and disease process. Interventions included, but were not limited to, assess resident's transfer status and provide assistance as needed, be sure the resident's call light is within reach and encourage the resident to use it for assistance as needed. The resident needs prompt response to all requests for assistance, educate the resident/family/caregivers about safety reminders and what to do if a fall occurs, encourage use of appropriate non-skid footwear while ambulating/transferring, place floor mat and bed in low position while the resident is in bed. A Change of Condition assessment, dated 7/17/24 at 5:30 p.m., indicated the resident had a fall and to refer to the Post Fall Evaluation for details. The Post Fall Observation sheet, dated 7/17/24 at 5:30 p.m., indicated the event happened in the resident's room and she was transferring immediately prior to the event. The event was witnessed by CNA 3. The resident denied the fall as well as pain. The resident's wheelchair and a Hoyer were in use at that time. Nurses' Notes, dated 7/19/24 at 11:40 p.m., indicated while the resident was receiving care, she stated that she had pain in her right leg and shoulder due to a fall that she had the other day. The resident recalled falling to the floor during a transfer from the wheelchair to the bed with the Hoyer lift. The resident indicated she did not have any pain initially, but since the incident she had been sore on the areas mentioned. The physician, Director of Nursing, and the resident's family were notified. Orders were received for a STAT (immediate) x-ray. Nurses' Notes, dated 7/19/24 at 11:53 p.m., indicated the contracted x-ray company was contacted, and their estimated time of arrival was the morning of 7/20/24. Nurses' Notes, dated 7/20/24 at 12:53 a.m., indicated the resident was in bed awake and watching television. The resident asked the writer if they had heard what happened to her and the resident was allowed to tell what occurred related to the recent fall. The resident allowed staff to obtain her vital signs and assess her. There were no signs of bruising, swelling, or redness to affected areas or otherwise. The resident was informed x-rays would be completed in the morning. She currently denied pain to the affected areas but did say her left heel was hurting. She was able to move extremities with assistance. Heel protectors were placed on the resident with immediate relief. The resident informed staff that she would let them if she was hurting in order to receive pain medication. Nurses' Notes, dated 7/20/24 at 8:59 a.m., indicated the x-rays were obtained as ordered. Nurses' Notes, dated 7/20/24 at 10:53 a.m., indicated the physician was notified of the x-ray results which indicated the resident had an acute fracture of the right distal fibula (lower leg). Orders were received to send the resident to the emergency room for evaluation. Nurses' Notes, dated 7/20/24 at 4:00 p.m., indicated the resident returned to the facility with a splint to the right lower leg. No swelling was noted, and the resident denied any pain. A Physician's Order, dated 7/20/24, indicated to monitor the splint to the right leg and notify the physician of any abnormal findings such as increased swelling, discoloration, or reports of increased pain every shift. The Fall Interdisciplinary Team (IDT) Note, dated 7/21/24 at 12:14 p.m., indicated the summary of the fall on 7/17/24 at 5:30 p.m. was due to inappropriate staff transfer. Review of the facility fall investigation on 8/9/24 at 10:34 a.m., indicated an inservice for nursing staff was held on 7/22/24 related to the use of the Hoyer lift. An audit tool was also implemented on 7/22/24 related to the use of the Hoyer lift and to ensure 2 staff members were present. Ten residents would be randomly audited weekly. Staff competencies were also completed related to use of the total mechanical lift, one person gait belt transfer, and sit to stand lift. Documentation of facility inservices and subsequent auditing was reviewed and confirmed to be completed by 7/22/24. Staff interviews and observations also indicated adequate knowledge related to Hoyer lift transfers. During an interview on 8/9/24 at 10:55 a.m., the Director of Nursing (DON) indicated she was made aware of the fall on 7/17/24. She interviewed the resident, and the resident denied she fell but she was being monitored. On 7/19/24, the resident started complaining about pain to her leg. At that time x-rays were ordered and the resident indicated there was an incident with the Hoyer the other day. CNA 3, who was caring for the resident on 7/17/24, was suspended but was not terminated because she admitted she transferred the resident by herself as she couldn't find anyone else to help her and the resident was demanding to get back into bed. Per the DON, the CNA indicated the resident started to lean in the sling and she got under her to break the fall and she thought the resident's leg may have hit the Hoyer lift. The resident also had a diagnosis of osteopenia (bone loss). A full house sweep was conducted related to the Hoyer slings and the Hoyer lifts themselves. An inservice was held related to Hoyer use, audits were initiated, and staff competencies were completed related to transfers and Hoyer use. During an interview on 8/9/24 at 2:35 p.m., the Assistant Director of Nursing indicated the facility practice was to have 2 staff member assistance for Hoyer transfers and that was the standard prior to the resident's incident. The Hoyer lift manufacturer's recommendations included using two staff during transfers. 3.1-45(a)(2)

Based on record review and interview, the facility failed to ensure a resident only received food in the form ordered by the physician related to the consumption of a regular donut during a transport which led to a choking incident and resulted in respiratory failure, cardiac arrest and ultimately his demise for 1 of 3 resident reviewed for mechanically altered diets. (Resident B) The immediate jeopardy began on [DATE] when the Administrator fed Resident B a regular donut, not in pureed form, which he consumed during a facility transport. Soon after, he turned blue, started choking and the Heimlich maneuver was performed. He then stopped breathing, CPR was initiated, and he was transferred to the hospital. The Regional [NAME] President Operations was notified of the immediate jeopardy on [DATE] at 10:51 a.m. The immediate jeopardy was removed and the deficient practice was corrected by [DATE], prior to the start of the survey, and was therefore past noncompliance. Finding includes: The closed record for Resident B was reviewed on [DATE] at 11:35 a.m. Diagnoses included, but were not limited to, metabolic encephalopathy, bipolar disorder with severe psychotic features, anxiety disorder, convulsions, dementia with behavioral disturbances, bipolar disorder, moderate intellectual disabilities, high blood pressure, and heart failure. The [DATE] Quarterly Minimum Data Set (MDS) assessment indicated the resident was rarely understood/understands and was severely impaired for decision making. The resident needed extensive assist with 1 person physical assist for eating. The Care Plan, updated [DATE], indicated the resident was at risk for impaired nutritional status due to a mechanically altered diet and a history of weight loss. The resident at times consumed his food in a hurried manor that placed him at risk for swallowing difficulties and choking. The approaches were for all staff to be informed of resident's special dietary and safety needs, provide the diet as ordered, and supervision with meal intake. Physician's Orders, dated [DATE], indicated the resident was to receive a regular diet with a pureed texture and thin liquids. A Discharge Speech Therapy Note from the hospital, dated [DATE], indicated pureed diet with 1 to 1 assist with feeding. Nurses' Notes, dated [DATE] at 1:14 a.m., indicated the resident was having behaviors during incontinence care. The resident was observed with verbal outbursts and slapping himself. A beverage was offered to redirect his behaviors. Nurses' Notes, dated [DATE] at 7:30 a.m., indicated the resident was provided care and was to be transported by a wheelchair in the facility bus to an offsite facility for a new patient consultation/meeting. The resident was to be accompanied by two facility staff members. Nurses' Notes, dated [DATE] at 10:00 a.m., identified as a late entry, indicated the resident was being transported to an appointment at which time he exhibited signs of choking. A staff member removed the resident from the chair and initiated the Heimlich maneuver and a mouth sweep. The nurse was able to dislodge the food, but the resident remained unresponsive. 911 was called and CPR was initiated. Paramedics arrived at the scene and took over. The resident was transported to the hospital for further evaluation and was admitted to the hospital with an initial clinical impression of aspiration, chocking, and cardiac arrest. A written timeline of events for the resident on [DATE], as documented and stated by the facility Administrator (who accompanied the resident to the appointment) on [DATE], was provided by the [NAME] President of Operations and indicated the following: - 7:10 a.m., A CNA indicated it was a rough night due to the resident having a lot of behaviors. - 7:35 a.m., The Administrator gave the resident a bed bath and shave. - 8:15 a.m., The resident received his breakfast and spit out his food. - 9:10 a.m., The resident left the facility by the way of the facility bus to attend his appointment. Around 9:25 a.m., he started getting anxious and beating himself on the head, which usually meant he was hungry, thirsty or needed to have a bowel movement. The Administrator sat on the floor next to his wheelchair, held his hand, and tried to soothe him with some soft music. Despite her efforts and interventions, his behaviors continued. - 9:45 a.m., The Administrator had the Maintenance Director (bus driver) stop at a gas station, where she purchased a slurpee and honey bun. She moistened the honey bun and gave him small pieces with the slurpee to drink. She remained on the floor next to him and held his hand, while feeding him the food. - 9:59 a.m., They arrived at the offsite facility for the evaluation. - 10 a.m., After getting ready to move the resident off the bus, she observed him slumped over and blue. She checked his mouth and airway and removed a small piece of the honey bun from his mouth. His breathing remained shallow. - 10:01 a.m., The Administrator called 911 and the Maintenance Director was attempting to do the Heimlich maneuver as his color was still blue. During the call with 911, they asked for the address of the location, and she did not see it on the building, so she ran inside. There were 3 ladies standing at the door and they told her the address. The Maintenance Director continued to do the Heimlich maneuver, while she left for approximately 30 seconds. She rushed back on the bus and the resident had spit up bites of food particles, however, his breathing was slow and shallow and his color remained blue. The resident's Guardian had arrived on the bus a few seconds later and held the phone with the 911 operator. His respirations had become slower so they decided to get him out of the wheelchair so they could attempt the Heimlich maneuver on the ground, hoping that position would be more effective. They got him out of the chair and the Maintenance Director performed the Heimlich maneuver again and the Administrator swept his mouth and nothing was there. He had stopped breathing, so CPR was initiated. Three staff members from the facility had come on the bus with oxygen and an AED (automated external defibrillator, used to help those experiencing sudden cardiac arrest) machine. Oxygen was placed on the resident at the highest liter and their staff took over CPR. She remained on the phone with 911 until the paramedics arrived at 10:11 a.m. Interview with Maintenance Director (Bus Driver) on [DATE] at 12:43 p.m., indicated the resident had an appointment at an outside facility for potential placement into a group home. They left the facility a little after 9:00 a.m. He was not able to secure the resident in his chair with the straps due to his behaviors, so they used all 4 straps and secured his wheelchair to the floor with the wheels. They also put a gait belt around him so he was secured in place. About 5 minutes into the ride, he started rocking back and forth and was getting very agitated. The Administrator told him to change the music station to a softer music and Christian music. The Administrator sat on the floor next to the resident trying to soothe him, but that was not working. She told him to stop at a gas station, and she would run inside to get the resident something to eat. He stayed on the bus while she went in to get him snacks. The Administrator bought him a slurpee and a honey bun, because He loved honey buns. While sitting on the floor, she broke off small pieces of the honey bun off and was feeding it to him and giving him the slurpee to drink. At that moment, everything was fine and the resident calmed down after had eaten mostly all of the food. While pulling into the parking lot of the facility, the Administrator got up and got his things together to get him off the bus. At that time, he was observed to raise his arms in a rapid motion and he was blue. He turned to the Administrator and indicated that he thought the resident was choking, so she told him to come around to the back of the wheelchair and was instructed to give the Heimlich maneuver, she performed a sweep of his mouth and removed about the size of one half of a Munchkin donut and other mushy food. She called 911 and his breathing was still rough, but his color was coming back. Seconds later, he started gasping and choked again, and his breathing was worse. They moved him to the floor, and he positioned himself behind the resident and was sitting on his knees, while he placed the resident in his lap to do the Heimlich again. The resident's Guardian came into the bus while all this was going on and observed them helping the resident. He stopped breathing altogether, so they laid him flat on the floor, and he initiated CPR with chest compressions. He indicated he did not want to hurt the resident but could feel the cracking of his ribs. The Administrator had positioned herself by his head, while tilting it back and securing it as well. An employee from the outside facility had entered the bus and at that time, he and the Administrator had switched positions and she continued CPR, while he started putting down the seats and making room for other people to help. They set up the AED machine and oxygen was placed on the resident. He left the bus and opened the back door. EMS arrived about 14 minutes later and the resident was taken to the hospital. A telephone interview with the RN from the group home intake facility, on [DATE] at 1:12 p.m., indicated she was called out of a meeting that someone needed help on a bus outside of the facility. She and 2 other staff members, a medication aide, and a nurse aide entered the bus. At that time, she observed a woman kneeling in the back of the bus with the patient on the floor in a sitting position. The woman indicated the patient had some swallowing problems and choked on a donut and he did have shallow breathing, however, the RN did not observe him breathing. The RN indicated the patient was very blue and she instructed her to lay him flat on the floor. The AED machine was connected to the patient and CPR was started. The woman then removed herself from the area and stood in the back of the bus out of the way. The donut that was retrieved from the patient's airway, was approximately 1.5 inches in length. Hospital notes, dated [DATE], indicated the patient arrived at the emergency room at 10:34 a.m. and was unresponsive. The EMS indicated the patient remained in asystole (when the heart's electrical system fails, causing your heart to stop pumping) en route and was given medications to revive him. A physical exam was performed by the attending physician and the patient had no withdrawal to painful stimulus, his pupils were equal and non-reactive, he was unresponsive to verbal stimulus. Through a physical exam, laboratory results, and a chest x-ray, it was suggested the resident suffered a significant hypoxic ischemic injury (brain damage caused by a lack of oxygen to the brain). He was removed from the ventilator and died on [DATE] at 1:31 p.m. Interview with the Regional [NAME] President of Operations on [DATE] at 10:45 a.m., indicated she and her nursing consultants had recognized the seriousness of the situation and immediately began inservicing all staff regarding CPR, the Heimlich maneuver, signs of choking, and recognizing and identifying resident's with mechanically altered diets. The past noncompliance immediate jeopardy began on [DATE]. The immediate jeopardy was removed and the deficient practice corrected by [DATE] after the facility implemented a systemic plan that included the following actions: the facility identified all other residents with the potential to be affected, staff were all inserviced on only giving residents their proper diets, the Heimlich maneuver, CPR, and signs of choking, as well as relating all of these items to a transport situation. This Federal tag relates to Complaint IN00413252 3XXX,d+[DATE](a)(3)

Based on observation, record review, and interview, the facility failed to ensure a resident was monitored for signs and symptoms of constipation. The lack of assessment and monitoring resulted in the resident being hospitalized with a severe fecal impaction for 1 of 1 residents reviewed for constipation. (Resident 60) The facility also failed to ensure a fall follow up assessment was completed and an assessment including vital signs was documented prior to hospitalization for 1 of 2 residents reviewed for falls and 2 of 3 residents reviewed for hospitalization . (Residents E and 12) Findings include: 1. During an interview on 7/24/23 at 10:12 a.m., Resident 60 indicated he has horrible constipation issues and sometimes only has 1 bowel movement a week. He did not think he always received his Miralax (a laxative medication) as scheduled. During an interview on 7/26/23 at 10:55 a.m., the resident indicated he was very constipated and had not had a bowel movement yet this week. Staff were supposed to order an enema, but he had not received it. The record for Resident 60 was reviewed on 7/26/23 at 9:40 a.m. The resident was admitted on [DATE]. Diagnoses included, but were not limited to acute spinal cord infarction, chronic ischemic heart disease, high blood pressure, type 2 diabetes, major depressive disorder, anxiety disorder, panic disorder, stroke with no residual, and coronary artery bypass graft. The resident was admitted to the hospital on 7/16/23 and return to the facility on [DATE]. The 5/30/23 Significant Change Minimum Data Set (MDS) assessment, indicated the resident was cognitively intact for daily decision making. The resident was an extensive assist with a 1 person physical assist for bed mobility, dressing, toilet use, and personal hygiene. He had an indwelling catheter and was frequently incontinent of bowel. There was no Care Plan for constipation. The bowel movement record in the last 30 days, indicated there was no documented bowel movement on 6/28, 6/30, 7/1, 7/2, 7/3, 7/4, 7/5, 7/6, 7/7, 7/8, 7/9, 7/11, 7/12, 7/14, 7/21, 7/22,7/23, 7/24, 7/25, and 7/26/23. The resident had a small bowel movement on 6/29, 7/10, and 7/13/23, and a medium bowel movement on 7/15/23. Physician's Orders, dated 5/17/23, indicated Norco (a narcotic medication) tablet 7.5-325 milligrams (mg), give 1 tablet by mouth three times a day for pain. Physician's Orders, dated 6/9/23, indicated Polyethylene Glycol 3350 Powder (a laxative medication), give 17 grams orally every other day for constipation and give 17 grams as needed for constipation. Physician's Orders, dated 6/16/23, indicated Docusate Sodium (a stool softener) tablet 100 mg (Docusate Sodium), give 1 tablet by mouth two times a day for constipation. Physician's Orders, dated 6/26/23, indicated Lactulose oral solution 20 grams/30 milliliters (ml), give 30 ml by mouth every 12 hours as needed for complaints of constipation. KUB (A kidney, ureter, and bladder X-ray, may be performed to assess the abdominal area for causes of abdominal pain) X-ray to rule out any gastrointestinal obstruction or impaction. Physician's Orders, dated 7/26/23, indicated prune juice twice a day for constipation. Fleets rectal enema, insert 1 application rectally every 24 hours as needed for constipation and Fleets rectal enema, insert 1 application rectally one time a day every Wednesday for constipation. The Medication Administration Record (MAR) for 6/2023 and 7/2023 indicated the Lactulose was not administered. The Polyethylene Glycol 3350 Powder was ordered every other day, however, it was signed out as being given two times a day. Nurses' Notes, dated 6/23/23 at 11:23 a.m., indicated the resident had complaints of abdominal discomfort. An assessment of the resident indicated bowel sounds were present times 4, firmness and pain to the left lower quadrant. He has had no bowel movement in multiple days. The Physician was notified and gave an order for a rectal enema one time. The 6/2023 MAR indicated the enema was administered on 6/24/23 at 1:32 p.m. There was no follow up assessment or documentation regarding the results of the enema. Nurses' Notes, dated 6/26/23 at 3:59 p.m., indicated the portable X-ray company was called and notified of the KUB ordered by the Physician. There was no follow up documentation or information after 6/26/23. There was no documentation the KUB X-ray was completed. Nurses' Notes, dated 7/12/23 at 1:24 p.m., indicated the resident had complaints of constipation for a few days. The Physician was notified and a new order for an enema was obtained. The 7/2023 MAR, indicated the enema was administered on 7/14/23 (2 days later) at 1:15 p.m. There was no documentation of the results of the enema. Nurses' Notes, dated 7/16/23 8:55 p.m., indicated the resident had complained of constipation and abdominal pain, the Physician was notified and ordered a KUB X-ray, however, the resident called EMS himself and was taken to the hospital, where he was diagnosed with a urinary tract infection. Hospital notes, dated 7/16/23, indicated a cat scan of the abdomen and pelvis showed significant constipation/fecal impaction. The resident was admitted to the hospital with constipation and a urinary tract infection. The resident returned to the facility on [DATE]. A Nurses' Note, dated 7/26/23 at 9:13 a.m., indicated the resident had complaints of constipation and not having a bowel movement in about a week. The Physician gave orders to send him out to the hospital. The resident did not want to go back to the hospital so in lieu of going out, he agreed to have an enema. Nurses' Notes, dated 7/27/23 at 12:19 a.m., indicated the pharmacy was called regarding the enema. The enema was not covered by insurance, so it had not been sent. The 7/2023 MAR indicated the enema was administered on 7/27/23 at 1:15 p.m. The current 9/20/21 Bowel Elimination Protocol policy, provided by the [NAME] President of Operations on 7/27/23 at 1:00 p.m., indicated residents who had no bowel movements for 72 hours will be considered for pharmacological intervention or non-pharmacological intervention, such as prune juice, or encourage increased fluid intake. If the resident continued to have no bowel movement after additional intervention, notify the medical doctor for further instructions. It should be considered that some residents may have a normal bowel pattern greater than 72 hours without constipation. Interview with the Nurse Consultant on 7/27/23 at 1:55 p.m., indicated the KUB X-ray was not completed as ordered in June 2023. The resident's bowel movement record indicated the resident was not having routine bowel movements and nursing staff were not monitoring how long the resident had gone without a bowel movement. The resident had a long history of constipation. 2. On 7/25/23 8:33 a.m., Resident E was observed in bed. At that time, she was observed with tremors to her left arm, hand and head. Her eyes were open, and she was lifting her left leg over her right leg. The resident was not responsive. At 8:50 a.m., the resident remained in bed, still having the tremors to the left arm and leg. Her eyes were open but she was staring and not responsive to her name. Interview with the day shift nurse, LPN 5, on 7/25/23 at 8:40 a.m., indicated the Physician was just here and assessed the resident. He indicated the resident was having a stroke and since she was hospice, he wanted us to call her sister to see if she wanted her sent out to the hospital. While standing at the nurses' station, the telephone rang, and it was the resident's sister, who informed the nurse her symptoms could be seizure activity. She indicated the last time she was admitted to the hospital for the same symptoms, it was a seizure and not a stroke. The sister informed the nurse she would reach out to the resident's niece to see what she wanted to do. During an interview on 7/26/23 at 9:37 a.m., the Interim Director of Nursing indicated the resident's niece came to the facility yesterday and decided to send her out to the hospital. The record for Resident E was reviewed on 7/27/23 at 10:00 a.m. The resident was admitted to the facility on [DATE]. Diagnoses included, but were not limited to, metabolic encephalopathy, type 2 diabetes, diabetic neuropathy, high blood pressure, anxiety disorder, heart failure, and convulsions. The resident was admitted to the hospital on 5/28/23 and returned to the facility on [DATE]. The resident was again admitted to the hospital on 7/25/23, where she remained. The 6/22/23 Significant Change Minimum Data Set (MDS) assessment, indicated the resident was not cognitively intact for daily decision making. The resident needed extensive assist with 1 person physical assist for bed mobility. She was an extensive assist with 2 person physical assist for transfers. The resident had a history of falls since the last assessment. A Care Plan, revised on 6/23/23, indicated the resident has had a fall. The approaches were for the resident to wear non skid socks when attempting to ambulate and when not wearing shoes. The resident had numerous falls since admission. The following list of falls were documented but lacked assessment and monitoring post fall: - On 5/15 at 4:44 p.m. the resident had a fall. There was a fall follow up on 5/16 and 5/17/23. - On 5/21/23 at 12 p.m. the resident had a fall. There was a fall follow up on 5/22 and a post fall observation assessment on 5/22 at 2:11 p.m. - On 5/22 at 1:40 p.m. the resident had a fall and there was no fall follow up or post fall observation assessments completed. - On 6/16 at 8:24 a.m. the resident had a fall and there was no fall follow up or post fall observation assessments completed. - On 6/28 at 6:24 p.m. the resident had a fall and there was no fall follow up assessment completed. There was a post fall observation in progress, dated 6/30/23. - On 7/3 at 3:48 p.m. the resident had a fall and there was a fall follow up assessment competed on 7/4, and a post fall observation assessment completed on 7/3 at 4:30 p.m. There was no post fall observation or fall follow up assessments completed for 72 hours for the all of the falls above. Nurses' Notes, dated 4/7/23 at 11:55 p.m., indicated the resident was observed sitting on he floor by the bed. Her face was bloody and the gown was saturated with blood. She has a small laceration on the forehead. 911 was called and the resident was transferred to the hospital. The ER (emergency room ) Discharge Notes, dated 4/8/23 at 2:37 a.m., indicated repaired head laceration. There was no documentation of the resident after she returned from the hospital or the time she returned. There was no assessment of the resident after her return or the extent of her injuries. Neuro checks were not initiated. Nurses' Notes, dated 4/9/23 at 11:32 a.m., indicated the resident was observed on the floor, near her bed, face down. The resident's nose was bleeding and upon further assessment, she complained of pain to the left arm. The Physician was notified and the resident was sent to the ER. The resident was admitted to the hospital with a broken nose. ER Notes, dated 4/9/23, indicated the patient had an unwitnessed fall at the nursing home and was found face down with a bloody nose. She was seen here yesterday for another fall where she had a scalp laceration, staples were placed and she was discharged back to the nursing home. There was no assessment or documentation regarding the head laceration and staples after she returned back to the facility. Nurses' Notes, dated 5/28/23 at 7:36 a.m., indicated Patient was sent out to hospital this am. Morning meds given. An E-Interact transfer form, dated 5/28/23 at 8:30 a.m., indicated the reason the resident was sent to the hospital was for GI bleeding (gastrointestinal). The vital sign documentation on the form was outdated. There were no recent vital signs documented for the resident prior to hospitalization . A Nurses' Note, dated 5/28/23 at 2:53 p.m., indicated the resident was admitted to the hospital, however, no tests had confirmed the source of the bleeding. There was no documentation in Nursing Progress Notes for the most recent hospital admission on 7/25/23 regarding her change of condition. A blood pressure of 192/97 was recorded in the vital sign section, however, no other vital signs were checked or recorded. A hand written Nurses' Note, dated 7/25/23 at 10:10 a.m., by the Interim DON, indicated the Hospice Nurse was here for the evaluation of the resident and her tonic clonic seizure to the right side. A relative came in to see the resident and she wanted her sent to the hospital. There was no other documentation or an assessment of the resident prior to the hospitalization . Interview with the Nurse Consultant on 7/27/23 at 4:00 p.m., indicated neuro check assessments were initiated for the above mentioned falls, however, were not completed. Nurses were to document on the residents and complete an assessment for 72 hours post fall. Fall follow up documentation and assessments were not completed for the resident. Interview with the Nurse Consultant on 7/28/23 at 8:30 a.m., indicated the computer system was down during the late morning hours on 7/25/23, so the Nurse's Note was hand written. There were no other notes regarding when the tremors started, an assessment of the resident at the time, or a current set of vital signs. There was no complete assessment after the resident returned with the staples post fall or prior to going out to the hospital for GI bleed. The current 2/12/21 Fall Reduction Program policy provided by the [NAME] President of Operations on 7/27/23 at 1:00 p.m., indicated each nurse, each shift will observe the resident and document for 72 hours in the resident's medical record which included vital signs, neuro checks for unwitnessed falls, behavior changes, and physical changes. 45666 3. The record for Resident 12 was reviewed on 7/26/23 at 11:29 a.m. Diagnoses included, but were not limited to, end stage renal disease, dependence on renal dialysis, and type 2 diabetes mellitus. The Quarterly Minimum Data Set (MDS) assessment, dated 6/27/23, indicated the resident was cognitively intact for daily decision making. He required supervision only for activities of daily living. He received insulin injections and dialysis treatments. A Care Plan, dated 11/10/21, indicated the resident was at risk for complications related to diabetes and insulin use. Interventions included, but were not limited to, administered diabetic medications as ordered, educate the resident regarding medications and importance of compliance, and educate as to the correct protocol for glucose monitoring and insulin injections. The July 2023 Physician's Order Summary indicated the resident received insulin detemir (long-acting insulin) solution per a sliding scale twice daily and insulin lispro (short-acting insulin) solution per a sliding scale before meals. A Nurses' Note, dated 7/18/2023 at 5:09 a.m., indicated a nurse from the hospital called at approximately 3:19 a.m. to report the resident was seen in the emergency department for diabetic hyperglycemia and would be discharged back to the facility. The resident arrived to the facility at 5:12 a.m. via ambulance. Upon arrival he was alert and oriented in his normal demeanor with a blood sugar of 174. The record lacked documentation of a completed assessment of the resident's condition prior to leaving the facility. Interview with the Nurse Consultant on 7/27/23 at 3:50 p.m., indicated she was unable to locate any documentation or assessments completed related to the transfer to the hospital on 7/18/23. 3.1-37(a)

Based on record review and interview, the facility failed to ensure care and treatment was provided in accordance with professional standards related to transportation to Physician and Pain Clinic appointments not provided for 2 of 3 residents with ongoing appointments scheduled. This resulted in ongoing pain concerns and emotional distress for 2 of 2 residents reviewed for outside consults. (Residents C & D) Findings include: 1. On 5/9/19 at 8:50 a.m., Resident C was observed in bed. Her meal tray was at the bedside. Interview with Resident C at that time, indicated she had been having bad headaches for several weeks and the facility ordered a CT scan of her head. The results showed a mass. The facility notified the Nurse Practitioner and the Physician. An appointment to see a Neurosurgeon was set up for 4/22/19. Staff forgot to send the CT Scan Disc with her to the appointment, so the office sent her back to the facility, as the Neurosurgeon needed the CT Scan Disc before completing an examination. Another appointment was made for 4/26/19. The appointment was canceled by the facility due to lack of transportation. A third appointment made for 5/6/19 was also canceled. Resident C stated, I'm so scared, can you imagine being told you have a mass in your head and not knowing what's going on? The record for Resident D was reviewed on 5/9/19 at 10:17 a.m. [DIAGNOSES REDACTED]. An MDS (Minimum Data Set) Annual assessment was completed on 4/12/19. The resident's cognitive skills for decision making were intact with no behaviors or rejection of care. Extensive assist of 2 staff members was needed for bed mobility and transfers. Extensive assist of one staff was needed for personal hygiene and dressing. Range of motion was impaired in both lower extremities. A wheel chair was needed for mobility. Physician orders [REDACTED]. - 4/4/19 CT Scan of the head without contrast for complaints of severe headaches. - 4/9/19 Follow with Dr. (name of Neurologist). Director of Nursing made the appointment. A Nurse Practitioner Progress Note, dated 4/11/19 at 12:59 p.m., indicated The resident was seen for an acute visit follow up for pain and anxiety. She was alert and orientated. CT scan results were reviewed. The CT report showed 'Extra-axial partially calcified 25 cm (centimeters) x 13 cm lesion along the left vertex consistent with a monition with slight mass effect. Blood pressure stable and most likely not causing the headaches. Orders for ASAP Neuro (neurologic) follow up.' The (MONTH) 2019 Social Services Notes indicated, Social Service, Director of Nursing, and the Assistant Director of Nursing met with the resident on 4/9/19 at 3:59 p.m. to discuss results of recent tests. The resident was tearful, asked several questions, and expressed concern due to her family medical history. April 2019 and (MONTH) 2019 Nursing Progress Notes indicated the following: - 4/15/19 at 1:57 p.m.: An appointment was originally made with MD B, but MD C, who is in the same office, had an earlier appointment available for 4/22/19 at 1:30 p.m. in Merrillville. Films of the head CT Scan from the hospital were needed. - No entries were made on 4/22/19. - 4/25/19 at 3:45 p.m.: Nursing staff scheduled an appointment with the Neurosurgeon for 5/6/19 at 2:00 p.m. - 5/6/19 at 9:34 a.m.: The arranged transportation was unable to transport due to there isn't enough transport providers in the area. Appointment will be rescheduled. Results of the 4/5/19 CT Scan of the head indicated, a partially calcified extra-axial paramedic midline lesion along the calvarial vertex consistent with a menigioma ([DIAGNOSES REDACTED]). This measures 15 mm (millimeters) in width and 13.5 mm in cephalocaudal dimension. Mass effect on the frontal lobe along the vertex was noted. When interviewed on 5/9/19 at 11:47 a.m., the Director of Nursing indicated Resident C had a CT scan of the head a few weeks ago and the Nurse Practitioner was aware of the results. She went to the Neurosurgeon on 4/22/19 after having the CT scan. The paperwork was sent with the resident, but the CT Scan Disc was not sent. The facility did have a copy of the disc in the facility and it was not sent with the resident to the 4/22/19 appointment. When interviewed on 5/10/19 at 9:34 a.m., the Administrator indicated the facility van had been in for repairs and was just returned yesterday. Resident C did miss appointments on 4/26/19 and 5/6/29 due to no available transportation. 2. On 5/10/19 at 10:46 a.m., Resident D was observed in bed. The resident indicated he had pain every day due to breaking his hip. Appointments to the Pain Clinic had been canceled and then later rescheduled. The record for Resident D was reviewed on 5/9/19 at 12:53 p.m. [DIAGNOSES REDACTED]. An Admission MDS assessment was completed on 2/1/19. Cognitive skills were intact. No behaviors or rejection of care occurred. Extensive assistance of one staff was needed for bed mobility, transfers, and personal hygiene. Range of motion was impaired in both lower extremities. A physician progress notes [REDACTED]. The resident complains of inability to sleep and increasing pain. He indicated he was sleeping 'about 2 hours a night. A Nursing Progress Note, completed on 4/22/19 at 1:58 p.m., indicated the (name of transportation) company was scheduled to pick up and transport the resident to the Pain Clinic on 4/24/19 at 2:30 p.m. A Nursing Progress note, completed on 4/24/19 at 2:19 p.m., indicated the resident's Pain Clinic appointment had been canceled and rescheduled for 5/1/19 due to transportation not showing up. When interviewed on 5/10/19 at 9:34 a.m., the facility Administrator indicated the Resident missed appointments to the Pain Clinic due to transportation not being available. This Federal tag relates to Complaints IN 456 and IN 584. 3.1-37(a)

Based on observation, record review, and interview, the facility failed to provide adequate supervision related to staff leaving a resident unattended on the toilet in the bathroom resulting in a laceration and fracture for 1 of 3 residents reviewed for falls. (Resident C) Finding includes: On 7/2/18 at 8:20 a.m., Resident C was observed in a low bed. A mattress was on the floor next to the bed. A staff member was present in the room and indicated 1:1 supervision was being provided due to falls. The record for Resident C was reviewed on 7/2/18 at 10:08 a.m. [DIAGNOSES REDACTED]. A Quarterly Minimum Data Set assessment, dated 3/16/18, indicated cognitive skills for decision making were severely impaired. Extensive assistance of staff was required for transfers and toilet use. The resident was not steady moving from a seated position to a standing position. A wheel chair was used for mobility. Two or more falls occurred since admit or the prior assessment. An Admission Fall Risk Observation, dated 1/8/18, indicated at high risk for falls. A Quarterly Fall Risk Observation, dated 6/4/18, also indicated high risk for falls. A current Care Plan, initiated on 11/9/2018 and last revised on 6/25/18, indicated high risk for falls related to a past history of falls, artificial right hip joint, and inter-vertebral disc displacement. Interventions included, but were not limited to, alarm floor mat, low bed, and scoop mattress. Nursing Progress Notes completed on 6/20/18 at 12:20 p.m. indicated the writer (Nurse) was called to the room and observed the resident on the bathroom floor lying on his left side. Bleeding from his left cheek and a cut above the left eye were observed. No changes in range of motion. The Physician and Responsible Party were notified. Ambulance service called for transport to the emergency room . A Nursing Progress Note, dated 6/20/18 at 1:29 p.m., indicated there was an open wound to the left facial cheek. The wound measured 5.0 x 4.0 cm (centimeters) in size. Hospital records indicated the resident was seen in the emergency roiagnom on [DATE] and transferred to another hospital due to his condition on the same day. Records from the second hospital indicated the resident had an unwitnessed fall in the bathroom and sustained a superior orbital laceration. A CT scan was completed with a mildly displaced [MEDICAL CONDITION] maxillary sinus. The [MEDICAL CONDITION] measured 2.5 cm and suture repair completed. During an interview on 7/2/18 at 2:00 p.m., the Director of Nursing indicated the resident fell off the toilet on 6/20/18. The CNA had assisted the resident on to the toilet and stepped out of the bathroom to obtain incontinence care supplies. The resident fell off the toilet while unsupervised before the CNA returned to the bathroom. This Federal tag relates to Complaints IN 312 and IN 314. 3.1-45(a)(2)

Based on record review and interview the facility failed to ensure interventions were in place to monitor hydration related to the failure to assess fluid intake to ensure the resident's estimated fluid intake levels were before and after IV fluids were provided which resulted in a hospital admission with a [DIAGNOSES REDACTED]. (Resident #B) Finding includes: The closed record for Resident #B was reviewed on 1/19/16 at 9:00 a.m. The resident's [DIAGNOSES REDACTED]. The resident was discharged to the hospital on [DATE]. Review of the 12/9/15 Nutrition Observation re-admission assessment indicated the resident was to be evaluated on her return from the hospital. The assessment indicated the resident's current weight was 125 pounds and her ideal body weight was 130 pounds. The assessment indicated the resident had Stage III and Stage IV pressure ulcers and the resident's overall nutritional risk was high. The resident's estimated fluid needs were 1500-1710 cc's (cubic centimeters) per day. The 12/2015 Physician orders [REDACTED]. An order was written on 12/3/15 for the resident to received Nepro (a liquid supplement) one can daily. The Nepro was discontinued on 12/16/15. An order was written on 12/17/15 for the resident to receive one can of Ensure three times a day. The 12/20/15 Vital Signs records and Medication Record were reviewed. The records indicated the amount of fluids the resident consumed as follows: 12/03/15 Nepro (240 cc/can)one can daily- % consumed unknown Other fluids: 240 cc 12/4/15- Nepro- 50% consumed Other fluids not recorded 12/5/15 Nepro - 50% consumed Other fluids not recorded 12/6/15 Nepro -100% consumed Other fluids: 480 cc 12/7/15 Nepro -100% consumed Other fluids: 80 cc 12/8/15 Nepro -% consumed unknown Other fluids: 360 cc 12/9/15 Nepro- % consumed unknown Other fluids not recorded 12/10/15 Nepro - % consumed unknown Other fluids: 120 cc 12/11/15 Nepro - % consumed unknown Other fluids: 480 cc 12/12/15 Nepro 240 cc Other fluids not recorded 12/13/15 Nepro - 50% consumed Other fluids:240 cc 12/14/15 Nepro -25 % consumed Other fluids not recorded 12/15/15 Nepro- not signed out as given 12/16/15 Nepro- not signed out as given Other fluids: 240 cc 12/17/15 Ensure 240 cc per can)- One Can TID (three times a day) 75%, 75%, and 25% consumed Other fluids: 580 cc 12/18/15 Ensure TID: 75%, 50%, 100% unconsumed Other fluids: 240 cc 12/19/15 Ensure TID: 50 %, unknown %, 100% consumed Other fluids: 480 cc 12/20/15 Ensure TID: 0% x 3 consumed Other fluids: 360 cc 12/21/15 Ensure TID: Unknown %, 50% , 100% consumed Other fluids: 2464 cc 12/22/15 Ensure TID: Unknown % x 3 Other fluids: 240 cc 12/23/15 Ensure TID: 11%, 75%, 100% consumed Other fluids: 360 cc 12/24/15 Ensure TID: 100%, unknown x 2 Other fluids: 460 cc 12/25/15- Ensure TID: 25%, 25%, 50% consumed Other fluids: 600 cc 12/26/15 Ensure TID: percent unknown x 2, 100% No other fluids recorded. 12/27/15 Ensure TID: % unknown x 3 Other fluids: 480 cc 12/28/15 Ensure TID: 25%, 100%, 100% Other fluids: 100 cc 12/29/15 Ensure- TID: 98%, unknown x 2 Other fluids: 240 cc Review of the 11/2015 and 12/2015 Laboratory tests results indicated CMP (Comprehensive Metabolic Panel) results were as follows: 11/20/2015 BUN: 34 (normal 8-28) Creatinine: 1.74 (normal 0.40-1.60) 12/04/2105 BUN: 55 Creatinine: 2.38 12/09/2015 BUN: 71 Creatinine: 2.75 The 12/2015 Progress Notes were reviewed. A Nursing entry made on 12/6/15 at 9:30 p.m. indicated the attending Physician was called related to recent laboratory tests results. The Notes indicated an order was obtained for IV (intravenous) fluids of sodium chloride at 30 cc/hour continuously and to obtain a CMP laboratory test after 48 hours. The order indicated indicated the laboratory test results were to be faxed to the renal (kidney) Doctor in the a.m. An entry made on 12/11/15 at 12:18 p.m. indicated there was an order to d/c fluids. An entry made on 12/11/15 at 4:58 p.m. indicated the IV line was discontinued. Review of the 12/7/15 through 12/10/15 Nursing Progress Notes indicated there was no indication of the laboratory test results having been faxed or called to the renal Doctor. A Nursing entry made on 12/9/15 at 3:51 p.m., indicated the resident remained on IV fluids for dehydration. A Nursing entry made on 12/11/15 at 1:59 p.m., indicated an order was obtained to discontinue the IV fluids. An entry made on 12/12/15 at 2:27 p.m. indicated the resident remained in bed this shift. Encouragement to get up was given to the resident and was not successful. The Nurse talked with the resident and the resident stated she didn't want to walk. An entry made on 12/13/15 at 10:25 a.m. indicated the CNA reported the resident had been refusing all her meals since 12/12/15. The Nurse talked to the resident and the resident stated she did not want the meal. The Nurse offered an Ensure supplement and the resident consumed the supplement. The next entry was made on 12/13/15 at 2:59 p.m. This entry indicated the resident did not participate in any activities or therapy. The resident stated she was tired and refused her wound treatment also. The next entry was made on 12/14/15 at 12:51 p.m. This entry indicated the Nurse was called to the room to assess the resident. The resident presented with congestion and wheezing to the right lung. An entry made by Occupational Therapy staff was made on 12/14/15 at 4:45 p.m. indicated the resident required maximum rest breaks, fatigued easily, and required maximum verbal cues to stay awake. Review of the 12/16/15 Registered Dietitian Progress Note indicated the resident was noted to have weight loss of 6.5 % in the last (30) days. The resident had a decreased appetite lately and the weight loss was unplanned. Recommendations were to discontinue the Nepro supplement and start Ensure one can three times a day. There was no accurate and complete recording of the total measurements of the resident's oral fluid intake. There was no Intake and Output recorded during December 2015. A physician progress notes [REDACTED]. A Nursing Progress note was made on 12/30/15 at 9:30 a.m. The entry indicated the Nurse was notified of a change in the resident's condition. The resident was pale, cool, and lethargic. The resident was given a sternal rub and did not arouse. An oxygen saturation level reading was unable to be read. Oxygen was started and the resident started to open her eyes. An order was obtained to send the resident to the hospital and 911 was activated. There was no record of any I & O (Intake and Output) records being recorded during the dates the resident received the IV fluids. The resident's hospital records were reviewed. The resident present to the hospital on [DATE] at 9:52 a.m. The resident's [DIAGNOSES REDACTED]. The ED (Emergency Department) notes were reviewed. The notes indicated the resident came from a Nursing Home for increased lethargy and being unresponsive. The EMT'S(Emergency Medical Technician) stated the resident's blood pressure was 60/40, she was lethargic, a non rebreather oxygen mask was applied, and IV fluids were infusing. The resident's vital signs on 12/30/15 at 9:54 a.m. were as follows: BP 89/48, Heart rate 94, and Respiratory rate 24. The resident's blood pressure was running 80's/40's at 1:09 p.m. The resident was lethargic at 3:25 p.m. and her blood pressure was in the 60's systolic (the upper number). The resident's laboratory tests from the ED were reviewed. BUN: 58 Creatinine: 3.14 The ED Physician notes were reviewed. The notes indicated the resident presented with fatigue and dehydration was suspected. The resident was hypotensive (low blood pressure) with severe fluid loss and was to be admitted for dehydration and diuresis. An entry at 1:39 p.m. indicated the resident's blood pressure was 116/65. An entry at 3:25 p.m. indicated the resident's was lethargic and blood pressure was in the 60's again. [MEDICATION NAME](a medication to increase blood pressure) was to be started to increase the blood pressure and the resident was to be transferred to the Intensive Care Unit. Review of the 1/1/16 Physician History and Physical indicated the resident arrived from the Nursing home on a 100% rebreather oxygen mask. The resident was significantly hypotensive (low blood pressure) and her systolic blood pressure was 60. Very concentrated urine was noted. The resident was significantly dehydrated and was given multiple boluses of IV fluids. The patient did get better with IV fluids. Recommendations were to continue with aggressive hydration and to be monitored closely in the Intensive Care unit. When interviewed on 11/19/15 at 2:00 p.m., the Director of Nursing indicated there were no orders for the resident to be a DNR (Do Not Resuscitate). The DON indicated a Hospice Evaluation was completed. The resident declined Hospice services. When interviewed on 11/20/16 at 11:00 a.m., the Director of Nursing indicated the resident's I& O was not recorded as per the policy. The Director of Nursing indicated the resident's oral fluid intake was not recorded consistently to monitor for dehydration. The facility policy titled Intake, Measuring and Recording was reviewed on 1/20/16 at 11:50 a.m. The Director of Nursing provided the policy and indicated it was current. The policy was dated September 2005. The policy indicated the procedure was applicable when indicated by the resident's condition and treatment such as IV fluids and parental nutrition. This Federal tag relates to Complaint IN 737. 3.1-46(2)(b)

Based on record review, interview and observation, the facility failed to ensure a resident who was established as a known elopement risk was provided adequate supervision to prevent elopement which resulted in the resident leaving the facility through an alarmed door for 1 of 3 residents reviewed for elopement. This was related to the failure of staff to complete every 2 hours observation rounds and the failure to ensure staff followed protocol by turning off the alarming exit door and not notifying other charge staff when no residents or staff members were observed outside of the exit door. The resident was last seen at 6:30 p.m. and discovered missing at 9:45 p.m. This resulted in an Immediate Jeopardy. This deficiency resulted in an Immediate Jeopardy. The Immediate Jeopardy began on 11/25/15 when Resident #D exited the facility unsupervised and was not identified as missing after the exit alarm sounded at 8:30 p.m. and was turned off. The Administrator and the Director of Nursing were notified of the Immediate Jeopardy on 12/28/15 at 2:40 p.m. The Immediate Jeopardy was removed, and the deficient practice was corrected on 12/6/15, prior to the start of the survey and was therefore Past Noncompliance. Finding includes: The closed record for Resident #D was reviewed on 12/28/15 at 9:30 a.m. Resident D was admitted to the facility on [DATE]. The [DIAGNOSES REDACTED]. A Social Services Elopement Risk Review was completed on 12/16/14 at 4:22 p.m.,. after the resident was noted to be wandering. This review indicated the resident had memory problems and had a history of [REDACTED]. The review also indicated the resident had been wandering into other rooms and opening doors by restricted areas stating she wanted to leave the facility to get fresh air. The resident was issued a Wanderguard device (a device to notify staff when at risk residents are near exit doors) at this time and wore it on her wrist. The current Physician orders, original date of 12/16/14, indicated there was an order written [REDACTED]. The 9/17/15 Minimum Data Set (MDS) quarterly assessment indicated the resident's BIMS (Brief Interview for Mental Status) score was 4. A score of 4 indicated the resident's cognitive patterns were severely impaired. The assessment also indicated the resident was able to walk in her room and in the corridor with supervision. The Progress Notes entries indicated the following: On 11/01/2015 at 3:10 p.m., the Nurse was informed by another resident that Resident #D had pulled the curtain down in her room. The Nurse went to the room and observed the window screen was torn in the middle and a white sheet was hanging from the resident's window. The resident stated she was going to get out the window to get away from bad people. The resident was started on (15) minute checks at the above time. On 11/5/15 at 1:48 p.m., the resident was moved from her room on the second floor to a room on the first floor. On 11/25/15 at 10:00 p.m., the Nurse was informed by the 2:00 p.m.- 10:00 p.m. shift CNA (Certified Nursing Assistant) that he could not find Resident #D in her room. Staff began checking both floors. The resident was last seen before dinner. On 11/25/15 at 10:15 p.m., the Police Department was notified. On 11/26/15 at 2:30 a.m., the resident was observed at a local restaurant. The resident was taken to a local hospital at this time and the Police were notified of the resident's current location. A local Police report was reviewed. The report indicated they were contacted on 11/25/15 at 10:53 p.m. by the facility and informed that Resident #D was missing and had left the facility between 6:00 p.m. and 10:15 p.m. on 11/25/15 and the resident suffered from dementia. The report indicated staff reported the resident was last seen at (Location #1, a local grocery store) at approximately 11:15 p.m. on 11/25/15. The report also indicated the resident was found by facility staff at a (Location #2, a local fast food restaurant) on 11/26/15 at 2:35 a.m. and had been transported to the hospital. The mileage calculations noted the following: Lake County Nursing & Rehabilitation to Location #1: 1.3 miles Location #1 to Location #2: 3.4 miles Location #2 to Lake County Nursing & Rehabilitation: 3.1 miles. A facility Incident Report investigation, dated 11/26/15, indicated the Resident #D was not observed during routine bed checks on 11/25/15 and was later located at a nearby restaurant by staff who were out looking for the resident. The entire building and grounds were checked. Staff interviews were conducted related to the incident. A written statement made by RN (Registered Nurse) #1 (Nurse assigned to care for the resident) indicated Resident #D was last seen before 6:00 p.m. walking up and down the hallway of the first floor on 11/25/15. RN #1 went up the second floor to pass medications and returned to the first floor. At 10:00 p.m. the RN was notified by a staff CNA that they could not find the resident in her room and both floors were immediately checked for the resident. The ADON (Assistant Director of Nursing was in the facility and the DON (Director of Nursing) and the Administrator were notified. The resident was later found at a restaurant on 11/26/15 at 2:30 a.m. A statement from CNA #2 (the CNA assigned to care for Resident #D on 11/25/15 during the 2:00 p.m.-10:00 p.m. shift) indicated he saw the resident around 6:30 p.m. at meal time. The statement indicated the CNA indicated he was doing rounds around 9:45 p.m. and when he went into the resident's room at this time, she was not in her room. The Nurse was told and staff began searching for the resident. A statement from CNA #3 indicated she responded to the Employee Break Room door alarm on 11/25/15 at 8:15 p.m. The statement indicated the CNA looked outside and did not see anyone, shut off the alarm, and went back to work. The statement also indicated the CNA did not notice her coat was missing at that time. A statement from the ADON indicated she was present in the facility and was notified by RN #1 that Resident #D was not in the facility and a search was made throughout the facility as well as surrounding grounds outside. The resident was not located. The ADON went with local Police to the gas station nearby and staff there indicated the resident had last been seen 20 minutes prior. The ADON continued her search and at approximately 2:30 a.m., the resident observed through the window of a local restaurant. A statement completed by the DON (Director of Nursing) indicated she had received call around 10:30 p.m. on 11/25/15 and was notified that Resident #D could not be located in the building. The ADON was instructed to call the Police. The DON received a call from staff who had checked the closest gas station and they informed then they had seen the resident and she was asking other customers for money. The DON later was told the resident had been spotted at the Location #1 and also at Location #3 (a local fast food restaurant) about 20 minutes prior to Location #1 and was seen heading North. The ADON observed the resident at Location #2 and the resident was taken to the hospital to be evaluated for mental status change. When interviewed on 12/28/15 at 8:39 a.m., Maintenance staff #1 indicated all the exit doors in the facility were to be locked at all times. Staff #1 indicated there were cameras at the Nurses' Station so Nursing could see who was at door and let them in if needed. Nursing staff had to buzz them out. The exit doors were fire doors and if someone pushed on them they would alarm and open. There was a receptionist at the front desk till about 7:30 p.m. The Maintenance staff further indicated there were four exits and all of them were equipped to alarm when opened. The Maintenance staff indicated they were responsible to check the alarms three times a week until recently and now they were to check more frequently. The Maintenance Staff indicated recently the Administrator placed a binder at the front desk to have ancillary staff complete the checks and sign on the weekends. The Maintenance staff indicated the weekend managers were responsible for completing the checks on weekends when maintenance was not in the facility. When interviewed on 12/28/15 at 9:58 a.m., the DON indicated Resident #D was to have a Wanderguard in place at the time she was reported missing. The DON indicated the Wanderguard bracelet was cut off and a few days later was found in the laundry. The resident did not have her Wanderguard in place when she was located outside of the facility. The facility Administrator and the DON were interviewed on 12/28/15 at 10:39 a.m. The DON indicated the ADON was in the building at the time and notified her the resident could not be located at 10:30 or 10:35 p.m. The ADON reported they had searched the building and the outside grounds and were not able to locate the resident. The DON indicated she instructed them to check the building again and call the Police. The DON indicated staff later called and informed her they had been going to nearby business places around the building to look for the resident. Staff went to a nearby gas station and was told they had seen Resident #D at the gas station approximately 20 minutes earlier. The DON indicated she also informed another staff member had gone to Location #1 searching for the resident and the store reported the resident had been there about 1/2 hour earlier. Staff also went to Location #3 and staff at Location #3 stated they saw the resident heading towards a gas station. This gas station was one block from Location #3. No one from the gas station reported seeing the resident. The DON indicated the resident was found at Location #2 by the ADON at 2:25 to 2:30 a.m. on 11/26/15. The resident had a staff members coat from the break room The resident was taken to the hospital at this time after being assessed by the ADON. Continued interview with the DON and the Administrator indicated the resident was last seen on rounds by CNA #2 at approximately 6:30 p.m. when he was doing rounds. When CNA #2 was doing rounds 9:45 p.m., he could not locate the resident in her room and informed RN #1. RN #1 indicated she last saw the resident before 6:00 p.m. The DON indicated the CNA #3 reported she had heard the alarm sounding outside of the first floor employee lounge at 8:15 p.m. on 11/25/15. The CNA reported she responded to the alarm and looked outside and did not see anyone so she returned to work. The CNA reported she did not inform the Nurse on duty or the ADON who was in the facility at the time. The DON and the Administrator indicated when an exit alarm sounds staff were to respond and check the surrounding area. If no residents were seen a head count of the residents was to be completed at that time to account for all residents and this was not done. A Code Pink for elopement was to be called to search for missing residents and this was not done. The Administrator and DON indicated this exit door was frequently used as it was the staff break room and they would exit to go smoke outside of the exit door. On 12/28/15 at 11:15 a.m., the above employee lounge room was observed with the DON and the Administrator. The room was at the end of one of the two hallways on the first floor. There was a punch code alarm and a Wander Guard device box on the door frame to exit door to the outside patio area. The door opened and alarmed when pushed on by the DON. There was a brick wall around the patio area with cyclone gates on either side. One gate was locked with a chain and the other was not. The open gate lead to an open area along an alley heading North with a fence on the East side. Another fence intersected and went towards the West. There was a gate on this side of the fence which was not locked. This gate opened directly to an alley. The open area continued towards the front of the Building, the parking lot and a street. When interviewed on 12/28/15 at 11:25 a.m., the facility Administrator indicated residents should be observed every two hours on rounds and this was most likely not done based on the time CNA #2 indicated he had seen the resident in his statement. The Administrator indicated a head count of the residents should have been done when CNA #3 first responded to the exit alarm sounding and no residents or staff were observed outside at that time. The Administrator indicated they no longer allowed staff to smoke outside of the break room after Resident #D had eloped. The Administrator indicated staff could have gotten used to hearing the alarm sounding each time staff went out to smoke. When interviewed on 12/28/15 at 12:40 p.m., the Director of Nursing indicated 15 minute checks for the resident were initiated on 11/1/15 at 3:00 p.m. after staff found a sheet hanging out from the resident's window. The Director of Nursing indicated 15 minutes checks were completed for three days. The resident was then moved to a room on the first floor and no further incidents were observed. When interviewed on 12/28/15 at 3:10 p.m., the Restorative/MDS RN indicated the Elopement assessments were to be completed quarterly on residents with Wanderguard devices in place. On 12/28/15 at 11:25 a.m., the Administrator provided the Elopement and Search (Code Pink) policy, dated February 2014, and indicated the policy was the one currently being used by the facility. The policy indicated all Nursing personnel were responsible for knowing the whereabouts of their residents and were also to make observations of their residents at no less then two hour intervals. The policy indicated in the event that a resident could not be located the Charge Nurse was to announce a Code Pink over the paging system. The Charge Nurse was to assign tasks to the staff. The policy also indicated the facility exit door alarms were to be checked daily. The past noncompliance Immediate Jeopardy began on 11/25/15. The Immediate Jeopardy was removed and the deficient practice corrected by 12/6/15 after the facility implemented a systemic plan that included the following actions: All staff members were in-serviced on the need to complete rounds on each resident every two hours and the current elopement policy which included responding to exit door alarms, observing the surrounding area for any residents, and reporting the results of the observation to the Charge Nurse or management immediately. All staff in-servicing also included review of the Code Pink (missing resident) policy and protocol. The CNA who did not observe the resident every two hours was disciplined. The CNA who turned off the exit alarm and did not report to the Charge Nurse was also disciplined. The facility also implemented a an Alarm Audit binder for Weekend Manager to verify completion of daily alarm checks on the weekends to ensure all alarms were checked daily. This was initiated on December 1, 2015 though no entry was made on the Weekend log on Saturday December 5, 2015. Elopement Risk Assessments were completed for all residents by November 28, 2015. The facility smoking protocol was changed on 11/27/15 and staff were not allowed to smoke outside of the exit door from the Employee lounge area where Resident #D could have eloped from. Staff interviews completed on 12/28/15 and 12/29/15 indicated staff members from various departments and disciplines were aware of the the current elopement policies and procedures. This Federal tag relates to Complaint IN 701. 3.1-45(a)(2)

Based on observation, record review and interview, the facility failed to provide acceptable parameters of nutrition related to providing supplements as ordered by the Physician for 3 of 3 residents reviewed for nutrition of the 19 residents who met the criteria for nutrition and for ensuring a resident who received [MEDICAL TREATMENT] was provided a lunch before leaving for 1 of 1 residents reviewed for [MEDICAL TREATMENT]. The facility also failed to ensure Registered Dietitian (RD) recommendations were implemented, supplement intake was monitored, and a resident was being monitored in Nutrition at Risk Meetings. This resulted in the resident not being monitored for a 15.5% weight loss and being below her recommended body mass index (BMI). (Residents #56, #88 and #97) Findings include: 1. The record for Resident #88 was reviewed on 7/9/14 at 9:48 a.m. The resident was admitted to the facility on [DATE]. The resident [DIAGNOSES REDACTED]. The Minimum Data Set (MDS) Admission assessment dated [DATE], indicated the resident had a BIMS (Brief Interview for Mental Status) score of 14, which indicated she was cognitively intact. Her functional status indicated she needed extensive assistance with bed mobility and transferring. She had no or unknown significant weight loss or gain in the six months prior to admission. Her weight was 129 pounds and her BMI (Body Mass Index) on admission was 22.8, which was within normal range. On 7/10/14 at 9:00 a.m., the resident's breakfast tray was observed being removed from her room. The super cereal had not been touched. On 7/10/14 at 12:40 p.m., a staff member removed the resident's lunch tray from her room. There was no health shake on the tray or in the resident's room. CNA #4 indicated she did not get the resident her health shake and would notify the nurse. On 7/11/14 at 12:50 p.m., the lunch tray was removed from the resident's room. The health shake was on the cart but had not been opened. On 7/14/14 at 8:50 a.m., the breakfast tray was removed from the room. Only one bite of super cereal had been taken. The resident's weights were as follows: 2/27/14 129 pounds 3/6/14 124 pounds 3/12/14 125 pounds 3/27/14 118.4 pounds 4/10/14 115.4 pounds 5/3/14 112.8 pounds 6/5/14 111.4 pounds 7/10/14 109 pounds The resident had a 20 pound weight loss in less than 6 months, resulting in a significant weight loss of 15.5%. Physician diet orders dated 6/13/14, indicated the resident received a regular, mechanical soft diet with double protein and super cereal at breakfast. Whole milk with all meals and health shake with lunch. A Dietary Progress note dated 3/13/14, indicated the resident reported drinking the health shakes and had a good appetite. A 4 pound weight loss was noted, continue to monitor oral intake. A Dietary Progress note dated 4/10/14, indicated the resident received double protein and health shakes twice daily, recommend adding super cereal to address weight loss. A Dietary Progress note dated 5/14/14, indicated the resident had been referred to the RD due to weight loss. The resident's current weight was 112.8 pounds, her BMI was 19.9% which was below desirable range. The RD recommended weekly weights for closer monitoring. A Dietary Progress note dated 6/11/14, indicated the resident's current BMI was below desirable range at 19.7%. The resident was receiving health shake, double protein and super cereal. The resident reported her appetite was good. Interview with MDS Coordinator on 7/10/14 at 12:45 p.m., indicated the resident had been put on NARS (Nutrition At Risk) on 3/6/14 after her initial weight loss. She was taken off NARS on 4/10/14 because she did not have a significant weight loss that month. She indicated the weekly weights recommended by the RD on 5/14/14 had not been implemented. She indicated the CNA's would document how much each resident ate for each meal. They did not document health shakes, double protein or super cereal specifically. NARS relied on Nursing staff to let them know if the resident was eating the supplements provided. She was not aware the resident was not eating super cereal or health shakes. Further interview with the MDS Coordinator on 7/14/14 at 10:05 a.m., indicated there was not a nutritional care plan for the resident. She indicated there should have been a care plan in place. 2. Interview with Resident #97 on 7/9/14 at 9:05 a.m., indicated his [MEDICAL TREATMENT] days were Tuesdays, Thursdays, and Saturdays. He further indicated the ambulance company usually came to pick him up around 12:15 p.m. or 12:30 p.m. He indicated he did not always get a hot lunch before he left. He indicated he usually comes back to the facility around 5:30 p.m., and then eats supper. On 7/10/14 at 12:12 p.m., the resident was observed in his bed. His head was under the blankets. He indicated he had not been offered lunch at that time. He indicated no staff had been in to give him his hot lunch before he left for [MEDICAL TREATMENT]. Continued observation on 7/10/14 at 12:15 p.m., indicated the ambulance service had arrived to take the resident to [MEDICAL TREATMENT]. The resident had not had lunch at that time. Further observation at 7/10/14 at 12:22 p.m., indicated the resident was observed on the stretcher ready to go to [MEDICAL TREATMENT]. At that time, one of the attendants came up to the Nurses' station and asked LPN #3 if the resident had a lunch to go. The nurse shook her head no and stated, "He usually does not eat lunch." The LPN then yelled over to the resident and asked him if he wanted a lunch and he said "that was ok." The attendants then left with the resident. Interview with LPN #3 at that time, indicated they save the resident's lunch for him so he eats it when he comes back. The LPN further indicated he usually gets back on the evening shift around 5:30 p.m. The record for Resident #97 was reviewed on 7/9/14 at 9:20 a.m. The resident was admitted to facility on 5/27/14. The resident's [DIAGNOSES REDACTED]. Review of the Minimum Data Set (MDS) Admission assessment dated [DATE] indicated the resident was alert and oriented with a Brief Interview for Mental Status (BIMS) score of 15. The resident needed extensive assist with two person physical assist for transfers. He was limited assist with one person physical assist for bed mobility and needed physical help with one person assist for bathing. Review of the current plan of care dated 6/8/14, indicated the resident required a therapeutic diet related to his medical diagnoses. The Nursing approaches were the resident will adhere to therapeutic diet through next review. Diet as ordered, encourage oral intake of food and fluids, and monitor weight. Review of the resident's weights indicated he weighed 142 pounds on 5/28/14, 147 on 6/4/14, 149 on 6/10/14, 149 on 6/13/14, 149 on 6/18/14 and 141 on 7/8/14. Review of Physician order [REDACTED]. A half cup of milk per day and double protein at breakfast daily. Review of the food consumption logs indicated the resident's meal were only monitored on 6/5 for breakfast and dinner, 6/10 for breakfast, and 6/25/14 for dinner. There was no documentation to indicate the resident received a noon meal everyday. There was no documentation to indicate if he received his lunch before he went to [MEDICAL TREATMENT]. Review of Nursing Progress Notes dated 6/1-7/9/14, indicated there was no evidence of any documentation to indicate the resident refused his meals. Interview with the Dietary Food Manager on 7/9/14 at 10:00 a.m., indicated she sends a food tray to the resident before he leaves on [MEDICAL TREATMENT] days. Continued interview with the Dietary Food Manager on 7/10/14 at 1:10 p.m., indicated she did not deliver the resident's room tray today. She further indicated she does deliver the resident's lunch tray before [MEDICAL TREATMENT], however, today she did not. She also indicated it was the responsibility of the cook on Saturday to deliver the tray, however, she does not know for sure if the resident gets his lunch tray before [MEDICAL TREATMENT] on Saturdays. Interview with LPN #3 on 7/9/14 at 10:15 a.m., indicated the resident will sometime tell us to hold his lunch until he comes back. Interview with the Assistant Director of Nursing on 7/10/14 at 1:55 p.m., indicated it was the resident's choice to have a hot lunch and not a cold lunch before he left for [MEDICAL TREATMENT]. Interview with the Director of Nursing on 7/10/14 at 2:00 p.m., indicated the LPN should have called dietary and sent some kind of lunch with the resident or got him a tray to go. 3. On 7/9/14 at 12:50 p.m. Resident #56 was observed lying in bed. He had just been served his lunch tray. He was served ground meat, potatoes, green beans, brownie, and a carton of skim milk. There was no magic cup (a nutritional supplement) observed on his tray. On 7/10/14 at 9:00 a.m., the resident was observed in bed eating breakfast. At that time, he was served a piece of raisin toast, egg casserole, thickened juice and water as well as a bowl of oatmeal. There was no skim milk, nor a magic cup observed on his tray. On 7/10/14 at 12:40 p.m., the resident was observed in bed. He was served his lunch tray. He received ground meat, creamed corn, mashed potatoes, and two cookies. The resident had a red thickened juice and thickened water. The resident did not receive a carton of skim milk nor a magic cup with his lunch. The record for Resident #56 was reviewed on 7/9/14 at 11:25 a.m. The resident was admitted to the facility on [DATE]. The resident's [DIAGNOSES REDACTED]. Review of the Admission Minimum Data Set (MDS) assessment dated [DATE] indicated the resident was moderately impaired for decision making, and had no [MEDICAL CONDITION] or mood issues. The resident needed extensive assist with two person assist with bed mobility and transfers. The resident needed supervision and one person assist with eating. Review of Physician order [REDACTED]. Interview with LPN #3 on 7/9/14 at 1:40 p.m., indicated she received the order for the magic cup supplement on 7/7/14. Review of the current weights for the resident indicated on 6/18 he weighed 161 pounds, on 6/25/14 he weighed 155 pounds, on 7/2 he weighed 143 pounds and on 7/4/14 he weighed 144 pounds. Review of the Registered Dietitian (RD) Progress Note dated 7/9/14, indicated the resident had a 11.1% weight loss times one month. The weight loss was suspected due to hospitalization , decreased meal intake, and refusal of care. Health shakes three times a day discontinue, magic cup started with all meals. Recommend 60 cubic centimeters (cc) house supplement three times a day. Will continue to monitor. Review of the current plan of care dated 7/2014, indicated there was no care plan for the resident's weight loss and nutritional approaches. Review of the food consumption log indicated the resident's meals were only recorded on 6/4 dinner, 6/5 breakfast and dinner, 6/9 breakfast, 6/16 dinner, and on 6/25/14 dinner. The resident's intakes were noted as not taken on 6/4, 1-25% for both meals on 6/5, none for 6/9, 51-75% on 6/16, and 1-25% on 6/25/14. Interview with the Director of Nursing on 7/10/14 at 2:50 p.m., indicated the resident should have received his magic cup supplement and the CNAs were to be charting meal consumption in the point of care tracker. 3.1-46(a)(1) 3.1-46(a)(2)

Based on observation, record review and interview, the facility failed to identify and implement a plan of action to correct a quality deficiency related to nutrition for 2 of 3 residents reviewed for nutrition of the 19 residents who met the criteria for nutrition and for ensuring nutritional parameters were maintained for 1 of 1 residents reviewed for [MEDICAL TREATMENT]. This had the potential to affect the 70 residents who resided in the facility. (Residents #56, #88, and #97) Findings include: The facility failed to ensure acceptable parameters of nutrition were monitored for Residents #56, #88, and #97 related to the lack of monitoring of a significant weight loss which resulted in the resident falling below her recommended body mass index, implementing Registered Dietitian (RD) recommendations, providing supplements and monitoring the consumption of those supplements as well as meal consumption, completing weekly weights, and ensuring a resident received a lunch tray prior to going to [MEDICAL TREATMENT]. Interview with MDS Coordinator on 7/10/14 at 12:45 p.m., indicated Resident #88 had been put on NARS (Nutrition At Risk) on 3/6/14 after her initial weight loss. She was taken off NARS on 4/10/14 because she did not have a significant weight loss that month. She indicated the weekly weights recommended by the RD on 5/14/14 had not been implemented. She indicated the CNA's would document how much each resident ate for each meal. They did not document health shakes, double protein or super cereal specifically. NARS relied on Nursing staff to let them know if the resident was eating the supplements provided. She was not aware the resident was not eating her super cereal or health shakes. Interview with the Director of Nursing on 7/10/14 at 2:50 p.m., indicated Resident #56 should have received his magic cup supplement and the CNAs were to be charting meal consumption in the point of care tracker. Interview with the Dietary Food Manager on 7/9/14 at 10:00 a.m., indicated she sends a food tray to Resident #97 before he leaves on [MEDICAL TREATMENT] days. Continued interview with the Dietary Food Manager on 7/10/14 at 1:10 p.m., indicated she did not deliver the resident's room tray today. She further indicated she does deliver the resident's lunch tray before [MEDICAL TREATMENT], however, today she did not. She also indicated it was the responsibility of the cook on Saturday to deliver the tray, however, she does not know for sure if the resident gets his lunch tray before [MEDICAL TREATMENT] on Saturdays. Interview with the Administrator on 7/14/14 at 12:45 p.m., indicated the Quality Assurance committee met monthly. She indicated nutrition issues were discussed at the meeting. However, an action plan had not been put into place related to ensuring supplements were provided and meal consumption was continuously monitored. 3.1-52(b)(2)

Based on record review and interview, the facility failed to ensure each residents' drug regimen was free from unnecessary drugs related to the adequate monitoring of an anticoagulant medication for 1 of 2 residents who were receiving [MEDICATION NAME] (a blood thinner) in the sample of 3. This resulted in an immediate jeopardy due to the resident being hospitalized with a critical PT/INR ([MEDICATION NAME] time/international normalized ratio) (a blood clotting study) as well as a critical hemoglobin (red blood cell component) and having to receive two units of blood. This had the potential to affect the 10 residents residing in the facility who were receiving [MEDICATION NAME]. (Resident #B) The immediate jeopardy began on July 20, 2013 at 12:30 a.m., when Resident #B ' s PICC line dressing had to be changed for a second time within one hour and forty-five minutes due to bleeding. The resident was admitted to the hospital with [REDACTED]. The Administrator, Director of Nursing and the Corporate Nurse Consultant were notified of the immediate jeopardy at 2:55 p.m. on July 31, 2013. The immediate jeopardy was removed on August 1, 2013, but noncompliance remained at the lower scope and severity level of isolated with a potential for more than minimal harm. Findings include: The record for Resident #B was reviewed on 7/31/13 at 10:45 a.m. The resident's [DIAGNOSES REDACTED]. A physician's orders [REDACTED]. A physician's orders [REDACTED]. Review of the Nursing progress notes for the month of July 2013, indicated the resident had a peripherally inserted central catheter (PICC) inserted on July 11, 2013 for intravenous antibiotic therapy to treat osteo[DIAGNOSES REDACTED] (a bone infection). An entry in the Nursing progress notes on 7/19/13 at 10:45 p.m. (recorded as a late entry on 7/29/13 at 5:20 a.m. by RN #1) indicated the resident's transparent PICC line dressing was changed due to a moderate amount of blood noted (5-10 milliliters). The area was cleaned and a pressure gauze dressing was applied to the site to try to stop the bleeding. Very slight bleeding continued. Will continue to monitor closely. An entry in the Nursing progress notes on 7/20/13 at 12:30 a.m. (recorded as a late entry on 7/29/13 at 5:23 a.m. by RN#1) indicated the resident's pressure dressing to the left PICC line site was changed due to continued bleeding. Ten to fifteen milliliters (ml) noted. Cleaned site. Observed closely for over one minute and bleeding had stopped. New pressure dressing applied. Will continue to monitor closely. Documentation in the Nursing progress notes on 7/20/13 at 3:30 a.m. (recorded as a late entry on 7/23/13 at 7:16 a.m. by LPN #1) indicated the resident called the writer into her room. Writer met resident at bedside, resident alert and verbally responsive. Resident showed writer her left arm PICC site. PICC site noted with moderate amount of blood. Writer applied pressure, cleaned site and applied pressure dressings. Resident denied pain or discomfort. Call light within reach. An entry in the Nursing progress notes on 7/20/13 at 3:44 a.m. (recorded as a late entry on 7/23/13 at 7:18 a.m. by LPN#1) indicated the resident was laying in bed, dressing to PICC site intact. No drainage noted. Site clean, dry and intact. Resident denied pain or discomfort. Resident alert and verbally responsive. Call light within reach. Documentation in the Nursing progress notes on 7/20/13 at 6:54 a.m. (recorded as a late entry on 7/23/13 at 7:23 a.m. by LPN #1) indicated the resident called the writer into her room. Writer noted moderate amount of blood from resident's PICC site. Co-nurse called into resident's room. Pressure applied. Site cleaned and pressure dressings applied. Resident denied feeling light headed, pain or discomfort. Documentation at 7:20 a.m., indicated while in report per the midnight nurse, the resident had saturated 3 PICC dressings. Resident was currently on [MEDICATION NAME] per order, writer also was told the resident had a critical hemoglobin (Hgb) approximately 2 weeks ago. Skin warm and dry to touch. No complaints of pain or distress. Dr. (Physician's name) called, no answer. Dr. (Physician's name) called and texted. Resident and father aware. At 7:35 a.m., the writer observed the treatment nurse in the room removing an old saturated dressing. No complaints of fatigue nor lightheadness (sic). No complaints of pain nor discomfort. At 7:47 a.m., the writer noted a small amount of blood coming through the dressing. Dr. (Physician's name) called, new order to send to emergency room . The Director of Nursing and the Assistant Director of Nursing were called. Documentation at 10:39 a.m., indicated the resident was admitted to the hospital for a critical PT/INR and hemoglobin. Review of the laboratory results for the months of June and July 2013, indicated there was no PT/INR available for review. The last PT/INR in the resident's record was dated 5/31/13. The resident's PT was low at 13.2 and her INR was low at 1.28. The resident's [MEDICATION NAME] was increased to 12 mg at this time. The resident had a complete blood count drawn on 7/1/13, which indicated the resident's hemoglobin was low at 8.3 (normal 12-16). There was no PT/INR drawn on this date. Review of the hospital History and Physical dated 7/20/13, indicated the resident's hemoglobin on admission was low at 6.6 and her PT was greater than 75 (normal 20.2-30.8 seconds) and her INR was greater than 10 (normal 2-3 ratio). The resident's [MEDICATION NAME] was held, she received Vitamin K (a medication used to clot the blood) and two units of blood. Interview with the Director of Nursing on 7/31/13 at 1:45 p.m., indicated the resident's last PT/INR was drawn on 5/31/13. She indicated the resident was scheduled to have a PT/INR drawn on 7/22/13, however, the resident was in the hospital at that time. She was not aware the resident had an order for [REDACTED]. Further interview with the Director of Nursing at 2:30 p.m., indicated the resident did not have a history of refusing labs and she does not know why the resident's PT/INR was not drawn with the CBC on 7/1/13. She indicated that she had a call out to the lab to see why the resident's PT/INR was missed. The immediate jeopardy that began on July 20, 2013 was removed on August 1, 2013 when the facility inserviced their Nursing staff on PICC line care and complications as well as Physician notification, [MEDICATION NAME] monitoring, the implementation of a "Record of [MEDICATION NAME] Administration" flow sheet, INR audits that were to be done five times a week for six (6) months, a house audit of all lab orders to be completed by the contracted laboratory, and lab tracking audits. Any issues will be immediately addressed and the Director of Nursing will track and trend audits and present at the Quality Assurance meeting for further review and update as indicated. Noncompliance of facility procedures will result in education and/or disciplinary actions on going. The noncompliance remained at the lower scope and severity level of isolated with potential for more than minimal harm due to the fact the resident's PT/INR levels were not drawn as ordered on 6/3 and 7/1/13, the resident ' s Physician was not notified in a timely manner related to the bleeding from the PICC line site, and the resident was hospitalized with a critical PT/INR and Hgb which resulted in a transfusion of fresh frozen plasma and packed red blood cells. This Federal tag relates to Complaint IN 417. 3.1-48(a)(3)

Based on observation, record review and interview, the facility failed to ensure all residents were free from pain, related to the lack of assessment for a resident observed screaming and crying without staff intervention, and lack of monitoring the effectiveness of the resident's pain regime, for 2 of 3 residents reviewed for pain of the 3 residents who met the criteria for pain, in the sample of 41. (Residents #33 and #38) Findings include: 1. Resident #33 was heard screaming loudly at 5:40 a.m. on 2/10/11. The door to the resident's room was closed. During observation at that time, no staff members were observed going into her room to see what was wrong. At 6:05 a.m., the resident was observed in her bed laying on her right side. The resident had a heel boot on the right foot and a dressing was noted on her buttocks. The resident stated, "take it off" and pointed to her bottom and her feet. The resident was observed to be crying and screaming out loud. The resident continued to scream and did not stop. At 6:30 a.m., the resident was still screaming, and no staff were observed going into her room. CNA #4 was interviewed at 6:30 a.m. on 2/10/11. She was asked, "Who is screaming?" CNA #4 replied, "It is (Resident #33's name), she has been doing that all night." On 2/10/11 at 6:35 a.m., LPN #8 was asked what was wrong with Resident #33. LPN # 8 indicated "I think she is in pain, she has scheduled [MEDICATION NAME] (a pain medication) pain medication, but that is not doing the trick." Both staff members did not go back into the room, and the resident continued to scream. The resident was observed on 2/11/11 at 6:46 a.m., seated in her wheelchair. The resident's head was bent forward and her eyes were closed. She appeared to be asleep in the wheelchair. CNA #1 was interviewed at that time. She indicated that the resident was gotten out of bed on the midnight shift, prior to 6:00 a.m. She indicated the resident seems to be uncomfortable in bed and cries and yells when in bed. She also indicated the resident does not yell and cry when up in the wheelchair and that is why the resident is gotten out of bed on the midnight shift. Interview with LPN #11 on 2/11/11 at 6:55 a.m., indicated she was the nurse working the night shift. She indicated the resident will yell at times when in the bed and believes the resident has pain, she indicated the resident had been yelling prior to getting out of bed. She indicated the resident never yells when up in the chair. LPN #11 indicated that repositioning the resident's legs sometimes helps to stop the pain. The LPN indicated the resident received routine pain medication and as needed pain medication. The record for Resident #33 was reviewed on 2/9/11 at 2:30 p.m. The resident had [DIAGNOSES REDACTED]. The quarterly MDS (Minimum Data Set) assessment with an assessment reference date of 11/9/10, indicated the resident was rarely or never understood and sometimes understands. The assessment indicated the resident did not have pain. There was a physician's orders [REDACTED]. There was a physician's orders [REDACTED]. Review of the February 2011 Medication Administration Record, indicated the resident did not receive any as needed pain medication from 2/4/11 through 2/14/11. She did not receive as needed pain medication on 2/10/11 when observed to be screaming and crying and she did not receive as needed pain medication on 2/11/11 when staff indicated the resident had been yelling in pain. Review of the January 2011 Medication Administration Record, indicated the routine pain medication, [MEDICATION NAME] 7.5-325 mg to be given three times per day was not administered from January 1, 2011 until January 13, 2011. The resident's care plan for pain dated 2/22/10 and revised on 1/13/11 indicated, "The resident had a [DIAGNOSES REDACTED]." The care plan had not been revised to indicate that the resident had increased pain when in bed, as indicated by the staff. The form titled "Pain Screen and Assessment" was completed on 11/9/10. It indicated the resident is capable of reporting presence or absence of pain. It also indicated the resident reports no pain and exhibits no behaviors indicative of pain. Medications make the pain feel better and movement makes the pain worse. The effects of pain for the resident was listed as "crying." Interview with the Director of Nursing on 2/14/11 at 11:15 a.m., indicated the pharmacy had made an error and omitted the physician's orders [REDACTED]. The DON also indicated the resident's pain was not assessed and interventions not provided when the resident screamed in pain on the mornings of 2/10/11 and 2/11/11. The DON indicated the resident's pain plan of care needed to be reviewed and revised. 2. The record for Resident #38 was reviewed on 2/9/11 at 8:32 a.m. The resident's [DIAGNOSES REDACTED]. The Quarterly Minimum Data Set (MDS) assessment dated [DATE], indicated the resident was on a scheduled pain management regimen and received as needed pain medications. The plan of care dated 12/14/10, indicated the resident had complaints of acute and chronic pain due to recent tibia and fibula fracture and chronic pai[DIAGNOSES REDACTED]. The interventions indicated the following: Observe for and record any complaints of pain: location, duration, quality, quantity, alleviating factors, aggravating factors Observe for and record any non-verbal signs of pain. Administer medications as ordered and return to assess effectiveness. Encourage resident to request pain med before pain becomes unbearable. Modify activities to avoid undue stress and irritation to area. Review of the February 2011 physician's orders [REDACTED]. Review of the December 2010 Medication Administration Record (MAR), indicated the resident had received the prn [MEDICATION NAME] on the following dates: 12/1, 12/13, 12/14, 12/17, 12/19, 12/20, 12/21, 12/23, 12/26, and 12/30/10. The medication was given for pain, however, there was no documentation on the back of the MAR of the effectiveness of the medication. The January 2011 MAR, indicated the prn [MEDICATION NAME] was signed out as being given on 1/1-1/7, 1/10, 1/11, 1/13, 1/17, 1/18, 1/20, and 1/26-1/28/11. The medication was given for left leg pain, again, there was no documentation related to the result of the pain medication. Interview with RN #1 on 2/11/11 at 9:53 a.m., indicated when a resident is requesting a prn pain medication, first she asks the resident where their pain is and what it ranks on a scale of 1-10. She checks to see when the prn pain medication was last received. She then proceeds to give the medication and signs the medication out on the back of the MAR and the reason it was given and then goes back in an hour to check the effectiveness of the medication. Interview with the Director of Nursing on 2/11/11 at 3:00 p.m., indicated the effectiveness of the prn pain medication should have been documented on the back of the resident's MAR. 3.1-37(a)