Every finding on record at Harbourwood Post-Acute and Rehabilitation Center

Based on interview, record review and clinical professional standards, the facility failed to ensure medications were administered as prescribed, with physician orders for four residents (#1, #2, #3, and #10) out of six sampled.Findings Included: A review of Resident #1's admission record showed an admission date of 4/22/2026, with diagnoses including type 2 Diabetes Mellitus, protein calorie malnutrition, and high blood pressure. A review of Resident #1's physician order summary report showed orders dated 4/22/26 for the following: oxycodone 5 mg (milligram) by mouth every 6 hours as needed for pain, pain evaluation every shift to monitor the resident's pain level, and pain management consult with treatment as needed. A review of Resident #1's nurse's note dated 4/23/26 at 3:57 p.m. showed: Resident ambulating around unit. Complains of pain (9/10). Attempted to retrieve [medication] from the automated medication dispensing machine and request denied. Tylenol given and resident states are not effective. Resident able to make needs known. Will monitor for changes. A current order for acetaminophen (Tylenol) was not found on the Resident #1's order summary report, dated 4/22/26. A review of Resident #1's Medication Administration Record (MAR) dated April 2026 showed on 4/23/26 during the 7:00 a.m.-3:00 p.m. the resident reported a pain level of 9 on a 0-10 scale, and during the 11:00 p.m. to 7:00 a.m. a pain level of 6. On 4/24/26 during the 7:00 a.m.-3:00 p.m. shift, a pain level of 8 was documented. On 4/22/26 at 8:30 p.m. the order for oxycodone 5 mg by mouth every 6 hours as needed for pain was ordered, Resident #1's first dose was administered on 4/24/26 at 1:10 p.m. During an interview on 5/18/26 at 3:31 p.m. with the Director of Nursing (DON) and the Regional Director of Clinical Services (RDCS). The DON said the first dose of oxycodone Resident #1's received was on 4/24/26 at 1:12 p.m. The DON said the process is to email or fax the prescription to the facility's pharmacy which may take 10-15 minutes, and pharmacist reviews the orders. She expects staff to reassess the resident, call the physician. The DON said she is not sure why the medication request was denied and will contact the staff member for additional information. A review of Resident #2's admission record showed an initial admission date of 4/22/25 and readmission on [DATE], with diagnoses including metabolic encephalopathy, infection of the skin and subcutaneous tissue, and cellulitis of the right lower extremity. A review of Resident #2's order summary report, as of 5/18/26, showed an order with a start date of 4/22/26 for Doxycycline 100 mg by mouth two times a day, a one day course for treatment of a urinary tract infection (UTI). A review of Resident #2's Medication Administration Record (MAR) for April 2026 showed an order for Doxycycline 100 mg by mouth two times a day for treatment of a urinary tract infection (UTI) for a one day course. The MAR documentation showed on 4/22/26 during the 7:00 p.m. to 11:00 p.m. medication pass, code 9 (other, see progress notes) was listed for this medication, and the antibiotic was administered on 4/23/26, during the 7:00 a.m. to 11:00 a.m. medication pass. A review of Resident #2's progress notes did not show documentation related to the missed dose of the Doxycycline or any notification to the physician regarding the missed medication. A review of the facility's automated medication dispensing machine inventory showed that Doxycycline 100 mg capsules were included in the available stock. During an interview on 5/18/26 at 3:31 p.m. with the DON and the RDCS, the DON said staff should have followed the physician orders and confirmed the Doxycycline order dated 4/22/26 for a one day course was to be completed on 4/22/26. A review of Resident #3's admission record showed an admission date of 4/22/2026, with diagnoses including metabolic encephalopathy, A review of Resident #3's order summary report showed active orders that included: blood thinners-check for bleeding and bruising every shift; Apixaban (Eliquis) 5 mg by mouth two times daily for clot prevention; Synthroid 200 mcg (microgram) by mouth daily for hypothyroidism; Metoprolol Tartrate 37.5 mg by mouth two times daily for hypertension; and Sertraline 100 mg, two tablets by mouth daily, for depression. A review of Resident #3's MAR showed an active order for Synthroid 200 mcg by mouth daily, with a start date of 4/23/26 at 6:00 a.m.; code 9 (other, see progress notes) was documented instead of administration. The order for Sertraline 100 mg, two tablets by mouth daily, with a start date of 4/23/26 at 7:15 a.m., showed no documentation on the MAR. The order for Apixaban (Eliquis) 5 mg by mouth, with a start date of 4/23/26 at 7:00 a.m., showed code 9 (other, see progress notes) documented in place of administration. The order for Metoprolol Tartrate 37.5 mg by mouth, with a start date of 4/23/26 at 9:00 a.m., also showed code 9 (other, see progress notes) documented. A review of Resident #3's admit/readmit progress note dated 4/22/26 at 11:49 p.m. showed the entry: Arrived on the unit approximately 7:00 p.m. Reasons for missed or late medication administration and/or notification of the medical team are not documented in the progress note. A review of the facility's automated medication dispensing machine inventory showed Eliquis 2.5 mg tablets and Synthroid 25 mcg tablets are included in the available stock. During an interview on 5/18/26 at 3:31 p.m. with the DON and the RDCS, the DON said Resident #3 arrived at the unit on 4/22/26 at approximately 7:00 p.m. and the medications were ordered during admission. The DON reviewed the MAR and acknowledged that several medications-Synthroid, Apixaban (Eliquis), Metoprolol Tartrate, and Sertraline-were documented with code 9 (other, see progress notes) or left blank. The DON said Synthroid is a high-risk medication and if it was not available in the automated drug dispensing machine staff are expected to notify the doctor. The DON said staff are expected to notify the doctor when high risk medications are not administered and complete documentation. A review of Resident #6's admission record showed an initial admission date of 8/7/23, and a readmission date of 3/14/24, with diagnoses including cerebral infarct, type 2 Diabetes Mellitus, difficulty walking and dementia. A review of Resident #6's prescription dated 5/1/26 for Amoxicillin-clavulanate (Augmentin) 875-125 mg per tablet, take 1 tablet two times daily, start date 5/1/26. A review of Resident #6's nurse's note dated 5/3/26 at 7:15 p.m. showed the following entry: Patient's daughter came in today and asked if the patient had started on the antibiotic that was prescribed when the resident went to his appointment with the urologist on 5/1. She stated that she gave the script to the unit manager when they returned. I reached out to the unit manager, and she stated she gave the script to the primary nurse on the cart that day. The nurse passed on to the oncoming nurse to let the nurse in the morning know to call the urologist in the morning to obtain an order for the antibiotic. A review of Resident #6's Medication Administration Record (MAR) for May 2026 showed an order for Amoxicillin and Potassium Clavulanate (Augmentin), one tablet by mouth two times daily for 14 days, for treatment of a urinary tract infection (UTI). The MAR showed the first dose was administered on 5/4/26 during the 7:00 p.m. to 11:00 p.m. medication administration time. During an interview on 5/18/26 at 3:31 p.m. with the DON and the RDCS, the DON said there was a delay with administering antibiotics to Resident #6. A review of Resident #10's admission record showed an admission date of 5/16/26 with diagnoses including hypothyroidism and hypertension. A review of Resident #10's order summary report showed orders to include Levothyroxine 100 mcg in the morning for hypothyroidism, start date 5/16/26 A review of Resident #10's Medication Administration Record (MAR) for May 2026 showed that on 5/16/26 during the 4:00 a.m. to 7:00 a.m. medication pass, the administration of Levothyroxine 100 mcg was documented with code 9 indicating other, see progress notes. A review of Resident #10's orders administration note showed the entry: New admission, medication on order. There was no documentation indicating that the medical team was notified that the medication had not been administered as ordered. A review of the facility's automated medication dispensing machine inventory showed Levothyroxine 25 mcg tablets are included. During an interview on 5/18/26 at 3:31 p.m. with the DON and the RDCS, the DON said medications were ordered on the 6/16/26 an Resident #10 first doses were administered on the 5/17/27. She said if Atorvastatin is not available in the automated drug dispensing machine staff has to wait for the pharmacy delivery. The DON confirmed Synthroid was not administered as ordered and there should have been a progress note regarding why the medication was held and the physician was notified. She said the Metoprolol said the medication may have been held due to the resident's BP and the reason medication were not administered is not documented. A Review of the facility's medication administration policy, revised 1/2026 showed the following: Policy: Medications are administered by licensed nurses, or other staff who are legally authorized to do so in this state, as ordered by the physician and in accordance with professional standards of practice, in a manner to prevent contamination or infection. Compliance guidelines . 20. Sign MAR after administered. For those medications requiring vital signs, record vital signs onto the MAR .22. Report and document any refusals Institute for Safe Medication Practices (ISMP) high-alert medication list for long-term care emphasizes increased risk when doses are missed and recommends safeguards like documentation protocols and escalation procedures for errors. Retrieved on 5/25/2026 https://www.ismp.org/sites/default/files/attachments/2017-11/LTC-High-Alert-List.pdf

Based on observations, interviews, and record review, the facility failed to protect the residents' right to be free from abuse for one resident (#3) out of 3 sampled residents. Findings included: An interview was conducted on 09/17/2025 at 10:30 a.m with Staff A,PCA (Personal Care Attendant). Staff A stated they witnessed Resident #3 being verbally abused by Staff B, CNA, whom they were training with that day. Staff A stated Resident #3, had finished receiving incontinence care from Staff B and was on the edge of the bed when Staff B voiced, Don't put your [EXPLICIT] hands on me or I'll let you fall on the [EXPLICIT] floor. Staff A stated they then saw the CNA aggressively lift up and set resident into her wheelchair and the resident was shaking after that. While assisting the resident with her shoe that had fallen off while being transferred into the chair, Staff A stated the resident voiced that the other CNA, Staff B, thought she was crazy. Staff A reported her observation to the Director of Nursing (DON), who directed them to return to the floor training with another CNA. Staff A stated the facility did an investigation, but the CNA did not know whether or not Staff B was still employed with the facility. Staff A reported being retaliated against because of reporting the abuse and stated being told when writing her statement, not to go into detail but write down the major points. Staff A stated Staff B came back upstairs and made a statement Snitches get stitches and this staff member felt it was directed to her. Staff A stated ever since that happened, the workplace has felt hostile, they talk about how some employees lie on other employees and they get fired. On 09/18/2025 at 2:55 p.m. an interview was conducted with Staff B, CNA. Staff B stated thinking Staff A, PCA, doesn't like me and she doesn't like to work because I made her get up and help change the resident and then they pulled me into the office and told me that the PCA complained about me. Staff B stated being suspended but refused to answer the question related to why she was suspended. She said she came back on the holiday and then a few days later she got suspended again because she was in the parking lot saying, snitches get stitches referring to Staff A. Staff B refused to acknowledge the allegation for Resident #3 and stated being done with the facility and not coming back to the facility. Staff B stated she already started another job and discontinued the interview. An observation of Resident #3 on 09/17/2025 at 3 p.m. revealed the resident in bed, resident appeared clean and dressed appropriately. Resident #3 presented pleasantly confused and was unable to answer questions about their care at the facility. When a CNA entered the room during the interview, the resident leaned back in the bed, closed eyes, and as though they were sleeping. The resident did not respond the CNA and discontinued the interview. Review of the admission record revealed Resident #3 was admitted to the facility on [DATE] with diagnoses to include unspecified dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety, mood disorder due to known physiological condition with depressive features, muscle weakness (generalized), unspecified protein-calorie malnutrition, sarcopenia, and anemia. A review of Resident #3's Minimum Data Set (MDS) dated [DATE] revealed the resident to have a Brief Interview for Mental Status (BIMS) score of 99 indicating severe cognitive impairment. The MDS revealed the resident required partial/moderate assistance for oral hygiene, eating; substantial/maximal assistance for personal hygiene and upper body dressing, and was dependent for toileting hygiene, showering/bathing, lower body dressing, and footwear and revealed resident was always incontinent of bowel & bladder. Review of Resident #3's care plan focus on self-care performance revised on 10/03/2034 showed the resident has deficits related to confusion, dementia, visual deficit r/t (related to) bilateral cataracts, depression and anxiety with goal of resident maintaining current level of function through the review. Interventions showed the resident was to request from staff to turn/reposition in bed, staff to check resident's nail length and trim as necessary, resident was to be assisted by staff with dressing, eating, bathing, and oral/personal hygiene. Staff was to observe for redness, open areas, scratches, cuts, bruises and report changes to the nurse.A second focus in the same care plan showed the resident was at risk for falls related to cognitive deficits, weakness, incontinence, visual deficit and side effect of medication use with goal of resident would not sustain serious injury through the next review date and interventions of 1/4 side rails (sides of bed) per consent to aid in positioning, staff would anticipate and meet the resident's needs, staff to ensure resident's call light was within reach and encourage the resident to use it for assistance as needed. The resident needed prompt response to all requests for assistance, staff to encourage the resident to participate in activities that promote exercise, physical activity for strengthening and improved mobility, staff to encourage the resident to participate in activities that promote exercise, physical activity for strengthening and improved mobility, staff to ensure that the resident was wearing nonskid footwear when out of bed, resident needed a safe environment with even floors free from spills and/or clutter; adequate, glare-free light; call light within reach, personal items within reach. On 09/17/ 2025 at 5:00p.m., the DON and the Nursing Home Administrator (NHA) reviewed the incident for Resident #3. The NHA stated on 8/22/2025 at approximately 12 p.m. the DON notified them of an allegation of verbal abuse. The DON told them they were approached by Staff A alleging that Staff B used curse words and was aggressive with Resident #3 while providing care. The DON stated an investigation was completed with the staff and resident, and the resident did not have any psychosocial distress, so they deemed the investigation inconclusive. The NHA stated they did not substantiate the allegation based on their investigation and Staff B returned to work 4 days after the incident and a suspension. The NHA stated all staff who interviewed Resident #3 after the investigation found no concerns of abuse and neglect from the resident or other residents in the area. The DON stated because Resident #3 had cognitive deficits and was not able to answer interview questions, they looked for nonverbal cues or behaviors different from resident's baseline when interviewing and they did not feel any of those were present. The DON stated the reason the resident was not seen by psych until 08/28/2025 when the incident occurred on 08/22/2025 was because the PMNP was on vacation and the facility did not realize the resident had not been evaluated until their 5-day report, when they then got in touch with the psych doctor and did a telehealth evaluation. The DON stated that they use a lot of agency staff, and they just want to pass meds and leave. The DON said, They are not invested in the residents. On 09/18/25 at 3:54 p.m. an interview was conducted with Resident #3's Psychiatric-Mental Health Nurse Practitioner (PMHNP). The PMHNP stated they had signed a note for the resident dated 08/28/2025. The PMHNP stated the facility told him that there was a verbal altercation between staff and the resident. The PMHNP stated he could not remember the specific words used. He stated he conducted a telehealth visit the resident and she was extremely confused and couldn't remember anything or give him any details. He stated he believed they told him of the altercation, and he did the telehealth the same day. The PMHNP could not comment if there was any psychosocial impact as the resident was extremely confused. Review of a psychiatry progress note dated 08/28/2025 showed the resident was seen via telehealth following a reportable safety allegation from staff. During the interview, the patient appeared confused and was unable to engage in meaningful conversation. From the telehealth assessment, the patient appeared safe and stable with no immediate risk factors observed. Staff will continue to monitor. In the interview with DON on 09/17/ 2025 at 5:00 p.m. the DON stated because Resident #3 had a baseline of confusion and was severely cognitively impaired. The DON stated they relied on monitoring behavior changes and body language to determine if the resident had any psychosocial distress. A review of a social services progress note dated 08/22/2025 showed, This SW (social Worker) visited with [Resident#3] post incident in her room. She was resting with her eyes open in bed. [Resident#3] presented with no signs and symptoms of distress. She was pleasant with confusion but was able to engage in simple questions. [Resident#3] was unable to recall the incident. An interview was conducted with multiple CNAs on 09/17/2025 from 9:56 a.m. Staff D stated hearing of an instance where there was an allegation of verbal abuse to a resident. Staff D stated it was brought up in the education, but they weren't given the details. Staff D stated if they heard of any type of abuse, they would immediately report it to Risk Manager. Staff E stated hearing about an incident upstairs where one of the aides was really rough with a patient and wasn't cleaning them. Staff E stated a few weeks ago- heard it got reported and the police came. Staff F, CNA stated there was a verbal abuse incident recently and to their knowledge, that staff member was let go. Staff G, CNA confirmed hearing of the abuse incident and said one of the residents reported the CNA was was really rough with the resident, and it was reported. the CNAs all confirmed having received abuse and neglect training. An interview was conducted with resident #3's Primary Care Physician (PCP). The PCP stated they were notified of the abuse allegation the day it happened. they stated the facility stated they were investigating, and their NP (nurse Practitioner) may have seen the resident during rounds. The PCP did not have anything else to add regarding the incident. Review of a facility policy titled, Abuse, Neglect and Exploitation, dated 09/01/2023 revealed - It is the policy of this facility to provide protections for the health, welfare and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation and misappropriation of resident property.Definitions: Abuse means the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish, which can include staff to resident abuse and certain resident to resident altercations. Abuse also includes the deprivation by an individual, including a caretaker, of goods or services that are necessary to attain or maintain physical, mental, and psychosocial well-being. Instances of abuse of all residents, irrespective of any mental or physical condition, cause physical harm, pain or mental anguish. It includes verbal abuse, sexual abuse, physical abuse, and mental abuse including abuse facilitated or enabled through the use of technology.Prevention of Abuse, Neglect and Exploitation: The facility will implement policies and procedures to prevent and prohibit all types of abuse, neglect, misappropriation of resident property, and exploitation that achieves: A). Establishing a safe environment that supports, to the extent possible, a resident's consensual sexual relationship and by establishing policies and protocols for preventing sexual abuse. This may include identifying when, how, and by whom determinations of capacity to consent to a sexual contact will be made and where this documentation will be recorded; and the resident's right to establish a relationship with another individua which may include the development of or the presence of an ongoing sexually intimate relationship.Possible indicators of abuse include but are not limited to: 5.) Verbal abuse of a resident overheard.

Based on observations, interviews, and record review, the facility failed to ensure licensed nursing staff were knowledgeable and competent to provide care and services for three residents (#1, #3, and #4) out of four residents sampled related to: 1) failure to recognize a change in condition and provide care resulting in a hospitalization 2) failure to follow physician orders for laboratory testing; 3) failure to report abnormal laboratory results.Findings Included: A review of Resident #3’s admission record revealed an initial admission date of 8/20/24 and a readmission date of 7/20/25 from a hospital stay, and a discharge date of 3/30/25, with diagnoses to include metabolic encephalopathy-7/20/25, acute renal failure with hypoxa-7/20/25, atrial fibrillation,- 7/20/25 and chronic kidney disease (stage 2)-8/20/24. A review of Resident #3’s July 2025 Order Recap Report revealed the following orders: On 7/3/25 a stat chest x-ray (CXR) for lethargy, urinalysis culture and sensitivity test (UA C&S) for symptoms of a Urinary Tract Infection (UTI) were ordered. On 7/3/25 the UA C&S was discontinued and reordered on 7/4/25. A progress note dated 7/5/25 at 11:59 P.M. revealed “No straight cath [catheter] kits available at this time .” The medical record did not include documentation the medical team was notified the test was reordered and not completed. On 7/4/25 at 5:50 A.M. Resident #3’s laboratory reports revealed serum sodium and chloride tests were not completed (TNC) due to presence of unknown interfering substance(s). The medical record did not include documentation the medical team was notified the tests were not completed. On 7/5/25 at 1:03 P.M of Resident #3’s eINTERACT Summary for Providers note, revealed “there was a change in condition due to the altered mental status, shortness of breath and unresponsiveness.” Nursing observations: “resident unresponsive with 02 sat [oxygen saturation] at 91%. Dyspnea observed started 02 [oxygen] at 2 liters via nasal canula .obtained order to send to the ER [emergency room] for evaluation. A review of Resident #3’s hospital records revealed transfer to the hospital by Emergency Medical Service (EMS) presenting with acute mental status change and shortness of breath. Blood tests results included abnormal values white blood cell (WBC) 11.2 K/ul, hemoglobin 15.0 g/dl, sodium 183 mEq/L (critical value), chloride 145 mEq/L and potassium 4.3 mEq/L Resident #3 was placed on heated hi flow oxygen 60%. The resident was admitted to the critical care unit (CCU) with diagnoses including acute hypoxic respiratory failure, severe hyponatremia and acute renal insufficiency. A review of Resident #3’s Hospital Discharge Instructions dated 7/20/25 revealed diagnoses including acute hypernatremia, acute hypoxemic respiratory failure, altered mental status and dehydration During an interview on 7/28/25 at 11:45 the Director of Nursing (DON), said Resident #3’s CXR ordered on 7/3/25 was not completed, “it fell through the cracks.” She confirmed the medical team was not notified Resident #3’s CXR and UA C&S was not completed. The DON said on 7/4/25 the facility expected staff to notify the medical team Resident #3’s sodium and chloride levels were not included in the lab results. A review of Resident #4’s admission record revealed Resident #4 was admitted to the facility on [DATE] with diagnoses including heart failure, cardiac pacemaker and high blood pressure (HBP). A review of Resident #4’s order recap report, dated 6/1/25 to 7/31/25 revealed on 7/25/25 a stat troponin test was ordered. On 7/26/25 at 2:50 A.M. Resident #4’s Troponin level of 37ng/L (range 0-22) was available in the facility’s lab vendor portal. On 7/26/25 at 11:34 A.M. Resident #4’s Advanced Registered Nurse Practitioner (ARNP) note, revealed chief complaint (cc) follow up brief syncopal episode and labs .troponin T is 37ng/L On 7/27/25 a.t 1:19 P.M Resident #4’s SBAR summary for provider note revealed “ . The resident’s labs are abnormal, new orders obtained from NP to transfer to the emergency room (ER) for evaluation for elevated Troponin level 37 .” Resident #4’s medical record did not show the medical team was notified of elevated Troponin level before labs were reviewed by the ARNP. On 7/28/25 at 12:06 P.M, during an interview with Staff G, Licensed Practical Nurse said she checks for laboratory results at the beginning and end of her shift. On 7/28/25 at 12:30 P.M., during an interview Staff H, RN, Unit Manager said nurses are expected to notify the medical team of all tests results normal or abnormal and document in the medical record On 7/28/2025 at 4:30 P.M. during an follow-up interview the DON said on 7/24/25 when Resident #4’s elevated troponin level was available staff were expected to notify the medical team right away. She said when orders are received nurses are expected to enter the order(s) in the resident’s electronic health record (EHR) and the facility radiology vendor portal. The facility’s process is for nurses to check the lab vendor portal throughout their shift for test results. Stat orders for blood and radiology tests are completed within four hours. When orders are not completed staff are expected to notify the physician and follow orders. On 7/28/25 at 1:03 P.M. during a telephone interview Resident #4’s PCP said on 7/26/25 when troponin results were available, the on-call medical team should have been notified. On 7/28/2025 at 8:30 a.m. an interview with Resident #1 was conducted. Resident #1 stated about a month and a half ago, he did not feel well and had pneumonia. He stated he kept telling staff that something wasn’t right. The resident stated he was throwing up continuously for almost 3 days before anything was done for him. He stated staff didn’t seem to know what they were doing. He stated, “I told them if they weren’t going to take care of me, I will just go to the hospital.” The resident stated he called 911. Resident #1 further explained when he went to the hospital, the doctors told him his blood was toxic, and his kidneys weren’t working very well, and he needed dialysis. He stated he was not receiving dialysis before he went to the hospital, now he is currently on dialysis and is upset with his situation. A review of Resident #1’s medical record revealed he was admitted to the facility on [DATE] major depressive disorder, type 2 diabetes mellitus, anemia, anxiety disorders, hypertension, chronic kidney disease stage 3, hyperlipidemia, need for assistance with personal care, congestive heart failure. A review of Resident #1’s most recent Minimum Data Set (MDS) Section C- Cognitive Patterns revealed a Brief Interview of Mental Status (BIMS) summary score of 15, indicating he is cognitively intact. A review of a nursing progress note dated 6/10/2025 revealed the following text: “patient is continuously vomiting, med held per on call np {nurse practitioner} KUB {kidney, ureter, bladder x-ray}, CBC {complete blood count-lab test}, BMP {basic metabolic panel-lab test} is ordered for the morning” Further review of the medical record revealed no orders for the KUB, CBC, or BMP were entered or obtained on 6/10/2025. No change in condition was completed. A review of a nursing progress note dated 6/12/2025 revealed the following text: “alerted NP due to sudden weakness of resident. Resident was unable to use the slide board this shift to transfer to chair. VS {vital signs} were assessed, O2 sat {oxygen saturation} was 83%, NP ordered O2 {oxygen} at 2L{liters} via NC {nasal cannula}. diminished lung sounds posterior, chest x-ray ordered, Resident stated he had diarrhea for 2 days and emesis {vomiting} the past two days as well…Labs ordered for morning.” Further review of the medical record revealed a change in condition was completed on 6/12/2025. Review of the Lab Results Report revealed the lab sample for CBC and BMP were collected 6/13/2025 at 6:10 a.m. and were reported to the facility on 6/13/2025 at 10:33 a.m. The lab result Blood Urea Nitrogen (BUN) was 101 mg/dL (milligram per deciliter) with a reference range of 7-25 mg/dL indicating a high level. The lab result Creatinine serum was 3.89 mg/dL with a reference range of 0.7-1.3 mg/dL indicating a high level. Further review of the Progress notes revealed a change in condition on 6/14/2025 at 12:25 p.m. which stated the following: “The resident states he was not feeling well and wanted to transfer to the hospital…checked the resident labs and noted the BUN result was 101 on 6/13/2025…instructed the assigned nurse to transfer the resident to the ER {Emergency Room}…During the process, the resident called 911 himself to transfer to the ER. The resident is his own self representative. During an interview on 7/28/2025 at 11:30 a.m. with Staff F. Licensed Practical Nurse (LPN) She stated for lab orders, the doctor will put it in or will give us a verbal order to put it in. We put the lab order in for overnight shift and lab will come draw in the morning. Stat labs are called in to the lab, she stated she is not sure how long it takes for them to come complete stat labs. Same process for chest x-ray, she is not sure how long it takes for those to be completed stat, but routine she thinks should be completed within 24 hours. She stated they view the lab in the electronic medical record and call to let the doctor know they have resulted. If a lab result came back incomplete, she stated she would call the doctor and ask if they wanted to re-draw the lab. She stated if a resident was vomiting, she would call the doctor and do a change in condition. During an interview on 7/28/2025 at 11:35 a.m. with Staff I, LPN Unit Manager, she stated she checks to make sure labs are drawn, in the morning. When the results come in, she or the nurse would notify the physician or NP. If they are abnormal a change in condition should be done. Stat labs are to be done in 4 hours. During an interview on 7/28/2025 at 11:47 a.m. with the Director of Nursing (DON), she stated a change in condition should have been done on 6/10/2025. A review of the Licensed Nurse Competency form used to educate the licensed nurses provided by the DON revealed the following: Competency: Nursing Skills: Identification of Changes in Condition -Physical assessment -Lab values -Physician notification… Review of facility policy titled Provision of Physician Ordered Services, revised 5/7/24 revealed Policy: The purpose of this policy is to provide a reliable process for the proper and consistent provision of physician ordered services according to professional standards of quality. Definition: Professional Standards of Quality means that care and services are provided according to accepted standards of clinical practice. Policy Explanation and Compliance Guidelines: 1.Facility will maintain a schedule of diagnostic tests (laboratory and radiology) in accordance with the physician's orders. 2) Qualified nursing personnel will submit timely requests for physician ordered services (laboratory, radiology .) 3)Qualified nursing personnel will receive and review the diagnostic test reports . and communicate the results to the ordering Physician, physician assistant, nurse practitioner or clinical nurse specialist within 24 hours of receipt unless the reports fall outside of clinical reference ranges in accordance with facility policies and procedures for notification of a practitioner or per the ordering physician' s orders. Ordering Provider will be notified of results upon receipt if deemed critical and/or require immediate attention. 4)Documentation of consultations, diagnostic tests, the results, and date/time of Physician notification will be maintained in the resident's clinical record . A review of the facility’s Licensed Practical Nurse and Registered Nurse job descriptions includes the following: Major Duties and Responsibilities: -Ensures that policies and procedures are complied with by nursing personnel assigned. -Evaluates for changes in residents' status, notifying the physician and resident's family or representative and documenting accordingly. -Transcribes physician orders to medical record and carries out orders as written. Additional Tasks: -Must be able to relay information concerning a resident's condition. -Must be able to follow oral and written instructions -Communicates with medical and nursing staff, and other departments -This job description is intended to convey the general scope of the major duties and responsibilities inherent in this position

Based on record review and interviews, the facility failed to follow professional standards of care and protect the residents' right to be free from neglect for two residents (#3, and #4) out of four residents sampled related to 1) failure to follow up physician orders for laboratory and radiology testing, and failure to report abnormal laboratory test results. Findings included:Review of Resident #3's admission record revealed an initial admission date of 8/20/24 and a readmission date of 7/20/25 from a hospital stay, and a discharge date of 3/30/25, with diagnoses to include metabolic encephalopathy-7/20/25, acute renal failure with hypoxa-7/20/25, atrial fibrillation,- 7/20/25 and chronic kidney disease (stage 2) -8/20/24. Review of resident #3's care plan revealed the following focuses and interventions:-Focus: ADL - interventions include . requires total assist with feeding-is NPO (Nothing by Mouth) and had a PEG (Percutaneous Endoscopic Gastrostomy) tube in place.-Focus: Hypertension-interventions include observe, document and report any s/sx [signs and symptoms] of causative factors: dehydration .-Focus: .has a urinary tract infection- interventions include encourage adequate fluid intake and follow up as indicated. Focus: Nutrition care plan-interventions include observe lab diagnostic work as ordered. Report results to the MDReview of Resident #3's progress note dated 7/3/25 at 7:30 P.M. resident lethargic can follow simple commands . notified provider ordered labs and cxr [chest x-ray]. Review of Resident #3's July 2025 Order Recap Report revealed the following orders:On 7/3/25 a stat chest x-ray (CXR) for lethargy, urinalysis culture and sensitivity test (UA C&S) for symptoms of a Urinary Tract Infection (UTI) were ordered. On 7/3/25 the UA C&S was discontinued and reordered on 7/4/25. A progress note dated 7/5/25 at 11:59 P.M. revealed No straight cath [catheter] kits available at this time . The medical record did not include documentation the medical team was notified the test was reordered and not completed. On 7/4/25 at 5:50 A.M. Resident #3's laboratory reports revealed serum sodium and chloride tests were not completed (TNC) due to presence of unknown interfering substance(s). The medical record did not include documentation the medical team was notified the tests were not completed. A review of an eINTERACT Summary for Providers note, dated 7/5/25 at 1:03 P.M revealed there was a change in condition due to the altered mental status, shortness of breath and unresponsiveness. Nursing observations: resident unresponsive with 02 sat [oxygen saturation] at 91%. Dyspnea observed started 02 [oxygen] at 2 liters via nasal canula .obtained order to send to the ER [emergency room] for evaluation. Review of Resident #3's hospital records revealed transfer to the hospital by Emergency Medical Service (EMS) presenting with acute mental status change and shortness of breath. Blood tests results included abnormal values white blood cell (WBC) 11.2 K/ul, hemoglobin 15.0 g/dl, sodium 183 mEq/L (critical value), chloride 145 mEq/L and potassium 4.3 mEq/L Resident #3 was placed on heated hi flow oxygen 60%. The resident was admitted to the critical care unit (CCU) with diagnoses including acute hypoxic respiratory failure, severe hyponatremia and acute renal insufficiency. Review of Resident #3's Hospital Discharge Instructions dated 7/20/25 revealed diagnoses including acute hypernatremia, acute hypoxemic respiratory failure, altered mental status and dehydration During an interview on 7/28/25 at 11:45 the DON said Resident #3's CXR ordered on 7/3/25 was not completed, it fell through the cracks. She said the Resident #3's medical record did not show the medical team was notified the CXR was not completed Staff did not notify the medical team when Resident #3's sodium and chloride levels were not reported on 7/4/25 and the UA C&S was not completed.Review of Resident #4's admission record revealed Resident #4 was admitted to the facility on [DATE] with diagnoses including heart failure, cardiac pacemaker and high blood pressure (HBP). Review of Resident #4's care plans revealed the following: a-Focus: Potential for complications r/t (related to ) an alteration in cardiac function d/t (due to) diagnoses of HBP, atrial fibrillation, has pacemaker. Interventions include labs and diagnostic tests as ordered; update physician of results. observe for c/o (complaints of ) and sx/sx (signs and symptoms) of cardiac complications; notify physician if noted. It was initiated on 6/23/21. On 7/25/25 at 11:51 A.M. Resident #4's progress note revealed Spoke to nurse practitioner [name] about the patient appearing lethargic. He was very difficult to arouse despite trying to wake him up. Vital signs are within normal range. Received orders for a stat . troponin . Review of Resident#4's order recap report, dated 6/1/25 to 7/31/25 revealed on 7/25/25 a stat troponin test was ordered. On 7/26/25 at 2:50 A.M. Resident #4's Troponin level of 37ng/L (range 0-22) was available in the facility's lab vendor portal. On 7/26/25 at 11:34 A.M. Resident #4's Advanced Registered Nurse Practitioner (ARNP) note, revealed chief complaint (cc) follow up brief syncopal episode and labs .troponin T is 37ng/L. On 7/27/25 a.t 1:19 P.M Resident #4's SBAR summary for provider note revealed . The resident's labs are abnormal, new orders obtained from NP to transfer to the emergency room (ER) for evaluation for elevated Troponin level 37 . Resident #4's medical record did not show the medical team was notified of elevated Troponin level before labs were reviewed by the ARNP. On 7/29/25 at 12:06 P.M, during an interview with Staff G, Licensed Practical Nurse said she checks for laboratory results at the beginning and end of her shift. On 7/29/25 at 12:30 P.M., during an interview Staff H, RN, Unit Manager said nurses are expected to notify the medical team of all tests results normal or abnormal and document in the medical record. On 7/29/2025 at 4:30 P.M. during an interview the Director of Nursing (DON) said on 7/24/25 when Resident #4's elevated troponin level was available staff were expected to notify the medical team right away. She said when orders are received nurses are expected to enter the order(s) in the resident's electronic health record (EHR) and the facility radiology vendor portal. The facility's process is for nurses to check the lab vendor portal throughout their shift for test results. Stat orders for blood and radiology tests are completed within four hours. When orders are not completed staff are expected to notify the physician and follow orders. On 7/28/25 at 1:03 P.M. during a telephone interview Resident #4's PCP said on 7/26/25 when troponin results were available, the on-call medical team should have been notified. Review of facility policy titled Provision of Physician Ordered Services, revised 5/7/24 revealedPolicy: The purpose of this policy is to provide a reliable process for the proper and consistent provision of physician ordered services according to professional standards of quality.Definition:Professional Standards of Quality means that care and services are provided according to accepted standards of clinical practice. Policy Explanation and Compliance Guidelines:1.Facility will maintain a schedule of diagnostic tests (laboratory and radiology) in accordance with the physician's orders. 2) Qualified nursing personnel will submit timely requests for physician ordered services (laboratory, radiology .) 3)Qualified nursing personnel will receive and review the diagnostic test reports . and communicate the results to the ordering Physician, physician assistant, nurse practitioner or clinical nurse specialist within 24 hours of receipt unless the reports fall outside of clinical reference ranges in accordance with facility policies and procedures for notification of a practitioner or per the ordering physician' s orders. Ordering Provider will be notified of results upon receipt if deemed critical and/or require immediate attention. 4)Documentation of consultations, diagnostic tests, the results, and date/time of Physician notification will be maintained in the resident's clinical record . Review of facility policy titled Documentation in Medical Record, implement 3/24 revealed Each resident's medical record shall contain an accurate representation of the actual experiences of the resident and include enough information to provide a picture of the resident's progress through complete, accurate, and timely documentation.Policy Explanation and Compliance Guidelines:1) Licensed staff and interdisciplinary team members shall document all assessments, observations, and services provided in the resident's medical record in accordance with state law and facility policy. 2) Documentation shall be completed at the time of service, but no later than the shift in which the assessment, observation, or care service occurred . Review of facility policy titled Change in Condition, undated revealedPurpose: To ensure the facility promptly notifies the resident, his or her provider, and legal representative of changes in the resident's medical/mental condition .Process: The nurse supervisor/charge nurse will notify the resident's provider or on-call provider when there has been: 1d) A significant change in the resident's physical condition.

Based on interviews and record review the facility failed to review and revise the comprehensive care plan for one resident (#1) out of 3 residents reviewed.Based on interviews and record review the facility failed to review and revise the comprehensive care plan for one resident (#1) out of 3 residents reviewed.Findings include:Review of Resident #1's admission Record revealed he was admitted to the facility on [DATE]. Resident was discharged on 6/14/2025 and re-entered the facility on 6/28/2025.Further review of the medical record revealed the following diagnoses with a date of 6/28/2025: Non-ST Elevation myocardial infarction, type 2 diabetes, peripheral vascular disease, chronic obstructive pulmonary disease, dependence on renal dialysis.A review of Resident #1's active care plan revealed the following:-Focus: Resident#1 takes Plavix d/t {due to} having increased risk of blood clots, stroke, and heart attack. At risk for bleeding and bruising. -Goal: . will have no adverse effects of ASPIRIN use through next review. -Intervention: Administer Aspirin as ordered.-Focus: .is on diuretic therapy r/t {related to} edema, hypertension. -Interventions: Administer diuretic medications as ordered by physician.A review of the Order Summary Report revealed the following order: Clopidogrel Bisulfate {Plavix} Tablet 75 MG {milligram}. Give 1 tablet by mouth one time a day for blood clot prevention.There was no order for Aspirin.There was no order for diuretic medications.An interview on 7/28/2025 at 3:00 p.m. was conducted with Staff J, Licensed Practical Nurse (LPN) MDS and Staff K, Registered Nurse (RN), MDS Coordinator. They stated they are responsible for the care plans. They stated the process is to have a care plan meeting with the resident, which is usually attended by the unit manager. They do not attend the care plan meeting. They stated they do a review of the care plan when the quarterly Minimum Data Set (MDS) is completed. Staff J, LPN MDS stated Resident #1's care plan should have been updated. They stated Resident #1 should not have a diuretic therapy focus; it should not be there. They stated the care plan should have been updated to include administering Plavix, not aspirin. A review of the policy Comprehensive Care Plans with a revision date of 1/2025 Revealed the following: Policy: Policy Explanation and Compliance Guidelines:5. The comprehensive care plan will be reviewed and revised by the interdisciplinary team after each comprehensive and quarterly MDS assessment. 6. The comprehensive care plan will include measurable objectives and timeframes to meet the resident's needs as identified in the resident's comprehensive assessment. The objectives will be utilized to monitor the resident's progress. Alternative interventions will be documented as needed.

Based on observations, review of medical records and facility policies, and interviews with residents and physicians, the facility failed to protect the resident's right to be free from physical, verbal and psychological abuse and failed to identify, correct and intervene in situations in which abuse and neglect was more likely to occur for one resident (#1) of two residents sampled. Findings included: During an interview on 04/13/25 at 10:51 a.m. Resident #1 stated he was forced to receive care by an [African American] CNA (Certified Nursing Assistant) who is a profanity, too rough and always has to have his way. Resident #1 said, I sometimes refuse care, but the [African American] CNA forced me to accept his care. When that CNA [Staff A] comes into my room I feel a sense of panic because I know he is going to be rough with me. The resident stated it had to be the CNA's way or no way. Resident #1 stated the CNA [Staff A] forcibly crossed his arms over his chest and was mean to him by laughing at him. Resident #1 said, I do not want him again and I have not seen him since. I feel like I have the right to choose to refuse care and I have choices, and it is against my rights and the law to force me to do something. The resident stated regarding PTSD (Post Traumatic Stress Disorder) diagnosis, I do not want to talk about it. During this interview, an observation revealed the resident had two dressings, one on the left wrist dated 04/12/25 and one on the right back of hand dated 04/12/25. Resident #1 stated those dressings were from the incident with the CNA. Review of a Situation Background Assessment and Recommendation (SBAR) note dated 04/10/25 at 7:33 p.m. showed, The Change In Condition/s (CIC) evaluation were: Skin wound or ulcer. The nursing observations, evaluation, and recommendations showed, Resident got skin tears from a staff member grabbing his arms. Review of a skin observation progress note dated 04/10/25 showed, Resident has existing skin impairment - Bruise Existing skin tear on left forearm: - Bruising and skin tear left hand. Review of the Admission Record showed Resident #1 was readmitted to the facility on [DATE] with diagnoses to include metabolic encephalopathy, adjustment disorder recurrent, insomnia, and generalized anxiety disorder. Review of a quarterly MDS (Minimum Data Set) dated 02/22/25, showed in section C, the resident had a Brief interview for Mental status (BIMS) score of 13 out of 15, indicating intact cognition. Section GG under toileting hygiene showed a code 01- which meant Resident #1 was dependent - meaning helper does all effort during care. Review of active physician orders for Resident #1 for the month of April 2025 showed: Cleanse left arm with n/s (normal saline), apply xeroform and dcd (dry clean dressing) daily and p.m., every day shift, date order 04/09/25. Cleanse right hand with n/s (normal saline), apply xeroform and dcd (dry clean dressing) daily and p.m., every day shift, date order 04/09/25. A telephone interview was conducted on 04/13/25 at 11:24 a.m. with Staff A, CNA. Staff A stated he was suspended on 04/10/25 after speaking with the Risk Manager (RM), about a claim a resident made. Staff A stated he worked with Resident #1 on 04/08/25 from 2.45 p.m. to 11:15 p.m. He stated the resident had used the typical references which are vulgar. Staff A said, I prepared him for dinner gave him snacks, water, and asked if he needed to be changed. I changed him around 7 p.m. and 11 p.m. I was by myself. He is one person for changing in bed. Staff A stated Resident #1 yelled profanity that night and at times used profanity and racial slurs on the staff member. The staff member said during care, the resident will have a reaction, like not wanting to be changed and when you try to assist him, he will use all kinds of words and then he will apologize. He says it is something he can't help. His reactions vary. He is unpredictable. Staff A stated when he changed Resident #1 on the 8th, he had asked for more clean linens and for some reason the resident went on a rant, name calling. Staff A stated Resident #1 had swung at him before, and this night he swung a few times. Staff A denied knowing the source of Resident #1's injuries after the care was completed and said, I don't know if he hit anything, he was swinging at me. He did not say stop caring from me. I was not near him. I walked out after that and yes, I changed him. Staff A said regarding the bruises and skin tears on the resident, I do not know how the injuries happened. He did not receive any injuries from me. Staff A stated he did not report this incident because Resident #1 had been doing this all along. An interview was conducted on 04/13/25 at 12:01 p.m. with the Social Services Director (SSD). She stated Resident #1 had tendencies that are unusual. He uses racial slurs towards some staff. He yells out for staff. The SSD stated the resident has it more or so with male CNAs, especially African America males. The SSD stated the resident would much later in the day apologize. She stated when this happens, it has ended up being allegations that they report. The SSD said, Sometimes he says I got angry and that resolves it. The SSD stated none of the incidents had been substantiated. The SSD reviewed the care plan which showed general interventions which did not specify expectations for the staff when Resident #1 was yelling and cussing. The SSD said, I would hope staff would bring themselves down and not be confrontational with him and encourage him to express himself better. The SSD said on 4/7/25 she had visited Resident #1 in his room because of an incident that happened on 4/6/25 when he said a CNA had grabbed him by the throat. The SSD stated the resident could not tell what day specifically or what CNA it was. The SSD stated the resident had reported the CNA was caring for him, he did not want him to, and the CNA grabbed him by the throat. The SSD stated she had screened Resident #1 for trauma and the resident had reported an extensive history of sexual abuse. The SSD said on 12/2/24 Resident #1 had reported African American CNAs are short with him. The SSD stated regarding the follow up, I don't think I did anything with that information. I should have referred him to psych. I don't know if I did. The SSD stated when Resident #1 makes complaints of staff being rough or short with him, they should remove the CNA from his care. The SSD could not confirm if this had been done or not. An interview was conducted with the Risk Manager (RM) on 04/13/25 at 1:15 p.m. The RM stated Resident #1 has had two incidents. He stated on Sunday 4/6/25 he received a phone call from Staff B, Registered Nurse (RN). She stated she was called to the resident's room approximately 6 p.m., and the resident reported that an unidentified male staff member delivered his food to his next-door neighbor. He stated the staff member had threatened to take his wife. The resident said around 7:30 a.m. he had requested water, and the unidentified CNA said it was not his job to bring him water and they started arguing. The resident said at some point, the CNA grabbed him by the neck and left shortly after. He stated they started arguing and he started to choke him, and the resident choked him back. The RM stated they reported this incident. The RM stated the resident alleged to the law enforcement officer he had been battered and scratched by a light skinned male, but the officer did not find evidence of scratches. During the interview on 04/13/25 at 1:15 p.m., the Risk Manager (RM) stated the second incident occurred on 4/8/25 at 11 p.m., and the incident was reported to the administration on 4/9/25 at 7:50 a.m. The RM stated Resident #1 called the desk and had told the receptionist he wanted to report abuse. The Nursing Home Administrator (NHA) and the RM went and spoke with the resident. The RM stated the resident reported an African American male with dreadlocks came into his room, referring to the evening of 4/8/25, as the resident wanted to be changed. Resident #1 refused and asked the staff member to leave. He stated, he did not like CNA [Staff A] because he is rude and walks like derogatory words. The RM stated the resident said that he and the staff member had words. The resident reported he crossed my hands and held me down, I was trying to hit the staff member but could not. The RM stated the resident said the staff member grabbed both of his hands and crossed them and pushed them down to his chest. The RM said during that interview the resident showed two areas post skin tear and another medial fore arm tear and wrist area tear to the left arm and a single area of bruises on left arm. The RM said the resident bruises easily and could have hit his arms on the end of the bedside table. The RM stated the resident appeared to have a problem with people of color. He stated the expectation was if they go in and he is yelling or says no, they are to leave. The RM stated he was not aware the resident had a history of sexual trauma or why he would potentially target African American male staff. The RM stated regarding the care plan, No, I did not review his care plan. I was not aware he had a history of abuse. If we would have thought so, we could have looked at the incidents differently. I did not know. A second interview was conducted on 4/14/25 at 9:25 a.m. with the Risk Manager (RM). The RM stated he had interviewed Staff A, CNA who reported Resident #1 had been abusive and called him derogatory and inappropriate racial slurs. The CNA stated he did not see the bruises and skin tears. The RM stated Staff A did not answer yes, or no, when asked if the resident had attempted to hit him. The RM stated Staff A confirmed he had changed the resident but denied causing him any injury. He stated he had interviewed Staff C, LPN/Agency assigned to Resident #1 that night and Staff C denied having knowledge of the incident. On 04/13/25 at 2 p.m. an interview was conducted with Staff D, LPN/Unit Manager (UM). Staff D stated Resident #1 had problems with dark skinned people. She said, He yells at them, sometimes he does not want care from them, they will come to the room, and he says he does not want to be changed. When he says that they come to me, I go to him and see if he needs to be changed, or if he has a smell, he then lets me change him. Staff D stated about a month earlier she became aware of the resident's history of abuse. She stated she reported it to the SSD. Staff D stated on the first day of the incident, I saw the bruising on his left arm, a small open area, which is now scabbed. On the Right arm, it was open, purple- ish in color, the bruising was not there before the incident. Staff D stated she saw the resident the day before, I saw the right arm, he has some drainage. I did treatment and xeroform dressing for the scabbed area on the left too. An interview with Resident #1's psychiatrist on 04/13/25 at 2:35 p.m. revealed she had seen the resident on 04/08/25 following an allegation of a staff member who molested him. The psychologist stated during the visit Resident #1 mentioned very little of the incident and wanted to discuss his sleep issues instead. The psychiatrist reported being unaware of this resident's history of trauma. She said, I have not been made aware of PTSD concerns or any events that could trigger him. She stated the Psychologist would probably be the one to provide the coping mechanisms as it was not something she was aware of, or she was addressing. On 04/13/29 at 4:49 p.m. an interview was conducted with Resident 1's psychologist. The psychologist stated she had assessed the resident following concerns of high anxiety. She stated she had witnessed an incident where an unidentified CNA had raised his voice at Resident #1. She stated when that CNA walked into the resident's room that day, the resident said, this is why I am so scared, this is the guy. The Psychologist stated the CNA raised his voice again. She stated, It was not a good response. The psychologist stated she notified the psych nurse and asked her to review medications and evaluate possible PTSD. The psychologist reported the resident said, I have crazy dreams that wake me up and cause me irritability. She stated they reviewed his medications. The Psychologist said, I know he has stated he does not like to be changed as he is afraid of people. He does not trust others. He likes to be isolated, and he wished his blinds were darker. He wished to be by himself. The Psychologist said she was not aware of the resident's history of sexual abuse. She stated that could be the reason he was refusing care and could explain the fear. She stated he was also afraid of a family member who had donehorrendous things. The psychologist stated the resident had not said why he was against African American staff, but confirmed they are doing some things he does not like. The psychologist could not explain what those things were. Review of a care plan for Resident #1 dated 3/5/25 showed a focus, Resident #1 is resistive to care, refusals to lab draws r/t (related to) Adjustment Disorder with mixed anxiety and depressed mood. Date Initiated: 01/24/2025, created on and revised on 02/26/2025. Interventions included to allow Resident #1 to make decisions about treatment regime, to provide a sense of control, encourage as much participation/interaction by the resident as possible during care activities, give clear explanation of all care activities prior to and as they occur during each contact. Resident #1 resists (ADLs) Activities of Daily living, reassure resident, leave and return 5-10 minutes later. Review of a psych progress note dated 04/09/25 revealed, As per collected information, the resident made an abuse allegation. As per his report, [Resident #1] felt threatened at the moment of the incident. He also complained about not been able to sleep through the night. As reported by staff, he has been irritable . No evidence of mania, psychosis, or agitation has been noted . History of Present Illness revealed [Resident #1] was seen upon request of SSD due to an allegation of aggression by staff member. Patient reports he has been tired during the day. Patient was asked to be seen after incident that happened over the weekend. Patient reports an African American male worker attacked him and his voice is not as clear. Provider talked about how the situation happened. Patient indicated that the staff came, and they were joking around and then he put his hands on his neck. His response was to do the same thing to defend himself. Patient previously has stated that he enjoys isolation and that he is afraid that something awful might happen. Patient stated he notices depression and anxiety are affecting him. Patient reports being aware and alert because he feels threatened. Provider addressed safety and calming techniques with patient such as deep breathing and being assertive. Patient reports he does not know the name of the staff member . Summary of the session: [Resident #1] reports from his bed and calming down techniques were discussed. Patient was approachable and shared an incident that was shared with facility staff. Patient is under the impression that he was attacked. According to patient. Staff member (African American male) put his hand on his neck after both were joking. Patient reports he also tried to defend himself and extended his arms. Facility staff is aware of incident. Review of a psychiatry note dated 3/25/25 showed Resident #1 was seen upon request of SSD. Patient apparently enjoys being alone and does have altercations with people of color that work at the facility stating racial slurs. Patient reports fair eating and sleep is disturbed . Patient is under the impression that he is not getting helped at night especially after midnight. Patient reports having nightmares at night and wanting to talk to someone about his nightmare. Provider will contact psych nurse to address sleep medication and mood stabilizer if possible. Review of a facility policy titled Abuse, Neglect and Exploitation dated 09/07/22 showed it is the policy of this facility to provide protections for the health, welfare and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation and misappropriation of resident property. Definitions: Abuse means the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish, which can include staff to resident abuse and certain resident to resident altercations. Abuse also includes the deprivation by an individual, including a caretaker, of goods or services that are necessary to attain or maintain physical, mental, and psychosocial well-being. Instances of abuse of all residents, irrespective of any mental or physical condition, cause physical harm, pain or mental anguish. It includes verbal abuse, sexual abuse, physical abuse, and mental abuse including abuse facilitated or enabled through the use of technology. Under Policy Explanation and Compliance Guidelines: 1. The facility will develop and implement written policies and procedures that: a. Prohibit and prevent abuse, neglect, and exploitation of residents and misappropriation of resident property. b. Establish policies and procedures to investigate any such allegations; and c. Include training for new and existing staff on activities that constitute abuse, neglect, exploitation, and misappropriation of resident property, reporting procedures, and dementia management and resident abuse prevention; and d. Establish coordination with the QAPI program. Under prevention of Abuse, Neglect and exploitation: B. Identifying, correcting and intervening in situations in which abuse, neglect, exploitation, and/or misappropriation of resident property is more likely to occur with the deployment of trained and qualified, registered, licensed, and certified staff on each shift in sufficient numbers to meet the needs of the residents, and assure that the staff assigned have knowledge of the individual residents' care needs and behavioral symptoms. C. Assuring an assessment of the resources needed to provide care and services to all residents is included in the facility assessment. D. The identification, ongoing assessment, care planning for appropriate interventions, and monitoring of residents with needs and behaviors which might lead to conflict or neglect.

Based on observations, interviews and record review, the facility failed to assess, develop and implement a care plan related to a documented PTSD (Post Traumatic Stress Disorder) diagnosis and failed to care plan potential trauma triggers for one resident (#1) of two residents sampled. Findings included: Review of the Admission Record for Resident #1 showed he was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses to include metabolic encephalopathy, adjustment disorder recurrent, insomnia, and generalized anxiety disorder. Review of an admission level I Pre-admission Screening and Resident Review (PASARR) dated 02/29/24 showed Resident #1had a diagnosis of adjustment disorder and PTSD (Post Traumatic Stress Disorder). Review of a social services progress note dated 04/07/25 showed, Resident has a history of trauma and or PTSD. Review of a document titled Social Services Trauma Screen dated 04/10/25 showed question P: Resident has a history of trauma and or PTSD (Post Traumatic Stress Disorder). Under questions A through N, it was noted the resident did not answer Yes, or No. It was marked prefers not to answer/unable. Question O. Events that really bothered the resident, it was noted, altercation with a male CNA. The question under P. on Trauma/PTSD assessment was marked, Yes. The question if the care plan was updated to reflect the resident's experiences, preferences, and cultural differences in order to eliminate or mitigate triggers that may cause re-traumatization, the answer showed - N/A (Not Applicable). Review of a document titled Social Services Trauma Screen dated 01/15/25 showed: Question O, [Resident #1] communicated that he was abused and talked about as a child and all through his life by his peers . Question P. showed the resident had PTSD. The question if the care plan was updated to reflect the resident's experiences, preferences, and cultural differences in order to eliminate or mitigate triggers that may cause re-traumatization, the answer showed - N/A. Review of a document titled Social Services Trauma Screen dated 12/02/24 showed in J. Resident's mother passed away and it still affects him at times. In Question O: List any events that really bothered you that were not mentioned, Resident #1 answered, While in the facility, he thinks he hears rumors of the facility throwing him out, feels he is served old food, and states the Black CNAs (Certified Nursing Assistants) are abrupt and short with him. The trauma/PTSD question was marked, No. Review of a document titled Social Services Trauma Screen dated 10/02/24 showed in F. Quetion - If the resident was forced to have sexual contact - as a child? The resident preferred not to answer. In question O. List events that really bothered you, Resident #1 answered, molested as a child. Question P. on Trauma/PTSD assessment was marked No, and the care plan update was not considered. Review of a document titled Social Services Trauma Screen dated 08/12/24 showed Question F. - If the resident was forced to have sexual contact - as a child? The resident answered, Yes F(2.) Describe what happened- it is noted, molested as a young child. He never told anyone. When asked if anyone got hurt, or if the resident was afraid someone else might get hurt, and if he felt afraid, helpless or horrified, Resident #1 answered, yes to all these questions. In question P. History of Trauma and or PTSD (Post Traumatic Stress Disorder) was checked, Yes. The question if the care plan was updated to reflect the resident's experiences, preferences, and cultural differences in order to eliminate or mitigate triggers that may cause re-traumatization, the question was left blank. Review of a Quarterly MDS (minimum Data Set) dated 02/22/25 revealed in Section I active diagnosis, the resident did not have a PTSD or trauma related diagnosis indicated. Review of a care plan for Resident #1 initiated 08/12/24 showed a Focus, Resident #1 has experienced trauma related to adjustment issues affecting the follow sadness - sad face, affect, statements of sadness. A focus on 1/23/25 showed Resident #1 expressed feelings of being claustrophobic - being afraid in enclosed areas/places. Date Initiated: 01/23/2025. Interventions included - Ensure that door in his room is open at all times. Refer to psychiatry and psychology services for medication review and behavior management. On 4/14/25 at 10:37 a.m. an interview was conducted with the Social Services Director (SSD) Risk Manager (RM) and the Nursing Home Administrator (NHA). The SSD stated regarding the process of ensuring communication with providers she stated, If a concern that warrants the care plan to be updated is brought up, it is discussed with nursing staff and IDT (Interdisciplinary Team) to make sure they can capture what they are looking for. She stated Resident #1's history of sexual abuse was discussed with the previous DON (director of Nursing). The SSD stated the resident was referred to psych on 8/12/24. Review of the psych note revealed there was no mention of the sexual abuse history or trauma related concerns. The SSD stated a care plan was put in place related to the resident being Claustrophobic, but not related to the abuse. The SSD said, The care plan should show known triggers if they are identified. I do not know if he had any. The SSD stated the plan of care should include letting staff know to approach the resident in a non-threatening manner, give space and observe for anxiety. The SSD reviewed the care plan and stated she did not see the interventions regarding sexual abuse or trauma. During an interview on 04/13/25 at 12:05 p.m. with Staff E, Licensed Practical Nurse, he stated he was Resident #1's nurse every time he works. The LPN said, Resident #1 has problems with his brief being changed. This is a behavior that he has. Staff E, LPN stated he did not know if Resident #1 had PTSD. He looked on the admission record and said, No, there is PTSD diagnosis. It is not on his list of diagnoses so, he must not have PTSD, and no triggers have been identified. Staff E, LPN stated changing his brief was the biggest problem and also closing his door when he was in his room alone. An interview was conducted with Staff F, CNA on 04/13/25 at 12:20 p.m. She stated she worked with Resident #1 sometimes, and he refuses care related to brief changes and he absolutely hates that. She stated he frequently refuses, and she tells him he would need to let her change his brief that is soiled, at least once before her shift is over. Staff F stated no one has ever told her Resident #1 had PTSD or any history of trauma. An interview was conducted on 04/13/25 at 12:00 p.m. with Staff G, CNA. She stated she worked with Resident #1 and he does say racially and derogatory comments but as a CNA I signed up to put up with that and I just ignore it. He does refuse to change his brief often. Staff G stated most of the time she would ask him 3 or 4 times during her shift. Staff G said, This is just a behavior that he has. Staff G denied knowing if Resident #1 had PTSD or history of any kind of trauma. Staff G stated she was never told of this and had not been trained on any triggers. She stated she had been told to always have another person in with her when providing his care. Staff G said, He is usually good with me just not when it is time to change his brief he hates it and gets upset about it almost every time. Review of a care plan for Resident #1 dated 3/5/25 showed a focus, Resident #1 is resistive to care, refuses lab draws r/t (related to) Adjustment Disorder with mixed anxiety and depressed mood. Date initiated: 01/24/2025, created on and revised on 02/26/2025. Interventions included to allow Resident #1 to make decisions about treatment regime, to provide a sense of control, encourage as much participation/interaction by the resident as possible during care activities, give clear explanation of all care activities prior to and as they occur during each contact. Resident #1 resists (ADLs) Activities of Daily living, reassure resident, leave and return 5-10 minutes later. During an interview on 04/13/25 at 10:51 a.m. Resident #1 stated that he was forced to receive care by an [African American] CNA (Certified Nursing Assistant) who is a profanity, too rough and always has to have his way. Resident #1 said, I sometimes refuse care, but the [African American] CNA forced me to accept his care. When that CNA [Staff A,] comes into my room I feel a sense of panic because I know he is going to be rough with me. The resident stated it had to be the CNA's way or no way. Resident #1 stated the CNA [Staff A] forcibly crossed his arms over his chest and was mean to him by laughing at him. Resident #1 said, I do not want him again and I have not seen him since. I feel like I have the right to choose to refuse care and I have choices, and it is against my rights and the law to force me to do something. The resident stated regarding PTSD (Post Traumatic Stress Disorder), I do not want to talk about it. During this interview, an observation revealed the resident had two dressings, one on the left wrist dated 04/12/25 and one on the right back of hand dated 04/12/25. Resident #1 stated those dressings were from the incident with the CNA. Interviews were conducted with Resident #1's CNAs on 04/13/25 from 2:50 p.m. to 3:45 p.m. regarding his care and any knowledge of trauma history. The interviews revealed the following: Staff H, CNA said, Resident #1 has a problem with people. He yells at people and uses racial slurs with CNAs and the roommate. He says he has PTSD he is claustrophobic. He does not like people in his space. Staff I, CNA stated Resident #1 always asks her to hold his hand. He is always yelling. She stated she did not know of a PTSD or trauma diagnosis. She stated she was not trained on identifying triggers. Staff J, CNA stated Resident #1 refuses to be changed. He said, He used to cuss me out. I tried to be nice, I would go to the kitchen and get him sandwiches to pacify him. Staff J stated the previous nurse practitioner said to him, Do not do him alone he said you tried to kill him. Staff J stated he has heard Resident #1 calling racial slurs and did not know why. He denied knowing of a PTSD or trauma diagnosis. He stated he had not been told. He stated he did not know what would be triggering Resident #1. On 0n 04/14/25 an interview was conducted with Staff B, Registered Nurse (RN). She stated Resident #1 yells racial slurs all day. She sated he says he does not like black derogatory term. Staff B stated when CNAs say he does not want to be changed, she tries to help. She stated Resident #1 refuses to be changed because he does not like the African American CNAs. She stated they had African American CNAs on assignment most of the time. Staff B, RN stated she was unaware of any history of abuse, trauma or a PTSD diagnosis. On 04/13/25 at 2 p.m. an interview was conducted with Staff D, LPN/Unit Manager (UM). Staff D stated Resident #1 had problems with dark skinned people. She said, He yells at them, sometimes he does not want care from them, they will come to the room, and he says he does not want to be changed. When he says that, they come to me, I go to him and he says he is refusing because he is dry, but I can see he needs to be changed, or he has a smell. He then lets me change him. Staff D stated about a month earlier she became aware of the resident's history of abuse. She stated she reported it to the SSD. An interview was conducted with the Director of Nursing (DON) and the Nursing Home Administrator (NHA) on 4/14/25 at 12:01 p.m. The DON stated they had one resident with a PTSD diagnosis, but was taken off the diagnosis because they did not meet criteria. The DON stated she was not aware Resident #1 had a history of PTSD or any history of sexual abuse. She stated he would have to be assessed. The NHA stated Resident #1 was inconsistent. Sometimes he is receptive to care and sometimes he was not. The DON stated psych was planning an on-site visit. An interview with Resident #1's psychiatrist on 04/13/25 at 2:35 p.m. revealed she had seen the resident on 04/08/25 following an allegation of a staff member who molested him. The psychologist stated during the visit Resident #1 mentioned very little of the incident and wanted to discuss his sleep issues instead. The psychiatrist reported being unaware of this resident's history of trauma. She said, I have not been made aware of PTSD concerns or any events that could trigger him. She stated the Psychologist would probably be the one to provide the coping mechanisms as it was not something she was aware of, or she was addressing. On 04/13/29 at 4:49 p.m. an interview was conducted with Resident 1's psychologist. The psychologist stated she had assessed the resident following concerns of high anxiety. She stated she had witnessed an incident where an unidentified CNA had raised his voice at Resident #1. She stated when that CNA walked into the resident's room that day, the resident said, this is why I am so scared, this is the guy. The Psychologist stated the CNA raised his voice again. She stated, It was not a good response. The psychologist stated she notified the psych nurse and asked her to review medications and evaluate possible PTSD. The psychologist reported the resident said, I have crazy dreams that wake me up and cause me irritability. She stated they reviewed his medications. The Psychologist said, I know he has stated he does not like to be changed as he is afraid of people. He does not trust others. He likes to be isolated, and he wished his blinds were darker. He wished to be by himself. The Psychologist said she was not aware of the resident's history of sexual abuse. She stated that could be the reason he was refusing care and could explain the fear. She stated he was also afraid of a family member who had donehorrendous things. The psychologist stated the resident had not said why he was against African American staff, but confirmed they are doing some things he does not like. The psychologist could not explain what those things were. Review of a facility policy titled Comprehensive Care Plans, dated 9/7/22 showed it is the policy of this facility to develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights, that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the resident's comprehensive assessment. Under definitions: Trauma-informed care is an approach to delivering care that involves understanding, recognizing, and responding to the effects of all types of trauma. A trauma-informed approach to care delivery recognizes the widespread impact, and signs and symptoms of trauma in residents, and incorporates knowledge about trauma into care plans, policies, procedures and practices to avoid re-traumatization. Policy Explanation and Compliance Guidelines: 1. The care planning process will include an assessment of the resident's strengths and needs and will incorporate the resident's personal and cultural preferences in developing goals of care. Services provided or arranged by the facility, as outlined by the comprehensive care plan, shall be culturally competent and trauma-informed. 2. The comprehensive care plan will be developed within 7 days after the completion of the comprehensive MOS (Measurable Objective Statements) assessment. All Care Assessment Areas (CAAs) triggered by the MOS will be considered in developing the plan of care. Other factors identified by the interdisciplinary team, or in accordance with the resident's preferences, will also be addressed in the plan of care. The facility's rationale for deciding whether to proceed with care planning will be evidenced in the clinical record. 3. The comprehensive care plan will describe, at a minimum, the following: a. The services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being. b. Any services that would otherwise be furnished, but are not provided due to the resident's exercise of his or her right to refuse treatment. c. Any specialized services or specialized rehabilitation services the nursing facility will provide as a result of PASARR recommendations. d. The resident's goals for admission, desired outcomes, and preferences for future discharge. e. Discharge plans, as appropriate. f. Resident specific interventions that reflect the resident's needs and preferences and align with the resident's cultural identity, as indicated. If the resident is non-English speaking, the facility will identify how communication will occur with the resident. The care plan will identify the language spoken and tools used to communicate. g. Individualized interventions for trauma survivors that recognizes the interrelation between trauma and symptoms of trauma, as indicated. Trigger-specific interventions will be used to identify ways to decrease the resident's exposure to triggers which re-traumatize the resident, as well as identify ways to mitigate or decrease the effect of the trigger on the resident.

Based on interviews and record review, the facility failed to report and thoroughly investigate an allegation of abuse in a timely manner for one resident (#31) out of three residents sampled. Findings included: A review of Resident #31's Admission Record showed an admitted [DATE] with a diagnoses to include Alzheimer's disease, contracture of right knee, contracture of left knee, age-related nuclear cataract, bilateral, unspecified dementia, unspecified severity, without behavioral, psychotic, mood, and anxiety disturbances, brief psychotic disorder, cognitive communication deficit, and history of falling. A review of Resident #31's Minimum Data Set (MDS), Section GG- Functional Abilities, showed the resident dependent for eating, toileting, hygiene, shower/bathe, dressing upper and lower body and personal hygiene. Resident #31 was dependent for mobility to roll left to right or from sit to lying in bed. Resident #31 had not attempted due to medical condition or safety concerns checked for chair/bed to chair transfer. On [DATE] at 3:06 p.m., an interview was conducted with the Nursing Home Administrator (NHA) and the Director of Nursing (DON). The DON stated she had received a phone call Friday the 27th of December approximately 6:00 p.m. from Staff M, Licensed Practical Nurse (LPN). Staff M, LPN informed the DON of an alleged abuse scenario where Resident #31 was struck by Staff R, Certified Nurse Assistant (CNA) approximately two weeks ago. Staff M, LPN stated Staff N, CNA stated the information to her via her personal cell phone minutes prior to calling the DON. Staff M, LPN stated Staff N, CNA will be calling the DON to give her testimony to the events of alleged abuse. The DON stated Staff N, CNA was calling her the same time Staff M, LPN was calling her and took Staff M's call first. The DON stated it was a short conversation between her and Staff M, LPN. The DON stated she had a telephone conversation [DATE] with Staff N, CNA after her brief phone call from Staff M, LPN informing her of an alleged abuse to Resident #31. The DON stated she talked to Staff N, CNA and took her statement. Staff N, CNA told the DON she received report from Staff R, CNA and noticed a scrape Resident #31's nose and asked Staff R, CNA if the resident had a fall. Staff N said Staff R, CNA stated to her she hit the resident because he would not let go of her. The DON asked Staff N, CNA if she had reported this allegation to anyone at time and Staff N, CNA stated she had not. The DON asked Staff N, CNA why she had not reported this allegation and Staff N, CNA stated she was in fear of retribution from Staff R, CNA. The DON stated there was a connection of Staff N's child to Staff R's family. The DON stated after she had informed the NHA/Abuse Coordinator, she called Staff R, CNA. Staff R, CNA stated she had provided care for Resident #31 on a couple of occasions. Staff R, CNA denied any inappropriate physical acts towards Resident #31. Staff R, CNA stated the resident was not combative with her. Staff R, CNA told the DON an incident occurred approximately two weeks ago when she provided care for Resident #31 and he hit his face on the side rails and sustained an injury. Staff R, CNA stated Resident #31 sustained a skin tear to the bridge of his nose and immediately reported to the nurse supervisor, which the DON stated would have been Staff E, LPN/Supervisor. The DON stated Staff R, CNA was suspended pending the investigation. Staff N, CNA was not suspended and was allowed to work her normal hours as a weekend staff member. The DON stated she interviewed Staff E, LPN/Supervisor to verify she placed a note regarding the incident to Resident #31's medical record. The DON stated Staff E, LPN/Supervisor stated someone told her about the skin tear to the bridge of his nose but she could not recall who told her. The DON stated they interviewed seven residents in the same vicinity as Resident #31 and all the residents denied any concern of abuse. The NHA stated he completed the reporting side of the allegation. He contacted law enforcement on [DATE] at 7:57 p.m., and the Department of Children and Family Services (DCF) via their portal at 7:53 p.m. The NHA stated law enforcement arrived at the facility, visited the resident and called the NHA and stated no further investigation was warranted. The NHA stated DCF arrived at the facility on [DATE] and interviewed Staff N, CNA but could not state if the conversation was done via by phone or in person. The NHA stated DCF representative who came to their facility stated there is a [NAME] between the two staff members. The NHA stated from the information they had gathered during their investigation, Staff N, CNA's conduct was done in a spiteful manner and was terminated for failure to report abuse, neglect and/or misappropriation in a timely manner. The DON stated she arrived at the facility on [DATE] and conducted a skin assessment for Resident #31. The physician was notified but unfortunately a communication lapse occurred in the notification of the family. The DON stated the family was notified on [DATE] after staff realized they were not notified immediately post allegation. The DON stated Staff R, CNA was adamant she did not hit Resident #31 and her story matched with the events documented in the resident's medical records. The facility decided to move Staff R, CNA to the first floor and terminated Staff N, CNA for failure to report the abuse in a timely manner per policy. On [DATE] at 6:35 p.m., a phone interview was conducted with Staff N, CNA. Staff N, CNA stated her normal assignments would include Resident #31. Staff N, CNA stated she normally will work doubles exclusively on the weekends from the ,d+[DATE] p.m. and ,d+[DATE] a.m. shifts. Staff N, CNA described the resident as normally confused due to his Alzheimer's/dementia, Spanish-speaking only but would understand simple questions. Staff N, CNA stated the resident has a good relationship with another CNA, Staff T, who speaks his native language and has a good relationship with the resident's family. Staff N, CNA stated she has known Staff R, CNA since 2006. Staff N, CNA stated she was on friendly terms with Staff R, CNA. Staff N stated Staff R, CNA worked the same doubles on the weekends. Staff N stated on Saturday, [DATE], she received report from Staff U, CNA. Staff N, CNA stated Staff U, CNA did not mention Resident #31's face to her. Staff N, CNA stated she started her shift as she normally would and brought linen into Resident #31's room as well as his roommate. Staff N, CNA stated Resident #31 was in his bed. Staff N, CNA stated Staff R, CNA came into Resident #31's room as she was placing linen onto Resident #31's roommate's bed. Staff N stated Staff R, CNA walked into the room behind her and stated, Did you see his face? When Staff N, CNA looked to see Resident #31's face she saw a left black eye with a gash over his left eyebrow. Staff N, CNA stated she did not receive report about concerns to the resident's face. Staff N, CNA stated she thought he had a fall but Staff R, CNA stated she punched the resident because he had her fingers bent backwards and would not let go of her. Staff N, CNA stated she had no idea why Staff R, CNA divulged this information to her. Staff N, CNA stated Staff R, CNA did this a few days ago on a Tuesday or Wednesday. Staff N, CNA stated Staff R told her she left Resident #31's room to check on another resident but she said something told her to go back and check on Resident #31. Staff N, CNA stated Staff R stated Resident #31 had a gash with blood running into his eye down his nose. Staff N, CNA stated Staff R stated she put on a pair of gloves and rubbed it into the resident's bloodied face and then took the bloodied glove and wiped it on the inside of the left side rail. Staff N, CNA stated Resident #31 tends to navigate to his left side naturally. Staff N, CNA stated Staff R, CNA stated to her she went out to notify the nurse the resident hit the side of the rail when she was rolling him. Staff N, CNA stated Staff R, CNA told her this information (alleged abuse) as she was beginning her shift the first day of the weekend, [DATE]th, 2024. Staff N, CNA stated she did not report it the day she was told but stated, It did not sit right with me. Staff N, CNA stated she could not tell upper management because, I felt it would have been swept under the rug. Staff N, CNA stated the next day she tried calling Staff M, LPN/Supervisor on her personal cell phone but she (Staff M) stated she was busy and stated she would call her back but she did return her call. Staff N, CNA stated she eventually called Staff M, LPN/Supervisor a week to a week and a half after her first attempt and explained the whole situation to her. Staff N, CNA stated Staff M, LPN/Supervisor told her to immediately call the DON and report this allegation of abuse. Staff N, CNA stated Staff M, LPN/Supervisor stated because she was told this information she now will report to the DON as well. The DON called Staff N, CNA to discuss the allegations of abuse with Staff N, CNA. After Staff N, CNA gave her statement, she was allowed to return to work the next day for her normal weekend shifts. Staff N, CNA stated DCF interviewed her. Staff N, CNA stated the DCF representative took her statement along with images of Resident #31. Staff N, CNA stated she gave the same statement. The DCF representative asked Staff N, CNA why she had waited to report the allegation of abuse in which Staff N, CNA stated she was afraid of retribution. Staff N, CNA stated she was terminated on [DATE]. On [DATE] at 11:09 a.m., an interview was conducted with Staff R, CNA related to the allegation of abuse to Resident #31. Staff R, CNA stated she will work doubles on the weekends from ,d+[DATE] p.m. to ,d+[DATE] a.m. shift. Staff R, CNA stated her normal assignment is rooms ,d+[DATE] but stated her assignment may change for the ,d+[DATE] a.m. shift depending on the number of CNAs available. Staff R, CNA stated if the number of CNAs goes down to three, she will pick up ,d+[DATE] as well as 212 around the corner. Staff R, CNA stated one night shift she was doing her room checks she noticed Resident #31's feet were hanging out of his bed, and his hand was on the left side rail. Staff R, CNA stated she went into the room and placed herself in front of Resident #31 to prevent him from falling out of the bed. Staff R, CNA stated she placed one of her arms under the resident's legs and her other hand to undo the resident's tight grip on the side rail. Staff R, CNA denied she asked for help and stated there was no one in the hallway or nurse's station to assist her. Staff R, CNA stated she was able to loosen Resident #31's hand from the side rail and basically barrel rolled him to the other side and flipped him to his right side. Staff R, CNA stated Resident #31 hit his face onto the side rail. Staff R, CNA stated she started to see a lump form on his forehead but could not describe on what side and stated there was no blood. Staff R, CNA stated she got Staff S, Registered Nurse (RN) to report the event. Staff R, CNA stated Staff S, RN examined the resident and got a gauze to see if there were any openings to his face and reported her findings to Staff E, LPN/Supervisor after she returned from her break. Staff E, LPN/Supervisor had Staff R, CNA write a statement on the events of the incident and stated Staff E, LPN /Supervisor coached her to write the letter by stating moving forward she will utilize a two -person assist. Staff R, CNA stated Staff N, CNA has a problem with her family. Staff R, CNA stated she did not have any issues with Staff N. Staff R, CNA stated she received a call from the DON the day after Christmas stating an allegation was made against her. Staff R, CNA stated DCF called her on Monday, [DATE] for an interview. During survey 13 separate interviews were conducted with various nursing staff employees. Staff directly involved with Resident #31 and others working on the same floor as the resident. All staff members stated none of them were interviewed regarding any allegation of abuse or abuse towards Resident #31. On [DATE] at 12:20 p.m., a second interview was conducted with the DON and the NHA with the facility's investigative folder regarding allegations of abuse towards Resident #31. The DON confirmed an incident report was completed by Staff E, LPN/Supervisor. The DON stated incident reports are reviewed by the Interdisciplinary Team (IDT) but this report was not reviewed. The DON stated pillows were added to Resident #31's ,d+[DATE] side rails to protect his face. The DON stated a written statement was found in the nurses' station on [DATE] from Staff R, CNA regarding the incident on [DATE] of the resident sustaining injuries during ADL (activities of daily living) care. The letter was not dated. The DON stated no interviews were conducted with the nursing staff who was immediately notified by Staff R, CNA. The DON stated Staff Q, CNA who was working with Staff R, CNA the night the incident occurred, [DATE]th, 2024, was not interviewed. The DON stated Staff R, CNA was giving report to Staff N, CNA in real time on [DATE]/,d+[DATE]. A review of the time punch card for Staff N, CNA showed a punch in at 2:09 p.m. and a punch out time of 11:39 p.m. Staff N, CNA did not work on [DATE]. A review of the facility's policy and procedure titled, Abuse, Neglect and Exploitation, implemented on [DATE], showed the following: Policy statement: It is the policy of this facility to provide protections for the health, welfare and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation and misappropriation of resident property. Policy Explanation and Compliance Guidelines: 1. The facility will develop and implement written policies and procedures that: a. Prohibit and prevent abuse, neglect, and exploitation of residents and misappropriation of resident property. b. Established policies and procedures to investigate any such allegations; and c. Include training for new and existing staff on activities that constitute abuse, neglect, exploitation, and misappropriate of resident property, reporting procedures, and dementia management and resident abuse prevention; and d. Establish coordination with the QAPI I program 2. V. Investigation of Alleged Abuse, Neglect and Exploitation A. An immediate investigation is warranted when suspicion of abuse, neglect or exploitation, or reports of abuse, neglect or exploitation occur. B. Written procedures for investigations include: 1. Identifying staff responsible for the investigation: 2. Exercising caution and handling evidence that could be used in a criminal investigation (example, not tampering or destroying evidence) 3. Investigating different types of alleged violations. 4. Identifying and interviewing all involved persons, including the alleged victim, alleged perpetrator, witnesses, and others who might have knowledge of the allegations. 5. Focusing the investigation on determining if abuse, neglect, exploitation, and /or mistreatment has occurred, the extent, and cause; and 6. Providing complete and thorough documentation of the investigation.

Based on observations, interviews, and record review, the facility failed to ensure the Quality Assessment and Assurance (QAA) Committee developed and implemented an effective Quality Improvement and Performance action plan, to correct deficient practice identified during a recertification survey conducted on 12/2/24 to 12/5/25, related to citations at F 552, F 677, F 686, F 777, and F 880. Findings included: Review of the facility's policy, Quality Assurance and Performance Improvement (QAPI), dated 08/25/2022, showed the following: It is the policy of this facility to develop, implement, and maintain an effective, comprehensive, data-driven QAPI program that focuses on indicators of the outcomes of care and quality of life and addresses all the care and unique services the facility provides. Policy Explanation and Compliance Guidelines: 1. The QAPI program includes the establishment of a Quality Assessment and Assurance (QAA) Committee and a written QAPI plan. 3. the QAPI plan will address the following elements: C. Process addressing how the committee will conduct activities necessary to identify and correct quality deficiencies. Key components of this process include, but not limited to, the following: i. Tracking and measuring performance ii. Establishing goals and thresholds for performance improvements. Iii. Identifying and prioritizing quality deficiencies. Iv. Systematically analyzed and underlying causes of systemic quality deficiencies. V. Developing and implementing corrective action or performance improvement activities. VI. Monitoring and evaluating the effectiveness of corrective action / performance improvement activities and revisiting as needed. D. The prioritization of program activities that focus on resident safety, health outcomes, autonomy, choices and quality of care, as well as high-risk, high-volume, or problem-prone areas as identified in the facility assessment that reflects the specific units, programs, departments and unique population the facility serves the facility must also consider the incidents, prevalence and severity of problems or potential problems identified. F. Process to ensure care and services delivered meet accepted standards of quality. Program Development Guidelines: 1. Program design and scope--- a. the QAPI program will be ongoing, comprehensive, and will address the full range of care and services provided by the facility. 4. Program activities---a. All identify problems will be addressed and prioritized, whether by frequency of data collection, monitoring or by the establishment of sub-committees. Considerations include, but are not limited to: i. high- risk, high-volume, or problem-prone areas. ii. Incidence, prevalence, and severity of problems in those areas. iii. Measures affecting resident health, safety, autonomy, choice and quality of care. During an interview on 01/16/2025 at 2:05 p.m. the Nursing Home Administrator (NHA) and the DON stated they had an ADHOC (a meeting called suddenly to discuss a pressing issue) on 12/20/2024 after receiving the Statement of Deficiencies. They stated they reviewed the citations to match the education they had already started after the exit of the survey on 12/06/2024. They stated they adjusted the audit tools they had already created. They stated they determined the frequency of the audits. They discussed the findings with the Medical Director over the phone on 12/20/2024. They validated the Plan of Correction binders were prepared. The NHA left the interview and the DON continued with the interview. 1. The DON stated the F-tag 552 was related to Change in Condition notifications to the resident and resident representatives associated with x-ray results. The DON stated they educated the staff on change in condition which included the policy of notification of changes. The DON stated they started the education with the licensed staff on 12/16/2024 and completed it on 01/03/2025. The DON stated they did a look back of 30 days of labs and x-rays to ensure all had been reported to the medical providers, residents and families. The DON stated the audit did not show if they had to update anyone or not. The DON stated the ADON was to review the x-ray results to ensure the medical provider, resident and resident representative was notified. The DON stated the ADON took ownership and was responsible for the audits, Monday through Friday. The ADON was to give any results that needed to be reported to the Unit Managers for follow-up. The Unit Manager was to report or ensure the floor nurse had reported the results. The DON stated the ADON was supposed to be checking behind the staff to ensure the results were being reported. The DON stated the ADON was sick Monday (01/13/2025) and did not review and the when she returned on Tuesday (01/14/2025), the Unit Manager was off, so the labs were not reported to the appropriate people. The DON stated the ADON cannot be solely responsible. The DON stated the ADON was the checker and the floor nurse needs to notify all parties. The DON stated they would re-educate the staff regarding notifications for change in conditions. Resident #37 was admitted on [DATE] and readmitted on [DATE]. Review of the admission record showed diagnoses included cellulitis of the lower limb, COPD (Chronic Obstructive Pulmonary Disease) diabetes, protein-calorie malnutrition, acute bronchitis due to rhinovirus, anemia, and atrial fibrillation. Review of the physician orders showed two view chest x-rays for congestion on 01/12/2025. Review of the Chest X-ray results were dated 01/12/2025 at 8:50 p.m. showed the conclusion was mild pulmonary vascular congestion. Review of the progress notes showed On 01/13/2025, radiology note showed chest x-ray negative. On 01/14/2025, Physician Assistant (PA) progress note showed on 01/14/2025 at 4:40 p.m., She (Resident #37) reports new onset cough. Primary obtained CXR (chest x-ray) which was negative. She has finished ABX (antibiotics) for cellulitis. She reports decreasing left leg pain. Denies chest pain, SOB (shortness of breath), dizziness. No other concerns at this time. Review of the care plans showed Resident #37 had a potential for complications of respiratory distress related to diagnoses of: COPD, history of Respiratory failure and current smoker Date Initiated: 11/10/2021 Created on: 11/10/2021 Revision on: 04/28/2024. Interventions included but not limited to Labs/diagnostics as ordered; notify physician of results Date Initiated: 11/10/2021 Created on 11/10/2021. Resident #38 was admitted on [DATE] and readmitted on [DATE]. Review of the admissions record showed diagnoses included but not limited to Parkinson's, acute and chronic respiratory failure, congestive heart failure, COPD, hypertension, atrial fibrillation. Review of the physician's orders showed portable 2 view chest x-ray for cough on 01/14/2025. Review of the chest x-ray dated 01/14/25 at 2:00 p.m. showed the cardiac silhouette and mediastinal contours are normal. The lungs are free of infiltrates and focal consolidations. Elevation of the right hemidiaphragm is noted. No pleural fluid or masses are noted. No pneumothorax is present. Conclusions: No acute intrathoracic disease process. Review of the progress notes showed On 01/14/2025 at 12:127 p.m., attending physician visits and orders a 2 view CXR (chest x-ray) for continued cough. Resident continues on ABT (antibiotics) for URI (upper respiratory infection) at this time to same. No s/sx (signs and symptoms) of adverse effects noted at this time. Review of the Infection Care Plan showed resident was on antibiotic therapy related to URI as of 01/10/2025. Interventions included but not limited to observe for worsening respiratory symptoms such as increases SOB and rpt to MD. During an interview on 01/15/2025 at 2:19 p.m. the DON (Director of Nursing) verified Resident #37 did not have documentation in her chart verifying Resident #37 or her responsible party was aware of Resident #37's x-ray reports. The DON verified Resident #38 had no documentation the medical provider, the resident nor her responsible party had been notified of Resident #38's x-ray results. The DON stated she would expect to see documentation in the progress notes the medical providers and either the residents or responsible parties had been notified of the results. The DON stated the ADON (Assistant DON) was supposed to be auditing all x-ray and lab results and confirming the results had been notified to the medical provider or resident and responsible party. If the ADON was not here it was the UM's (Unit Manager's) responsibility. During an interview on 01/15/2025 at 2:40 p.m. with the DON and the ADON, the ADON stated she had called Resident #38's medical provider and informed the resident of the x-ray results this morning (01/15/2025) but did not document it in the medical record. The DON and the ADON verified Resident #37's x-ray results were available on 01/12/2025 (Sunday). They verified the medical provider knew about the x-ray results for Resident #37 on 01/14/2025 (Tuesday). The DON and ADON verified the x-ray results for Resident #37 came to the facility on [DATE] at 8:50 p.m. The DON and ADON confirmed the medical provider was not informed for 2 days of the x-ray results for Resident #37. The DON stated the nurse may not have wanted to inform the medical provider until the next day (01/13/2025 Monday). The DON stated the supervisor should have called the medical provider over the weekend (01/12/2025) due to the results of Resident #37's x-ray showed mild pulmonary vascular congestion. The DON stated she did not know right now why they (x-ray) fell through the cracks. The ADON stated she was off on Monday sick, and she was responsible for the audits. The ADON stated the UM makes the calls to the medical provider and resident or representative as needed. The ADON stated the UM was off on Tuesday, so no calls were made. During an interview on 01/16/2025 at 12:04 p.m. the DON stated she spoke with the attending physician for Resident #38. The DON stated that the physician stated that if an X-ray result was normal the facility could wait until the next business hours to report to the physician. If it (x-ray result) was abnormal, they should call the on-call person. The DON stated that neither resident required new orders. The DON was informed her nurse s stated on interview that they were responsible to inform the medical provider and resident or representative with the results. The DON agreed the nurses had not documented they had called the appropriate persons. The DON agreed the checkers (ADON and UMs) should have been double checking the results were informed to the appropriate persons not being the staff who was to having to provide the x-ray results. 2. Review of education/ in-service attendance log, provided by the ADON, dated 12/5/24, with objectives related to nail care/shaving included the following information: staff must ensure that resident nails are clipped and cleaned underneath, failure to properly trim and clean resident nails can lead to health issues, Certified Nursing Assistants (CNAs) and nurses can clip resident's fingernails. CNAs are not allowed to clip the nails of residents who are diabetic, Patient Care Assistants (PCA) cannot clip fingernails but can file it. The signature page included the signatures of 110 staff members. Review of a resident census report, undated, showed a full audit was complete and done. Review of audit, dated 1/8/25, related to observations of ADLs related to shaving and nail care. The ongoing monitoring included quality review of five residents related to shaving and nail care, weekly for four weeks, then monthly for two months or until substantial compliance. Ten residents were observed for clean and trimmed nails, all residents were in compliance. Review of the admission Record showed Resident # 56's initial admission date to the facility was on 8/7/23. Review of Resident #56's annual Minimum Data Set (MDS), dated [DATE], showed a Brief Interview for Mental Status (BIMS) score of 3 which indicated severe cognitive impairment. Section GG, functional abilities showed Resident #56 required supervision or touching assistance with shower/bath and was independent with personal hygiene. Review of the ADL care plan showed a focus for Resident #56, as follows: Has Activities of Daily Living (ADL) performance deficit related to Alzheimer's, dementia, musculoskeletal impairment, pain and history of a stroke, date initiated 8/14/23. The care plan's goal was Resident #56 will maintain current level of function through the review date. The interventions included checking nail length and trim and clean on bath day and as necessary. Report any changes to the nurse. On 1/15/25 at 10:40 A.M. during interview and observation, Resident #56 was observed sitting in his wheelchair and said he did not like the length of his fingernails [it is] hard to pick up a spoon. His nails were approximately 1/8 inch in length. (Photographic evidence obtained with permission of resident). Review of Resident #56's task, titled: GG-Shower/Bathe self, showed on 1/6/25 supervision or touching assistance was provided. On 1/9/24 Resident #56 was independent with the task. Review of the admission Record showed Resident # 55's initial admission date to the facility was on 2/29/24. Review of Resident #55's quarterly Minimum Data Set (MDS) dated [DATE], showed a Brief Interview for Mental Status (BIMS) score of 13 which indicates intact cognition. Section GG, functional abilities showed Resident #55 is dependent (helper does all the effort) for shower/bathe self and required substantial /maximal assistance with personal hygiene. Review of the ADL care plan showed a focus for Resident #55, as follows: Has and ADL self-care performance deficit related weakness, adult failure to thrive, cognitive deficit, depression and anxiety and requires maximum to dependent ADLs. Decline is expected related to terminal condition. The care plan goal was Resident #55 will maintain current level of function through the review date, created on 3/4/24. The care plan's goal was Resident #55 will maintain current level of function through the review date. The interventions included the resident required assistance by one staff with personal hygiene and personal care On 1/16/25 at 10:56 A.M. during interview and observation, Resident #55 was observed lying in bed, and said he would like to have his fingernails trimmed. His fingernails were approximately ¼ inch in length, yellowing, with dry gray and yellow substance between the nail and nail bed. Resident #55 said he prefers bed baths. Review of Resident #56's task, titled: GG-Shower/Bathe self, showed daily between 1/10/25 and 1/16/25 he was dependent (helper does all the effort) with completing this task. Review of the admission Record showed Resident # 57's initial admission date to the facility was on 6/16/22. Review of Resident #57's quarterly Minimum Data Set (MDS) dated [DATE], showed a Brief Interview for Mental Status (BIMS) score of 3 which indicated severe cognitive impairment. Section GG, functional abilities showed Resident #57 required substantial/ maximal assistance with shower/bath and required supervision or touching assistance with personal hygiene. Review of the ADL care plan showed a focus for Resident #57, as follows: Has Activities of Daily Living (ADL) performance deficit related to confusion, dementia, visual deficits, depression and anxiety created on 6/18/22. The care plan's goal was Resident #57 will maintain current level of function through the review date. The interventions included checking nail length and trim and clean on bath day and as necessary. Report any changes to the nurse. Resident #57 required assistance by 1 staff with personal hygiene and oral care. On 1/15/25 at 10 :30 A.M. during an interview and observation Resident #57's fingernails were approximately 1/8 inch in length, under the nails contained large amount of dry dark gray and black substances, and the edges between the finger and fingernail contained caked on brownish and black substances. (Photographic evidence obtained with resident permission). Review of Resident #57's task, titled: GG-Shower/Bathe self, showed daily between 1/10/25-1/14/25 the resident was dependent (helper does all the effort) for this task. During a group interview on 1/15/25 at 2:49 P.M. Certified Nursing Assistants (CNA) said they were recently provided education to offer nail care to each resident on their shower days and to document on the shower sheets. During an interview on 1/16/25 at 12:05 PM, the Assistant Director of Nursing (ADON) said Staff are expected to provide nail care with bathing. During an interview on 1/16/25 at 2:10 P.M. the Director of Nursing (DON) said nail care should be completed on shower days and documented on the shower sheets or weekly skin checks. Review of facility's policy titled, Activities of Daily Living (ADLs), date implemented 9/7/22 revealed: Policy- the facility will, based on the resident's comprehensive assessment and consistent with the resident's needs and choices, ensure a resident's abilities and ADL's do not deteriorate unless deterioration is unavoidable. Care and services will be provided for the following activities of daily living: 1) bathing, dressing, grooming and oral care 2) transfer and ambulation 3) Toileting 4) Eating to include meals and snacks 5) Using speech, language or other functional communication systems. Policy explanation and compliance guidelines: 1) conditions which may demonstrate unavoidable decline in ADL include 1 a) natural progression of the resident's disease state with known functional decline. 1b) Deterioration of the resident's physical condition associated with the onset of an acute physical or mental disability while receiving care to restore or maintain functional abilities. 1c) Refusal of care and treatment by the resident or his/her representative to maintain functional abilities after efforts by the facility to inform and educate about the benefits/risks of the proposed care and treatment, council and our offer alternatives to the resident or representative. 2) the facility will provide a maintenance and restorative program to assist a resident in achieving and maintaining the highest practicable outcome based on the comprehensive assessment. 3) A resident who is unable to carry out activities of daily living will receive the necessary services to maintain good nutrition, grooming and personal and oral hygiene. 4) The facility will identify resident triggers through the Care Area Assessment (CAA) process to assess causal factors for decline, potential decline or lack of improvement. 5) The facility will maintain individual objectives of the care plan and periodic review and evaluation. 3. The DON stated the F-tag 686 was related to pressure ulcers and skin sweeps. She stated they performed skin sweeps on the entire building from 12/09/2024 t 12/13/2024. She stated they looked at the whole body. They educated the nurses on treatment services to prevent and heal pressure ulcers on 12/08/2024. They educated the staff that skin evaluations must be completed by a licensed nurse weekly, wounds must be evaluated weekly by an RN. The DON stated they educated the staff the medical provider must be contacted of a new skin impairment, and well as the resident and resident representative which includes change or addition of a treatment. The DON stated they are auditing 5 residents with wounds a week for 4 weeks. The DON stated they are auditing for process, skin checks completed, skin evaluations completed weekly, evidence of responsible party and medical provider notification. The DON stated she did the audits herself and visualized the dressings also. The DON stated she did not know what happened (dressings for Residents #39 and #40). The DON stated the ADON was re-educating the nursing staff on documentation process and following through with medical provider orders. The DON stated the nurse that documented she provided care for Resident #40 on 01/15/2025 stated, She did not have time to do the care. The DON stated the nurse stated she did not do the care on 01/15/2025 even though she documented she did. The DON stated they will continue to audit after the nurses have been re-educated. The DON stated they will discuss the audit frequency during the next ADHOC meeting with the team. Resident #39 was admitted on [DATE] and readmitted on [DATE]. Review of the admission record showed the diagnoses included nontraumatic chronic subdural hemorrhage, pneumonitis due to inhalation of food, acute respiratory failure, adult failure to thrive, Peripheral vascular disease, heart failure, dementia, and hypertension. Observation on 01/16/2025 (Thursday) at 10:28 a.m. of Resident #39 with Staff B, RN (Registered Nurse) and Staff C, CNA (Certified Nursing Assistant). Staff C, CNA was already in room with gloves in place, no gown. Staff B, RN entered room after applying gloves, no gown. Resident #39 was lying in bed. He had contractures of the lower extremities. Staff B and Staff C moved his blankets down and revealed his left heel dressing. The heel was wrapped in gauze and tape but was not dated. The heel dressing had a small amount of brownish draining on the heel area. The staff lowered the head of the bed and raised Resident #39's gown. His thigh had a dressing in place dated 01/13/2025 (Monday). The staff turned the resident onto his right side, toward Staff B. Resident #39's brief was opened, and the coccyx area was observable. The coccyx wound had no dressing applied. The coccyx area was a golf ball size open area. During the turning of the resident, Staff B, RN touched her gloved hand to her right sleeve, moving it up. The resident was placed back onto his back and the head was elevated. Staff B removed her gloves and hand sanitized. Staff B, RN stated he was on enhanced barrier (precautions). Staff B stated, I do not need to use a gown because I was not changing his dressings. When asked about touching his dressings, briefs, blankets, etc. stated she, I was not changing his dressings. Staff C, CNA was asked about the resident being on enhanced barriers, she just looked at the surveyor and had no response. Staff C stated if the resident was on enhanced barriers she should have had a gown on. During an interview on 01/16/2025 at 11:25 a.m. Staff D, RN, Unit Manager stated she verified the wound care for Resident #39. She stated the thigh dressing was to be done on Monday, Wednesday and Friday. She stated his coccyx wound was to be done daily. She stated the heel dressing was to be done daily. Staff D stated it (wound care) should have been done per the physician orders. Staff D, RN stated the negative outcomes could have included an increased size in pressure ulcer, worsening, infection, sepsis, not healing. Review of the physician orders showed cleanse coccyx with normal saline, apply calcium alginate and cover with superabsorbent border dressing daily as of 01/06/2025 cleanse left lateral thigh with normal saline, apply xeroform and border gauze 3 times a week, Monday, Wednesday and Friday as of 01/13/2025. Left heel, apply Santyl, xeroform, superabsorbent, and wrap with kerlix and apply zinc for peri-wound every shift as of 01/07/2025. Review of the January Treatment Administration Record (TAR) showed Cleanse coccyx with normal saline, apply calcium alginate and cover with superabsorbent border dressing daily as of 01/06/2025. The TAR showed the dressing was changed on 01/07/25, 01/08, 01/09, 01/10, 01/11, 01/12, 01/13, 01/14, 01/15/2025. The resident did not have a dressing on his coccyx during the observation. Cleanse left lateral thigh with normal saline, apply xeroform and border gauze 3 times a week, Monday, Wednesday and Friday as of 01/13/2025 (Monday). The thigh wound was observed dated 01/13/2025. Left heel, apply Santyl, xeroform, superabsorbent, and wrap with kerlix and apply zinc for peri-wound every shift as of 01/07/2025. The TAR showed the wound was performed on 01/07/25, 01/08, 01/09, 01/10, 01/11, 01/12, 01/13, 01/14, 01/15/2025. Review of the care plans showed Resident #39 was on Enhanced Barrier Precautions per CDC guidelines for Gastrostomy tube, wounds as of 04/14/2024. Interventions included but not limited to persons caring for the resident and providing high-contact resident care activities will require personal protective equipment (PPE), the use of gown and gloves. As of 4/17/2024. Clear signage will be posted on wall outside of room as of 07/01/2024. Resident #39 had a pressure ulcer located on the left heel stage 3 and coccyx stage 3. Decline in skin integrity is expected related to terminal condition as of 04/04/2024, revised on 12/27/2024. Interventions included but not limited to current treatment per order as of 04/04/2024. Document weekly: stage, length times width times depth, order, progress or lack of progress as of 04/04/2024. Notify MD and family for changes in wound status as of 04/04/2024. During an interview on 01/16/2025 at 11:25 a.m. Staff D, RN, Unit Manager stated she verified the wound care for Resident #39. She stated the thigh dressing was to be done on M-W-F. She stated his coccyx wound was to be done daily. She stated the heel dressing was to be done daily. Staff D stated it (wound care) should have been done per the physician orders. Staff D, RN stated the negative outcomes could have included an increased size in pressure ulcer, worsening, infection, sepsis, not healing. Resident #40 was admitted on [DATE] and readmitted on [DATE]. Review of the admission record showed diagnoses included cancer of the prostate, urinary catheter, hypertension, bladder-neck obstruction, and unspecified protein-calorie malnutrition. Observation on 01/16/2025 (Thursday) at 10:44 a.m. of Resident #40 with Staff D, RN. Staff D applied a gown and gloves after hand sanitizing. She entered the resident room and put his bed down and pulled up his gown. His suprapubic dressing was dated 01/13/2025 (Monday), there was drainage present on the dressing. Staff D placed his gown down and walked to the door. She removed her gloves and donned a new pair of gloves without hand sanitizing. She came back to the resident's bedside and pulled the cover up from his right lower extremity. His right heel was dressed, and it was dated 01/13/2025 (Monday). The resident stated his coccyx wound was healed and did not have a dressing. Staff D removed her gloves and gown and washed her hands. Review of the physician orders showed Cleanse right heel with normal saline, pat dry, apply xeroform, cover with border dressing every day as of 01/06/2025 to start on 01/07/2025 and discontinue as of 01/15/2025. Cleanse right heel with normal saline, pat dry, apply xeroform, cover with border dressing on Monday, Wednesday, Friday as of 01/13/2025 to start on 01/15/2025. Cleanse suprapubic catheter area with normal saline, pat dry, apply silver calcium alginate, cover with superabsorbent border dressing every day as of 01/06/2025 Review of the January 2025 TAR showed Cleanse right heel with normal saline, pat dry, apply xeroform, cover with border dressing every day as of 01/06/2025 to start on 01/07/2025 and discontinue as of 01/15/2025 showed performed on 01/07/25, 01/08, 01/09, 01/10, 01/11, 01/12, 01/13/25 Cleanse right heel with normal saline, pat dry, apply xeroform, cover with border dressing on Monday, Wednesday, Friday as of 01/13/2025 to start on 01/15/2025 (Wednesday), showed IA on 01/15/2025. Cleanse suprapubic catheter area with normal saline, pat dry, apply silver calcium alginate, cover with superabsorbent border dressing every day as of 01/06/2025 showed care performed on 01/16/25, 01/07, 01/08, 01/09, 01/10, 01/11, 01/12, 01/13, 01/14, 01/15/2025. Review of the care plans showed Resident #40 had a pressure ulcer care plan due to unstageable to right heel as of 04/02/2024. Interventions included but not limited to current treatment per order; document weekly: stage, length x width x depth, odor, progress or lack of progress; Notify MD and family. During on 01/16/25 at 11:12 a.m. Staff D, RN stated the heel was supposed to be dressed on Monday, Wednesday (01/15/2024) and Friday. Staff D, RN stated the nurse documented IA on the TAR which she does not know what that is. Staff D stated she would ask the nurse what that meant. Staff D stated the suprapubic dressing was to be performed daily and her nurse documented it was done. Staff D stated the nurse reported she did not have time to perform the care and told the next shift to do it. During an interview on 01/16/2025 at 12:04 p.m. the DON stated that the staff was to perform the wound care as per the medical provider order. The enhanced barrier precautions was to be performed during direct contact. 4. The DON stated F-777 related to reporting the x-ray results to the medical provider timely. She stated they used the same education and audits as for F-552. The DON stated she will re-talk about the process with the QAPI team. The DON stated they need to educate the nursing staff again to be the persons reporting the results and the ADON as the backup. Resident #37 was admitted on [DATE] and readmitted on [DATE]. Review of the admission record showed diagnoses included cellulitis of the lower limb, COPD (Chronic Obstructive Pulmonary Disease) diabetes, protein-calorie malnutrition, acute bronchitis due to rhinovirus, anemia, and atrial fibrillation. Review of the physician orders showed two view chest x-rays for congestion on 01/12/2025. Review of the Chest X-ray results were dated 01/12/2025 at 8:50 p.m. showed the conclusion was mild pulmonary vascular congestion. Review of the progress notes showed On 01/13/2025, radiology note showed chest x-ray negative. On 01/14/2025, Physician Assistant (PA) progress note showed on 01/14/2025 at 4:40 p.m., She (Resident #37) reports new onset cough. Primary obtained CXR (chest x-ray) which was negative. She has finished ABX (antibiotics) for cellulitis. She reports decreasing left leg pain. Denies chest pain, SOB (shortness of breath), dizziness. No other concerns at this time. Review of the care plans showed Resident #37 had a potential for complications of respiratory distress related to diagnoses of: COPD, history of Respiratory failure and current smoker Date Initiated: 11/10/2021 Created on: 11/10/2021 Revision on: 04/28/2024. Interventions included but not limited to Labs/diagnostics as ordered; notify physician of results Date Initiated: 11/10/2021 Created on 11/10/2021. Resident #38 was admitted on [DATE] and readmitted on [DATE]. Review of the admissions record showed diagnoses included but not limited to Parkinson's, acute and chronic respiratory failure, congestive heart failure, COPD, hypertension, atrial fibrillation. Review of the physician's orders showed portable 2 view chest x-ray for cough on 01/14/2025. Review of the chest x-ray dated 01/14/25 at 2:00 p.m. showed the cardiac silhouette and mediastinal contours are normal. The lungs are free of infiltrates and focal consolidations. Elevation of the right hemidiaphragm is noted. No pleural fluid or masses are noted. No pneumothorax is present. Conclusions: No acute intrathoracic disease process. Review of the progress notes showed On 01/14/2025 at 12:27 p.m., attending physician visits and orders a 2 view CXR (chest x-ray) for continued cough. Resident continues on ABT (antibiotics) for URI (upper respiratory infection) at this time to same. No s/sx (signs and symptoms) of adverse effects noted at this time. Review of the Infection Care Plan showed resident was on antibiotic therapy related to URI as of 01/10/2025. Interventions included but not limited to observe for worsening respiratory symptoms such as in[TRUNCATED]

Based on observation, record review, and interview, the facility failed to follow professional standards to help prevent the development and transmission of communicable diseases and infections related to 1. hand hygiene for three (#85, #93, and #104) of eight sample residents, 2. Personal Protective Equipment (PPE) use for one (#27) of one sampled resident, and 3. cleaning of equipment for two (#4 and #27) of eight sampled residents. Findings included: On 12/3/24 at 11:58 a.m., Staff U, Certified Nursing Assistant (CNA) was observed in Resident #27's room without PPE (gloves and gown) On 12/3/24 at 12:48 p.m., Staff P, RN, Staff U, CNA entered Resident's #27 providing direct care (repositioning) without wearing PPE (gowns and gloves). On 12/04/24 at 9:21 a.m., Staff U, CNA existed in Resident #27's room without wearing PPE. Staff U, CNA said she was assisting Resident #27 with personal care (brushing her hair). Review of Resident #27's admission record showed admitted , 11/2/2024. Review of Resident #27's, order summary report, active orders as of 12/4/24 revealed contact precautions for extended-spectrum beta-lactamase (ESBL) in the urine (Urinary Tract Infection). During an interview on 12/4/24 at 9:26 a.m. Staff U, CNA said she wore gloves and used the hand gel or washed her hands before providing resident care. During an interview on 12/4/24 at 10:30 a.m., Staff B, RN, Unit Manager (UM) said she expected staff to wear gloves, gowns, and masks for residents in contact precautions. During an interview on 12/4/24 at 9:05 a.m., the DON said she expected staff to clean their hands between residents. She said multi resident use items should be cleaned and disinfected between residents and staff were expected to follow the posted PPE signs. 2. On 12/4/24 at 8:12 a.m., during medication administration observation, Staff J, LPN entered Resident #27's room, administered medication, on return to the medication cart placed the used blood pressure cuff and stethoscope on top of the medication cart. The items were returned to the case and placed in the medication cart. During an interview on 12/4/24 at 9:01 a.m., Staff P RN said blood pressure cuffs should be cleaned between patient use. On 12/2/24 during meal delivery observation for Resident #104 and Resident # 85, staff did not offer to provide or assist with hand hygiene during tray delivery. On 12/2/24 at 11:42 a.m., in an interview with Resident #104 she said she did not clean her hands before eating lunch and staff never offered or assisted with hand hygiene prior to meals. On 12/2/24 at 11:47 a.m., in an interview with Resident # 85 she said she did not clean her hands before eating lunch and staff did not offer or assist with hand hygiene prior to meals. 3. On 12/4/24 at 9:18 a.m., Staff J, LPN prepared to administer Resident # 4's Victoza and Glargine-yfgn pen-injectors. The rubber septum was not disinfected with alcohol prior to piercing with the needle and administering the medications. After administering the medications Staff J, LPN placed the pen injectors without caps in her pocket and returned the medications to the medication cart. On 12/04/24 at 8:21 a.m., during Resident #93's medication administration observation, Staff J, LPN, removed gloves from the glove box while wearing gloves that had been in direct contact with the resident. At the Resident #93's bedside Staff J, LPN, exchanged gloves. Hand hygiene was not performed after removing gloves and before donning clean gloves. On 12/5/24 at 8:33 a.m., during an interview with the Infection Preventionist (IP), Staff K, RN, and the Regional Nurse Consultant, the DON said staff were expected to clean and disinfect blood glucose machines, and perform hand hygiene before and after glove use. Review of the facility's Infection Prevention and Control Program policy, date implemented, 8/25/22, revised 7/13/23 revealed the following: Policy: The facility has established and maintains an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections as per accepted national standards and guidelines. Definitions: Staff includes all facility staff direct and indirect care functions, .who provide care and services to residents on behalf of the facility . Policy Explanation and Compliance guidelines: 1) the designated infection preventionist is responsible for oversight of the program and serves as a consultant for our staff on infectious diseases .2) All staff are responsible for following all policies and procedures related to the program. 4) . Standard precautions: All staff shall assume that all residents are potentially infected or colonized with an Organism that could be transmitted during the course of providing resident care services. Hand hygiene shall be performed in accordance with our facilities established hand hygiene procedures. All staff shall use personal protective equipment PPE according to established facility policy governing the use of PPE. Licensed staff shall adhere to safe injection and medication administration practices, as described in relevant facility policies. A resident with an infection or communicable disease shall be placed on transmission-based precautions. Review of the Centers for Disease Control and Prevention (CDC) revealed .In the absence of manufacturers' instructions, non-critical medical equipment (e.g. stethoscopes, blood pressure cuffs .,) require cleansing followed by low- to intermediate-level disinfection, depending on the nature and degree of contamination. Ethyl alcohol or isopropyl alcohol . is often used to disinfect small surfaces (e.g., rubber stoppers of multiple-dose medication vials . and thermometers) and external surfaces of equipment (e.g., stethoscopes and ventilators). However, alcohol evaporates rapidly, which makes extended contact times difficult to achieve unless items are immersed, a factor that precludes its practical use as a large-surface disinfectant. Retrieved on 12/6/24 Cleaning of Medical Equipment

Based on observations, interviews, and record reviews, the facility failed to ensure residents and/or resident representatives, were informed and provided written notice of the right to accept or decline medical and surgical treatments to formulate an Advance Directive for ten residents (#68, #167, #1, #93, #15, #48, #76, #43, #168, and #57) out of forty-eight residents sampled. Findings included: 1. On 12/2/2024 1:00 p.m. Resident #167 was visited while in her room. Resident #167 stated she had been at the facility for rehabilitation services for about ten days and staff members had gone over her admission packet when she was admitted . Resident #167 stated related to her Advance Directive, I'm not sure I know what exactly that is, and is that related to the decision if I want emergency staff to keep my heart going if something happens to me? Resident #167 stated she was not sure all the involvement with the advance directive and felt staff did not explain it to her in detail. She stated she was her own decision maker and only remembers signing a document to support the admission packet was gone over with her. She stated she was not told about her rights to decline medical and surgical treatments during the admission process. Review of Resident #167's medical record revealed she was admitted to the facility on [DATE] for short term rehabilitation services. Review of the Advance Directive section on the face sheet revealed the resident was her own decision maker. Review of the Admission Minimum Data Set (MDS) assessment, dated 11/26/2024, revealed; (Section C. Cognition/Brief Interview Mental Status (BIMS) 15 of 15, which indicated the resident was able to speak with relation to her medical care and services and all other daily decisions). Review of the medical record, under the Evaluations section/tab revealed, SUN Advance Directives, dated 11/25/2024. The Advance Directive section revealed an acknowledgement section ( C ), indicating I have received copy of center's policies on Advance Directives and have been given the chance to ask questions regarding my rights to make decisions regarding my medical care. I understand that I have the right to refuse or accept medical and / or surgical treatment, and the right to formulate advance directives concerning my health care. Honoring resident choices requires providing the center with necessary and / or legal documentation appropriate for Advance Directives. This electronic form had a section for Resident signature, Representative signature, and Center representative signature. The Resident and Resident Representative section was blank and had no documentation to indicate the resident was provided with this information. The document was electronically signed by Staff W, who was the Social Service Assistant. On 12/4/2024 at 10:00 a.m. an interview with Staff C, Social Service Director (SSD) revealed all residents are to have Advance Directives reviewed during the admission process. She stated there was a signature of understanding page at the end of the admissions packet and this acknowledgement form is to show that a resident/resident representative understood and received the admission packet during the admission process. Staff C. stated the signature of understanding did not necessarily show a resident and/or resident representative was in full understanding of the Advance Directive rights. Staff C. provided a signature page from the admission packet that Resident #167 electronically signed on 12/3/2024, which was eleven days after she was admitted to the facility. Staff C agreed this signature page still did not reveal Resident #167 was provided with, and in full understanding of her advance directives rights. 2. On 12/2/2024 at 1:00 p.m. Resident #1 was interviewed while in her room. Resident #1 stated she had been at the facility for rehabilitation services for about a month and she did remember upon her admitted , staff members had gone over her admission packet. Resident #1 did not remember staff going over advance directives with her, but she remembered signing a sheet to show she received the admission packet. Resident #1 stated the Social Worker, or the staff who works with Social Services went through the packet very quickly and it was a lot of information to take in. Resident #1 stated she did know what Advance Directive rights were, but did not remember staff going over those rights with her. She stated she certainly did not remember staff explaining she had the right to decline medical services and outside services as part of her advance directive rights. Review of Resident #1's medical record revealed she was admitted to the facility on [DATE] for short term rehabilitation services. Review of the advance directives notes on the face page revealed Resident #1 was her own responsible party. Review of the admission Minimum Data Set (MDS) assessment, dated 11/10/2024, revealed; (Cognition/Brief Interview Mental Status BIMS - 15 of 15, which indicated the resident was able to speak to her daily decisions and medical care and services). Review of Resident #1's medical record to include the Miscellaneous tab/section, revealed, Authorization for Treatment while Residing at the Healthcare, dated 11/5/2024. Under the Resident/Responsible party signature section, it was documented; Verbal. The resident did not sign this authorization. It was only signed and dated by a staff witness on 11/5/2024. Under the Evaluations section/tab of the record revealed, SUN Advance Directives dated 11/5/2024. The Advance Directive section revealed an acknowledgement section ( C ), indicating I have received copy of center's policies on Advance Directives and have been given the chance to ask questions regarding my rights to make decisions regarding my medical care. I understand that I have the right to refuse or accept medical and /or surgical treatment, and the right to formulate advance directives concerning my health care. Honoring resident choices requires providing the center with necessary and /or legal documentation appropriate for Advance Directives. This electronic form had a section for Resident signature, Representative signature and Center representative signature. Resident and Resident Representative section was blank and had no documentation to indicate Resident #1 was provided with this information. The document was only electronically signed by the Staff C. On 12/4/2024 at 10:00 a.m. an interview was conducted with Staff C., SSD. Staff C. provided a signature page from the admission packet Resident #1 electronically signed on 11/7/2024, which was two days after she was admitted to the facility. Staff C. confirmed this signature page does not reveal Resident #1 was provided with, and in full understanding of her advance directive rights. 3. On 12/2/2024 at 2:00 p.m. Resident #15 was observed in her room and lying in bed with her Head Over Bed (HOB) approximately forty-five degrees. The resident stated she had been at the facility for many years. She stated admission process was too many years ago for her to remember in detail, but she was aware of what Advance Directives were. She stated she did not remember ever signing any paperwork to show she understood this right. Resident #15 confirmed over the past few years she had been readmitted at the facility after she was hospitalized . Resident #15 could not remember any staff going over her Advance Directive rights when she returned from the hospital visits. Resident #15 revealed though she has her daughter who makes her medical decisions, she (Resident #15) still would have and is part of her daily decision making to include advance directive. Review Resident #15's medical record revealed she was admitted to the facility on [DATE] and readmitted on [DATE]. Review of the advance directives section of the resident profile revealed Resident #15 had a Power of Attorney in place to make her medical decisions. Review of the current Quarterly Minimum Data Set (MDS) assessment, dated 10/11/2024, revealed: (Cognition/Brief Interview Mental Status - 15 of 15, which indicated the resident was interviewable and able to speak related to her care and services).; Review of Resident #15's medical record, under the Evaluation tab/section, it did not indicate a SUN Advance Directive. There was no evidence in the chart the resident or resident representative was informed of and offered Advance Directive information. There was no evidence in the medical record of any signature of understanding from the resident/representative related to this right. On 12/4/2024 at 1:00 p.m. an interview with Staff C., SSD. The SSD could not find documentation to support notification and receipt of Advance Directives with regards to Resident #15 4. On 12/2/2024 at 11:00 a.m. Resident #168 was interviewed related to his care and services and revealed he had been admitted at the facility for less than two weeks and he was at the facility for rehabilitation, with plans to return home. Resident #168 revealed he remembered the social worker going over his admission rights and admission packet the day or day after he was admitted . He revealed he signed a form to show he received information, but did not remember the Social Worker, or even the Admission's coordinator going over any Advance Directive rights. He confirmed he was not aware he could refuse outside medical treatment, or medical services, and or surgical treatments. He confirmed he did not sign any paperwork of understanding related to those rights. Review of Resident #168's medical record revealed he was admitted at the facility on 11/25/2024. Review of the advance directives section of the resident profile revealed Resident #168 was his own responsible party. Review of the current Admission Minimum Data Set (MDS) assessment, dated 11/29/2024, revealed; (Cognition/BIMS score - 15 of 15, which indicated the resident was able to speak related to his medical care and service). Under the Evaluations section/tab of the medical record revealed, SUN Advance Directives dated 11/29/2024. The Advance Directive section revealed an acknowledgement section ( C ), indicating I have received copy of center's policies on Advance Directives and have been given the chance to ask questions regarding my rights to make decisions regarding my medical care. I understand that I have the right to refuse or accept medical and/or surgical treatment, and the right to formulate advance directives concerning my health care. Honoring resident choices requires providing the center with necessary and / or legal documentation appropriate for Advance Directives. This electronic form had a section for Resident signature, Representative signature and Center representative signature. Resident and Resident Representative section was blank and had no documentation to indicate the resident was provided with this information. The document was electronically signed by Staff C. There was no documented evidence in the chart that Advanced Directives rights were acknowledged and signed for by Resident #168. 5. A review of Resident #43's Admission Record revealed an original admitted [DATE] and a re-admitted [DATE]. The Admission Record revealed diagnoses to include Chronic Obstructive Pulmonary Disease, unspecified, Hemiplegia and Hemiparesis following cerebral infarction affecting left non-dominant side, aphasia following cerebral infarction, muscle weakness (generalized), and Chronic Kidney Disease, Stage 2 (mild). The Admission Record revealed the following under Advance Directive, Code Status: Full Code. On 12/2/24 at 4:38 p.m., an interview with the Social Service Director revealed when a resident is initially admitted or readmitted to facility the 3008 form from the hospital is reviewed to determine the resident's Advance Directive choices. She stated the Advance Directive is explained to the residents through the admission packet. She stated the Advanced Directive are also discussed in care plan meetings. The Social Service Director stated she talked to resident about Advanced Directive. She stated the health care surrogate election and documents the family, or resident, already has is discussed. She stated a hard copy of Advanced Directive, such as Do Not Resuscitate (DNR), are kept in her office as well as in each unit nurses' station. The Social Service Director stated Advanced Directive information can be found in the resident's care plan and in the electronic medical record. She stated the Advanced Directive documents should be uploaded to the resident's electronic medical record. She stated once or twice a month she does an audit regarding Advanced Directives. The Social Service Director stated if the resident is a non-English speaker, then she uses a tablet the facility has with a translating service to discuss Advanced Directive rights. She stated if the resident is not able to make decisions due to their cognitive level, then Advanced Directives are discussed with the health care surrogate or Power of Attorney (POA). She stated if a resident comes to the facility with an Advanced Directive of, Full code, then she would speak to them about continuing with those wishes or if they wanted to make changes. The Social Service Director stated she was not sure if a signature page or acknowledgement regarding Advanced Directive is included in the admission packet. On 12/3/24 at 10:48 a.m., an observation of Resident #43 revealed she was lying down in bed. An interview with the resident revealed she does not recall advanced directive rights being discussed with her by facility staff. She confirmed she was told she has the right to refuse services. A review of Resident #43's evaluations revealed a document titled, SUN Advance Directives, with an effective date of 10/14/24 and an admitted [DATE]. A review of the document under, Acknowledgement, revealed no evidence of the Resident or Resident Representative's signature. Further review of the document revealed the Social Service Director's name next to the area which indicated, Center Representative Signature. A review of Resident #43's medical record revealed no evidence of acknowledgement of advanced directive, to include their right to formulate an advanced directive, or their right to accept/refuse medical or surgical treatment. A review of the resident's medical record revealed no documented evidence the facility provided Advance Directive information. 6. A review of Resident #76's Admission Record revealed an original admitted [DATE] and a re-admitted [DATE]. The Admission Record revealed diagnoses to include Type 2 Diabetes Mellitus with diabetic Polyneuropathy, muscle weakness (generalized), and moderate non-proliferative diabetic retinopathy without macular edema, bilateral. The Admission Record revealed the following under Advance Directive, Full Code. On 12/3/24 at 10:52 a.m., Resident #76 was observed ambulating herself in the wheelchair from the first floor nurses' station to the common room. An interview with the resident revealed a family member handled her medical decisions. She stated the advanced directive was discussed with her and most likely her family member as well. Resident #76 stated she did not recall signing a document to acknowledge advanced directive was discussed with her. A review of Resident #76's evaluations revealed a document titled, SUN Advance Directives, with an effective date of 11/25/24 and an admitted [DATE]. A review of the document under, Acknowledgement, revealed no evidence of the Resident or Resident Representative's signature. Further review of the document revealed the Social Service Director's name next to the area which indicated, Center Representative Signature. A review of Resident #76's medical record revealed no evidence of acknowledgement of advanced directive, to include their right to formulate an advanced directive, or their right to accept/refuse medical or surgical treatment. A review of the resident's medical record revealed no documented evidence the facility provided Advance Directive information. 7. A review of Resident #93's Admission Record revealed an initial admitted [DATE], original admitted [DATE], and a re-admitted [DATE]. The Admission Record revealed diagnoses to include acute myeloblastic leukemia, not having achieved remission, systemic lupus erythematosus, unspecified, muscle weakness (generalized), other specified soft tissue disorders, conversion disorder with seizures or convulsions, and Sjogren syndrome. The Admission Record revealed the following under Advance Directive, Code Status: DNR - Do Not Resuscitate. A review of Resident #93's Admission Agreement, on page 6, revealed an electronic acknowledgement from the resident and her representative. The document revealed no indication the signed agreement was related to Advance Directive discussion and acknowledgement. A review of Resident #93's medical record, under miscellaneous documents, revealed signed forms to include durable power of attorney, designation of a healthcare surrogate, and a living will. Resident #76's medical record revealed no evidence of acknowledgement of advanced directive, to include their right to formulate an advanced directive, or their right to accept/refuse medical or surgical treatment. A review of the resident's medical record revealed no documented evidence the facility provided Advance Directive information. On 12/5/24 at 2:16 p.m., an interview was conducted with the SSD, the Director of Nursing (DON), and Staff K, Registered Nurse (RN) Consultant. The SSD stated the Advanced Directive acknowledgement is in the resident's admission agreement. She stated in the admission agreement, there is a section related to Advanced Directive. The SSD stated the resident welcome packet also included Advanced Directive information. She stated during the review of the Admission Agreement the resident and/or resident representative are present. A review of page 14 of the Admission Agreement revealed it is the acknowledgment, and the signature page related to Advanced Directive. The RN consultant stated the document titled, Sunview evaluations, is what the facility used for the Advanced Directive Acknowledgement. She stated the use of the Sunview form is a fairly new process the facility started implementing in 11/2024. The SSD stated when the resident is initially admitted or readmitted , she reviews the code status. She stated she interviews the resident and asks them information related to choosing a health care surrogate, completing a living will, delegating a durable POA and if they have any prepared paperwork related to Advanced Directive. The SSD stated she offers assistance if residents do not have a healthcare surrogate or power of attorney in place. The SSD confirmed she reviewed and discussed Advanced Directive with residents, however, there is no evidence of the resident's signature or documentation that she did. She stated when she completes the Social Service Assessment, she includes in her documentation she reviewed Advanced Directive, but confirmed the residents did not sign the acknowledgement form. 8. During an interview on 12/02/2024 at 2:48 p.m., with Resident #57's family member (FM) he stated he is happy with the care his father is receiving and had no concerns. He stated he was unsure of any triggers regarding Resident #57's Post Traumatic Stress Disorder (PTSD). He stated the facility, and staff are good at handling his care. Review of Resident #57's admission record revealed an initial admitted [DATE] and a readmitted [DATE]. Resident #57 was admitted to the facility with diagnosis of major depressive disorder, moderate brief psychotic disorder, other specified anxiety disorders, unspecified mood affective disorder, PTSD and seizures. Review of the medical record under the Evaluation section did not indicate a SUN Advance Directive. There was no evidence in the chart the resident/resident representative was informed of and received information on Advance Directive. 9. Review of the Admission Record showed Resident #68's initial admitted to the facility was on 10/11/24. Resident # 68's diagnoses included chronic respiratory failure, Chronic Obstructive Pulmonary Disease, Diabetes Mellitus Type 2, Chronic Kidney Disease, atherosclerotic heart disease, and cardiac pacemaker. Review of Resident #68's Minimum Data Set (MDS), annual dated 10/15/24, Brief Interview for Mental Status (BIMS) revealed a score is 13 indicating, intact cognition. During an interview on 12/4/24 at 1:37 P.M., Resident # 68 was lying in bed, wearing nasal cannula and said he did not remember the facility discussing his right to accept or refuse medical treatment. A review of Resident #68's medical record on 12/2/24 and 12/3/24, revealed no signed acknowledgement of Advanced Directive were reviewed with Resident #68 or their resident representative. 10. Review of the Admission Record showed Resident #48's initial admitted to the facility was on 1/9/2020. Resident # 48's diagnoses included dementia, prostate cancer, heart disease, and Chronic Obstructive Pulmonary Disease (COPD). A review of Resident #48's medical record on 12/2/24 and 12/3/24, revealed no signed acknowledgement of Advanced Directive was reviewed with Resident #48 or the resident representative. Review of facility's policy titled, Residents' Rights Regarding Treatment and Advanced Directive, date implemented 12/1/2022 revealed the following: Policy: It is the policy of this facility to support and facilitate a resident's right to request, refused and or discontinue medical or surgical treatment and/to formulate an advanced directive. An advanced directive is a written instruction, such as a living will or durable power of attorney for health care, recognize under State law (whether statutory or as recognized by courts of the State), related to the provision of health care when the individual is incapacitated. Compliance Guidelines includes the following: 1) On admission, the facility will determine if the resident has executed an advanced directive, and if not, determine whether the resident would like to formulate an advance directive. 2) The facility will provide the resident or resident representative information, in a manner that is easy to understand, about the right to refuse medical or surgical treatment and formulate an advanced directive. 3) Upon admission, should the resident have an advanced directive, copies will be made and placed on the chart as well as communicated to the staff. 4) The facility will periodically assess the resident for decision-making abilities and approach the health care proxy or legal representative if the resident is determined not to have decision making capacities. 5) The facility will identify or arrange for an appropriate representative for the resident to serve as primary decision maker if the resident is assessed as unable to make relevant healthcare decisions. 6) The facility will define and clarify medical issues and present them to the resident or legal representative as appropriate. 7) During the care planning process, the facility will identify, clarify, and review with the resident or legal representative whether they desire to make changes related to any advanced directives. 8) Decisions regarding advanced directives and treatment will be periodically reviewed as part of the comprehensive care planning process, the existing care instructions and whether the resident wishes to change or continue these instructions. 9) Any decision making regarding the resident's choices will be documented in the resident's Medical record and communicated to the interdisciplinary team and staff responsible for the resident's care. 10) The facility will not discharge or transfer our resident should they refuse treatment either through an advanced directive are directly unless the criteria for transfer or discharge are otherwise met. 11) Should the resident refuse treatment of any kind, the facility will document the refusal in the residence chart. 12) The facility will not initiate or discontinue any other care based on refusal of care by the resident. 50570 50434 49227

Based on interview and record review the facility failed to notify the attending physician, resident, and /or resident representative about a change in condition related to radiology results for two residents (#37 and #38) out of three residents sampled. Findings included: 1. Resident #37 was admitted on [DATE] and readmitted on [DATE]. Review of the admission record showed diagnoses included cellulitis of the lower limb, COPD (Chronic Obstructive Pulmonary Disease) diabetes, protein-calorie malnutrition, acute bronchitis due to rhinovirus, anemia, and atrial fibrillation. Review of the physician orders showed two view chest x-rays for congestion on 01/12/2025. Review of the Chest X-ray results, dated 01/12/2025 at 8:50 p.m., showed the conclusion was mild pulmonary vascular congestion. Review of the progress notes showed the following: On 01/13/2025, radiology note chest x-ray negative. On 01/14/2025, Physician Assistant (PA) progress note, dated 01/14/2025 at 4:40 p.m., She (Resident #37) reports new onset cough. Primary obtained CXR (chest x-ray) which was negative. She has finished ABX (antibiotics) for cellulitis. She reports decreasing left leg pain. Denies chest pain, SOB (shortness of breath), dizziness. No other concerns at this time. Review of the care plans showed the following: Resident #37 had a potential for complications of respiratory distress related to diagnoses of: COPD, history of Respiratory failure and current smoker Date Initiated: 11/10/2021 Created on: 11/10/2021 Revision on: 04/28/2024. Interventions included but not limited to Labs/diagnostics as ordered; notify physician of results Date Initiated: 11/10/2021 Created on 11/10/2021. 2. Resident #38 was admitted on [DATE] and readmitted on [DATE]. Review of the admissions record showed diagnoses included Parkinson's, acute and chronic respiratory failure, congestive heart failure, COPD, hypertension, atrial fibrillation. Review of the physician's orders showed portable 2 view chest x-ray for cough on 01/14/2025. Review of the chest x-ray, dated 01/14/25 at 2:00 p.m., showed the cardiac silhouette and mediastinal contours are normal. The lungs are free of infiltrates and focal consolidations. Elevation of the right hemidiaphragm is noted. No pleural fluid or masses are noted. No pneumothorax is present. Conclusions: No acute intrathoracic disease process. Review of the progress notes showed the following: On 01/14/2025 at 12:127 p.m., attending physician visits and orders a 2 view CXR (chest x-ray) for continued cough. Resident continues on ABT (antibiotics) for URI (upper respiratory infection) at this time to same. No s/sx (signs and symptoms) of adverse effects noted at this time. Review of the Infection Care Plan showed the resident was on antibiotic therapy related to URI (upper respiratory infectin) as of 01/10/2025. Interventions included but not limited to observe for worsening respiratory symptoms such as increases SOB and report to MD. During an interview on 01/15/2025 at 2:19 p.m. the DON (Director of Nursing) verified Resident #37 did not have documentation in her chart verifying Resident #37 or her responsible party was aware of Resident #37's x-ray reports. The DON verified Resident #38 had no documentation the medical provider, the resident nor her responsible party had been notified of Resident #38's x-ray results. The DON stated she would expect to see documentation in the progress notes the medical providers and either the residents or responsible parties had been notified of the results. The DON stated the ADON (Assistant DON) was supposed to be auditing all x-ray and lab results and confirming the results had been notified to the medical provider or resident and responsible party. If the ADON was not here it was the UMs (Unit Manager's) responsibility. During an interview on 01/15/2025 at 2:40 p.m. with the DON and the ADON, the ADON stated she had called Resident #38's medical provider and informed the resident of the x-ray results this morning (01/15/2025) but did not document it in the medical record. The DON and the ADON verified Resident #37's x-ray results were available on 01/12/2025 (Sunday). They verified the medical provider knew about the x-ray results for Resident #37 on 01/14/2025 (Tuesday). The DON and ADON verified the x-ray results for Resident #37 came to the facility on [DATE] at 8:50 p.m. The DON and ADON confirmed the medical provider was not informed for 2 days of the x-ray results for Resident #37. The DON stated the nurse may not have wanted to inform the medical provider until the next day (01/13/2025 Monday). The DON stated the supervisor should have called the medical provider over the weekend (01/12/2025) due to the results of Resident #37's x-ray showed mild pulmonary vascular congestion. The DON stated she did not know right now why they (x-ray) fell through the cracks. The ADON stated she was off on Monday sick, and she was responsible for the audits. The ADON stated the UM makes the calls to the medical provider and resident or representative as needed. The ADON stated the UM was off on Tuesday, so no calls were made. During an interview on 01/16/2025 at 12:04 p.m. the DON stated she spoke with the attending physician for Resident #38. The DON stated the physician stated if an X-ray result was normal the facility could wait until the next business hours to report to the physician. If it (x-ray result) was abnormal, they should call the on-call person. The DON stated neither resident required new orders. The DON was informed her nurse s stated on interview they were responsible to inform the medical provider and resident or representative with the results. The DON agreed the nurses had not documented they had called the appropriate persons. The DON agreed the checkers (ADON and UMs) should have been double checking the results were informed to the appropriate persons not being the staff who was to having to provide the x-ray results. Review of the facility's policy titled, Notification of Changes, dated 09/07/22 showed the purpose of this policy is to ensure the facility promptly informs the resident, consults the residents of physician; and notifies, consistent with his or her authority, the residence representative when there is a change requiring notification. Compliance Guidelines: The facility must inform the resident, consult with the resident physician and or notify the residents family member or legal representative when there was a change requiring such notification. Circumstances require notification include: 2. Significant change in the resident's physical, mental or psychosocial condition such as deterioration and health, mental or psychosocial status. This may include: a. Life- threatening conditions, or B. Clinical complications. 3. Circumstances that require a need to alter treatment. This may include: a. New treatment. B. Discontinuation of current treatment due to: i. Adverse consequences. II. Acute condition. III. Exacerbation of a chronic condition. Additional considerations: 1. Competent Individuals: a. The facility must still contact the resident's physician and notify resident's representative, if known. B. A family that wishes to be informed would designate a member to receive calls. C. When resident is mentally incompetent, such a designated family member should be notified of significant changes in the resident's health status because the resident may not be able to notify them personally, especially in the case of sudden illness or accident. 2. Residents incapable of making decisions: a. The representative would make any decisions that have to be made. B. The resident should still be told what is happening to him or her. Review of the facility's policy titled, Provision of Physician Ordered Services, dated 8/25/2024, showed Policy, The purpose of this policy is to provide a reliable process for the proper and consistent provision of physician ordered services according to professional standards of quality. Policy Explanation and Compliance Guidelines: 3. Qualified nursing personnel will receive and review the diagnostic test reports or consults and communicate the results to the ordering Physician, physician assistant, nurse practitioner or clinical nurse specialist within 24 hours of receipt unless the reports fall outside of clinical reference ranges in accordance with facility policies and procedures for notification of a practitioner or per the ordering physician's orders. Ordering Provider will be notified of results upon receipt if deemed critical and/or require immediate attention. 4. Documentation of consultations, diagnostic tests, the results, and date/time of Physician notification will be maintained in the resident's clinical record.

Based on observation, record review, and interview, the facility failed to provide a safe, clean, home like environment on one (2nd floor) out of 2 floors observed. Findings include: An observation was made on 12/2/2024 at 10:00 am. in room [ROOM NUMBER] on the second floor. The bathroom was observed with a hole in one of the ceiling tiles. Further observation showed a section of the bathroom floor tiled lifted from the floor. On 12/2/2024 at 1:00 p.m., during an observation on the second floor, three residents were seen sitting in their wheelchairs next to grab rails/chair rails near the nursing station. The rails were observed with a separated section and sharp gaps with potential to cause injuries. Photographic evidence obtained. 49227 2. On 12/2/24 at 10:10 a.m., a portable air conditioner unit with an exhaust hose to the outside was observed in room [ROOM NUMBER]. The resident in the room said the portable air conditioner had been in her room since admission to the facility. On 12/3/24 at 11:16 a.m., the portable air conditioner unit in room [ROOM NUMBER] had a thick layer of grey dust coating the filter located on the back part of the machine. A layer of particles coated the inside of the white air conditioner portable exhaust hose. On 12/5/24 at 11:26 a.m., an observation and interview was conducted with Staff I, Licensed Practical Nurse (LPN), Unit Manager (UM) in the second-floor shower room. The grab bars in three of four shower stalls had various areas of reddish-brown flaky coating. The third shower stall contained a shower gurney with a blue foam pad. Staff I, LPN, UM confirmed the shower gurney was a multi-resident use equipment. The blue foam pad had an approximately five inches by 0.5-inch linear tear on the upper half. Staff I, LPN, UM said a replacement foam pad for the shower gurney would be ordered. Photographic Evidence Obtained. On 12/5/24 at 5:02 p.m., a facility tour was conducted with the Nursing Home Administrator (NHA), Maintenance Director, and the Regional Maintenance Director (RMD). The Maintenance Director said the portable air conditioner unit would be removed. When shown the dust on the filter and in the tubing, he said I see. After observation of the rusted grab bars in the shower room the Maintenance Director said, that's an easy fix. Review of a facility's policy titled Safe and Homelike Environment, implementation date not documented revealed: In accordance with resident's rights, the facility will provide a safe, clean, comfortable and home light environment, allowing the resident to use his or her personal belongings to the extent possible. This includes ensuring that the resident can receive care and services safely and that the physical layout of the facility maximizes residence independence and does not pose a safety risk. Comfortable and safe temperature levels mean that the ambient temperature should be in a relatively narrow range that minimizes residents' susceptibility to loss of body heat and risk of hypothermia hyperthermia and is comfortable for the residents. Comfortable sound levels means levels that do not interfere with the residents hearing, levels that enhance privacy when privacy is desired, and levels that encourage interaction when social participation is desired. Environment refers to any environment in the facility that is frequented by residents, including (but not limited to) the residents' room, bathrooms, hallways, dining areas, lobby, outdoor patios, therapy areas and activity areas. A home like environment is one that de-emphasizes the institutional character of the setting, to the extent possible, and allows the resident to use those personal belongings that support a home like environment. A determination of home like should include the resident's opinion of the living environment. Orderly is defined as an uncluttered physical environment that is neat and well kept. Sanitary includes, but is not limited to, preventing the spread of disease- causing organisms by keeping resident care equipment clean and properly stored. Resident care equipment includes, but is not limited to equipment used in the completion of activities of daily living. Policy explanation guidelines includes: 1) the facility will create and maintain, to the extent possible, a home like environment and de-emphasize the institutional character of the setting. 1a) the facility will allow residents to use their personal belongings, including furnishings and clothing ( as space permits) to assist in creating and maintaining a home like environment. This use must not infringe upon the rights or health and safety of other residents. 1b) The social service designee, or another designated staff member, will encourage residents and their family to bring in personal belongings (within space constraints) to personalize residents' rooms. 1c) the facility will honor and document a resident's choice not to personalize his/her room. 2) The facility exercises reasonable care for the protection of the residents property from loss or theft. 3) housekeeping and maintenance services will be provided as necessary to maintain a sanitary, orderly and comfortable environment. 4) The facility will provide and maintain bed and bath linens that are clean and in good condition. 5) The facility will provide sufficient individual closet space in each resident room. 6) the facility will provide and maintain adequate and comfortable lighting levels in all areas. 6a) The maintenance director will perform periodic rounds to ensure functioning lights. 6b) Even light levels should be utilized in common areas and hallways to avoid patches of low light. 6c) Daylight should be utilized as much as possible. 7. The facility will maintain comfortable and safe temperature levels. 7a) the facility should strive to keep the temperature in common resident areas between 71 F and 81 F. 7b) if and when a resident prefers his or her room temperature be kept below 71 F or above 81 F, the facility will assess the safety of this practice on the resident and the resident's roommate. 7c) if and when residents who share a room do not agree on the temperature of the room, the facility will assist in negotiating a compromise that the residents agree on, or will assist in a room change. 8) The facility will maintain comfortable sound levels in the facility. Overhead paging will be limited to emergency situations and as needed for providing prompt care and treatments of residents.

Based on record review and interviews, the facility failed to ensure the Preadmission Screening and Resident Review (PASARR) were completed accurately and updated to reflect new Mental Illness (MI), or Suspected Mental Illness (SMI) diagnoses for five residents (#51, #66, #75, #57, and #69) of forty-nine sampled residents. Findings included: 49227 1. Review of Resident #51's Admission Record showed an admitted [DATE], with diagnoses to include bipolar disorder, major depressive disorder, and claustrophobia. Review of Resident #51's Level I PASRR, dated 7/29/2024, showed the following: - Section I-Part A. MI (Mental Illness) or suspected MI: Bipolar and Depressive Disorder were marked. Part B. ID (Intellectual disability) or suspected ID was blank. - Section II: Other Indications for PASRR Screen Decision-Making: Questions 1 through 7 were marked no. - Section III: PASRR Screen Provisional Admission or Hospital Discharge Exemption: Not a Provisional Admission was marked. - Section IV: PASRR Screen Completion: Individual may be admitted to a Nursing Facility (check one of the following): No diagnosis or suspicion of Serious Mental Illness or Intellectual Disability indicated. Level II PASRR evaluation not required was marked. During a review of Resident #51's electronic health records, a Level II PASARR could not be located. 2. Review of Resident #66's Admission Record showed an admitted [DATE], with diagnoses to include alcohol abuse, major depressive disorder, and anxiety disorder. Review of Resident #66's Level I PASRR, dated 11/29/2024, showed the following: - Section I-Part A. MI (Mental Illness) or suspected MI: Depressive Disorder and Substance Abuse were marked. Part B. ID (Intellectual disability) or suspected ID, was blank. - Section II: Other Indications for PASRR Screen Decision-Making: Questions 1 through 7 were marked no. - Section III: PASRR Screen Provisional Admission or Hospital Discharge Exemption: Not a Provisional Admission was marked. - Section IV: PASRR Screen Completion: Individual may be admitted to a Nursing Facility (check one of the following): No diagnosis or suspicion of Serious Mental Illness or Intellectual Disability indicated. Level II PASRR evaluation not required was marked. During a review of Resident #66's electronic health records a Level II PASARR could not be located. On 12/03/2024 at 4:38 p.m. a request was made to the Social Services Director (SSD) for copies of resident #51 and #66's Level II PASARRs. On 12/4/2024 the SSD provided resident #51 and #66's Level I PASARRs and Level II PASARRs were not provided. On 12/5/2024 at 1:34 p.m. an interview was conducted with the Director of Nursing (DON), SSD, and Regional Clinical Nurse (RNC). The SSD confirmed Level II PASARRs were not available for residents #51 and #66. 50434 3. During an observation on 12/3/2024 at 8:50 a.m., Resident #75 was heard screaming Help from her room. During an observation on 12/04/2024 9:55 a.m., Resident #75 was heard screaming from her room. Review of Resident #75's Admission Record showed Resident #75 was initially admitted on [DATE] and a readmitted [DATE] with diagnoses of unspecified dementia, unspecified severity with agitation, bipolar disorder, current episode manic without psychotic features, and major depressive disorder, recurrent. Review of Resident #75's Level I PASRR, dated 11/26/2024, showed the following: - Section I-Part A: MI (Mental Illness) or suspected MI: Bipolar and Depressive disorder were marked. Part B. ID (Intellectual disability) or suspected ID, was blank. - Section II: Other Indications for PASRR Screen Decision-Making: Questions 1 through 7 were marked no. - Section III: PASRR Screen Provisional Admission or Hospital Discharge Exemption: Not a Provisional Admission was marked. - Section IV: PASRR Screen Completion: Individual may be admitted to a Nursing Facility (check one of the following): No diagnosis or suspicion of Serious Mental Illness or Intellectual Disability indicated. Level II PASRR evaluation not required was marked. 4. During an interview on 12/2/2024 at 2:48 p.m. with Resident #57's family member (FM), he stated he is happy with the care his father is receiving and had no concerns. He stated he was unsure of any triggers regarding resident #57's Post Traumatic Stress Disorder (PTSD) and the facility, and staff are good at handling his care. Review of Resident #57's Admission Record revealed an initial admitted [DATE] and a readmitted [DATE]. Resident #57 was admitted to the facility with diagnosis of major depressive disorder, moderate brief psychotic disorder, other specified anxiety disorders, unspecified mood affective disorder, post-traumatic stress disorder and seizures. Review of the Level I PASRR, dated 3/14/2022, showed the following: - Section I-Part A MI (Mental Illness) or suspected MI (Mental Illness): major depressive disorder, moderate brief psychotic disorder, other specified anxiety disorders, unspecified mood affective disorder, post-traumatic stress disorder, and seizures, were not marked. Part B. ID (Intellectual disability) or suspected ID (Intellectual disability) was blank. - Section II: Other Indications for PASRR Screen Decision-Making: Questions 1 through 7 were marked no. - Section III: PASRR Screen Provisional Admission or Hospital Discharge Exemption: Not a Provisional Admission was marked. - Section IV: PASRR Screen Completion: Individual may be admitted to a Nursing Facility (check one of the following): No diagnosis or suspicion of Serious Mental Illness or Intellectual Disability indicated. Level II PASRR evaluation not required was marked. 46498 5. Review of Resident #69's Admission Record showed Resident #69 was admitted to the facility on [DATE] with diagnoses to include but not limited to encephalopathy, unspecified, unspecified dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety, major depressive disorder recurrent, moderate, and bipolar disorder, current episode depressed, mild. Review of a Document titled Florida Preadmission Screening and Resident Review (PASRR) Level II Determination Summary Report Administrative Closure dated 8/22/2024 showed Resident #69's review was closed due to the facility submitting an incomplete referral packet. On 12/5/2024 at 1:58 p.m. an Interview was conducted with Staff Z, Registered Nurse (RN) and 3 p.m. to 11 p.m. Supervisor. Staff Z, RN stated a Level II Preadmission Screening and Resident Review was submitted for Resident #69. The resident was triggered for a Level II due to her diagnoses. Staff Z, RN stated she reached out to KePRO regarding the Level II PASRR and was told she had to resubmit paperwork due to the lack of information submitted the first time. She stated she reached out to KePRO a while back but did not hear back from them. Review of the facility policy titled Resident Assessment - Coordination with PASARR Program, last revised on 12/20/2023, showed under the section titled Policy, this facility coordinates assessments with the preadmission screening and resident review (PASARR) program under Medicaid to ensure that individuals with a mental disorder, intellectual disabilities, or a related condition received cares and services in the most integrated sitting appropriate to their needs. The policy also showed under the section titled Policy Explanation and Compliance Guidelines, 1. All applicants to this facility will be screened for serious mental disorders or intellectual disabilities and related conditions in accordance with the State's Medicaid rules for screening. 6. The Social Services Director will be responsible for keeping track of each resident's PASARR screening status and referring to the appropriate authority. 9. Any resident who exhibits a newly evident or possible serious mental disorder, intellectual disability, or related condition will be referred promptly to the state mental health or intellectual disability authority for a Level II resident review.

Based on observation, record review, and interview, the facility failed to ensure the medication error rate was less than 5%. Twenty-eight medication administration opportunities were observed, and seven errors were identified for four residents (#4, #15, #68 and #93) of eight residents observed. These errors constituted a medication error rate of 25%. Findings Included: 1. On 12/04/24 at 7:28 a.m., during medications administration observation with Staff P, Registered Nurse (RN), Staff P administered Fiasp FlexTouch (insulin aspart) 30 units subcutaneously (SQ) to Resident #15. Review of Resident's #15's order summary report, active orders as of 12/4/24 revealed orders to include Fiasp FlexTouch 15 unit subcutaneously in the morning for (Diabetes Mellitus (DM) and Fiasp FlexTouch 15 unit subcutaneously with meals for DM. At the time Staff P administered Fiasp FlexTouch 30 units SQ Resident #15 was not eating, and meal trays were not being served. 2. On 12/4/24 at 8:21 a.m. during medications administration observation with Staff J, Licensed Practical Nurse (LPN), Staff J administered the following medications to Resident #93: Furosemide 20 mg Hydroxyurea 500 mg Levetiracetam 500 mg Metoprolol 25 mg Multiple Vitamins with Minerals 1 tab Omeprazole 20 mg Timolol Maleate Ophthalmic Solution 1 drop in each eye. Review of Resident #93's order summary report, active orders as of 12/4/24 revealed the following orders: Furosemide 20 mg Hydroxyurea 500 mg Levetiracetam 500 mg Metoprolol 25 mg Multiple Vitamins with Minerals 1 tab Omeprazole 20 mg Timolol Maleate Ophthalmic Solution 1 drop in each eye Cholecalciferol 125 mcg Eliquis 2.5 mg Fluticasone Nasal Spray 1 inhalation in nostrils. Review of the Medication Administration Record revealed Staff J, LPN initialed the record, indicating Cholecalciferol 125 mcg, Eliquis 2.5 mg, and Fluticasone Nasal Spray 1 inhalation in nostrils was administered. The administration of Cholecalciferol 125 mcg, Eliquis 2.5 mg, and Fluticasone Nasal Spray 1 inhalation in nostrils was not observed. During an interview on 12/4/24 at 1:28 p.m. with the Director of Nursing (DON), Regional Nurse Consultant (RNC) and Staff J, Staff J confirmed she did not administer all the medications initialed on the Medication Administration Record as administered. 3. On 12/4/24 at 9:18 a.m., during medications administration observation with Staff J, Staff J administered Victoza Pen-injector Inject 1.2 mg SQ and Insulin Glargine-yfgn pen-injector Inject 30-unit SQ to Resident #4. Prior to administration Staff J failed to use the proper technique of priming [procedure to ensure the correct dose is administer] the insulin pens prior to administration. Review of Resident #4's order summary report, active orders as of 12/4/24 showed orders to include: Victoza Subcutaneous Solution Pen-injector 18 MG/3ML (Liraglutide) Inject 1.2 mg subcutaneously one time a day related to Type 2 DM with unspecified diabetic retinopathy with macular edema and Insulin Glargine-yfgn 100 unit/ml Solution pen-injector Inject 30 unit subcutaneously two times a day related to Type 2 DM with unspecified diabetic retinopathy with macular edema. During an interview on 12/04/24 at 9:43 a.m., Staff J said she did not know insulin pens should be primed prior to medication administration. During an interview on 12/4/24 at 1:28 p.m. with the DON and the RNC, the DON said the expectation was for insulin pens to be primed before administration. 4. On 12/04/24 at 1:01 p.m., Staff R, LPN was observed administrating medications to Resident #68. Staff R said all medications due to be administered at 2:00 p.m. had been administered. On 12/04/24 at approximately 1:40 p.m., the medication order reconciliation review showed Staff R documented administration of Ipratropium-Albuterol Solution 0.5-2.5 three ml by nebulizer to Resident #68. During an interview on 12/4/24 at 1:52 p.m. with the DON and Resident #68, Resident #68 said he had not received a breathing treatment for more than 24 hours. During an interview on 12/04/24 at 3:34 p.m. with the DON and the RNC, the RNC said Staff R admitted he had not administered Ipratropium-Albuterol Solution as documented on the Medication Administration Record. Review of a facility's policy titled, Liberalized and Standardized Medication Administration Schedules revealed the following: Policy: in keeping with our philosophy of person-centered care and resident rights, medications will be delivered in a manner that is least restrictive and intrusive while allowing for optimal therapeutic effect of medications.time sensitive medications are medications with a narrow therapeutic index or medications that require specific administration times for clinical safety and efficacy . Medications are considered timely as long as they are administered within one hour before or after the standard administration time . a list of suggested time sensitive medications are .insulins . Review of a facility's policy titled, Administration of Injections, date implemented 1/22/23, revealed the following: Policy: Injections are administered by licensed nurses as ordered by the physician and in accordance with professional standards of practice.

Based on observations, interviews, and record review, the facility failed to ensure the Quality Assessment and Assurance (QAA) Committee developed and implemented an effective Quality Improvement and Performance action plan, to correct deficient practice identified during a recertification survey conducted on 12/2/24 to 12/5/25, related to citations at F 552, F 677, F 686, F 777, and F 880. Findings included: Review of the facility's policy, Quality Assurance and Performance Improvement (QAPI), dated 08/25/2022, showed the following: It is the policy of this facility to develop, implement, and maintain an effective, comprehensive, data-driven QAPI program that focuses on indicators of the outcomes of care and quality of life and addresses all the care and unique services the facility provides. Policy Explanation and Compliance Guidelines: 1. The QAPI program includes the establishment of a Quality Assessment and Assurance (QAA) Committee and a written QAPI plan. 3. the QAPI plan will address the following elements: C. Process addressing how the committee will conduct activities necessary to identify and correct quality deficiencies. Key components of this process include, but not limited to, the following: i. Tracking and measuring performance ii. Establishing goals and thresholds for performance improvements. Iii. Identifying and prioritizing quality deficiencies. Iv. Systematically analyzed and underlying causes of systemic quality deficiencies. V. Developing and implementing corrective action or performance improvement activities. VI. Monitoring and evaluating the effectiveness of corrective action / performance improvement activities and revisiting as needed. D. The prioritization of program activities that focus on resident safety, health outcomes, autonomy, choices and quality of care, as well as high-risk, high-volume, or problem-prone areas as identified in the facility assessment that reflects the specific units, programs, departments and unique population the facility serves the facility must also consider the incidents, prevalence and severity of problems or potential problems identified. F. Process to ensure care and services delivered meet accepted standards of quality. Program Development Guidelines: 1. Program design and scope--- a. the QAPI program will be ongoing, comprehensive, and will address the full range of care and services provided by the facility. 4. Program activities---a. All identify problems will be addressed and prioritized, whether by frequency of data collection, monitoring or by the establishment of sub-committees. Considerations include, but are not limited to: i. high- risk, high-volume, or problem-prone areas. ii. Incidence, prevalence, and severity of problems in those areas. iii. Measures affecting resident health, safety, autonomy, choice and quality of care. During an interview on 01/16/2025 at 2:05 p.m. the Nursing Home Administrator (NHA) and the DON stated they had an ADHOC (a meeting called suddenly to discuss a pressing issue) on 12/20/2024 after receiving the Statement of Deficiencies. They stated they reviewed the citations to match the education they had already started after the exit of the survey on 12/06/2024. They stated they adjusted the audit tools they had already created. They stated they determined the frequency of the audits. They discussed the findings with the Medical Director over the phone on 12/20/2024. They validated the Plan of Correction binders were prepared. The NHA left the interview and the DON continued with the interview. 1. The DON stated the F-tag 552 was related to Change in Condition notifications to the resident and resident representatives associated with x-ray results. The DON stated they educated the staff on change in condition which included the policy of notification of changes. The DON stated they started the education with the licensed staff on 12/16/2024 and completed it on 01/03/2025. The DON stated they did a look back of 30 days of labs and x-rays to ensure all had been reported to the medical providers, residents and families. The DON stated the audit did not show if they had to update anyone or not. The DON stated the ADON was to review the x-ray results to ensure the medical provider, resident and resident representative was notified. The DON stated the ADON took ownership and was responsible for the audits, Monday through Friday. The ADON was to give any results that needed to be reported to the Unit Managers for follow-up. The Unit Manager was to report or ensure the floor nurse had reported the results. The DON stated the ADON was supposed to be checking behind the staff to ensure the results were being reported. The DON stated the ADON was sick Monday (01/13/2025) and did not review and the when she returned on Tuesday (01/14/2025), the Unit Manager was off, so the labs were not reported to the appropriate people. The DON stated the ADON cannot be solely responsible. The DON stated the ADON was the checker and the floor nurse needs to notify all parties. The DON stated they would re-educate the staff regarding notifications for change in conditions. Resident #37 was admitted on [DATE] and readmitted on [DATE]. Review of the admission record showed diagnoses included cellulitis of the lower limb, COPD (Chronic Obstructive Pulmonary Disease) diabetes, protein-calorie malnutrition, acute bronchitis due to rhinovirus, anemia, and atrial fibrillation. Review of the physician orders showed two view chest x-rays for congestion on 01/12/2025. Review of the Chest X-ray results were dated 01/12/2025 at 8:50 p.m. showed the conclusion was mild pulmonary vascular congestion. Review of the progress notes showed On 01/13/2025, radiology note showed chest x-ray negative. On 01/14/2025, Physician Assistant (PA) progress note showed on 01/14/2025 at 4:40 p.m., She (Resident #37) reports new onset cough. Primary obtained CXR (chest x-ray) which was negative. She has finished ABX (antibiotics) for cellulitis. She reports decreasing left leg pain. Denies chest pain, SOB (shortness of breath), dizziness. No other concerns at this time. Review of the care plans showed Resident #37 had a potential for complications of respiratory distress related to diagnoses of: COPD, history of Respiratory failure and current smoker Date Initiated: 11/10/2021 Created on: 11/10/2021 Revision on: 04/28/2024. Interventions included but not limited to Labs/diagnostics as ordered; notify physician of results Date Initiated: 11/10/2021 Created on 11/10/202. Resident #38 was admitted on [DATE] and readmitted on [DATE]. Review of the admissions record showed diagnoses included but not limited to Parkinson's, acute and chronic respiratory failure, congestive heart failure, COPD, hypertension, atrial fibrillation. Review of the physician's orders showed portable 2 view chest x-ray for cough on 01/14/2025. Review of the chest x-ray dated 01/14/25 at 2:00 p.m. showed the cardiac silhouette and mediastinal contours are normal. The lungs are free of infiltrates and focal consolidations. Elevation of the right hemidiaphragm is noted. No pleural fluid or masses are noted. No pneumothorax is present. Conclusions: No acute intrathoracic disease process. Review of the progress notes showed On 01/14/3025 at 12:127 p.m., attending physician visits and orders a 2 view CXR (chest x-ray) for continued cough. Resident continues on ABT (antibiotics) for URI (upper respiratory infection) at this time to same. No s/sx (signs and symptoms) of adverse effects noted at this time. Review of the Infection Care Plan showed resident was on antibiotic therapy related to URI as of 01/10/2025. Interventions included but not limited to observe for worsening respiratory symptoms such as increases SOB and rpt to MD. During an interview on 01/15/2025 at 2:19 p.m. the DON (Director of Nursing) verified Resident #37 did not have documentation in her chart verifying Resident #37 or her responsible party was aware of Resident #37's x-ray reports. The DON verified Resident #38 had no documentation the medical provider, the resident nor her responsible party had been notified of Resident #38's x-ray results. The DON stated she would expect to see documentation in the progress notes the medical providers and either the residents or responsible parties had been notified of the results. The DON stated the ADON (Assistant DON) was supposed to be auditing all x-ray and lab results and confirming the results had been notified to the medical provider or resident and responsible party. If the ADON was not here it was the UM's (Unit Manager's) responsibility. During an interview on 01/15/2025 at 2:40 p.m. with the DON and the ADON, the ADON stated she had called Resident #38's medical provider and informed the resident of the x-ray results this morning (01/15/2025) but did not document it in the medical record. The DON and the ADON verified Resident #37's x-ray results were available on 01/12/2025 (Sunday). They verified the medical provider knew about the x-ray results for Resident #37 on 01/14/2025 (Tuesday). The DON and ADON verified the x-ray results for Resident #37 came to the facility on [DATE] at 8:50 p.m. The DON and ADON confirmed the medical provider was not informed for 2 days of the x-ray results for Resident #37. The DON stated the nurse may not have wanted to inform the medical provider until the next day (01/13/2025 Monday). The DON stated the supervisor should have called the medical provider over the weekend (01/12/2025) due to the results of Resident #37's x-ray showed mild pulmonary vascular congestion. The DON stated she did not know right now why they (x-ray) fell through the cracks. The ADON stated she was off on Monday sick, and she was responsible for the audits. The ADON stated the UM makes the calls to the medical provider and resident or representative as needed. The ADON stated the UM was off on Tuesday, so no calls were made. During an interview on 01/16/2025 at 12:04 p.m. the DON stated she spoke with the attending physician for Resident #38. The DON stated that the physician stated that if an X-ray result was normal the facility could wait until the next business hours to report to the physician. If it (x-ray result) was abnormal, they should call the on-call person. The DON stated that neither resident required new orders. The DON was informed her nurse s stated on interview that they were responsible to inform the medical provider and resident or representative with the results. The DON agreed the nurses had not documented they had called the appropriate persons. The DON agreed the checkers (ADON and UMs) should have been double checking the results were informed to the appropriate persons not being the staff who was to having to provide the x-ray results. 2. Review of education/ in-service attendance log, provided by the ADON, dated 12/5/24, with objectives related to nail care/shaving included the following information: staff must ensure that resident nails are clipped and cleaned underneath, failure to properly trim and clean resident nails can lead to health issues, Certified Nursing Assistants (CNAs) and nurses can clip resident's fingernails. CNAs are not allowed to clip the nails of residents who are diabetic, Patient Care Assistants (PCA) cannot clip fingernails but can file it. The signature page included the signatures of 110 staff members. Review of a resident census report, undated, showed a full audit was complete and done. Review of audit, dated 1/8/25, related to observations of ADLs related to shaving and nail care. The ongoing monitoring included quality review of five residents related to shaving and nail care, weekly for four weeks, then monthly for two months or until substantial compliance. Ten residents were observed for clean and trimmed nails, all residents were in compliance. Review of the Admission Record showed Resident # 56's initial admitted to the facility was on 8/7/23. Review of Resident #56's annual Minimum Data Set (MDS), dated [DATE], showed a Brief Interview for Mental Status (BIMS) score of 3 which indicated severe cognitive impairment. Section GG, functional abilities showed Resident #56 required supervision or touching assistance with shower/bath and was independent with personal hygiene. Review of the ADL care plan showed a focus for Resident #56, as follows: Has Activities of Daily Living (ADL) performance deficit related to Alzheimer's, dementia, musculoskeletal impairment, pain and history of a stroke, date initiated 8/14/23. The care plan's goal was Resident #56 will maintain current level of function through the review date. The interventions included checking nail length and trim and clean on bath day and as necessary. Report any changes to the nurse. On 1/15/24 at 10:40 A.M. during interview and observation, Resident #56 was observed sitting in his wheelchair and said he did not like the length of his fingernails [it is] hard to pick up a spoon. His nails were approximately 1/8 inch in length. (Photographic evidence obtained with permission of resident). Review of Resident #56's task, titled: GG-Shower/Bathe self, showed on 1/6/25 supervision or touching assistance was provided. On 1/9/24 Resident #56 was independent with the task. Review of the Admission Record showed Resident # 55's initial admitted to the facility was on 2/29/24. Review of Resident #55's quarterly Minimum Data Set (MDS) dated [DATE], showed a Brief Interview for Mental Status (BIMS) score of 13 which indicates intact cognition. Section GG, functional abilities showed Resident #55 is dependent (helper does all the effort) for shower/bathe self and required substantial /maximal assistance with personal hygiene. Review of the ADL care plan showed a focus for Resident #55, as follows: Has and ADL self-care performance deficit related weakness, adult failure to thrive, cognitive deficit, depression and anxiety and requires maximum to dependent ADLs. Decline is expected related to terminal condition. The care plan goal was Resident #55 will maintain current level of function through the review date, created on 3/4/24. The care plan's goal was Resident #55 will maintain current level of function through the review date. The interventions included the resident required assistance by one staff with personal hygiene and personal care On 1/16/24 at 10:56 A.M. during interview and observation, Resident #55 was observed lying in bed, and said he would like to have his fingernails trimmed. His fingernails were approximately 1/4 inch in length, yellowing, with dry gray and yellow substance between the nail and nail bed. Resident #55 said he prefers bed baths. Review of Resident #56's task, titled: GG-Shower/Bathe self, showed daily between 1/10/25 and 1/16/25 he was dependent (helper does all the effort) with completing this task. Review of the Admission Record showed Resident # 57's initial admitted to the facility was on 6/16/22. Review of Resident #57's quarterly Minimum Data Set (MDS) dated [DATE], showed a Brief Interview for Mental Status (BIMS) score of 3 which indicated severe cognitive impairment. Section GG, functional abilities showed Resident #57 required substantial/ maximal assistance with shower/bath and required supervision or touching assistance with personal hygiene. Review of the ADL care plan showed a focus for Resident #57, as follows: Has Activities of Daily Living (ADL) performance deficit related to confusion, dementia, visual deficits, depression and anxiety created on 6/18/22. The care plan's goal was Resident #57 will maintain current level of function through the review date. The interventions included checking nail length and trim and clean on bath day and as necessary. Report any changes to the nurse. Resident #57 required assistance by 1 staff with personal hygiene and oral care. On 1/15/24 at 10 :30 A.M. during an interview and observation Resident #57's fingernails were approximately 1/8 inch in length, under the nails contained large amount of dry dark gray and black substances, and the edges between the finger and fingernail contained caked on brownish and black substances. (Photographic evidence obtained with resident permission). Review of Resident #57's task, titled: GG-Shower/Bathe self, showed daily between 1/10/25-1/14 the resident was dependent (helper does all the effort) for this task. During a group interview on 1/15/24 at 2:49 P.M. Certified Nursing Assistants (CNA) said they were recently provided education to offer nail care to each resident on their shower days and to document on the shower sheets. During an interview on 1/16/24 at 12:05 PM, the Assistant Director of Nursing (ADON) said Staff are expected to provide nail care with bathing. During an interview on 1/16/13 at 2:10 P.M. the Director of Nursing (DON) said nail care should be completed on shower days and documented on the shower sheets or weekly skin checks. Review of facility's policy titled, Activities of Daily Living (ADLs), date implemented 9/7/22 revealed: Policy- the facility will, based on the resident's comprehensive assessment and consistent with the resident's needs and choices, ensure a resident's abilities and ADL's do not deteriorate unless deterioration is unavoidable. Care and services will be provided for the following activities of daily living: 1) bathing, dressing, grooming and oral care 2) transfer and ambulation 3) Toileting 4) Eating to include meals and snacks 5) Using speech, language or other functional communication systems. Policy explanation and compliance guidelines: 1) conditions which may demonstrate unavoidable decline in ADL include 1 a) natural progression of the resident's disease state with known functional decline. 1b) Deterioration of the resident's physical condition associated with the onset of an acute physical or mental disability while receiving care to restore or maintain functional abilities. 1c) Refusal of care and treatment by the resident or his/her representative to maintain functional abilities after efforts by the facility to inform and educate about the benefits/risks of the proposed care and treatment, council and our offer alternatives to the resident or representative. 2) the facility will provide a maintenance and restorative program to assist a resident in achieving and maintaining the highest practicable outcome based on the comprehensive assessment. 3) A resident who is unable to carry out activities of daily living will receive the necessary services to maintain good nutrition, grooming and personal and oral hygiene. 4) The facility will identify resident triggers through the Care Area Assessment (CAA) process to assess causal factors for decline, potential decline or lack of improvement. 5) The facility will maintain individual objectives of the care plan and periodic review and evaluation. 3. The DON stated the F-tag 686 was related to pressure ulcers and skin sweeps. She stated they performed skin sweeps on the entire building from 12/09/2024 t 12/13/2024. She stated they looked at the whole body. They educated the nurses on treatment services to prevent and heal pressure ulcers on 12/08/2024. They educated the staff that skin evaluations must be completed by a licensed nurse weekly, wounds must be evaluated weekly by an RN. The DON stated they educated the staff the medical provider must be contacted of a new skin impairment, and well as the resident and resident representative which includes change or addition of a treatment. The DON stated they are auditing 5 residents with wounds a week for 4 weeks. The DON stated they are auditing for process, skin checks completed, skin evaluations completed weekly, evidence of responsible party and medical provider notification. The DON stated she did the audits herself and visualized the dressings also. The DON stated she did not know what happened (dressings for Residents #39 and #40). The DON stated the ADON was re-educating the nursing staff on documentation process and following through with medical provider orders. The DON stated the nurse that documented she provided care for Resident #40 on 01/15/2025 stated, She did not have time to do the care. The DON stated the nurse stated she did not do the care on 01/15/2025 even though she documented she did. The DON stated they will continue to audit after the nurses have been re-educated. The DON stated they will discuss the audit frequency during the next ADHOC meeting with the team. Resident #39 was admitted on [DATE] and readmitted on [DATE]. Review of the admission record showed the diagnoses included nontraumatic chronic subdural hemorrhage, pneumonitis due to inhalation of food, acute respiratory failure, adult failure to thrive, Peripheral vascular disease, heart failure, dementia, and hypertension. Observation on 01/16/2025 (Thursday) at 10:28 a.m. of Resident #39 with Staff B, RN (Registered Nurse) and Staff C, CNA (Certified Nursing Assistant). Staff C, CNA was already in room with gloves in place, no gown. Staff B, RN entered room after applying gloves, no gown. Resident #39 was lying in bed. He had contractures of the lower extremities. Staff B and Staff C moved his blankets down and revealed his left heel dressing. The heel was wrapped in gauze and tape but was not dated. The heel dressing had a small amount of brownish draining on the heel area. The staff lowered the head of the bed and raised Resident #39's gown. His thigh had a dressing in place dated 01/13/2025 (Monday). The staff turned the resident onto his right side, toward Staff B. Resident #39's brief was opened, and the coccyx area was observable. The coccyx wound had no dressing applied. The coccyx area was a golf ball size open area. During the turning of the resident, Staff B, RN touched her gloved hand to her right sleeve, moving it up. The resident was placed back onto his back and the head was elevated. Staff B removed her gloves and hand sanitized. Staff B, RN stated he was on enhanced barrier (precautions). Staff B stated, I do not need to use a gown because I was not changing his dressings. When asked about touching his dressings, briefs, blankets, etc. stated she, I was not changing his dressings. Staff C, CNA was asked about the resident being on enhanced barriers, she just looked at the surveyor and had no response. Staff C stated if the resident was on enhanced barriers she should have had a gown on. During an interview on 01/16/2025 at 11:25 a.m. Staff D, RN, Unit Manager stated she verified the wound care for Resident #39. She stated the thigh dressing was to be done on Monday, Wednesday and Friday. She stated his coccyx wound was to be done daily. She stated the heel dressing was to be done daily. Staff D stated it (wound care) should have been done per the physician orders. Staff D, RN stated the negative outcomes could have included an increased size in pressure ulcer, worsening, infection, sepsis, not healing. Review of the physician orders showed cleanse coccyx with normal saline, apply calcium alginate and cover with superabsorbent border dressing daily as of 01/06/2025 cleanse left lateral thigh with normal saline, apply xeroform and border gauze 3 times a week, Monday, Wednesday and Friday as of 01/13/2025. Left heel, apply Santyl, xeroform, superabsorbent, and wrap with kerlix and apply zinc for peri-wound every shift as of 01/07/2025. Review of the January Treatment Administration Record (TAR) showed Cleanse coccyx with normal saline, apply calcium alginate and cover with superabsorbent border dressing daily as of 01/06/2025. The TAR showed the dressing was changed on 01/07/25, 01/08, 01/09, 01/10, 01/11, 01/12, 01/13, 01/14, 01/15/2025. The resident did not have a dressing on his coccyx during the observation. Cleanse left lateral thigh with normal saline, apply xeroform and border gauze 3 times a week, Monday, Wednesday and Friday as of 01/13/2025 (Monday). The thigh wound was observed dated 01/13/2025. Left heel, apply Santyl, xeroform, superabsorbent, and wrap with kerlix and apply zinc for peri-wound every shift as of 01/07/2025. The TAR showed the wound was performed on 01/07/25, 01/08, 01/09, 01/10, 01/11, 01/12, 01/13, 01/14, 01/15/2025. Review of the care plans showed Resident #39 was on Enhanced Barrier Precautions per CDC guidelines for Gastrostomy tube, wounds as of 04/14/2024. Interventions included but not limited to persons caring for the resident and providing high-contact resident care activities will require personal protective equipment (PPE), the use of gown and gloves. As of 4/17/2024. Clear signage will be posted on wall outside of room as of 07/01/2024. Resident #39 had a pressure ulcer located on the left heel stage 3 and coccyx stage 3. Decline in skin integrity is expected related to terminal condition as of 04/04/2024, revised on 12/27/2024. Interventions included but not limited to current treatment per order as of 04/04/2024. Document weekly: stage, length times width times depth, order, progress or lack of progress as of 04/04/2024. Notify MD and family for changes in wound status as of 04/04/2024. During an interview on 01/16/2025 at 11:25 a.m. Staff D, RN, Unit Manager stated she verified the wound care for Resident #39. She stated the thigh dressing was to be done on M-W-F. She stated his coccyx wound was to be done daily. She stated the heel dressing was to be done daily. Staff D stated it (wound care) should have been done per the physician orders. Staff D, RN stated the negative outcomes could have included an increased size in pressure ulcer, worsening, infection, sepsis, not healing. Resident #40 was admitted on [DATE] and readmitted on [DATE]. Review of the admission record showed diagnoses included cancer of the prostate, urinary catheter, hypertension, bladder-neck obstruction, and unspecified protein-calorie malnutrition. Observation on 01/16/2025 (Thursday) at 10:44 a.m. of Resident #40 with Staff D, RN. Staff D applied a gown and gloves after hand sanitizing. She entered the resident room and put his bed down and pulled up his gown. His suprapubic dressing was dated 01/13/2025 (Monday), there was drainage present on the dressing. Staff D placed his gown down and walked to the door. She removed her gloves and donned a new pair of gloves without hand sanitizing. She came back to the resident's bedside and pulled the cover up from his right lower extremity. His right heel was dressed, and it was dated 01/13/2025 (Monday). The resident stated his coccyx wound was healed and did not have a dressing. Staff D removed her gloves and gown and washed her hands. Review of the physician orders showed Cleanse right heel with normal saline, pat dry, apply xeroform, cover with border dressing every day as of 01/06/2025 to start on 01/07/2025 and discontinue as of 01/15/2025. Cleanse right heel with normal saline, pat dry, apply xeroform, cover with border dressing on Monday, Wednesday, Friday as of 01/13/2025 to start on 01/15/2025. Cleanse suprapubic catheter area with normal saline, pat dry, apply silver calcium alginate, cover with superabsorbent border dressing every day as of 01/06/2025 Review of the January 2025 TAR showed Cleanse right heel with normal saline, pat dry, apply xeroform, cover with border dressing every day as of 01/06/2025 to start on 01/07/2025 and discontinue as of 01/15/2025 showed performed on 01/07/25, 01/08, 01/09, 01/10, 01/11, 01/12, 01/13/25 Cleanse right heel with normal saline, pat dry, apply xeroform, cover with border dressing on Monday, Wednesday, Friday as of 01/13/2025 to start on 01/15/2025 (Wednesday), showed IA on 01/15/2024. Cleanse suprapubic catheter area with normal saline, pat dry, apply silver calcium alginate, cover with superabsorbent border dressing every day as of 01/06/2025 showed care performed on 01/16/25, 01/07, 01/08, 01/09, 01/10, 01/11, 01/12, 01/13, 01/14, 01/15/2025. Review of the care plans showed Resident #40 had a pressure ulcer care plan due to unstageable to right heel as of 04/02/2024. Interventions included but not limited to current treatment per order; document weekly: stage, length x width x depth, odor, progress or lack of progress; Notify MD and family. During on 01/16/25 at 11:12 a.m. Staff D, RN stated the heel was supposed to be dressed on Monday, Wednesday (01/15/2024) and Friday. Staff D, RN stated the nurse documented IA on the TAR which she does not know what that is. Staff D stated she would ask the nurse what that meant. Staff D stated the suprapubic dressing was to be performed daily and her nurse documented it was done. Staff D stated the nurse reported she did not have time to perform the care and told the next shift to do it. During an interview on 01/16/2025 at 12:04 p.m. the DON stated that the staff was to perform the wound care as per the medical provider order. The enhanced barrier precautions was to be performed during direct contact. 4. The DON stated F-777 related to reporting the x-ray results to the medical provider timely. She stated they used the same education and audits as for F-552. The DON stated she will re-talk about the process with the QAPI team. The DON stated they need to educate the nursing staff again to be the persons reporting the results and the ADON as the backup. Resident #37 was admitted on [DATE] and readmitted on [DATE]. Review of the admission record showed diagnoses included cellulitis of the lower limb, COPD (Chronic Obstructive Pulmonary Disease) diabetes, protein-calorie malnutrition, acute bronchitis due to rhinovirus, anemia, and atrial fibrillation. Review of the physician orders showed two view chest x-rays for congestion on 01/12/2025. Review of the Chest X-ray results were dated 01/12/2025 at 8:50 p.m. showed the conclusion was mild pulmonary vascular congestion. Review of the progress notes showed On 01/13/2025, radiology note showed chest x-ray negative. On 01/14/2025, Physician Assistant (PA) progress note showed on 01/14/2025 at 4:40 p.m., She (Resident #37) reports new onset cough. Primary obtained CXR (chest x-ray) which was negative. She has finished ABX (antibiotics) for cellulitis. She reports decreasing left leg pain. Denies chest pain, SOB (shortness of breath), dizziness. No other concerns at this time. Review of the care plans showed Resident #37 had a potential for complications of respiratory distress related to diagnoses of: COPD, history of Respiratory failure and current smoker Date Initiated: 11/10/2021 Created on: 11/10/2021 Revision on: 04/28/2024. Interventions included but not limited to Labs/diagnostics as ordered; notify physician of results Date Initiated: 11/10/2021 Created on 11/10/202. Resident #38 was admitted on [DATE] and readmitted on [DATE]. Review of the admissions record showed diagnoses included but not limited to Parkinson's, acute and chronic respiratory failure, congestive heart failure, COPD, hypertension, atrial fibrillation. Review of the physician's orders showed portable 2 view chest x-ray for cough on 01/14/2025. Review of the chest x-ray dated 01/14/25 at 2:00 p.m. showed the cardiac silhouette and mediastinal contours are normal. The lungs are free of infiltrates and focal consolidations. Elevation of the right hemidiaphragm is noted. No pleural fluid or masses are noted. No pneumothorax is present. Conclusions: No acute intrathoracic disease process. Review of the progress notes showed On 01/14/3025 at 12:127 p.m., attending physician visits and orders a 2 view CXR (chest x-ray) for continued cough. Resident continues on ABT (antibiotics) for URI (upper respiratory infection) at this time to same. No s/sx (signs and symptoms) of adverse effects noted at this time. Review of the Infection Care Plan showed resident was on antibiotic therapy related to URI as of 01/10/2025. Interventions included but not limited to observe for worsening respiratory symptoms such as increases SOB and rpt to MD. During an interview on 01/15/2025 at 2:19 p.m. the DON (Director of Nursing) verified Resid

Based on observation and interview, the facility failed to ensure dignity was providing by protecting and valuing residents' private space by knocking before entering one (#29) resident's room out of 31 residents sampled. Findings Included: During an observation on 12/02/2024 at 10:33 a.m., a staff member, in black scrubs was observed entering Resident #29's room without knocking or being invited in by Resident #29. During an observation on 12/03/2024 at 9:00 a.m., a staff member, in black scrubs was observed entering Resident #29's room without knocking or being invited in by Resident #29. During an observation on 12/04/2024 at 3:12 p.m., a staff member, in black scrubs was observed entering Resident #29's room without knocking or being invited in by Resident #29. During an interview on 12/04/2024 at 3:10 p.m., Staff F, Certified Nurse Assistant (CNA), stated that she usually knocked before entering a resident's room, she also made sure that the resident's door was closed, and the privacy curtain was pulled while she was providing care. During an interview on 12/04/2024 at 3:05 p.m., Staff G, CNA, stated he provided daily care to the residents. He stated he provided dignity to residents by closing curtains, talking with the residents while providing care, and asking if it was okay for him to provide their care. He stated he would also knock on the door before entering the room. During an interview on 12/04/2024 at 3:22 p.m., Staff H, CNA, stated before she entered a resident's room she knocked on the door. She stated if the resident did not answer she would ask if she could enter the room. During an interview on 12/04/2024 at 6:20 p.m., the Director of Nursing (DON) and Regional Nurse stated Dignity should be provided for every resident. They stated staff members were expected to knock before entering a resident's room. Review of the facility's policy titled Promoting/Maintaining Resident Dignity dated 09/072022 revealed: Policy: It is the practice of this facility to protect and promote resident rights and treat each resident with respect and dignity as well as care for each resident in a manner and environment, that maintains or enhances residents' quality of life by recognizing each resident's individuality. 1. All staff members are involved in providing care to residents to promote and maintain resident dignity and respect resident rights period. 11. Respect the residents living space and personal possessions . 12. Maintain resident privacy.

Based on observations, interviews, and record review, the facility failed to notify the resident representative about a change in condition for one resident (#67) out of eight residents sampled. Findings include: On 12/2/2024 at 10:00 am., Resident #67 was sitting up in her wheelchair, dressed well-groomed with her call light within reach. She presented with no signs of distress. She stated she had an incident two weeks ago when two nursing aides pulled her up in bed. She stated she felt a sharp pain in her back and legs after they repositioned her. She stated one of the aides told the nurse about the resident complaint and she was provided with an x-ray. She stated she was never told the results of the x-ray. Review of the Admission Record, dated 12/5/2024, showed Resident #67 was admitted to the facility on [DATE] and readmitted on [DATE], with diagnoses to include but not limited to, Type 2 Diabetes Mellitus with diabetic neuropathy, unspecified, presence of coronary angioplasty implant and graft. Review of the Quarterly Minimum Data Set (MDS) assessment, dated 9/23/2024, revealed in Section C: Cognitively Patterns a Brief Interview of Mental Status (BIMS) score of 10, which indicated moderate cognitive impairment. Review of a progress note, dated 11/25/2024 at 15:19, revealed the following: Resident complain of back pain this morning and could not move, resident stated, this morning CNAs was tried to reposition her on the bed and somehow hurt her back mostly on the waist. On 12/04/2024 at 12:00 p.m., an interview was conducted with Resident #67's Healthcare Surrogate. She stated a family member called her to tell her something happened to Resident #67 when she was positioned by two nursing aides in the room. She stated she was never notified by the facility of what happened and was never told about the results of the x-rays the facility took on the resident. On 12/04/2024 at 4:00 pm., an interview was conducted with Staff AA, Registered Nurse (RN). She stated the Certified Nursing Assistant (CNA) that took care of the resident on 11/25/2024 came to her to tell her Resident #67 was complaining about back pain. She stated Resident #67 told her the nursing aides tried to reposition her in the bed and somehow, she hurt her back, and the pain was mostly on the waist. The nurse stated she asked the resident if she would like to have pain medication. The nurse stated the resident said she did not want anything for pain. Staff AA stated she did not know she needed to call the resident family to tell them about the resident complaint. She stated she did not call the family or notify the doctor when the x-ray results came in, she only reported the x-rays to the nurse from the next shift. On 12/4/2024 at 4:10 pm., an interview was conducted with Staff I, License Practical Nurse (LPN)/ Unit Manager (UM). She stated the x-ray report came back to the facility at 6 pm, during the first shift. She stated the nurse should have notified the doctor, and the resident representative about the incident and the x-ray findings. On 12/4/2024 at 4:30 pm., an interview was conducted with the Director of Nursing (DON). The DON stated the nurse should have notified the physician, the resident, and the resident representative about the x-ray findings. The DON stated the nurse should have followed the process of what the physician would have provided for the resident. She stated, We will just have to do some education from this point moving forward. The facility did not provide a policy regarding this citation.

Based on observations, interviews, and record review, the facility failed to provide the opportunity to participate in care planning for one resident (#44) out of 8 residents sampled. Findings included: On 12/03/24 at 09:47 a.m., and 12:00 p.m., an observation was made of Resident #44. She was observed lying down in her bed with her call light in reach. She presented with no signs of distress. Resident #44 stated she would like to participate in her care plan meetings, but staff does not invite her to attend the meetings because her meetings are scheduled during the times she is out for her dialysis treatments. She stated she would like her voice to be heard. Review of the Admission Record, dated 12/5/2024, showed Resident #44 was admitted to the facility on [DATE], with diagnoses to include but not limited to, End Stage Renal Disease, Type 2 Diabetes Mellitus without Complication, Multiple Sclerosis, and need for assistance with personal care Review of the Quarterly Minimum Data Set (MDS), dated [DATE], revealed in Section C: Cognitively Patterns, a Brief Interview for Mental Status (BIMS) score of 15, which indicated cognitively intact On 12/04/2024 at 12:30 p.m., an interview was conducted with Resident #44's Healthcare Surrogate/ Power of Attorney. She stated she would really prefer Resident #44 be a part of the care plan meetings because she knows more about the care she is receiving at the facility. She stated the care plan meetings are scheduled on the days the resident has dialysis and that is why the resident is not invited to the meetings. On 12/05/2024 at 9:38 am. an interview was conducted with Staff V, MDS Coordinator. She stated Resident #44 is on the second floor, so her care plan meetings are held on Wednesdays. She stated the meetings are on the same day the resident goes to dialysis. She stated she does not conduct the care plan meetings, so she cannot answer questions as to why Resident #44 is not invited to her care plan meetings. She stated if a resident is not able to attend the meetings, then the Unit Manager should talk to the resident to provide an update about the meeting On 12/05/2024 at 10:00 a.m., an interview was conducted with Staff I, License Practical Nurse (LPN)/ Unit Manager (UM). Staff I stated every Wednesday she attends the care plan meetings. Resident #44 does not attend the meetings because the meeting is held on the same days she has dialysis. She stated when a resident is not able to attend a meeting, she or the Social Worker would go to the resident's room to update them about the care plan meeting. She said she has not followed up with Resident #44 about her care plan meetings. On 12/05/2024 at 1:00 p.m., an interview was conducted with Staff C, Social Service Director (SSD). The SSD stated she is provided with a list of residents who are scheduled for their care plan meeting for the week. She said care plan meetings are Tuesdays and Wednesdays. Tuesday meetings are for the first-floor residents and Wednesday meetings are for the second-floor residents. She said if a resident is not able to attend their meeting on their scheduled day, they would call the representative to inform them about the resident's plan of care. She stated she did not follow-up with Resident #44's care plan meeting because she was on vacation when her meeting was conducted. She stated nursing should have informed and followed -up with the resident about her care plan meeting. Review of the facility policy titled Comprehensive Care Plans, dated 9/7/22, showed the following: Policy Statement: It is the policy of this facility to develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights, that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the resident's comprehensive assessment. Policy Explanation and compliance Guidelines: 4. The comprehensive care plan will be prepared by an interdisciplinary team, that includes, but is not limited to: e. the resident and the resident's representative, to the extent practicable.

Based on observation and interview, the facility failed to ensure personal privacy was honored by providing a private space for one resident (R #16) out of 31 residents sampled to use the phone. Findings Included: During an observation on 12/03/2024 at 10:30 a.m., Resident #16 was observed sitting in a wheelchair in front of the nurse's station on the phone. During an interview on 12/03/2024 at 4:30 p.m., Resident #16 stated she did not want a phone in her room because there were plenty of other phones around the house she could use. An observation of Resident #16's room revealed Resident #16 did not have a phone in her room. Review of Resident #16's admission record revealed an admitted [DATE]. Review of the Resident #16's Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 03 out of 15 revealing severe cognitive impairment. During an interview on 12/4/24 at 3:59 p.m., the Resident Council President and Resident Council Secretary revealed most residents had cell phones and or a phone in their room. The Resident Council Secretary stated it was normal for residents to talk on the phone at the nurse's stations. She stated the phone had a long cord. She stated the residents could go all the way around when they need to, to get privacy. She stated most residents sat at the nurse's station and used the phone. The Resident Council Secretary stated she did not think residents or staff listened to their conversations when they were talking on the phone. During an interview on 12/03/2024 at 10:45 a.m., Staff I, LPN, Unit Manager, stated Resident #16's family called the nurses station to speak with the resident. She stated she was not able to transfer the call to the resident's room because the phone in the resident's room had connection issues. During an interview on 12/03/2024 at 6:20 p.m., the Director of Nursing (DON) stated if a family called the nurse's station to speak with a resident, the call should be transferred to the resident's room so they could have a private call. She stated if the resident decided to take a call at the nurse's station, the resident should be moved into the Unit Managers office, so they were provided with privacy. ON 12/05/2024 the facility was asked to provide a policy on Privacy and it was not provided.

Based on interviews and record review, the facility failed to ensure prompt notification to physicians of critical and abnormal lab values for two residents (#1 and #2) of 6 sampled residents, resulting in a delay in treatment. Findings Included: 1. Review of the Admission Record for Resident #1 shows he was admitted from an assisted living facility initially on 2/10/19 and with [DIAGNOSES REDACTED]. He was readmitted on [DATE]. Review of an Emergency Department physician note dated 5/13/19 showed the resident required hospitalization for combative behavior that began on 5/13/19. The note included the following: .presents to ER after being Baker acted by a clinical psychologist. Patient was angry and threatening staff members. Review of the Final Report from the hospital psychiatrist dated 5/15/19 showed, Patient is . now released, follow up at nursing home. Review of facility progress notes for Resident #1 showed an Interdisciplinary Team note dated 6/6/19, Resident requires increased assistance with ADLs (activities of Daily Living) since return from hospital. Resident continues to be less alert. In-house psych practitioner follows. Resident has not exhibited aggressive behaviors. Does not verbalize needs. Resident is currently on GDR (gradual dose reduction) of [MEDICATION NAME] .will continue to observe and work with PCP (primary care physician) and psych for med adjustments. Review of nursing progress notes for Resident #1 showed 6/6/19, 17:30, (5:50 pm) this writer was alerted by patient's aide that he kicked tray over, food hit floor and wall, patient alert and very agitated, . patient given [MEDICATION NAME], respirations even and unlabored with no signs and symptoms of distress. safety alarms in place for decreased safety awareness, patient is incontinent of bowel and bladder, fluids encouraged, call light in reach, will continue to monitor. signed Staff A, LPN. Review of the resident's physician orders [REDACTED]. Review of a Laboratory Result for the CBC and CMP for Resident #1 showed a collection date of 6/7/19 at 5:20 am, Final result approved 6/7/19 at 2:10 pm. Comments: 6/7/19 2:10 pm Critical result called to Staff A, LPN, by (lab personnel name) Results were read back to caller and result was faxed. The results included the following Critically High values: HCT (hematocrit) 64.4 (normal 40.0-52) Sodium 165 (normal 136-145) Chloride: 128 (normal 98-107) Other abnormal values in the results included: WBC(white blood cells) 27.55 high (normal 3.6-11.00) RBC(red blood cells) 6.27 high (normal 4.5-5.9) HGB (hemoglobin) 18.7 high (normal 13.0-18.0) Potassium: 5.2 high (normal 3.5-5.1) Creatinine 2.9 high (normal 0.6-1.3) Review of the lab result and the resident's progress notes showed no documentation that the physician was informed of the critical or abnormal lab results received on 6/7/19. Review of the resident's physician orders [REDACTED]. Review of the next progress note written after the lab test was drawn, dated 6/8/19 10:05 am, revealed, This nurse observed resident with SOB (shortness of breath) and SATs(blood oxygen saturations) were 87% at this time started oxygen therapy at 2L/m (liters per minute), [MEDICATION NAME] treatments and ABT (antibiotic therapy) therapy per doctors order. On observation resident showed s/s (signs and symptoms) of pain and discomfort. This nurse administered [MEDICATION NAME] for pain, after a while the resident showed s/s of anxiety, this nurse administered [MEDICATION NAME] as per order. During the day the resident cont. (continued) to decline. This nurse called the PCP and informed DR (doctor) the therapies administered and the resident appears to be getting worse. The PCP instructed this nurse to send to ER. Resident's wife at bedside and was agreeable with transport to ER. Signed the ADON (Assistant Director of Nurses), LPN. Review of medical records for Resident #1 from (local hospital name) revealed: ED Rapid Triage on 6/8 at 4:11 p.m. Chief complaint: confirmed pneumonia, [MEDICAL CONDITION]. Respiratory status upon arrival to ED: gasping. Vitals: BP 71/49, Pulse 121 bpm, RR: 30, 86% O2 sat on oxygen via nonrebreather mask. History of present illness: Patient presents with altered mental status and symptoms suspect for pneumonia. Patient appears severely dehydrated, eyes sunken, and has no gag reflex; probably aspirating. Onset was 1 week ago per the facility. Labs: WBC 25.3 sodium: 171 hemoglobin; 19.1 hematocrit: 61.9 bun >115 Creatinine 5.9 chloride >122. After IV fluids, antibiotics and vasopressors, wife requested no intubation to honor his DNR (do not resuscitate). Order given for comfort measures only. During an interview with Resident #1's Primary Physician, on 8/6/19 at 9:40 a.m., he said The resident had moderate to severe Dementia. I believe he was deteriorating, and failing to thrive. He did have a sudden change on that last day. The facility called me and said the resident was sleeping for quite a while, and then he wasn't responding. So EMS (Emergency Medical Services) was called and he was sent to the ER (emergency room ). I wasn't aware that the facility notified me late of the labs. I think they really need some continuing education on how to spot these red flags, not only with labs, but also when they are assessing the resident. They need to know how to identify things that are important to communicate to the doctor. They need to know how to assess changes in the resident's condition. I really think they would benefit from that education. On 8/6/19 at 1:00 pm Staff F, RN said, I remember him, I was here when he was Baker Acted. Before going to the hospital, he was able to ambulate. He would dance with his wife. I would say he was confused, maybe alert and oriented to himself. His wife came to see him often, and would stay a few hours with him. He was able to eat in the dining room without difficulty, he would just need set up assistance. He could take his meds whole, I don't remember any swallowing issues. Then one day, he got combative. There really hadn't been a buildup to that behavior. He ended up pushing one of the residents, and then he was put on 1:1. The psychologist was in the building and he saw him, and how he was acting, and he Baker Acted him. On 8/6/19 at 12:43 pm Staff G, LPN said, I only knew the resident after he came back from the hospital. Prior to that, he was upstairs and I didn't have much interaction with him. I just know he used to walk in the halls all the time. When he came back from the hospital, he was on the 1st floor. He was easily agitated, and combative. I can't really say if he was ambulating, I think he would get into the chair. I didn't really see his wife much. But I remember him throwing things, and trying to hit people. I don't think he was 1:1 at that point. But he didn't eat in the dining room anymore, he ate in his room. It was hard to get him to eat, and on one occasion, he threw his tray across the room. When I last saw him, he still had enough orientation in him. I didn't see him towards the end. If there was an abnormal lab on the fax, the nurse should call the doctor, take the orders, and most of the time, the same nurse would transcribe the orders to the MAR. If there was a critical lab, the lab calls the Nurse. Then it's up to the nurse to call the doctor. On 8/6/19 at 2:00 pm Staff A, LPN said I only knew him when he was on the first floor. He was mostly in bed, and he was alert/oriented x 1. He would sit in his chair in the room. He ate mostly in his room, and he would pick at his food. He was able to hold his utensils, but staff had to help him and encourage him to eat. Yes, he did cough a few times, but he wasn't congested. His cough was a dry cough, so I didn't give him any cough medication. I think I saw him that Thursday before he left. He was very combative that day, and threw his lunch tray. It hit the wall and was on the floor. I ended up giving him an [MEDICATION NAME] that day. If there is an abnormal lab or critical lab, we all the doctor ASAP (as soon as possible). Majority of the time, the lab calls the nurses with critical results. I don't remember seeing that lab with critical values, nor do I recall the lab calling me with any critical results. 2. Review of Resident #2's Admission Record showed she was admitted on [DATE] after a hospital stay for parainfluenza, her [DIAGNOSES REDACTED]. Review of a Nursing Progress note dated 5/20/19 12:37 p.m. revealed Patient has had loose stools x 2 days with foul odor. ARNP (advanced registered nurse practitioner) notified. New order for stool sample x 2 to rule out [MEDICAL CONDITION]. CBC and BMP in am. A review of Resident # 2's physician's orders [REDACTED]. 5/22/19 Urinalysis (U/A) with culture. Review of the CBC, BMP lab results for Resident #2 showed: CBC, Collection date 5/21/19 at 5:15 am, Final Approved 5/21/19 4:29 pm, BMP, Collection date 5/21/19 at 5:15 am, Final Approved 5/21/19 at 11:27 am, Abnormal values on the results included: Serum Sodium, 127, High, (normal 136-145) CO2, 19, Low, (normal 21-31) BUN, Serum, 39, High, (normal 8-23) WBC, 21.37, High, (normal 3.6-11.00) A handwritten notation on the Lab result showed STAT (immediate) Chest x ray, U/A c&s (urinalysis with culture and sensitivity), [MEDICAL CONDITION] consult, T.O. (telephone order) (provider name) NP (nurse practitioner). Review of the progress notes showed, 5/22/19 9:19 am MD (physician) made aware of lab results; n/o (new order) for chest x ray, U/A c&s (urinalysis with culture and sensitivity) and [MEDICAL CONDITION] consult, family made aware, Staff H, RN. Review of the progress notes showed on 5/23/19, Resident noted to be lethargic, x ray results negative, UA results reported to MD, Order given to send resident to ER for evaluation. Review of (hospital) medical records revealed Arrival on 5/23/19 for lethargy ongoing for 2-3 days. Neurologic: lethargic, drowsy, and cachectic. Initial Impression: dehydration with [MEDICAL CONDITIONS], UTI (urinary tract infection), [MEDICAL CONDITIONS] Metabolic [MEDICAL CONDITION] (secondary to [MEDICAL CONDITIONS]), profound hypoproteinemia. During an interview with Resident #2's Primary physician, on 8/8/19 at 12:30 p.m. he said Yes this facility has had problems with not getting antibiotics in time, and other delays in treatment, and I am not really happy with them. I wasn't aware that they notified me late about her labs. That is unacceptable to me. I don't have her records in front of me, but if I felt she was nearing the end of her life, I would have discussed palliative care with the resident's family or POA (Power of Attorney) and it would be reflected in my progress notes. But the fact that she was sent out to the ER, is not suggestive that this was the case for her, I just think it's crucial that doctors be notified about the labs on time. I mean, a day or two can make a world of difference in the outcome. And these things, [MEDICAL CONDITION], dehydration, [MEDICAL CONDITION], they are all things that can be immediately addressed at the facility. There should be no reason why they didn't let me know sooner about her loose stools. Not following physician orders, not notifying the physician about abnormal labs, or changes in the resident's condition, are very concerning issues. During an interview with the Director of Nursing (DON) and the Assistant Director of Nursing (ADON) on 7/24/19 at 4:30 p.m., the DON stated Yes, if the resident had critical labs or was having several loose stools, I would expect the nurse to contact the physician. During an interview with the DON and the ADON on 8/6/19 at 6:20 pm. the DON said, I interviewed several nurses on all different shifts, about notifying the doctors. They all didn't recall anything. So we did our audits after you finished our complaint survey on 7/24, and we looked to make sure that nobody else had labs that were missed. We compared all labs from 6/7 -7/24. Our labs were coming up on the fax machine at the nurse's station. Now, everything is computerized. We also changed the timing of the blood draws, now techs draw blood around 6-7 pm at night, and send it to the lab, so that the results are in early morning. Then, the labs are posted on the computer between 6-7 in the morning, and both the nurse and the ADON/DON get a forwarded copy. This way, there are two checks on each lab, and it won't get missed again, and doctors are notified right away. Review of the facility's policy, titled Lab and Diagnostic Test Results, revised in (MONTH) (YEAR), revealed Assessment and Condition: 1) The physician will identify and order diagnostic and lab testing based on the resident's diagnostic and monitoring needs. 2) The staff will process test requisitions and arrange for tests. 3) The laboratory or other testing source will report test results to the facility. Review by nursing staff: 1) when tests results are reported to the facility, a nurse will review the results. If staff who first receive or review the lab cannot follow the remainder of the procedure for reporting and documenting the results, then another nurse in the facility should follow or coordinate the procedure. Identifying situations that warrant immediate notification: 1) Nursing staff will consider the following factors to help identify situations requiring prompt physician notification concerning lab or diagnostic results: whether the result should be conveyed to a physician regardless of other circumstances (that is, the abnormal result is problematic regardless of any other factors), whether the resident's clinical status is unclear, or he/she has signs of acute illness or condition change, and is not stable. Options for physician notification: 1) Facility staff should document information about when, how, and to whom the information was provided, and the response. This should be done in the progress notes section because test results should be correlated with other relevant information such as the overall situation, current symptoms, and prognosis, etc.