Every finding on record at Hearthstone Health and Rehabilitation

Based on record review, interview, and review of facility's policy, the facility failed to ensure 4 of 5 residents (Resident (R) 1, R35, R90 and R97) reviewed for hospitalization out of 31 sampled residents were given a bed hold notice prior to or within 24-hours of emergency transfer to the hospital and/or failed to ensure the Ombudsman was notified of the emergent transfers to the hospital. This failure creates the potential for residents, and responsible parties to not have the information needed to safeguard their return to the facility, and for the Ombudsman not to have the knowledge of their transfer. Findings include: 1. Review of R35's Face Sheet located under the Profile tab of the electronic medical record (EMR) revealed R35 was admitted to the facility on [DATE]. Review of R35's Progress Note, dated 02/26/2026 and located under the Progress Notes tab of the EMR revealed R35 was sent to the hospital for vaginal bleeding. Review of R35's entire medical record revealed no documented evidence that the facility issued a bed hold notice to R35 and/or their responsible party at the time of the transfer or the day after. Further review indicated no documented evidence that the Ombudsman was notified of R35's transfer to the hospital on [DATE]. 2. Review of R90's Face Sheet located under the Profile tab of the EMR revealed R90 was admitted to the facility on [DATE] and readmitted on [DATE]. Review of R90's Progress Note, dated 12/27/2025 and located under the Progress Notes tab of the EMR revealed R90 was sent to the hospital from the dialysis center due to increased chills and shivering. Review of R90's entire medical record revealed no documented evidence that the facility issued a bed hold notice to R90 and/or R90's responsible party at the time of the transfer or the day after. Further review revealed no documented evidence that the Ombudsman was notified of R90's transfer to the hospital on [DATE]. 3. Review of R97's Face Sheet located under the Profile tab of the EMR revealed R97 was re-admitted to the facility on [DATE] with diagnoses which included chronic obstructive pulmonary disease (COPD). Review of R97's Progress Note, dated 12/19/2025 and located under the Progress Notes tab of the EMR revealed R97 was sent to the hospital for COPD exacerbation. Review of R97's entire medical record revealed no documented evidence that the facility issued a bed hold notice to R97 and/or R97's responsible party at the time of the transfer or the next day. Further review revealed no documented evidence that the Ombudsman was notified of R97's transfer to the hospital. During an interview on 03/04/2026 at 12:00 PM, the Administrator indicated that R35, R90, and R97 and/or their responsible parties were not issued a written bed hold notice when they were emergently transferred to the hospital. 4. Review of R1's undated Face Sheet, located under the Profile tab in the EMR indicated R1 was admitted to the facility on [DATE].Review of R1's Progress Note, dated 01/27/2026 at 4:30 PM and located under the Prog Notes tab in the EMR indicated R1 had been transferred to the ER to rule out a subdural hematoma after he fell and hit his head. Further review revealed no documented evidence that the Ombudsman was notified of the resident's emergent transfer to the hospital. During a subsequent interview on 03/04/2026 at 3:58 PM, the Administrator indicated that the Ombudsman was not made aware of R1, R35, R90, nor R97's emergent transfers to the hospital.Review of the facility's policy titled, Criteria for Transfer and Discharge, revised April 2025, indicated Prior to transfer or discharge, the Facility shall notify the resident and the resident's representative of the transfer or discharge and the reason for the transfer or discharge in writing in a language and manner they understand. The facility shall send a copy of the notice to the State Long-Term Care Ombudsman.

Based on observations, interviews, record review, facility policy review, and review of the facility's investigations, the facility failed to ensure 2 residents (Resident (R) 9 and R120) of 4 residents reviewed for abuse out of 31 sampled residents were free from verbal abuse. R120 was verbally abused by her roommate (R119), and R9 was verbally abused by Certified Nursing Assistant (CNA) 9. The facility's failure to ensure residents were free from abuse had the potential to cause emotional and/or psychosocial harm to the residents. Findings include:1. Review of R120's Face Sheet found in R120's electronic medical record (EMR) under the Resident tab indicated the resident was admitted to the facility on [DATE] with diagnoses which included cognitive communication deficit, anxiety disorder, and unspecified dementia.Review of R120's admission Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 09/15/2025 and located under the MDS tab of the EMR indicated the resident had a Brief Interview for Mental Status (BIMS) score of 6 out of 15 which indicated the resident was severely cognitively impaired. Review of R120's nursing Progress Notes, dated 10/06/2025 and located in the residents EMR under the Prog [progress] Notes tab indicated, Patient reported her roommate tv is too loud.When this patient turned on her tv, the roommate began yelling and cursing at this patient to turn her f****** [explicit] tv down. This patient stated she was afraid to go back into the room.No observations or interviews could be made of R120 as this resident had been discharged from the facility on 10/26/2025.Review of R119's Face Sheet found in R119's EMR under the Resident tab indicated the resident was admitted to the facility on [DATE] with diagnoses which included cognitive communication deficit and altered mental status.Review of R119's admission MDS with an ARD of 10/07/2025 and located under the MDS tab of the EMR indicated the resident had a BIMS score of 13 out of 15 which indicated the resident was cognitively intact. The assessment revealed the resident had no behaviors directed towards others.Review of R119's nursing Progress Notes, dated 10/06/2025 and located under the Prog tab revealed Reported by nursing staff that resident [R119] was heard yelling at her roommate [R120] Shut the f****** [explicit] TV off.No observations or interviews could be made of R119 as this resident had been discharged from the facility on 10/17/2025.Review of a Facility Incident Report dated 10/06/2025 and provided by the facility indicated Type of Incident-Verbal Abuse. Details of Incident-Per report by [name of Registered Nurse (RN)1] patients were in dispute over volume of TVs. [name of R120] entered the room and asked [name of R119] to turn her tv down to which R119 began yelling profanities to R120 calling her a f***ing [explicit] liar and telling her to get out of the room or she would have her ass. The incident report further indicated, Patients were separated and remain safe in the facility at this time. The incident report indicated, No injuries noted but patient [identified as R120] felt scared to go back into her room while the other patient was there.Review of an undated written statement from RN1 as part of the facility's investigation, indicated, So [name of R120] complained that the B bed [name of R119] TV was too loud. So, I got a headset and put in on [name of R119]. [name of R120] went back in the room, turned her TV on and [name of R119] started screaming Shut the F**** [explicit] TV off. [Name of R120] came out of the room and said anytime she goes in the room, the roommate cusses her out.Review of an undated statement from R120 regarding the incident indicated, I went to watch TV and she [referring to R119] yelled at me to turn my f'n [sic] tv down and told me if I don't, she's going to get my ass.During an interview on 03/04/2026 at 2:25 PM, the Director of Nursing (DON) stated that she was new at the time of this incident and was being trained by the previous DON on this incident of verbal abuse that occurred between R119 and R120. The DON stated, I vaguely remember the situation where [name of R119 and R120] were roommates and [name of R120] had gone in the room and [name of 119] started cussing and yelling at [name of 120] about the tv. [name of RN1] came and told me about it and the residents were separated. The DON then stated, As a result of the investigation, I believe we substantiated it as a type of verbal abuse. Yes.During an interview on 03/04/2026 at 3:56 PM, the Administrator stated, In reviewing this allegation, we determined it was an allegation of verbal abuse. Yes.2. Review of R9's Face Sheet, located under the Profile tab of the EMR revealed R9 was admitted to the facility on [DATE] and readmitted on [DATE]. Review of R9's annual Minimum Data Set (MDS), with an ARD of 01/16/2026 and located under the MDS tab of the EMR revealed a Brief Interview for Mental Status (BIMS) score of 15 out of 15 which indicated R9 was cognitively intact. The annual MDS indicated R9 was dependent on staff for incontinent care.Review of the Facility Reported Incident (FRI) investigation dated 12/24/2025 and provided by the facility revealed R9 was subjected to verbal abuse by a Certified Nursing Assistant (CNA 9). The Administrator reported that he was informed that a CNA yelled at resident [R9]. After interviewing [R9], she stated that she had not been changed timely. [The] Facility completed [an] investigation, and it was found that [CNA9] was involved in verbal alt (altercation) with [the] resident. The facility cannot determine that the CNA [CNA9] completed timely rounds. [CNA9] was terminated on completion of [the] investigation. [R9] states she feels safe an [sic] the facility at this tjme [sic]. The report noted that the accused staff member, (CNA9), was immediately placed on leave and terminated following the substantiation of the abuse. During an interview on 03/03/2026 at 9:40 AM, R9 recalled the incident and stated, She [CNA9] was very mean, yelled at me, wouldn't change me. She doesn't work here anymore, thank goodness.During an interview on 03/05/2026 at 9:00 AM, CNA8 who witnessed the verbal abuse repeated her witness statement confirming the verbal abuse of R9. CNA8 stated she heard yelling/screaming, walked around and found CNA9 coming out of R9's room screaming at her. The resident stated she had not been changed, that CNA9 was making excuses not to change her, and yelled at her. CNA8 observed CNA9 continue to yell at the resident and state, I'm not the type to be messed with and that CNA9 would make the resident's life a living hell. CNA8 immediately reported the incident to the charge nurse and the staff scheduler.During an interview on 03/05/2026 at 11:22 AM, the Administrator stated the investigation was substantiated, the CNA (CNA9) was terminated, and the Board of Nursing was notified.Review of the facility's policy titled Abuse: Prevention of and Prohibition Against, revised 08/2025 indicated, It is the policy of this facility that each resident has the right to be free from abuse.The facility will provide oversight and monitoring to ensure that its staff, who are agents of the facility, deliver care and services in a way that promotes and respects the rights of the residents to be from abuse. It further indicated, Verbal Abuse includes the use of oral, written, or gestured language that willfully includes disparaging and derogatory terms to residents or their representatives.regardless of their age, ability to comprehend, or disability. The policy indicated, Protection-If an allegation of abuse is reported, discovered or suspected, the facility will take the following steps to protect all residents from physical and psychosocial harm during and after the investigation.If the allegation of abuse involves another resident, the facility will: Separate the residents so they do not interact with each other until circumstances of the reported incident can be determined.a room change if appropriate.continue to assess, monitor and intervene as necessary to maximize resident health and safety.Cross reference with F609 and F610

Based on record review, interview, and facility policy review, the facility failed to report substantiated verbal abuse to local law enforcement for 2 of 4 residents reviewed for abuse (Resident (R) 9 and R120) out of 31 sampled residents. Certified Nursing Assistant (CNA) 9 verbally abused R9 by making intimidating and threatening statements to the resident and R120 was verbally abused by another resident; however, the facility did not identify the abuse as a possible crime and report it to local law enforcement. This failure left the residents being victims of abuse without proper investigation from law enforcement. Findings include: 1. Review of R9's Face Sheet, located under the Profile tab in the Electronic Medical Record (EMR) revealed R9 was admitted to the facility on [DATE]. and readmitted on [DATE]. Review of R9's annual Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 01/16/2026 and located under the MDS tab in the EMR revealed the facility assessed the resident to have a Brief Interview for Mental Status (BIMS) score of 15 out of 15 which indicated R9 was cognitively intact. The annual MDS also indicated R9 was dependent on staff for incontinent care.Review of the Facility Reported Incident (FRI) investigation, dated 12/24/2025 and provided by the Administrator revealed the facility substantiated that R9 was verbally abused by CNA9. During an interview on 03/03/2026 at 9:40 AM, R9 recalled the incident and stated, She (CNA9) was very mean, yelled at me, wouldn't change me. She doesn't work here anymore, thank goodness. When asked how the CNA's statements made her feel, the question triggered an event that happened historically involving a sheriff's deputy. R9 kept repeating the historic incident. During an interview on 03/05/2026 at 9:00 AM, CNA8 stated she witnessed CNA9 verbally abusing R9. Continued interview revealed CNA8 witnessed CNA9 making intimidating and threatening statements to R9.During an interview on 03/05/2026 at 11:22 AM, when asked if the Police Department had been notified, the Administrator stated, No, for verbal abuse. We determine if a crime has been committed before we notify the police. When asked how that determination was made, no information was provided. When asked how he viewed CNA9's statement of I'm not the type to be messed with and that CNA9 would make the resident's life a living hell, the Administrator said he viewed the statement as a threat. 2. Review of R120's Face Sheet found in R120's electronic medical record (EMR) under the Resident tab indicated the resident was admitted to the facility on [DATE].Review of R119's Face Sheet found in R119's EMR under the Resident tab indicated the resident was admitted to the facility on [DATE].Review of a Facility Incident Report dated 10/06/2025 and provided by the facility indicated Type of Incident-Verbal Abuse.R119 began yelling profanities to R120 calling her a f****** [explicit] liar and telling her to get out of the room or she would have her ass. The incident report further indicated, .patient [identified as R120] felt scared to go back into her room while the other patient was there.Review of the facility's investigation file dated 10/10/2025 and provided by the facility for the abuse incident involving R119 and R120 revealed no documented evidence the abuse was reported to local law enforcement.During an interview on 03/04/2026 at 2:25 PM, the Director of Nursing (DON) When asked if there was documentation Law Enforcement was notified, the DON stated, No, I don't see they were notified.During an interview on 03/04/2026 at 3:56 PM, when asked if there was documentation that Law Enforcement was notified regarding the facility's investigation of R120 being verbally abused, the Administrator stated, No. We have decided if we felt it was a crime then we would involve them. But no, they were not notified.Review of the facility's policy titled Abuse: Prevention of and Prohibition Against, dated 12/2023 revealed Allegations of abuse, neglect, misappropriation of resident property, or exploitation will be reported outside the facility and to the appropriate State or Federal agencies in the applicable timeframes as per this policy and applicable regulations.Cross reference with F600 and F610

Based on observations, interviews, record review, review of the facility's policy, and review of the facility incident reports and investigations, the facility failed to complete thorough investigations of allegations of abuse and neglect for 3 of 4 residents reviewed for abuse (Resident (R) 14, R68, and R120) out of 31 sampled residents. The facility's failure to complete thorough investigations placed residents at risk of being unprotected from abuse. Findings include:1. Review of R120's Face Sheet found in R120's electronic medical record (EMR) under the Resident tab indicated the resident was admitted to the facility on [DATE].Review of R120's admission Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 09/15/2025 and located under the MDS tab of the EMR indicated the resident had a Brief Interview for Mental Status (BIMS) score of six out of 15 which indicated the resident was severely cognitively impaired.Review of R119's Face Sheet found in R119's EMR under the Resident tab indicated the resident was admitted to the facility on [DATE].Review of R119's admission MDS with an ARD of 10/07/2025 and located under the MDS tab of the EMR indicated the resident had a BIMS score of 13 out of 15 which indicated the resident was cognitively intact. The assessment revealed the resident had no behaviors directed towards others.Review of a Facility Incident Report dated 10/06/2025 and provided by the facility indicated Type of Incident-Verbal Abuse.Details of Incident-Per report by [name of Registered Nurse (RN) 1] patients were in dispute over volume of TVs. [name of R120] entered the room and asked [name of R119] to turn her tv down to which R119 began yelling profanities to R120 calling her a f****** [explicit] liar and telling her to get out of the room or she would have her ass. The incident report further indicated, Patients were separated and remain safe in the facility at this time. The incident report indicated, No injuries noted but patient [identified as R120] felt scared to go back into her room while the other patient was there.Review of the facility's investigation file dated 10/10/2025 and provided by the facility for the abuse incident involving R119 and R120 indicated Investigation completed. Based on employee witness statements it appears [name of R119] did tell [name of R120] to Turn the [explicit tv down or she would have her ass. However, staff intervened right away. They were separated and redirected the residents as [name of R119] was moved to a different room. No negative adverse effects noted pertaining to this incident. The facility investigation did not indicate which staff intervened, and the investigation file only contained an undated statement from Registered Nurse (RN) 1 with no date indicated in the statement. There was no evidence additional staff or residents were interviewed regarding this incident. The facility investigation only contained one undated statement from RN1, an interview with R120 with no date/time or who interviewed R120 and no statement from R119.Review of an untitled and undated statement from RN1 as part of the facility investigation, indicated, So [name of R120] complained that the B bed [name of R119] TV was too loud. So, I got a headset and put in on [name of R119]. [name of R120] went back in the room, turned her TV on and [name of R119] started screaming Shut the F**** TV off. [Name of R120] came out of the room and said anytime she goes in the room, the roommate cusses her out. [Name of R120] said she was scared to go into her room.Review of an untitled and undated statement from R120 regarding the incident indicated, I went to watch TV and she [referring to R119] yelled at me to turn my f'n [sic] tv down and told me if I don't, she's going to get my ass. And then [name of previous Social Services Director] came and offered headphones to her and then she started saying to me Your nothing but a f'n [sic] liar and you went and told her to make me put these on.Review of the same untitled and undated document indicated, [name of R119] denies anything occurring. There was no evidence of any other written statements from the previous social services director, no additional staff, or residents.Review of R120's nursing Progress Notes, dated 10/06/2025 and located in the residents EMR under the Prog [progress] Notes tab indicated, Patient reported her roommate tv is too loud.When this patient turned on her tv, the roommate began yelling and cursing at this patient to turn her fucking tv down. This patient stated she was afraid to go back into the room.No observations or interviews could be made of R120 as this resident had been discharged from the facility on 10/26/2025.Review of R119's nursing Progress Notes, dated 10/06/25 and located under the Prog [prognosis] tab revealed Reported by nursing staff that resident [R119] was heard yelling at her roommate [R120] Shut the fucking TV off.No observations or interviews could be made of R119 as this resident had been discharged from the facility on 10/17/2025.An unsuccessful attempt to contact RN1 via phone was made on 03/04/2026 at 2:17 PM. During an interview on 03/04/2026 at 2:25 PM, the Director of Nursing (DON) stated, We would have gotten statements from anyone that was there, witnesses, or anyone that was involved but I see the report is incomplete. When reviewing the facility investigation file with the DON, she confirmed there was no statement from R119, no documentation from the previous social services director, no statement from the previous DON, no statements from any staff that were present at the time of the incident and no interviews/statements from additional residents that may have heard the incident. During an interview on 03/04/2026 at 3:56 PM, regarding the facility investigation of verbal abuse, the Administrator stated, In reviewing this allegation, we determined it was an allegation of verbal abuse. Yes. When reviewing the facility investigation file with the Administrator he stated, I do not see a date or time of the statement taken from [name of RN 1]. I have no idea of when the statement was given. He stated, I see [name of 119] was talked to but I don't see who interviewed her or a date or time and I'm not seeing a statement from [name of R120]. He further stated, I'm not sure when or who spoke to [name of 119] and I do not see any further statements from any other staff or residents here. When the Administrator was asked if he thought the investigation was complete, he stated, Based on what I see in the file. I would agree it's not a complete and thorough investigation. We are missing documentation to show interviews from staff were completed and any residents if they heard anything.2. Review of R68's Face Sheet found in R68's EMR under the Resident tab indicated R68 was admitted to the facility on [DATE] with diagnoses to include acute respiratory failure, cognitive communication deficit, and anxiety disorder.Review of R68's admission MDS with an ARD of 01/13/2026 and located under the MDS tab in the EMR indicated the resident had a BIMS score of five out of 15 which indicated the resident was severely cognitively impaired.Review of a Facility Incident Report regarding R68 dated 02/05/2026 indicated Type of Incident-Neglect. The incident report indicated On 02/05/26 at approximately 14:15 [2:15 pm], the incident occurred in room [R68's room number] .The resident was last seen leaving the facility in a wheelchair with a visitor.without notifying nursing staff.staff learned from the roommate that a woman had wheeled him out of the facility. The facility indicated the allegation was verified. The facility investigation further indicated, The facility initiated an internal investigation immediately upon discovery of the incident on 02/05/26. Interviews were conducted with involved staff, including nursing staff who observed the resident's absence, the DON, and the resident [identified as R68]. Staff also obtained information from the resident's roommate who reported that a woman packed the resident's belongings and wheeled him out of the facility.Review of R68's Social Services notes dated 02/05/2026 and located in the resident's EMR under the Prog [progress] Notes tab indicated, Notified that the pt. [patient] was taken out of the facility, however the individual who removed the pt. [patient] is unknown.Review of R68's nursing Progress Notes, dated 02/05/2026 and located in the resident's EMR under the Prog [progress] Notes tab indicated, This DON [Director of Nursing] was notified that the resident was no longer in his room and that the roommate had said a woman came and gathered his belongings and wheeled him out.During an observation and interview of R68 on 03/02/2026 at 1:45 PM, R68 was observed in his room laying in bed. He was observed to be alert and oriented. During an interview regarding the incident that occurred on 02/05/2026, R68 stated, I left for a day and a half then I came back. I left to a friend's house. At the time, my room was going to get painted and the next day my friend came to get me. I tried to see if anyone was around at the nurse's station to let them know but couldn't find anybody so I got in the car and left.During an interview on 03/02/2026 at 2:00 PM, Licensed Practical Nurse (LPN) 4 stated, That day of the incident I recall he [referring to R68] had a visitor. I didn't know she was going to take him .LPN4 stated, The CNA went into the room to answer the call light and saw he [R68] was gone then came to get me. I immediately went to the Administrator and the DON, and we called a Code Orange [missing resident. When LPN4 was asked if she was asked to write a written statement as part of the facility investigation she stated, No.During an interview on 03/02/2026 at 2:45 PM, regarding the facility investigation of R68, the Receptionist (REC) stated she recalled a visitor who came to see R68 on 02/05/26 and signed her name on the sign-in log. The receptionist then stated, she also recalled seeing R68 leave with the visitor out the front entrance and recalled seeing the same visitor return R68 the following day. When asked if she was asked to write a statement as to being a witness to seeing R68 leave the facility on 02/05/26, the receptionist stated, No.During an interview regarding the facility investigation on 03/03/2026 at 1:50 PM, the DON was asked if there was any documentation of staff interviewing R68's roommate as part of the investigation, she stated, No. During an interview and review of the facility's investigation file on 03/03/2026 at 3:26 PM, when the Administrator was asked if there was any evidence of documented statements from R68, R68's roommate, LPN4, additional staff that worked on 02/05/26 to include any CNAs, any other residents on the unit, the former DON, ADON, the former social services director, and the front receptionist, the Administrator stated, No. We did not get statements. 3. Review of R14's Face Sheet located under the Profile tab of the (EMR) revealed R14 was admitted to the facility on [DATE]. Review of R14's quarterly MDS with an ARD of 01/19/2026 and located in the resident's EMR under the MDS tab revealed the facility assessed the resident to have a Brief Interview for Mental Status (BIMS) score of 15 out of 15 which indicated the resident was cognitively intact. Review of the facility's final investigation report dated 01/18/2026, revealed R14 reported It was alleged that a CNA named [first name] told the resident to shut up and that she did not change her. It was reported that it was 'a couple of weeks ago.' . The initial allegation was reported on 01/13/2026.Review of the facility's investigation folder revealed interviews/statements were obtained from four other residents, one CNA, and a nurse. There was no written interview/statement from R14 in the folder. The facility's investigation revealed no documented evidence of other CNAs named [first name] were identified and interviewed who worked at the facility. The nursing schedules included were dated 01/10/2026 through 01/15/2026 and only included first names.Review of the facility's employee roster revealed there were six staff members named [first name] or similar. During an interview on 03/04/2026 at 3:09 PM, the Director of Nursing (DON) stated, I was the ADON [Assistant Director of Nursing] at the time. I interviewed [R14]. [R14] reported the CNA went in her room and [R14] needed a brief change. The CNA yelled at her. [R14] said the CNA's name was [first name] and described the CNA as younger with shorter light-colored hair. [R14] did not have a specific date but 2 weeks prior and occurred during mid-day. I interviewed the staff person that fit the description as [CNA7]. We didn't talk to other CNAs. Administration was out of town at the time of the allegation. When asked about the staffing schedules being reviewed for only four days prior and not during the time frame the resident alleged, the DON did not respond with a comment. During an interview on 03/04/2026 at 4:14 PM, the Administrator stated the facility's investigation of R14's allegation was not a complete investigation. The Administrator also stated he would have expected to see two weeks of staff schedules reviewed, would have expected all staff with [first name] to be interviewed, and would have expected other staff to be interviewed.Review of the facility's policy titled, Abuse: Prevention of and Prohibition Against revised 08/2025 indicated It is the policy of this facility that each resident has the right to be free from abuse, neglect. It further indicated Definitions: Neglect is the failure of the facility.to provide goods and services to a resident that are necessary to avoid physical harm, mental anguish, or emotional distress.Neglect occurs when the facility is aware of, or should have been aware of, goods or services that a resident(s) requires but the facility failed to provide them.Neglect includes cases where the facility's indifference or disregard for resident care, comfort, of safety resulted in or could have resulted in, physical harm, mental anguish, or emotional distress. The policy indicated, Verbal Abuse includes the use of oral, written, or gestures language that willfully includes disparaging and derogatory terms to residents.regardless of their age, ability to comprehend, or disability. The policy indicated, Investigation- all identified events are reported to the Administrator immediately.all allegations of abuse, neglect.will be promptly and thoroughly investigated by the Administrator or his/her designee.The investigation will include the following: An interview with the person(s) reporting the incident; an interview with the resident(s); interviews with any witnesses to the incident, including alleged perpetrator, as appropriate; an interview with staff members (on all shifts) who may have information regarding the alleged incident; interviews with other residents to whom the accused employee provides care or services or may have information surrounding the incident.At the conclusion of the investigation, the facility will attempt to determine if abuse, neglect.has occurred. The investigation, and the results of the investigation, will be documented. The policy indicated, Allegations of abuse, neglect.will be reported outside the facility and to the appropriate State or Federal agencies.Cross reference with F600 and F609

Based on record reviews, interviews, review of the Resident Assessment Instrument (RAI) Manual, and facility policy review, the facility failed to ensure the Minimum Data Set (MDS) assessments were completed accurately for 3 of 31 sampled residents (Resident (R) 10, R48, and R97). Staff failed to accurately code hospice for R10; failed to accurately code a multidrug-resistant bacteria (MDRO) infection for R48; and failed to accurately code intravenous (IV) feeding for R97. Failure to code the MDS correctly can lead to inaccurate federal reimbursement and inaccurate assessment and care planning for the residents. Findings include: 1. Review of R97's Face Sheet located under the Profile tab of the electronic medical record (EMR) revealed R97 was re-admitted to the facility on [DATE]. Review of R97's quarterly MDS, with an Assessment Reference Date (ARD) of 12/26/2025, located under the MDS tab of the EMR indicated, .Parenteral/IV feeding [as a yes] while a resident.Review of R97's physician Order Summary Report, dated 03/04/2026 and located under the Orders, tab of the EMR indicated no evidence of a physician's order for Parenteral/IV feedings. Review of R97's Medication Administration Record (MAR), dated December 2025 and located under the Orders, tab in the EMR indicated no evidence of an order to administer Parenteral/IV feedings. During an interview on 03/04/2026 at 4:10 PM, the MDS Director (MDSD) confirmed that R97 received IV feedings while in the hospital, not at the facility. The MDSD stated R97's quarterly MDS was miscoded, which indicated it was not accurately completed.2. Review of R10's Face Sheet located under the Profile tab of the EMR indicated the resident was admitted to the facility on [DATE] with diagnoses which included encounter for palliative care.Review of R10's physician's Order, dated 07/15/2025 and located under the Orders tab of the EMR, revealed R10 had an order for hospice services. Review of R10's quarterly MDS, with an ARD of 01/22/2026 and located under the MDS tab indicated the response to Hospice Care was not checked.During an interview on 03/05/2026 at 2:05 PM, the MDS Director (MDSD) stated [R10] was admitted to hospice services on 07/17/2025. The MDSD confirmed the MDS with an ARD of 01/22/2026 was marked No for hospice services. The MDSD also stated that it was marked No in error and should have been marked yes.3. Review of R48's Face Sheet located under the Profile tab of the EMR indicated the resident was admitted to the facility on [DATE] with diagnoses which includedextended spectrum beta lactamase (ESBL) resistance. Review of R48's quarterly MDS, with an ARD of 01/08/2026 and located under the MDS tab indicated the response to: Active Diagnoses in the last 7 days had Multidrug-Resistant Organism (MDRO) marked.Review of R48's physician Order, dated 05/07/2025 and located under the Orders tab of the EMR, revealed an order for Transmission Based Precautions for ESBL in urine. The order was discontinued on 05/10/2025. During an interview on 03/05/2026 at 2:58 PM, the Infection Preventionist (IP) stated R48 had a history of MDRO from the ESBL infection when she was admitted but did not have an infection in January 2026 during her MDS assessment. The IP stated the MDS was marked in error since R48 did not have an active infection at the time. During an interview on 03/05/2026 at 2:05 PM, the MDSD stated R48's MDS was marked in error on 01/08/2026 since she did not have an active infection during the review period.Review of the facility's policy titled, MDS Completion, Resident Assessment, dated February 2020, indicated, It is the policy of this facility to complete accurate and timely MDS assessments in accordance with Federal and State requirements. IDT [interdisciplinary team] Members Attest to accuracy of each item they are coding by signing each item for completion.Review of the Long-term Care Facility Resident Assessment Instrument 3.0 User's Manual, revised October 2025, revealed .the intent of this section is to identify any special treatments, procedures, and programs that the resident received or performed during the specified time periods.revealed the intent of this section is to code diseases that have a direct relationship to the resident's current functional status, cognitive status, mood or behavior status, medical treatments, nursing monitoring, or risk of death. One of the important functions of the MDS assessment is to generate an updated, accurate picture of the resident's current health status.the intent of this section is to assess the many conditions that could affect the resident's ability to maintain adequate nutrition and hydration. This section covers swallowing disorders, height and weight, weight loss, and nutritional approaches. The assessor should collaborate with the dietary staff to ensure that items in this section have been assessed and calculated accurately.It is important to note here that information obtained should cover the same observation period as specified by the MDS items on the assessment, and should be validated for accuracy [what the resident's actual status was during that observation period] by the IDT [Interdisciplinary] completing the assessment .

Based on record review, interview, and policy review, the facility failed to develop person centered care plans based on residents' comprehensive assessments for 2 of 31 sampled residents (Resident (R) 14 and R27). This failure placed the residents at risk of unmet care needs.Findings include:1. Review of R14's Face Sheet located under the Profile tab in the Electronic Medical Record (EMR) revealed the resident was admitted to the facility on [DATE] with diagnoses which included generalized muscle weakness, cognitive communication deficit, and major depressive disorder.Review of R14's quarterly Minimum Data Set (MDS) with Assessment Reference Date (ARD) 01/19/2026 and located under the MDS tab in the electronic medical record (EMR) revealed R14 had a Brief Interview for Mental Status (BIMS) score of 15 out of 15 which indicated she was cognitively intact. The assessment also indicated that R14 was dependent on staff for toileting and was incontinent of bowel and bladder.Review of R14's Documentation Survey Report dated December 2025 and January 2026, located under the Reports tab of the EMR, revealed R14 was incontinent of bowel and bladder.Review of R14's Care Plan located under the Care Plan tab of the EMR revealed there was not a care plan that indicated R14 was incontinent of bowel and bladder.During an interview on 03/05/2026 at 4:32 PM, the Director of Nursing (DON) confirmed urinary and bowel incontinence were not included on R14's care plan and stated urinary and bowel incontinence should have been care planned. 2. Review of R27's Face Sheet located under the Profile tab in the EMR revealed the resident was admitted on [DATE] with diagnoses which included complete loss of teeth, cognitive communication deficit, generalized muscle weakness, dementia, and generalized anxiety disorder.Review of R27's annual MDS with an ARD of 02/13/2026, located under the MDS tab in the EMR revealed a BIMS score of 14 out of 15 which indicated R27 was cognitively intact. The assessment also revealed that R27 required assistance with oral hygiene and bathing. Review of R27's Care Plan located under the Care Plan tab of the EMR revealed there was not a care plan that indicated R27 needed assistance with bathing, shaving, or dentures.During an interview on 03/05/2026 at 4:32 PM, the DON confirmed bathing, shaving, and denture care was not included in R27's care plan and stated these should have been care planned.Review of the facility's policy titled, Comprehensive Person-Centered Care Planning, revised August 2017, indicated It is the policy of this facility that the interdisciplinary team (IDT) shall develop a comprehensive person-centered care plan for each resident that includes measurable objectives and timeframes to meet a resident's medical, nursing, mental and psychosocial needs that are identified in the comprehensive assessment.Review of the facility's policy titled, Activities of Daily Living (ADLs), revised July 2015, indicated When developing plans of care for ADL'S, ascertain individual resident preferences to ensure the interventions are personalized to include such things as wake time, bed time, meal time, day/time/type of bathing, diversional activities/use of free time, and any other ADL/quality of life choice that is important to the resident.

Based on interviews, record review, and review of the medication manufacturer's instructions, the facility failed to ensure the nurse instructed 2 of 2 residents observed during medication administration (Resident (R) 70 and R123) to rinse their mouths after they were administered an inhaled steroid medication. The deficient practice could result in residents acquiring an oral infection.Findings include:1. Review of R70's Face Sheet located in the resident's electronic medical record (EMR) under the Profile tab revealed the resident was admitted to the facility on [DATE] with diagnoses which included chronic obstructive pulmonary disease (COPD).Review of R70's Medication Administration Record (MAR) located under the Orders tab of the electronic medical record (EMR), revealed an order for Breo Ellipta [used to treat COPD] Inhalation Aerosol Powder Breath Activated 100-25 MCG/ACT (Fluticasone Furoate-Vilanterol) one (1) inhalation inhale orally one time a day, originated 03/03/2025.During an observation on 03/04/2026 at 9:04 AM, Licensed Practical Nurse (LPN) 3 administered Breo Ellipta 100-25 milligrams (mg) inhaler to R70 in R70's room. LPN3 did not instruct R70 to rinse his mouth after use. During an interview on 03/04/2026 at 10:55 AM, LPN3 confirmed that R70 did not rinse his mouth after using the Breo Ellipta inhaler and stated, I'm not sure if he needs to rinse his mouth after use. LPN3 reviewed the box for the Breo Ellipta inhaler and confirmed there was a label on the box that stated, Rinse mouth after each use.Review of a prescription drug guide at Drugs.com, revealed the medication, Breo Ellipta, is a steroid inhalation powder and the patient should rinse his/her mouth with water without swallowing to help reduce the risk of oropharyngeal candidiasis. Review of the Highlights of Prescribing Information .Breo Ellipta, dated May 2023, located at https://gskpro.com/content/dam/global/hcpportal/en_US/Prescribing_Information/Breo_Ellipta/pdf/BREO-ELLIPTA-PI-PIL-IFU.PDF read Candida albicans infection of the mouth and pharynx may occur. Advise the patient to rinse his/her mouth with water without swallowing after inhalation to help reduce the risk.2. Review of R123's Face Sheet located in the resident's EMR under the Profile tab revealed the resident was admitted to the facility on [DATE] with diagnoses which included COPD.Review of R123's MAR located under the Orders tab of the EMR revealed an order for Symbicort [used to treat COPD] Inhalation Aerosol 80-4.5 MCG/ACT (Budesonide- Formoterol Fumarate Dihydrate) (Breyna) two (2) puff inhale orally two times a day, originated 02/24/2026.During an observation on 03/04/2026 at 8:06 AM, LPN2 administered Breyna 80/4.5 micrograms (mcg) inhaler to R123 in R123's room. LPN2 did not instruct R123 to rinse her mouth after use.During an interview on 03/04/2026 at 10:37 AM, LPN2 confirmed R123 did not rinse her mouth after using the Breyna inhaler and stated, I don't think residents have to rinse their mouth after using the inhaler. LPN2 reviewed the Breyna box and confirmed the label stated, Rinse mouth after use.During an interview on 03/05/2026 at 4:32 PM, the Director of Nursing (DON) stated, Residents need to rinse their mouth after using Breyna and Breo Ellipta inhalers. My expectation is that the nurse instructs the residents to rinse their mouth after use.Review of a prescription drug guide at Drugs.com, revealed the medication, Breyna, is an inhaled corticosteroid medication and After inhalation, the patient should rinse the mouth with water without swallowing.Review of the Highlights of Prescribing Information .Breyna, dated February 2025 and located at https://dailymed.nlm.nih.gov/dailymed/fda/fdaDrugXsl.cfm?setid=dc529fc4-bddb-4673-8202-dc401f86166f&type=display read Localized infections: Candida albicans infection of the mouth and throat may occur. Monitor patients periodically for signs of adverse effects on the oral cavity. Advise the patient to rinse his/her mouth with water without swallowing after inhalation to help reduce the risk.

Based on observation, interview, record review, and facility policy review, the facility failed to provide staff assistance with activities of daily living (ADLs) for 1 of 2 sampled residents reviewed for ADLs (Resident (R) 27) out of 31 sampled residents. This failure had the potential to lead to a decline in activities of daily living.Findings include:Review of R27's Face Sheet, located under the Profile tab in the electronic medical record (EMR) revealed R27 was admitted on [DATE] and readmitted on [DATE] with diagnoses which included cognitive communication deficit, generalized muscle weakness, dementia, and generalized anxiety disorder.Review of R27's annual Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 02/13/2026, located under the MDS tab in the EMR, revealed the resident had a Brief Interview of Mental Status (BIMS) score of 14 out of 15 which indicated R27 was cognitively intact. The MDS also indicated R27 required assistance for showering/bathing.During an observation and interview on 03/02/2026 at 9:57 AM, R27 was lying in bed and had an unkept beard. R27stated staff help him shave when they give him a shower. R27 stated he had not had a shower or bathed for 2 weeks. During an observation and interview on 03/04/2026 at 12:55 PM, R27 still had facial hair and stated he still had not had a shower. Review of R27's Showers located under the Tasks tab of the EMR, revealed R27 was scheduled for showers on Mondays and Thursdays during day shift. Documentation showed R27 was last offered and refused a shower on 02/19/26. Review of R27's Documentation Survey Report dated February 2026, located in the resident's EMR under the Reports tab revealed CNA1 documented NA [not applicable] for a shower scheduled on 02/26/2026.During an interview on 03/04/2026 at 12:57 PM, Certified Nursing Assistant (CNA) 6 stated, Residents get showered twice per week and are scheduled twice per week. I work with [R27] once in a while. [R27] should have been showered yesterday. He is scheduled on Tuesday and Fridays during day shift. If a resident refuses, then we have the resident sign a refusal on the shower sheets. During an interview on 03/04/2026 at 1:37 PM, CNA1 stated Residents are showered or bathed twice per week. We document in the computer and on paper. If residents refuse, the resident signs the shower sheet. I've only worked with [R27] twice. I have not showered him. He wasn't scheduled when I worked with him. CNA1 showed the paper CNA assignment sheet that showed R27 was scheduled on Tuesdays and Fridays for a shower and the CNA that is assigned to the shower.During an interview on 03/05/2026 at 4:32 PM, the Director of Nursing (DON) stated the facility did not have documentation showing R27 was offered a shower/bath twice per week. The DON confirmed the resident's shower schedule in the computer was Mondays and Thursdays and the schedule on paper was Mondays and Thursdays. The DON confirmed the last documented shower offered was 02/19/2026. The DON stated it was her expectation that showers/baths were to be offered twice per week. If the resident refused, staff were to offer again later, set up a schedule with the resident, and notify the nurse. The DON also stated CNAs should document the refusal on the paper shower sheet as well as in the computer.Review of the facility's policy titled, Activities of Daily Living (ADLs), revised July 2015, indicated Nursing assistants will provide assistance with ADL's based on the resident's individualized plan of care. ADL support and resident performance will be documented electronically .

Based on observation, interviews, record review, and facility policy review, the facility failed to ensure that staff provided proper catheter care for 1 of 2 residents (Residents (R) 40) reviewed for catheter care out of 31 sampled residents. This failure placed the resident at risk for the transmission of an infection. Findings include: Review of R40's Face Sheet, located under the Profile tab in the electronic medical record (EMR) indicated the resident was admitted to the facility on [DATE] with a diagnosis of neuromuscular dysfunction of the bladder. During observation of catheter care on 03/02/2026 at 9:55 AM, CNA5 wiped R40's perineal area in a downward motion using a disposable wipe. CNA5 obtained another wipe, retracted the foreskin, and wiped twice in a circular motion. CNA5 did not clean R40's urinary catheter, the catheter tubing, or the body of the penis. CNA5 assisted R40 in rolling to his right side. CNA5 then wiped R40's buttocks with a disposable wipe, using a downward motion. It was observed R40 had a bowel movement (BM), and CNA5 was observed wiping BM off her gloves. During an interview on 03/04/2026 at 3:40 PM, CNA5 stated catheter care included using a downward motion to clean, retracting the foreskin, and cleaning the glans of the penis in a circular motion. CNA5 confirmed the body of the penis, the catheter, and catheter tubing should be cleaned when completing catheter care.Interview on 03/04/2026 at 2:53 PM, the Director of Nursing (DON) stated she expected staff to wipe from front to back when cleaning the perineal area and expected to include the shaft of the penis, along with the catheter and catheter tubing. Interview on 03/05/2026 at 3:00 PM, the Infection Preventionist (IP) stated that cleaning a resident should occur from the front to back when cleaning the perineal area. Review of facility policy titled, Indwelling Urinary Catheter Care revised 04/2005, indicated, It is the policy of this facility that each resident with an indwelling catheter care daily and as needed (PRN) to promote hygiene, comfort, and decrease the risk of infection. Procedure.8. [NAME] (put on) gloves.9. Moisten the washcloth and apply soap to the washcloth or using moistened disposable wipes, clean the catheter in a downward motion (front to back) beginning at the urinary meatus (insertion point) and at least four inches down (from resident toward the collection bag). Use a clean portion of the washcloth or fresh disposable wipe for one cleansing motion. 10. Repeat the procedure without soap to rinse as needed. 11. Dry the resident perineal area with a clean cloth. 12. May secure the tubing with a securement device, PRN to prevent migration, friction, or tension of the catheter.15. Remove gloves and perform hand hygiene with soap and water.

Based on observation, record review, and interview, the facility failed to ensure the exterior filter on the oxygen concentrator was clean for 1 of 3 residents reviewed for oxygen use (Resident (R) 9) out of 31 sampled residents. This failure created potential for the oxygen concentrator not to work efficiently, which could have reduced the purity of the oxygen delivered and placed R9 at risk of infection. Findings include:Review of R9's Face Sheet, located under the Profile tab in the Electronic Medical Record (EMR) revealed R9 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included asthma, mucopurulent chronic bronchitis, chronic obstructive pulmonary disease, dependence on supplemental oxygen, and anxiety disorder.Review of R9's annual Minimum Data Set (MDS), with an assessment reference date (ARD) of 01/16/2026 and located under the MDS tab in the EMR revealed a Brief Interview for Mental Status (BIMS) score of 15 out of 15 which indicated R9 was cognitively intact. The MDS revealed R9 received oxygen therapy while in the facility.Review of R9's March 2026 Physician Orders located under the Clinical Physician Orders tab in the EMR, revealed the following: a. Change tubing, clean filter and change O2 [oxygen] water bottle every night shift every 7 (seven) days b. Change filter on concentrator every 24 hours as needed c. Clean filter on concentrator Q [every] week, every night shift, every Wed [Wednesday] d. Change oxygen tubing and humidifier bottle every 24 hours as needed e. Oxygen at 2L/M [two liters per minute] via nasal cannula continuously - diagnosis: Chronic respiratory failureReview of R9's February 2026, Treatment Administration Record (TAR) noted: Clean filter on concentrator Q week every night shift every Wed. The filter was noted to have been cleaned on 02/25/2026. There was no indication the filter was cleaned after 02/25/2026 despite it being observed to be very dirty on 03/02/2026. During an observation and interview on 03/02/2026 at 8:54 AM, R9 was in bed with oxygen in place. R9 stated, .I have to have oxygen on always. Observation of the exterior filter on the oxygen concentrator revealed the filter was gray in color with a heavy build-up of dust and dirt. There was no date on the oxygen tubing as to when it had last been changed nor on the oxygen concentrator when the filter had last been cleaned. R9 asked to see the dirty filter and stated, I think they change the tubing every Wednesday, but I don't know when they clean that [filter].On 03/02/2026 at 9:06 AM, the Assistant Director of Nurses (ADON) was asked to observe the filter. The ADON stated, Oh that needs to be changed. When asked who was responsible for checking, changing, and/or cleaning the oxygen concentrator filters, the ADON stated, Let me check, I don't know for sure. I don't want to say the wrong thing. During an interview on 03/05/2026 at 11:22 AM, the Director of Nurses (DON) stated, I was told about the filter. We will need to check that it's being done. The DON did not state who should have cleaned the filter. Review of the oxygen Concentrators [DATE] - [DATE] work history report, provided by the Assistant Director of Nurses (ADON), revealed Cleaning the cabinet filter . remove the filter and clean as needed. Environmental conditions that may require more frequent inspection and cleaning of the filter include, but are not limited to high dust, air pollutants, etc. Clean the cabinet filter with a vacuum cleaner or wash with a mild liquid dish detergent (such as Dawn) and water. Rinse thoroughly. Thoroughly dry the filter and inspect for fraying, crumbling, tears and holes. Replace filter if any damage is found. Reinstall the cabinet filter. The report documented that the task had been completed on 03/01/2026 by maintenance.During an interview on 03/05/2026 at 11:22 AM, the Administrator stated the Maintenance Director had been terminated prior to the survey. There was no additional documentation to indicate that the filter had been cleaned as indicated in the Maintenance report as it was observed to be very dirty on 03/02/2026, one day post cleaning.Review facility's policy titled, Oxygen Administration, dated 03/2026 revealed the following Instructions for external filter cleaning: Filter is to be cleaned every seven (7) days or when visible soiled.

The facility failed to implement Enhanced Barrier Precautions (EBP), Transmission Base-Precautions (TBP), and provide care in a manner to prevent cross contamination for 2 of 31 sampled residents (Resident (R) 40 and R15) reviewed for infection control. These failures placed all residents of the facility at risk for the transmission and spread of infections.Findings include: 1. Review of R40's Face Sheet, located under the Profile tab in the electronic medical record (EMR) indicated the resident was admitted to the facility on [DATE] with a diagnosis of neuromuscular dysfunction of the bladder. During an observation on 03/02/2026 at 9:55 AM, a sign posted outside R40's room indicated that R40 was on Enhanced Barrier Precautions. The signage directed staff to perform hand hygiene before and after entering the room. Staff were to don (put on) gloves and gowns prior to entering the room to provide direct care to R40. Continued observation revealed an isolation cart outside of R40's room that contained yellow isolation gowns, and gloves. Certified Nursing Assistant (CNA) 5 was observed in R40's room without a gown on about to start catheter care when the surveyor knocked on R40's door and obtained the resident's permission to observe the catheter care. CNA5 double gloved her hands with two sets of gloves. CNA5 unhung the catheter and laid it on the bed and then emptied the catheter bag. CNA5 removed one set of gloves, placed them in her left gloved hand, and threw them in the waste basket between the bed and nightstand. Continued observation revealed the CNA kept the other pair of gloves on. CNA5 removed the rolled-up cloth drawsheet and brief placing it under R40's left side. CNA5 obtained disposable wipes from the overbed table and completed peri-care, and catheter care, all with the same gloves. Afterwards, CNA5 removed her gloves, and did not wash her hands nor sanitize her hands before placing a new pair of gloves on. CNA5 then assisted R40 in rolling over to his/her right side. CNA5 was cleaning the resident when she was observed wiping her gloves to remove bowel movement (BM) off the gloves. At this time, the CNA5 noticed that she was out of wipes, removed her gloves, and went out of the resident's room to the hallway linen cart and retrieved a package of wipes; however, CNA5 did not perform any type of hand hygiene before exiting the room. CNA5 returned to R40's room without performing hand hygiene or donning the required gown and gloves prior to entering the room. CNA5 finished placing the drawsheet and brief under R40, and adjusted R40's sheet prior to changing her gloves. After removing her gloves, CNA5 did perform any type of hand hygiene prior to leaving the room. Interview on 03/02/2026 at 3:40PM, CNA5 indicated that she was not sure what EBP was nor what type of personal protective equipment (PPE) to use while changing a resident that had a catheter. CNA5 stated she thought that PPE should be worn only when a resident had a wound. CNA5 also indicated she should have changed gloves when she went from dirty area to clean area. Interview on 03/04/2026 at 2:53 PM, the Director of Nursing (DON) stated that any resident that had a catheter was on EBP, which required that staff providing catheter care to wear a gown with gloves at a minimum. The DON indicated that gloves should be changed when going from a dirty area to a clean area, front to back. During an interview on 03/05/2026 at 3:00 PM, the Infection Preventionist (IP) stated the CNA should have worn the proper PPE during R40's catheter care. The IP also stated the CNA should have completed a glove change after she went from a dirty area and before she went back to the clean area. The IP further stated it was her expectation staff would perform hand hygiene in between glove changes. Review of facility's policy titled, Infection Prevention and Control Program, revised 12/2005, indicated, The infection prevention and control program is a facility-wide effort involving all disciplines and individuals and is an integral part of the quality assurance and performance improvement program .Scope of the Infection Control and Prevention Program: The infection prevention and control program is comprehensive in that it addresses detection, prevention and control of infections among residents and personnel. (Personnel covers staff, volunteers, visitors, and other individuals providing services under a contractual agreement) .3. The facility personnel will conduct themselves and provide care in a way that minimizes the spread of infection .b. Facility personnel will wash hands after all direct resident contact, for which hand washing is indicated by accepted professional practice. Soap and water must be used at least whenever hands are visibly soiled, after exposure to bodily fluids, after restroom use, and before handling food. Alcohol-based hand sanitizer is appropriate for routine hand hygiene and should be used when moving from a dirty task/area to a clean task/area, provided hands are not visibly contaminated. Review of facility policy titled, Infection Prevention and Control Program Standard and Transmission-Based Precautions revised 03/2026, indicated, Enhanced barrier protections: expand the use of PPE and refer to the use of the use of gown and gloves during high-contact resident care activities that provide opportunities for indirect transfer of MDROs to staff hands and clothing then indirectly transferred to residents or from resident-to-resident. (e.g., resident with wounds and indwelling medical devices are at especially high risk of both acquisition of a colonization with MDROs). a. PPE: The use of gown and gloves for high-contact resident care activities is indicated, when contact precautions do not otherwise apply, for nursing home residents with: i. Wounds and/or indwelling medical devices regardless of MDRO colonization as well as for residents. ii. MDRO infection or colonization.b. Examples of high-contact resident care activities requiring gown and glove uses for EBP include:.vii. Device care or use:. indwelling urinary catheter.2. Review of R15's Face Sheet located under the Profile tab of the EMR revealed R15 was admitted to the facility on [DATE] with diagnoses which included acute conjunctivitis.Review of R15's Medication Administration Record (MAR) dated March 2026, located under the Orders tab of the EMR, revealed an order for transmission based precautions: contact:Bacterial conjunctivitis: Apply PPE per protocol, originating 03/04/2026.Review of R15's Care Plan located under the Care Plan tab in the EMR revealed R15 was on contact precautions due to bacterial conjunctivitis dated 03/04/2026.Observation on 03/04/2026 at 8:37 AM revealed a Contact Precautions sign was posted outside R15's room. The sign read, Everyone must: clean their hands, including before entering and when leaving the room. Providers and staff must also: put on gloves before room entry. Discard gloves before room exit. Put on gown before room entry. Discard gown before room exit. Do not wear the same gown and gloves for the care of more than one person. Use dedicated or disposable equipment. Clean and disinfect reusable equipment before use on another person. Continued observation revealed Licensed Practical Nurse (LPN) 2 performed hand hygiene, donned gloves, and entered R15's room to administer medications. The LPN did not don a gown. The LPN then leaned across R15's bed and administered eye drops to R15. LPN2 forgot something on the medication cart and left the room wearing the same gloves and touched the medication cart with her gloved hands which indicated cross contamination. During an interview on 03/04/2026 at 10:37 AM, LPN2 stated, [R15] was on contact precautions for conjunctivitis. Gloves and gown are worn if changing the resident. I didn't have contact. I just administered eye drops and wore gloves. I didn't sanitize my hands. I don't recall when I removed my gloves. During an interview on 03/04/2026 at 10:44 AM, the Director of Nursing (DON) stated, Gloves and gown are worn when entering a room on contact precautions.Review of the facility's policy titled, IPCP Standard and Transmission Based Precautions, revised March 2026, indicated, Wear a gown and gloves for all interactions that may involve contact with the patient or the patient's environment. [NAME] [put on] PPE [personal protective equipment] upon room entry, then doff [take off] and properly discard PPE and perform hand hygiene before exiting the patient room to contain pathogens.

Based on clinical record review, interview and document review, the facility failed to: 1) perform nursing pre and post dialysis assessments and 2) access and maintain completed dialysis communication transfer forms in collaboration with the dialysis provider for 6 of 6 sampled residents on dialysis (Resident # 9, #20, #151, #51, #61, and #60). The deficient practice potentially placed the residents at risk for improper coordination of care between the facility and the dialysis provider. Findings include: Resident #9 Resident #9 was admitted to the facility on [DATE] and readmitted on [DATE], with diagnoses including end stage renal disease, type two diabetes mellitus without complications, and heart failure. Physician orders for Resident #9 documented the following: -05/31/2024: Hemodialysis: Monday-Wednesday-Friday. Special instructions; Vital signs (VS) after each session. Send/receive communication form with patient. Medical Records scan upon return, every day shift, every Monday, Wednesday, and Friday. -06/03/2024: Hemodialysis: Monday-Wednesday-Friday. Special instructions; VS before each session. Send/receive communication form with patient. Medical Records scan upon return, every day shift, every Monday, Wednesday, and Friday. -05/12/2024: check arteriovenous (AV) fistula every shift for positive thrill and bruit, access site right upper arm. Resident #9's Comprehensive Care Plan documented the following dialysis nursing interventions/tasks: -check arteriovenous fistula every day for bruit and thrill, -monitor/document peripheral edema, and -monitor/document/report to physician as needed any signs or symptoms of infection to access site: redness, swelling, warmth, or drainage. The facility Transportation Log documented Resident #9 was transported to dialysis on the following dates: -12/02/2024 -12/27/2024 -12/31/2024 -01/17/2025 -01/27/2025 Resident #9's clinical record lacked a Hemodialysis Communication Form and evidence of the resident's clinical assessments before, during, and after dialysis for the documented dialysis transportation dates. Resident #9's clinical record contained the following incomplete Hemodialysis Communication Forms: -11/04/2024: Lacked the pre dialysis access site assessment, pain assessment, medications held/given, signature, title, and time of transfer, the Dialysis Center's temperature measurement, the post dialysis vitals, access site assessment, pain assessment, signature, title, and time of return. -11/22/2024: Lacked the reason medications were not administered, signature, and time of transfer. -12/04/2024: Lacked the pre dialysis medications held/given and pain assessment, the Dialysis Center's pain assessment, and the post dialysis pain assessment. -12/13/2024: Lacked the pre dialysis medications held/given, access site assessment, and pain assessment, and the post dialysis pain assessment. -12/18/2024: Lacked the pre dialysis medications held/given, access site assessment, and pain assessment. -01/06/2025: Lacked the pre assessment time of transfer, and the reason why medications were not administered, and the Dialysis Center's pain assessment. -01/10/2025: Lacked the pre dialysis assessment time of transfer, and the Dialysis Center's pain assessment, access site assessment, VS, pre and post dialysis weights, and dialysis start and end times. -01/24/2025: Lacked the post dialysis vitals, pain assessment, access site assessment, signature, title, and date. On 02/26/25 at 1:47 PM, a Licensed Practical Nurse (LPN) explained the Hemodialysis Communication Form indicated the nursing facility was responsible for completion of the top portion of the form prior to the resident's treatment and should send the form with the resident to the Dialysis Center. Upon the resident's return from the Dialysis Center, the bottom portion was to be completed by the nursing facility. The Dialysis Center should have completed the middle section and returned the form to the nursing facility after the treatment was completed to advise of the resident's post dialysis status. On 02/26/2025 at 1:51 PM, the LPN explained a consequence to an incomplete or missing Hemodialysis Communication Form was the resident could be in trouble metabolically and the form was one way to track what was happening at the time and informing the nurse of what occurred during dialysis. Resident #20 Resident #20 was admitted to the facility on [DATE] and readmitted on [DATE], with diagnoses including type two diabetes mellitus with diabetic chronic kidney disease, dependence on renal dialysis, and acute posthemorrhagic anemia. Physician orders for Resident #20 documented the following: -10/07/2024: Dialysis every Tuesday, Thursday, and Saturday in the AM, every 48 hours for dialysis. -10/08/2024: Check AV fistula every shift for positive bruit and thrill, access site left upper arm every shift. -10/08/2024: Check the access site dressing to left upper arm every shift. -01/02/2025: Hemodialysis: Tuesday, Thursday, and Saturday. Special instructions; VS before and after each session. Send/receive communication form with patient. Medical Records to scan upon return, every day shift, every Tuesday, Thursday, and Saturday. Resident #20's Comprehensive Care Plan documented the following dialysis nursing interventions/tasks: -check and change dressing daily at access site, document, -check AV fistula every day for bruit and thrill, -monitor/document for peripheral edema, and -monitor/document/report to physician as needed any signs or symptoms of infection to access site: redness, swelling, warmth, or drainage. The facility Transportation Log documented Resident #20 was transported to dialysis on the following dates: -11/09/2024 -11/30/2024 -12/07/2024 -12/21/2024 -12/23/2024 -12/26/2024 -12/28/2024 Resident #20's clinical record lacked a Hemodialysis Communication Form and evidence of the resident's clinical assessments before, during, and after dialysis for the documented dialysis transportation dates. Resident #20's clinical record contained the following incomplete Hemodialysis Communication Forms: -11/12/2024: Lacked the Dialysis Center's access site assessment, pain assessment, and observations. -11/14/2024: Lacked the Dialysis Center's access site assessment, pain assessment, and observations. -11/23/2024: Lacked the facility nurse post dialysis access site assessment, pain assessment, date and signature. -11/28/2024: Lacked the Dialysis Center's access site assessment, pain assessment, dialysis start and end times, and post dialysis weight and the facility nurse post dialysis pain assessment. -12/14/2024: Lacked the Dialysis Center's access site assessment and the facility nurse post dialysis assessment, VS, signature, title and date. -12/31/2024: Lacked the Dialysis Center's access site assessment, post dialysis weight, dialysis start and end times, and the facility nurse's pre dialysis transfer time, the post dialysis access site assessment and vitals. -01/04/2025: Lacked the facility nurse post dialysis assessment, signature, title, and date. -01/07/2025: Lacked the facility nurse pre dialysis access site assessment, medication held/given, pain assessment, and the Dialysis Center's post dialysis weight. -01/16/2025: Lacked the facility nurse pre and post dialysis signatures, titles, time of departure, and post dialysis assessment. -01/23/2025: Lacked the facility nurse pre dialysis medications held/given and time of transfer, the Dialysis Center's access site assessment and pain assessment, and the facility nurse post dialysis access site assessment, VS, signature, title, date, and time of return. -01/28/2025: Lacked the Dialysis Center's access site assessment, dialysis start and end times, and pain assessment. -01/30/2025: Lacked the pre dialysis time of transfer, the Dialysis Center's access site assessment, pain assessment, and time of assessment, and the facility nurse post dialysis access site assessment, vitals, pain assessment, signature, title and time of return. -02/06/2025: Lacked the facility nurse pre dialysis access site assessment, pain assessment, medications held/given, signature, title, and time of transfer, the Dialysis Center's post dialysis weight, and facility nurse post dialysis access site assessment, pain assessment, signature, title, and time of return. -02/08/2025: Lacked the pre dialysis pain assessment and medications held/given, the Dialysis Center's access site assessment, pain assessment, and start and end times for dialysis. -02/13/2025: Lacked the time of transfer to dialysis and the facility nurse post dialysis access site assessment, pain assessment, vitals, signature, title, and date. Resident #151 Resident #151 was admitted to the facility on [DATE] and readmitted on [DATE], with diagnoses including acute and chronic respiratory failure with hypercapnia, anemia in chronic kidney disease, dependence on renal dialysis, and chronic atrial fibrillation, unspecified. Physician orders for Resident #151 documented the following: -01/09/2025: Hemodialysis: Monday-Wednesday-Friday. Special instructions; VS before each session. Send/receive communication form with patient. Medical Records scan upon return, every day shift, every Monday, Wednesday, and Friday. -01/09/2025: Hemodialysis: Monday-Wednesday-Friday. Special instructions; VS after each session. Send/receive communication form with patient. Medical Records scan upon return, every day shift, every Monday, Wednesday, and Friday. -02/19/2025: Receives hemodialysis three times per week on Monday, Wednesday, and Friday. -02/19/2025: Check AV fistula every shift for positive thrill and bruit, access site left AV. -02/19/2025: check the access site dressing to left intrajugular perma-cath, report signs and symptoms of infection to physician, every shift. Resident #151's Comprehensive Care Plan documented the following dialysis nursing interventions/tasks: -pain assessment every shift related to dialysis -monitor and report to physician as needed for any sign or symptom of decreased appetite, nausea/vomiting, complaints of stomach pain. Resident #151's clinical record contained the following incomplete Hemodialysis Communication Forms: -01/15/2025: Lacked the pre dialysis access site assessment, the Dialysis Center's access site assessment pain assessment, and time of assessment, and the facility nurse access site assessment post dialysis access site assessment, pain assessment, and time of return. -02/12/2025: Lacked the facility nurse pre dialysis access site assessment and time of transfer, the Dialysis Center's complete VS, dialysis start and end times, access site assessment and pain assessment, and the facility nurse post dialysis access site assessment. -02/14/2025: Lacked the pre dialysis medications given/held and time of transfer, and the facility nurse post dialysis access site assessment, pain assessment, signature, title, and return time. -02/21/2025: Lacked the Dialysis Center's post dialysis weight and the facility nurse post dialysis access site assessment, pain assessment, vitals, signature, title and return time. -02/24/2025: Lacked the Dialysis Center's access site assessment, pain assessment, resident's temperature, and time of assessment, and the facility nurse access site assessment and pain assessment. -02/26/2025: Lacked the pre dialysis medications given/held, pain assessment, and time of transfer, the Dialysis Center's access site assessment, and the facility nurse post dialysis access site assessment, pain assessment, signature, title and return time. Resident #61 Resident #61 was admitted to the facility on [DATE], with diagnoses including dependence on renal dialysis, type two diabetes mellitus without complications, and atherosclerotic heart disease of native coronary artery, and anemia in other chronic diseases classified elsewhere. Physician orders for Resident #61 documented the following: -12/12/2024: Receives Hemodialysis Tuesday, Thursday, and Saturday. -12/14/2024: Hemodialysis: Tuesday, Thursday, Saturday. Special instructions; VS before session. Send/receive communication form with patient. Medical Records to scan upon return, every shift, every Tuesday, Thursday, and Saturday. -12/14/2024: Hemodialysis: Tuesday, Thursday, Saturday. Special instructions; VS after session. Send/receive communication form with patient. Medical Records to scan upon return, every shift, every Tuesday, Thursday, and Saturday. Resident #61's Comprehensive Care Plan documented the following dialysis nursing interventions/tasks: -Monitor/document for peripheral edema, -Monitor/document/report to physician as needed any signs or symptoms of infection to access site: redness, swelling, warmth, or drainage, -Monitor/document/report to physician as needed for signs and symptoms of renal insufficiency: changes in level of consciousness, changes in skin turgor, oral mucosa, changes in heart and lung sounds, -Report significant changes in pulse, respirations, and blood pressure immediately. Resident #61's clinical record contained the following incomplete Dialysis Communication Forms: -12/18/2024: Lacked the pre dialysis access site assessment and time of transfer, the Dialysis Center's access site assessment, and the facility nurse post dialysis access site assessment. -01/04/2025: Lacked the pre dialysis access site assessment, pain assessment, medications given/held, signature, title, and time of transfer, the Dialysis Center's access site assessment and post dialysis weight. -01/08/2025: Lacked the pre dialysis access site assessment, the Dialysis Center's VS and access site assessments, visit documentation, and the facility nurse post dialysis access site assessment. -01/11/2025: Lacked the pre dialysis access site assessment, pain assessment, signature, title and time of transfer, and the Dialysis Center's access site assessment. Resident #51 Resident #51 was admitted to the facility on [DATE] and readmitted on [DATE], with diagnoses including end stage renal disease, type two diabetes mellitus without complications, chronic obstructive pulmonary disease, and anemia in chronic kidney disease. Physician orders for Resident #51 documented the following: -02/17/2025: Hemodialysis: Monday-Wednesday-Friday. Special instructions; VS before each session. Send/receive communication form with patient. Medical Records to scan upon return, every day shift, every Monday, Wednesday, and Friday. -02/17/2025: Hemodialysis: Monday-Wednesday-Friday. Special instructions; VS after each session. Send/receive communication form with patient. Medical Records to scan upon return, every day shift, every Monday, Wednesday, and Friday. -02/17/2025: Check the access site dressing right upper arm every shift. -02/24/2025: Check AV fistula every shift for positive thrill and bruit, access site right upper arm, every shift. Resident #51's Comprehensive Care Plan documented the following nursing interventions/tasks: -Administer medications as ordered, monitor/document for side effects and effectiveness, -Monitor VS as ordered and record, notify physician of significant abnormalities. The facility Transportation Log documented Resident #51 was transported to dialysis on the following dates: -02/03/2025 -02/05/2025 -02/07/2025 Resident #51's clinical record lacked a Hemodialysis Communication Form and evidence of the resident's clinical assessments before, during, and after dialysis for the documented dialysis transportation dates. Resident #51's clinical record contained the following incomplete Hemodialysis Communication Forms: -02/10/2025: Lacked the pre dialysis medications given/held, the Dialysis Center's access site assessment, pain assessment, pre and post dialysis weight, dialysis start and end times, signature and title. -02/19/2025: Lacked the Dialysis Center's access site assessment, pain assessment, pre and post dialysis weight, dialysis start and end times, signature, title, and time of assessment. A notation on the Dialysis Center portion of the form wrote Dialysis Center did not fill out. -02/21/2025: Lacked the Dialysis Center's post dialysis weight and dialysis start and end times. -02/24/2025: Lacked the pre dialysis VS, medications held/given, and time of transfer, and the Dialysis Center's access site assessment, pain assessment, VS, pre and post dialysis weight, dialysis start and end times, signature, and title. On 02/27/25 at 10:24 AM, the Director of Nursing Services (DNS) explained if a Hemodialysis Communication Record was not present in the clinical chart, it would mean the form was not implemented for the Dialysis visit. The DNS confirmed the missing forms were not present and confirmed the incomplete dialysis visit records for the reviewed residents. The expectation was the form would be filled out for every resident dialysis visit as a tool of communication between the facility and the Dialysis Center. The DNS confirmed if the visit was refused or canceled it should have been documented in a nursing progress note. The DNS explained if the Hemodialysis Communication Record had missing information from the Dialysis Center staff, the charge nurse on duty would call the Dialysis Center and get the information or have the information faxed to the facility. The DNS confirmed it was the responsibility of the charge nurse on duty to verify the Hemodialysis Communication Record was complete and accurately documented the resident's post dialysis status. On 03/03/25 at 12:30 PM, the DNS verbalized the DNS was the Dialysis Coordinator and had the overall responsibility for coordination of dialysis for facility residents. 40377 Resident #60 Resident #60 was admitted to the facility on [DATE], with diagnoses including end stage renal disease, type 2 diabetes mellitus without complication, renovascular hypertension, and dependence on renal dialysis. A physician's order dated 01/28/2025, documented Hemodialysis: Monday, Wednesday and Friday at 6:15 AM, Special Instructions: VS before each session. Send/receive communication form with patient. Medical Records to scan document upon return every day shift every Monday, Wednesday, and Friday. A physician's order dated 01/28/2025, documented Hemodialysis: Monday, Wednesday and Friday at 6:15 AM, Special Instructions: VS after each session. Send/receive communication form with patient. Medical Records to scan document upon return every day shift every Monday, Wednesday, and Friday. A physician's order dated 01/28/2025, documented check the access site dressing right chest every shift. Resident #60's Comprehensive Care Plan dated 02/04/2025, documented Resident #60 required hemodialysis resulting from renal failure with interventions including: - monitor and document for peripheral edema. - monitor/document and report to physician as needed any signs and symptoms of infection to access site: redness, swelling, warmth or drainage. - obtain VS and weight. Report significant changes in pulse, respirations and BP immediately. The facility Transportation Log documented Resident #60 was transported to dialysis on the following dates: - 01/29/2025 at 5:45 AM - 01/31/2025 at 5:45 AM - 02/03/2025 at 5:45 AM - 02/05/2025 at 5:45 AM - 02/07/2025 at 5:45 AM - 02/10/2025 at 5:45 AM - 02/12/2025 at 5;45 AM - 02/14/2025 at 5:45 AM - 02/17/2025 at 5:45 AM - 02/19/2025 at 5:45 AM - 02/21/2025 at 5:45 AM Resident #60's clinical record documented the following Hemodialysis Communication Records lacked completion: -On 01/29/2025, lacked assessment of the access site prior to dialysis, time of transfer to dialysis, and assessment of the access after dialysis and time of return. -On 02/03/2025, lacked medications given/held before dialysis, assessment of the access site before dialysis, time of transfer to dialysis, all of the dialysis center's clinical information, assessment of the access site after dialysis, nurses signature, title, and time of return. -On 02/05/2025, lacked reason medication held before dialysis, resident's VS after dialysis, assessment of access site, nurse's signature, title and time of return. -On 02/07/2025, lacked resident's VS prior to leaving, title of person signing form and time of transfer to dialysis, assessment of access on return from dialysis, nurse's signature, title and time of return. -On 02/10/2025, lacked medications given/held, assessment of access site, title of person signing form and time of transfer to dialysis, and all of the dialysis center's clinical information. -On 02/12/2025, lacked medications given/held before dialysis, the resident's VS upon return, and assessment of the access site. -On 02/17/2025, lacked reason medication held before dialysis, and title of person signing form after dialysis. -On 02/19/2025, lacked assessment of access site before dialysis, assessment of the access site after dialysis, the nurse's signature, title and time of return. -On 02/21/2025, lacked the resident's post dialysis weight, and the nurse's signature, title and time of return. -On 02/24/2025, lacked medications given/held, assessment of the access site before dialysis, the nurse's signature and time of transfer to dialysis, the resident's weight post dialysis, and the completion of the return section after dialysis, including resident vitals, access assessment, nurse's signature, title and time of return. On 02/26/2025 at 9:32 AM, the DNS verified the Hemodialysis Communication Records were missing the aforementioned VS and/or resident assessments and/or hemodialysis center's clinical assessment information associated with the aforementioned dates. On 02/26/25 at 9:36 AM, the DNS verbalized all residents receiving dialysis were sent with a Dialysis Communication Record. The facility nurse should complete the section prior to sending the resident to dialysis including any medications given or held, resident's VS (blood pressure, pulse, respirations, temperature), assessment of the access site, date and time of transfer and the nurse's signature and title. The dialysis center would complete the second section including resident's VS, the resident's weight pre and post dialysis, any new orders, dialysis start and ending time, assessment of the access site, any lab work, any recommendations, the dialysis center's address and phone number and the nurse's signature, title and time. Upon return to the facility, the facility nurse would complete the last section including resident's VS, access assessment, the nurse's signature, title and time of return. Resident #60's clinical record lacked documented evidence of a Hemodialysis Communication Record for the following dates Resident #60 was transported to dialysis: - 01/29/2025 - 02/14/2025 On 02/27/25 at 10:28 AM, the Assistant Director of Nursing verbalized the ADON expected staff to complete the Hemodialysis Communication Record before and after the resident's dialysis and to ensure the dialysis center completed their portion and if not, to call and have the information sent via facsimile or take a verbal report and document the information in a progress note. The ADON confirmed the facility did not have the Hemodialysis Communication Records for the aforementioned dates and no other documentation was available in the facility to record the required information. The American Heart Association (AHA) journal titled Risk Assessment for Sudden Cardiac Death in Dialysis Patients, Volume 3; Number 5, viewed 02/26/2025, documented patients with end-stage renal disease (ESRD) on long-term dialysis therapy had a very high mortality due to predominantly cardiovascular causes. The single most common form of death in dialysis patients was sudden cardiac death. Dialysis could cause significant sudden shifts in electrolytes and fluid volume and could act as a trigger to initiating life-threatening arrhythmias. Precipitating factors included hyper-hypokalemia, anemia, hypertension, diabetic autonomic neuropathy, rapid fluctuations in volume status and blood pressure around dialysis treatments, atrial dilation from fluid overload, fluctuations in electrolytes including potassium, around or during dialysis treatments, and acute changes in autonomic regulations during dialysis. A Dialysis Transfer Agreement, effective 03/14/2024, documented the Dialysis Center would provide to Facility information on aspects of the management of a Designated Resident's care related to the provision of dialysis services. The Facility would ensure that all appropriate medical, social, administrative, and other information accompany all Designated Residents to include the following: treatment provided to the Designated Resident, appropriate medical records, medications and any changes in a patient's condition (physical or mental), change of medication, and diet or fluid intake. A facility policy titled Hemodialysis Policy, undated, documented the facility would participate in ongoing communication with the dialysis center by using the Dialysis Communication Form filed in the resident's medical record.

Based on interview, clinical record review, and document review, the facility failed to ensure a Licensed Practical Nurse (LPN) spoke about a resident in a respectful manner and treated a resident with dignity for 1 of 3 residents sampled related to facility reported incidents (FRI) (Resident #251). This deficient practice had the potential to cause a resident to experience psychosocial harm or mental anguish because of not being treated with respect. Findings include: Resident #251 Resident #251 was admitted to the facility on [DATE], with diagnoses including cognitive communication deficit, anxiety disorder, unspecified, and sepsis due to methicillin susceptible staphylococcus aureus. A FRI, dated 01/28/2025, documented an LPN1 had entered the room of Resident #251 to hang the resident's intravenous (IV) antibiotic. The LPN1 had dropped the IV spike (the sharp end of an IV tube used to puncture an IV bag) into the garbage can and was going to continue to use the IV tubing. Resident #251 had noted to the LPN1 the tubing was contaminated and the LPN1 had responded to the resident the LPN1 would use an alcohol pad on the IV spike. The LPN1 then dropped the IV tubing on the floor, picked up the IV tubing, and was planning to use the IV tubing to administer the antibiotic to Resident #251 and the resident again requested the tubing not be used to administer the resident's antibiotic. LPN1 verbalized the resident was refusing the medication. The LPN1 left the resident's room and then came back with new IV tubing but the resident did not feel safe having the LPN1 hang medication based on the earlier conduct of the LPN1 and feared the LPN1 might have put something in the resident's IV bag. The final report from the facility, dated 01/31/2025, documented the facility had substantiated the allegations. An interview, dated 01/28/2025, conducted by the Assistant Director of Nursing (ADON) with an LPN2 who had worked with LPN1 on 01/28/2025 when the incident with Resident #251 had occurred documented the following: The LPN2 verbalized the LPN1 had not acted professionally. The LPN2 had asked the LPN1 to hang the IV medication for Resident #251. The LPN2 had observed the LPN1 coming out of the resident's room to get new IV tubing and the LPN1 referred to the resident as a derogatory name. The LPN1 continued referring to the resident by a derogatory name. The LPN2 followed the LPN1 into the resident's room and witnessed the LPN1 get angry and respond unprofessionally to Resident #251. Resident #251 had told the LPN1 to get out of the resident's room and the LPN1 left the room while talking about Resident #251. The LPN2 had stayed in the resident's room to speak with the resident and the resident was very upset by the way the resident had been treated by the LPN1. When the LPN2 approached the LPN1 at the nurse's desk, the LPN1 again started referring to Resident #251 by a derogatory name. An interview, dated 01/30/2025, conducted by the ADON with the LPN1documented the following. The LPN1 confirmed the LPN1 had dropped the IV tubing on the floor and the LPN1 informed the resident the LPN1 had an alcohol swab and would use the alcohol swab to clean the IV tubing. The LPN1 retrieved new IV tubing and returned to the resident's room. The resident asked the LPN1 for the LPN1's name and the LPN1 gave the resident the LPN1's name and then walked out of the room. The LPN1 explained the LPN1 was mad. The LPN1 verbalized the LPN1 may have called the resident a derogatory name because the LPN1 was upset. A Progress Note, dated 01/28/2025, documented a nurse had come to hang the resident's scheduled IV. The nurse had come out to the nursing station to request new IV tubing. The nurse had stated the patient refused to let the nurse reuse the IV tubing after the tubing was on the floor because it had been contaminated. The nurse documenting the progress note went into the resident's room to speak with the resident and apologize for the incident between the resident and the nurse. The resident was upset about the nurse being unprofessional. A Social Services note, dated 01/30/2025, documented the resident claimed the resident had never been treated the way the nurse had treated the resident on 01/28/2025 and felt the nurse was extremely hostile. On 02/26/2025 at 11:50 AM, the Director of Nursing Services (DNS) verbalized the LPN1 had dropped the IV tubing for Resident #251 on the floor when preparing to administer an IV antibiotic on 01/28/2025. The resident had brought the issue to the nurse's attention and the nurse had told the resident the nurse would wipe the tubing with an alcohol swab and the tubing would be safe to use. The DNS confirmed it would not have been okay to use the tubing after the IV spike had touched the floor. On 02/26/2025 at 12:02 PM, the Executive Director verbalized the facility had substantiated the events from the allegations in the FRI. The facility document titled Resident Rights, undated, documented a resident in the facility would have the right to be treated with respect and dignity. FRI #NV00073280

Based on interview, clinical record review, and interview, the facility failed to ensure the accuracy of a Minimum Data Set 3.0 (MDS) assessment for 1 of 3 closed records sampled residents (Resident #99). This deficient practice had the potential to deprive the resident of necessary needs and services relative to their current health management needs upon discharge home. Findings include: Resident #99 Resident #99 was admitted to the facility on [DATE], and discharged on [DATE], with diagnoses including encounter for surgical aftercare following surgery on the digestive system, cognitive communication deficit, prediabetes, and other abnormalities of gait and mobility. A Nursing Progress Note dated 12/18/2024, documented the resident was discharged home with all medications and belongings. A discharge MDS assessment dated [DATE], Section A - Discharge Status, documented the resident was discharged short-term to the hospital. On 02/25/2025 at 12:46 PM, the MDS Coordinator explained the MDS assessments were used to gather information for plan of care accuracy. Once information was gathered, the information was used for reimbursement and quality measures. The accuracy of MDS assessments were important to ensure proper care of residents at the level of care needed. The MDS Coordinator confirmed Resident #99's discharge MDS assessment documented the resident was discharged to the hospital and was incorrect. The MDS assessment should have accurately documented the resident was discharged home. The facility policy titled Resident Assessment and Associated Processes, last revised 12/2023, documented the facility would electronically transmit encoded, accurate, and complete MDS data to the Centers for Medicare & Medicaid Services (CMS) system. Transmission of the MDS data would include the discharge documents. The MDS data was electronically signed in the clinical health record.

Based on observation, interview, clinical record review, and document review, the facility failed to ensure: 1) a resident's behaviors of threatening staff members with physical and sexual violence were care planned for 1 of 22 sampled residents (Resident #78). This deficient practice had the potential to result in staff working with the resident being unaware of the resident's behaviors and the resident's behaviors worsening or escalating with no interventions in place, 2) edema and the use of diuretic medications were care planned for 1 of 22 sampled residents (Resident #83). This deficient practice had the potential to result in staff working with the resident to be unaware of the need to monitor the resident for edema, provide medications (diuretic) as indicated, and monitor for adverse side effects of the medication. Findings include: Resident #78 Resident # 78 was admitted to the facility on [DATE], and readmitted on [DATE], with diagnoses including alcohol dependence with alcohol-induced persisting dementia, schizoaffective disorder, unspecified, and hallucinations, unspecified. A Nursing Progress Note, dated 01/06/2025, documented the resident used profane language toward a License Practical Nurse (LPN) and called the LPN derogatory names. The resident told the LPN to get on the LPN's knees and perform a sexual act for the resident and apologize to the resident until the resident was tired of the LPN. The resident yelled and blocked the LPN from leaving the area. The resident threatened to break the LPN's face and was using numerous expletives. The resident then threatened to catch the LPN off-guard and rape the LPN. A Nursing Progress Note, dated 01/09/2025, documented the resident approached the LPN and started laughing while calling the LPN a derogatory name. A Nursing Progress Note, dated 01/15/2025, documented the LPN walked by Resident #78 and the resident called the LPN a derogatory name. The LPN walked away from the resident to avoid any further comments from the resident as the resident's use of derogatory language towards the LPN and other staff was an ongoing concern. The resident then threatened to rape the LPN and told the LPN the resident would wait for the LPN outside and would torture the LPN. The resident then referred to the LPN as a derogatory name in Spanish. A Nursing Progress Note, dated 01/30/2025, documented the resident walked by an LPN at a nurse's station and called the nurse a derogatory name. The Director of Nursing Services (DNS) and other staff were witnesses. The Care Plan for Resident #78 did not include the behaviors of threatening staff. On 02/26/2025 at 12:42 PM, the LPN verbalized the resident had snapped and the resident began making violent threats toward the LPN when the LPN had taken the resident's alcohol away. On 02/26/2025 at 4:08 PM, the Director of Nursing Services (DNS) verbalized the resident's behavior of making threats of sexual violence against staff should have been care planned for the safety of residents, visitors, and staff. The DNS confirmed the Care Plan did not include the behaviors and the behaviors should have been included on the Care Plan. The facility policy titled Comprehensive Person-Centered Care Planning, revised 12/2023, documented a comprehensive person-centered care plan would be developed for each resident and would include measurable objectives and timeframes to meet a resident's medical, nursing, mental and psychosocial needs. Cross reference with tag F740 43310 Resident #83 Resident #83 was admitted to the facility on [DATE] with diagnoses including chronic obstructive pulmonary disease, acute on chronic diastolic (congestive ) heart failure, and chronic kidney disease, stage 2, mild. The resident's list of diagnoses did not include edema. A Provider Visit note dated 02/21/2025, documented Resident #83 complained of significant edema. Edema was noted by the provider and a new order for furosemide 20 milligrams (mg) daily for edema was documented. On 02/24/2025 at 2:37 PM, Resident #83 complained of edema to bilateral lower extremities (BLE). Resident #83 verbalized the resident was not being provided medication for edema. Resident #83 had notable edema to the resident's BLE. Resident #83's clinical record did not include any additional documentation related to edema. Resident #83's physician's orders did not include an order for furosemide 20 mg daily for edema. On 02/262025 at 9:35 AM, LPN2 verbalized nurse entered care plans as needed and the care plans were reviewed by the Assistant Director of Nursing and/or the DNS. The LPN was not able to locate a care plan related to edema and/or the use of diuretic medications. One 02/27/2025 at 9:31 AM, the DNS confirmed Resident #83's Comprehensive Care Plan did not include a care plan related to edema or the use of diuretic medications. The facility policy titled Comprehensive Person-Centered Care Planning, revised 12/2023, documented a comprehensive person-centered care plan would be developed for each resident and would include measurable objectives and timeframes to meet a resident's medical, nursing, mental and psychosocial needs. Cross reference with tag F684

Based on interview, clinical record review, and document review the facility failed to ensure a medication ordered for edema was entered into a resident's order set and Medication Administration Record (MAR) for 1 of 22 sampled residents (Resident #83). This deficient practice resulted in the resident not receiving the medication and continuing to have edema and discomfort and the potential to result in an exacerbation of chronic illnesses. Findings include: Resident #83 Resident #83 was admitted to the facility on [DATE], with diagnoses including chronic obstructive pulmonary disease (COPD) and acute on chronic diastolic (congestive) heart failure (CHF), and pain, unspecified. The resident's diagnoses list did not include a diagnosis for edema. On 02/24/2025 at 2:37 PM, Resident #83 complained of edema to bilateral lower extremities (BLE). Resident #83 verbalized the resident was not being provided medication for edema. Resident #83 had notable edema to the resident's BLE. A Provider Visit note dated 02/21/2025, documented Resident #83 complained of significant edema. Edema was noted by the provider and a new order for furosemide 20 milligrams (mg) daily for edema was documented. Resident #83's clinical record did not include any additional documentation related to edema. Resident #83's physician's orders did not include an order for furosemide 20 mg daily for edema. On 2/26/2025 at 3:30 PM, a Licensed Practical Nurse (LPN) explained when providers ordered a new medication, the order was given to the resident's nurse, and the nurse entered the order into the resident's electronic health record (EHR) and faxed it to the pharmacy. The LPN confirmed Resident #83's orders did not include an order for furosemide. 02/27/25 at 8:24 AM, Resident #83 complained of edema and discomfort to the resident's BLE and was observed to have swelling consistent with edema to the resident's BLE. On 02/27/25 at 8:32 AM, the Director of Nursing Services (DNS) assessed Resident #83's BLE for edema and confirmed the resident had BLE edema. The DNS verbalized the edema was 1 to 2 plus (+) pitting edema and described the resident's feet and legs as feeling tight. On 02/27/25 at 9:06 AM, the DNS confirmed Resident #83's EHR included a providers note dated 02/21/2025, and the provider's note documented the resident was to have an order for furosemide 20 mg. The DNS was not sure why the order was not entered into the resident's order set and MAR. On 02/27/25 at 9:08 AM, the provider, an Advanced Practice Registered Nurse (APRN) verbalized when the APRN ordered new medications, the order was given to the resident's nurse verbally and in writing. The APRN confirmed the order for furosemide 20 mg for edema, should have been entered into Resident #83's EHR by the nurse on 02/21/2025 and administered to the resident. On 02/27/25 at 9:21 AM, the DNS confirmed the order for furosemide should have been entered into Resident #83's EHR and implemented on 02/21/2025 as ordered by the resident's provider. The DNS explained not implementing the order could have led to increased edema, an exacerbation of congestive heart failure and/or chronic obstructive pulmonary disease, increased pain and discomfort. The facility policy titled Nursing Policies and Procedures, dated 07/01/2016, documented nurses recorded the actual order received from the provider into the resident's medical record immediately.

Based on observation, interview, clinical record review, and document review the facility failed to ensure a resident's pain was managed, a physician was notified when pain medication was not effective and/or the resident's pain exceeded the parameters of the medication ordered for 1 of 22 sampled residents (Resident #83). This deficient practice could have the potential for unrelieved pain, discomfort, and inadequate pain management. Resident #83 Resident #83 was admitted to the facility on [DATE], with diagnoses including pain, unspecified, pain in left hip, cellulitis of left upper limb, restless leg syndrome, pain in left hip, and pain in right hip. A physician's order dated 04/19/2024, documented acetaminophen tablet 325 milligrams (mg). Give one tablet by mouth every four hours as needed for mild pain/headache not to exceed three grams per day. Resident #83's Medication Administration Record (MAR) for February 2025, documented the resident was administered one tablet of acetaminophen 325 mg for pain levels greater than 0-3 out 10 on a numeric pain scale of 10 as follows: -On 02/14/2025 at 3:57 PM, one 325 mg tablet of acetaminophen was administered for a pain level of 4 out 10. -On 02/15/2025 at 5:57 PM, one 325 mg tablet of acetaminophen was administered for a pain level of 5 out 10. -On 02/18/2025 at 12:15 AM, one 325 mg tablet of acetaminophen was administered for a pain level of 5 out 10. -On 02/20/2025 at 6:35 PM, one 325 mg tablet of acetaminophen was administered for a pain level of 7 out of 10. -On 02/23/2025 at 2:57 PM, one 325 mg tablet of acetaminophen was administered for a pain level of 10 out of 10. -On 02/24/2025 at 12:45 AM, one 325 mg tablet of acetaminophen was administered for a pain level of 5 out of 10. -On 02/24/2025 at 6:34 PM, one 325 mg tablet of acetaminophen was administered for a pain level of 5 out of 10. -On 02/25/2025 at 5:34 AM, one 325 mg tablet of acetaminophen was administered for a pain level of 4 out of 10. -On 02/26/2025 at 6:06 AM, one 325 mg tablet of acetaminophen was administered for a pain level of 6 out of 10. -On 02/26/2025 at 1:03 AM, one 325 mg tablet of acetaminophen was administered for a pain level of 6 out of 10. The MAR lacked documented evidence the resident's pain was reassessed to ensure efficacy of the medication. On 02/24/2025 at 2:30 PM, Resident #83 verbalized the resident had a history of knee replacement and had frequent knee pain. Resident #83 explained the resident's only ordered pain medication was acetaminophen and the medication did not effectively manage the resident's pain. On 02/26/2025 at 3:20 PM, a Licensed Practical Nurse (LPN) verbalized orders for pain medication instructed to give pain medication for either mild, moderate, and/or severe pain. The LPN explained a numeric scale of 0 - 10 was used to assess the severity of a resident's pain. Mild pain was 1-3/10, moderate pain was 4-6/10, and severe pain was 7-10/10. The LPN verbalized if a resident reported a pain level the resident's pain medication was not prescribed for, the expectation was the nurse would contact the resident's provider for instructions and/or new orders to treat the reported level of pain. On 02/26/2025 at 3:23 PM, the LPN reviewed Resident #83's MAR for February and confirmed pain levels documented above three, were moderate to severe pain and the resident's pain medication (acetaminophen) was prescribed for mild pain (1-3/10). On 02/26/2025 at 3:49 PM, the Director of Nursing Services (DNS) verbalized a pain rated as 0-3 on a numeric scale of 10 was mild pain and confirmed pain rated as 4 -10/10 was moderate to severe pain and was not to be considered mild pain. The expectation was when a resident reported a pain level outside of the parameters of the resident's prescribed pain medication, the nurse would contact the provider for instructions and/or new orders. On 02/27/2025 at 8:24 AM, Resident #83 complained of 10/10 knee pain and 8/10 neck and shoulder pain at rest, increasing to 10/10 with movement. The resident verbalized the pain was keeping the resident awake at night, limiting the resident's range of motion, and limiting the resident's ability to do things the resident enjoyed. The resident verbalized the facility was aware of the resident's pain but had not done anything to help alleviate the pain. The facility policy titled Pain Management, dated 05/05/2023, documented pain was whatever the experiencing person said it was and existed whenever the experiencing person said it did. Ongoing evaluations of a resident's pain was competed each shift and documented on the resident's MAR. Based on the evaluation, interventions were developed, implemented, monitored, and revised as necessary to prevent or manage the resident's pain.

Based on interview and personnel record review, the facility failed to ensure a Certified Nursing Assistant (CNA) had an annual performance evaluation completed timely for 2 of 2 CNAs employed greater than one year, sampled for personnel record review (Employee #7, and #8). Findings include: Employee #7 Employee #7 was hired on 01/01/2024, as a CNA. Employee #7's personnel record lacked documented evidence an annual performance review had been conducted by the employee's anniversary date of 01/01/2025. Employee #8 Employee #8 was hired on 01/01/2024, as a CNA. Employee #8's personnel record documented an annual performance review had been conducted on 02/25/2025, 55 days after the employee's anniversary date of 01/01/2025. On 02/25/2025 at 12:56 PM, the Human Resources Manager confirmed Employee's #7 did not have an annual performance evaluation for 2025 and Employee #8's annual performance evaluation for 2025 was completed late. The Human Resources Manager verbalized all CNAs were required to have an evaluation every year by the hire anniversary date and they were to be completed by the Director of Nursing. The Facility policy titled Performance Evaluations, revised 07/2010, documented performance evaluations would occur on but not limited to the employee's annual date of hire anniversary.

Based on observation, interview, clinical record review, and document review, the facility failed to ensure a resident's behaviors of threatening staff members with physical and sexual violence were monitored per facility policy for 1 of 22 sampled residents (Resident #78). This deficient practice had the potential to result in a resident's behaviors worsening or escalating with no monitoring in place. Findings include: Resident #78 Resident # 78 was admitted to the facility on [DATE], and readmitted on [DATE], with diagnoses including alcohol dependence with alcohol-induced persisting dementia, schizoaffective disorder, unspecified, and hallucinations, unspecified. A Nursing Progress Note, dated 01/06/2025, documented the resident used profane language toward the Licensed Practical Nurse (LPN) and called the LPN derogatory names. The resident told the LPN to get on the LPN's knees and perform a sexual act for the resident and apologize to the resident until the resident was tired of the LPN. The resident yelled and blocked the LPN from leaving the area. The resident threatened to break the LPN's face and was using numerous expletives. The resident then threatened to catch the LPN off-guard and rape the LPN. The task for Behavior Monitoring, documented the resident had no behaviors observed on 01/06/2025. A Nursing Progress Note, dated 01/09/2025, documented the resident approached the LPN and started laughing while calling the LPN a derogatory name. The task for Behavior Monitoring, documented the resident had no behaviors observed on 01/09/2025. A Nursing Progress Note, dated 01/15/2025, documented the LPN walked by Resident #78 and the resident called the LPN a derogatory name. The LPN walked away from the resident to avoid any further comments from the resident as the resident's use of derogatory language towards the LPN and other staff was an ongoing concern. The resident then threatened to rape the LPN and told the LPN the resident would wait for the LPN outside and would torture the LPN. The resident then referred to the LPN as a derogatory name in Spanish. The task for Behavior Monitoring, documented the resident had no behaviors observed on 01/15/2025. The Care Plan for Resident #78 did not include the behaviors of threatening staff. On 02/26/2025 at 12:42 PM, the LPN verbalized the resident had snapped and the resident began making violent threats toward the LPN when the LPN had taken the resident's alcohol away. On 02/26/2025 at 4:08 PM, the Director of Nursing Services (DNS) verbalized the resident's behavior of making threats of sexual violence against staff should have been care planned with interventions for the safety of residents, visitors, and staff. The DNS confirmed the Care Plan did not include the behaviors and the behaviors should have been included on the Care Plan. The DNS verbalized behavior monitoring should have included documentation of the behaviors for each day a behavior occurred. The facility policy titled Documentation - Licensed Nursing, revised 01/01/2016, documented behaviors would be documented and tracked as they occurred using the appropriate behavior tracking forms. Cross reference with tag F656

Based on observation, document review, and interview the facility failed to demonstrate effective administration by not ensuring pre and post dialysis assessments, documentation of the assessments, and communication with the dialysis center were completed and correctly documented. This deficient practice resulted in a substandard quality of care. On 03/03/2025 at 1:13 PM, the Executive Director confirmed the facility lacked a process to ensure pre and post dialysis assessments, documentation of the assessments, and communication with the dialysis center was completed and correctly documented on the facility's Dialysis Communication Record. The Executive Director explained it was important the process was followed to ensure continuity of care between the facility and the dialysis center. On 02/27/2025 at 3:02 PM, the Executive Director verbalized not understanding why the deficient practice was a substandard quality of care. It was explained to the Executive Director the scope and severity of the deficient practice included all of the facility's dialysis patients and was a systemic failure of the facility's dialysis process. The facility policy titled Dialysis-Hemodialysis, revised 07/01/2016, documented the facility staff participated in ongoing communication with the dialysis center by using the Dialysis Communication Form which was filed in the resident's medical record. Cross reference with F698

Based on clinical record review, document review and interview, the facility failed to ensure staff followed a resident's chosen code status prior to initiating emergency lifesaving measures (Resident #2) and residents' code status was accurate and complete for staff to access for 7 of 33 residents reviewed (Resident #25, #35, #40, #49, #56, #9 an #57). The failure to honor a resident's choice to not have life sustaining measures provided put the resident at imminent risk for psychosocial harm when a resident's life was extended by two days. During the survey, Immediate Jeopardy (IJ) was identified as a result of a resident receiving Cardiopulmonary Resuscitation (CPR) following a documented choice to be Do Not Resuscitate (DNR) on a Provider Order for Life-Sustaining Treatment (POLST). The IJ was called on [DATE] at 4:38 PM, in the presence of the Director of Nursing (DON). A Plan of Removal for the immediacy was requested to be provided to the State Agency (SA) within 20 minutes. On [DATE] between 5:43 PM and 5:53 PM, the SA rejected the Plan of Removal two times for lacking the necessary components for removing the immediacy. On [DATE] between 8:48 AM and 4:50 PM, the SA rejected the Plan of Removal six times for lacking the necessary components for removing the immediacy. On [DATE] at 8:40 AM, the SA rejected the Plan of Removal for lacking the necessary components for removing the immediacy. On [DATE] at 10:10 AM, the plan to remove the immediacy was accepted by the SA. The approved Plan of Removal/Abatement of the Immediate Jeopardy dated [DATE], provided by the facility, included a process to update and communicate changes in residents' code status to facility staff, educating staff, monitoring, and auditing the resident code status documentation. Attachments included a Code Status Checklist, Record of clinical staff code status, Code Blue in-service record, Advance Directives and Code Status Report, and Code Status Audit by facility. The immediacy was removed on [DATE] at 1:09 PM, after the plan was verified to have been implemented, and the DON was notified. The facility's implementation of the plan to remove the immediacy of the Immediate Jeopardy was verified as follows: Interviews were conducted with the DON, Assistant Director of Nursing, three Registered Nurses (RN), one Licensed Practical Nurse (LPN), and two Certified Nursing Assistants (CNA). Audits were conducted of the residents' code status, POLST and physician's orders in the electronic medical record, and physician's orders in the code status binder at the nurse's station in the A and B hallways. Findings include: Resident #2 Resident #2 was admitted to the facility on [DATE], readmitted on [DATE] and discharged on [DATE] with diagnoses including sepsis, unspecified organism, heart failure, unspecified, and sepsis due to Methicillin susceptible Staphylococcus aureus. A physician's order dated [DATE], and discontinued on [DATE], documented Resident #2's code status was a full code. A physician's order dated [DATE], documented Resident #2's code status was Do Not Resuscitate (DNR), Provider Order for Life-Sustaining Treatment (POLST) completed on [DATE]. Resident #2's care plan revised on [DATE], documented the resident was discharged from the facility to the hospital on [DATE]. The resident was readmitted to facility on [DATE], for ongoing short-term skilled nursing and rehab services. Resident was still expected to be discharged back home when stronger and after completion of intravenous (IV) antibiotic. The Durable Power of Attorney for Healthcare (person appointed for the resident) (DPOA) was at the bedside and agreed with discharge planning. Resident #2's care plan revised on [DATE], documented Problem: advanced care planning: code status was full code. The approach documented the resident had completed an advanced directive including a DNR. A Provider's Progress Note dated [DATE], documented the resident was in the standing frame (therapeutic device to help residents stand and maintain an upright posture) with therapy and collapsed. Resident was placed back in bed and noted to have no pulse and agonal (gasping respiration) breathing. Chest compressions were started, and an Automated External Defibrillator (AED) was placed on the resident advising no shock. The resident was determined to be DNR, and no further resuscitation attempts were made, however, the resident maintained a pulse and breathing improved. The Emergency Medical Services (EMS) arrived and assessed the resident and used an electrocardiogram (EKG) to check for the resident's heart condition. The DPOA declined transport to the hospital. On [DATE] at 3:51 PM, the DON confirmed Resident #2 chose a code status of DNR on [DATE]. The facility used the POLST to document a resident's choice. The DON verbalized staff should check the physician's order for code status choice, of full code or DNR. The DON confirmed Resident #2's code status choice was marked in the Advanced Directive Section in the electronic medical record (EMR) and was available in the code status binder at the nurse's station during the Code Blue event on [DATE]. On [DATE] at 3:54 PM, the DON confirmed Resident #2's care plan, started [DATE], documented the resident completed a POLST and was DNR. The DON confirmed Resident #2's Care Plan titled problems still documented code status was full code. The DON verbalized the DON expected the resident's problem in the care plan to be updated when resident's code status changed from full code to DNR. The DON verbalized when in doubt of the resident's code status, staff should start cardiopulmonary resuscitation (CPR) and call Code Blue. On [DATE] at 10:09 AM, the Registered Nurse (RN), Nurse Manager verbalized a Code Blue would be called when a resident stopped breathing, was having problems breathing and required assistance, or had no pulse. The Nurse Manager verbalized the Advance Directive binder or residents' Code Status binder was at the nurse's station and included the resident's facesheet with code status next to the resident's name. The facesheets were alphabetized by last name in the binder. The facility's Social Services department was responsible for keeping the residents' facesheets updated. The Nurse Manager verbalized Unit Managers communicated any resident changes, including code status changes, in the clinical daily meeting. The meeting was attended by Nurse Managers, the Licensed Social Worker, the Therapy Director, the DON, the Administrator, the Minimum Data Set (MDS) staff and the Dietitian. On [DATE] at 10:22 AM, an RN verbalized a Code Blue was when a resident was having cardiac arrest or a problem breathing. A call would be made by paging overhead Code Blue and the location of the resident. All available staff would respond to the incident and start emergency lifesaving measures. The RN verbalized before calling 911, staff should check the resident's chart and before CPR was started, staff should look for the resident's code status. On [DATE] at 10:47 AM, the DON verbalized there was no incident report found for Resident #2's Code Blue event on [DATE] and confirmed there was no progress note written for the incident by nursing. On [DATE] at 11:38 AM, the Physical Therapist (PT) verbalized the resident had septic infection from low back surgery and was unable to walk. The resident was maximum assist in transfer and standing. The PT used a standing frame to help Resident #2 stand up out of the resident's wheelchair. On [DATE], the PT verbalized the resident was standing for approximately one minute in the frame and the resident started to [NAME] the resident's head. The PT shook the resident to wake up and the resident was unresponsive. Another Therapist helped the PT sit the resident back down in the wheelchair and then moved the resident back to bed and notified the nurse. On [DATE] at 12:43 PM, the Licensed Social Worker (LSW) verbalized the LSW participated in the Interdisciplinary Team (IDT) meetings each morning, Monday through Friday only. The Unit Nurse Manager advised all attendees about any resident code status changes. Social Services was responsible for updating the resident's facesheet and orders in the Code Status binder at the nurse's station in the A and B Wings. The LSW verbalized the LSW met with the resident and resident's DPOA on [DATE], to discuss discharge planning. The LSW verbalized the resident and resident's DPOA thought the resident would get better with therapy and would be able to go home. On [DATE] at 10:37 AM, an LPN verbalized the LPN was doing wound care for Resident #2's roommate when the Physical Therapist brought Resident #2 to the room and informed the LPN the resident was not responsive and put him in bed. The LPN conducted a sternum rub. The resident had gasping (agonal) breaths and the LPN called for the charge nurse. The Charge Nurse called a code blue and chest compressions were started as a life saving measure. The resident's code status was not verified until after the compressions had begun. The LPN verbalized the event was documented on a sheet of paper from the crash cart, recording the times and events during the Code Blue. On [DATE] at 1:41 PM, Resident #2's DPOA verbalized the facility was doing physical therapy and the resident became unresponsive. The DPOA received a phone call from the paramedics who wanted to know if the resident had a DNR. The DPOA informed EMS Resident #2 had a DNR, and the paramedics stated the facility had revived the resident and the facility had not informed EMS of the resident's DNR. Prior to the incident, the DPOA verbalized the resident was making progress. The resident was admitted to the facility due to staph infection and need for IV antibiotics. The resident was planning to go home by the first of June. The DPOA and family did not expect the resident to die. The DPOA verbalized the DPOA had previously provided the DNR information to the Social Worker at the facility. The DPOA recalled the resident was semi-conscious after resuscitation and never regained full consciousness. The DPOA verbalized the resident lived for approximately two days after the event and in those two days, Resident #2 was living a life the resident did not consent to as a result of the resuscitation. Code Status Audit On [DATE], in the morning, an audit of the code status binder on the A and B Wing of the facility was completed. Resident #25 was admitted to the facility on [DATE], with a diagnosis of chronic systolic (congestive) heart failure. Resident #35 was admitted to the facility on [DATE], and readmitted on [DATE], with a diagnosis of pneumonia. Resident #40 was admitted to the facility on [DATE], with a diagnosis of hypertensive emergency. Resident #49 was admitted to the facility on [DATE] and readmitted on [DATE], with a diagnosis of chronic viral hepatitis. Resident #56 was admitted to the facility on [DATE] and readmitted on [DATE], with a diagnosis of chronic diastolic (congestive) heart failure. Resident #9 was admitted to the facility on [DATE], with a diagnosis of unspecified fracture of right femur, subsequent encounter for closed fracture with routine healing. Resident #57 was admitted to the facility on [DATE], with diagnoses including cellulitis of the left lower limb, hypertension, fluid overload, and chronic pain. The Code Status binder on the A and B Wing of the facility documented the following discrepancies: -Resident #25's physician's order dated [DATE], documented DNR and the facesheet documented DNR/DNI. -Resident #35's physician's order dated [DATE], documented full code and the facesheet documented DNR. -Resident #40's physician's order dated [DATE], documented DNR and the facesheet documented DNR/DNI. -Resident #49's POLST and physician's order dated [DATE], documented DNR and an Advanced Directive facility document in the EMR documented full code. -Resident #56's physician order dated [DATE], documented full code and the POLST dated [DATE], documented DNR. On [DATE] at 2:58 PM, the DON was informed an audit of the accuracy of facility residents' code status was completed and based on clinical record review and Code Status binder review the facility had not cleared the immediacy of the deficiency related to Resident #2, when the resident received CPR against the resident's wishes, thereby extending the resident's life by two days. On [DATE] in the morning, an audit of the Code Status binder on the A and B Wings of the facility lacked complete documentation to indicate an accurate code status for: -Resident #9's POLST had no mark for CPR or DNR and was not signed by the resident or a representative. -Resident #57's POLST was not signed by the physician. On [DATE] at 9:38 AM, the Advanced Practical Nurse (APRN) verbalized a Code Blue would be called when a resident was found without respirations or a heartbeat. When a Code Blue was called, facility staff would respond to the resident with the crash cart. The APRN's expectation was facility staff would know a resident's code status. The APRN recalled Resident #2 was working with PT in the therapy room when the Code Blue was called. The APRN responded to the resident in the therapy room. The resident was transported to the resident's room. Facility staff responded to the resident's room and started chest compressions. EMS arrived and chest compressions ceased. The resident had begun breathing again. The APRN was unaware of the resident's code status and assumed the nurses responding to the resident were aware of the resident's code status. The APRN verbalized the event was complicated due to the resident being in the therapy room, without a computer or the code status binder to refer to for the resident's code status. The APRN verbalized chest compressions should not be initiated on a resident with a DNR order. Chest compressions could result in broken ribs, the possibility of punctured lungs, and pain. The resident did not regain full consciousness after the Code Blue event. The APRN confirmed the resident had a DNR order on file. On [DATE] at 10:41 AM, the DON verbalized for a POLST to be valid it must contain the person's full name, date of birth, last four digits of their social security number, and gender. Section A designated CPR or DNR, Section B specified chosen medical interventions, and Section C selected artificial nutrition wanted. In Section D, the provider confirmed the person's decisional capacity. Section E required the form to be dated and signed by the resident or responsible party and the physician. If items in D or E were missing, the POLST was invalid, and the physician could not issue orders on it. The physician was responsible for filling the POLST, and the charge nurse had to verify its completeness. The EMS record, dated [DATE] at 9:41 AM, documented the resident was unresponsive and surrounded by staff upon arrival. The facility staff performed five chest compressions and then stopped as the resident gasped for air. Staff obtained vitals and waited for EMS. The resident was noted to be hypotensive and hypoxic. EMS placed the resident on oxygen at 10 liters per minute (LPM) and a 12-lead was obtained with vitals showing anterior infarct. Then the staff informed EMS the resident was DNR. EMS recommended transport and the spouse refused transport to the hospital. The EMS records lacked the facility's documented Code Blue event record. The facility policy titled Accident/Incident Reporting, revised [DATE], documented all incidents and accidents involving residents were immediately reported to the departmental or unit supervisor or in his/her absence, the house supervisor. Information related to the incident and accident was documented on the appropriate worksheet: Incident/Accident and Medication Error. The facility policy titled Cardiopulmonary Resuscitation, Emergency Code Blue, revised [DATE], documented Code Blue will be announced to notify appropriate team members to participate in a systematic, organized procedure during a potential life-threatening situation. The policy only applied to residents who were full code and did not apply to residents who have elected DNR (do not resuscitate) status. Send appropriate documentation with EMS and document in the EMR. The facility policy titled Advance Directives, complete revision [DATE], documented the facility recognizes the resident's right to formulate an advance directive. Upon admission to the facility, the Social Services Director will assist the resident to execute an advance directive in obtaining and completing the necessary forms and obtaining the needed orders. The SSD will add a copy of the advance directive and resident facesheet to the centrally maintained binder. The facility document titled Admission Handbook, revised [DATE], documented each resident had the right to a dignified existence, self-determination, and communication with and access to persons and services inside and outside the facility. Complaint #NV00068619

Based on clinical record review, interview, and document review the facility failed to protect 1 of 24 sampled residents (Resident #26) from physical abuse and ensure a resident was free from neglect when a resident with aspiration precautions and dysphagia was left in a room with no staff present, causing actual harm when the resident choked on a hot dog, had to be resuscitated, admitted to a hospital Intensive Care Unit and expired for 1 of 3 closed records (Resident #370). Findings include: Resident #26 Resident #26 was admitted to the facility on [DATE], and readmitted on [DATE], with diagnoses including hemiplegia and hemiparesis following cerebral infarction affecting right dominant side, diabetes mellitus type two, and bipolar disorder, unspecified. Resident #93 Resident #93 was admitted to the facility on [DATE], and readmitted on [DATE], with diagnoses including vascular dementia, unspecified severity, without behavioral disturbance, age-related cognitive decline, and cognitive communication deficit. A Progress Note dated [DATE], documented a Licensed Practical Nurse (LPN), witnessed Resident #93 strike Resident #26 on the left arm because Resident #26 wanted another resident's soda. On [DATE] at 7:14 AM, the Assistant Director of Nursing (ADON) confirmed the ADON had witnessed Resident #93 hit Resident #26 on the left arm. The ADON defined abuse as anything done to a resident that they did not want to happen or caused the resident stress. On [DATE] at 11:03 AM, the Executive Director (ED) explained Resident #26 and Resident #93 had been seated next to each other when the ADON witnessed Resident #93 hit Resident #26 on the arm. The facility policy titled Abuse, Neglect, Exploitation, or Mistreatment, revised [DATE], documented the facility prohibited neglect, mental, physical and/or verbal abuse. Instances of abuse of all residents, irrespective of any mental or physical condition, could cause physical harm, pain, or mental anguish. Types of physical abuse included hitting, slapping, pinching, or kicking. Resident #370 Resident #370 was admitted to the facility on [DATE], and readmitted on [DATE], with diagnoses including cerebral infarction due to unspecified occlusion or stenosis of unspecified carotid artery, cough, unspecified, need for assistance with personal care, hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side, dysphagia, oropharyngeal phase, and muscle weakness, generalized. FRI #NV00067331 dated [DATE], documented on [DATE], Resident #370 choked on a hot dog and required Cardiopulmonary resuscitation (CPR) to be performed as a result of the choking incident. On [DATE], Resident #370's roommate called for help when Resident #370 started choking. The nurses came in and noted the resident was choking and attempted the Heimlich maneuver without success and then initiated CPR. Emergency Medical Services (EMS) was called and continued CPR upon arrival. EMS was able to get the resident breathing and transported the resident to the hospital. A Progress Note dated [DATE], documented Resident #370 was transferred to an acute hospital after the resident's roommate yelled for help. The nurse came in and found the resident choking on a hot dog. The nurse attempted to retrieve a piece of food from the resident's mouth without success. CPR was initiated by a nurse as Emergency Medical Service (EMS) was called by another nurse. EMS arrived, continued CPR, and transferred the resident to the hospital. Resident #370's physician's order dated [DATE], documented risk of choking, swallowing, aspiration, weight loss/gain, and dehydration. A physician's order dated [DATE], documented modified barium swallow study for dysphagia, unspecified. A document titled Modified Barium Swallow Study, dated [DATE], documented Resident #370 was referred for the study due to a history of dysphagia related to a stroke in 2017. The Speech Language Pathologist's (SLP1) clinical impression documented the resident presented with severe oral dysphagia and a mild pharyngeal dysphagia. Resident #370 had swallowed whole pieces of soft solid food during the evaluation and was documented as a very high risk for aspiration and occlusion of the airway. SLP1s recommendations included close supervision and the patient may be left alone for less than five minutes at a time when eating. The visit diagnosis was documented as problems with swallowing and mastication and oropharyngeal dysphagia. A care plan with a problem start date of [DATE], revised on [DATE], documented impaired swallowing related to cerebrovascular accident (CVA) with dysphagia. Interventions included to observe resident closely for signs of choking and/or aspiration and to use aspiration precautions. On [DATE] at 1:22 PM, a Registered Nurse (RN1) explained Resident #370 frequently choked on foods and liquids and was able to self-feed. The RN communicated the CNAs would round on the resident within the hour while the resident was eating for a safety check, but it would not be documented. The CNA would verbally report any issues to the Nurse. On [DATE] at 2:56 PM, a Licensed Practical Nurse (LPN) explained aspiration precautions meant a resident was at risk for choking and should be monitored during meals. The LPN communicated care planned interventions of observe carefully during meals meant someone had to stay with the resident while eating. The LPN confirmed Resident #370 was on aspiration precautions for choking and was not monitored in the resident's room at mealtimes. On [DATE] at 2:59 PM, a CNA explained supervision for a resident choking during a meal meant a CNA would sit with the resident to observe for choking. On [DATE] at 3:02 PM, RN2 communicated a resident on aspiration precautions should be assisted with feeding, the head of the bed elevated during meals, and an appropriate diet ordered. RN2 explained Resident #370 was on aspiration precautions and would need to be monitored closely while eating to prevent choking. On [DATE] at 3:10 PM, the Assistant Director of Nursing (ADON) explained to observe a resident carefully for choking meant a staff member stayed with the resident to observe while eating. The ADON confirmed Resident #370 was not supervised during mealtimes because the resident was not identified as requiring meal assist. On [DATE] at 3:19 PM, SLP2 communicated a resident care planned to be observed carefully during meals and had risk of aspiration would mean someone would supervise the resident during meals. SLP2 explained a resident on aspiration precautions should eat in the common area or dining room for observation. The SLP had made the recommendation for Resident #370 to eat in a dining program for observation, however the ED would not reinstate the dining program due to low staffing during the COVID-19 pandemic. SLP2 communicated a resident with swallowing safety concerns meant the resident should be visible to staff during the meal. SLP2 had proposed removing hot dogs from the facility menu completely due to choking risk and the ED was not receptive to the recommendation. On [DATE] at 4:24 PM, an RN2 communicated Resident #370 was always coughing and could choke easily due to dysphagia and aspiration risk. On [DATE] at 4:30 PM, the Executive Director (ED) communicated Resident #370 would not have had someone in the room to observe as the resident fed themselves. The ED communicated aspiration precautions meant the resident was sat into an upright position with the meal tray within reach and someone would pop in and check on the resident periodically. The ED confirmed the dining program had not been reinstated since the COVID-19 pandemic. On [DATE] at 5:37 PM, the Director of Nursing (DON) explained Resident #370 was on aspiration precautions due to dysphagia and would require supervision at mealtimes. The DON confirmed the facility Standard of Practice was [NAME] and [NAME] and had not been followed for aspiration precautions. The facility's Standard of Practice titled [NAME] and [NAME], Clinical Nursing Skills and Techniques: 10th edition, Copyright 2021, page 1114 and ,d+[DATE], documented dysphagia led to disability or decreased functional status, increased likelihood of discharge to institutionalized care, and increased mortality. Staff should be aware of warning signs for dysphagia, which included cough during eating, change in voice tone or quality after swallowing, abnormal gag, delayed swallowing, and incomplete oral clearing. The facility policy titled Abuse, Neglect, Exploitation, or Mistreatment, revised [DATE], documented neglect was the failure to provide goods and services or treatment and care necessary to avoid physical harm, mental anguish, or mental illness. NV00067331 NV00068011

Based on observation, clinical record review, interview, and document review the facility failed to ensure supervision was provided during meals for a resident with aspiration precautions resulting in the resident choking on a hot dog, requiring cardiopulmonary resuscitation (CPR), and hospitalization for 1 of 3 closed records reviewed (Resident #370). Findings include: Resident #370 Resident #370 was admitted to the facility on [DATE], and readmitted on [DATE], with diagnoses including cerebral infarction due to unspecified occlusion or stenosis of unspecified carotid artery, cough, unspecified, need for assistance with personal care, hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side, and dysphagia, oropharyngeal phase. FRI #NV00067331 dated [DATE], documented on [DATE], Resident #370 choked on a hot dog and required CPR to be performed as a result of the choking incident. On [DATE], Resident #370's roommate called for help when Resident #370 started choking on a hot dog in the resident's room. The nurses came in and noted the resident was choking and attempted the Heimlich maneuver without success and then initiated CPR. Emergency Medical Services (EMS) was called and continued CPR upon arrival. EMS was able to get the resident breathing and transported the resident to the hospital. A Progress Note dated [DATE], documented Resident #370 was transferred to an acute hospital after the resident's roommate yelled for help. The nurse came in and found the resident choking on a hot dog. The nurse attempted to retrieve a piece of food from the resident's mouth without success. CPR was initiated by a nurse as Emergency Medical Service (EMS) was called by another nurse. EMS arrived, continued CPR, and transferred the resident to the hospital. A physician's order dated [DATE], documented risk of choking, swallowing, aspiration, weight loss/gain, and dehydration. A physician's order dated [DATE], documented modified barium swallow study for dysphagia, unspecified. A document titled Modified Barium Swallow Study, dated [DATE], documented Resident #370 was referred for the study due to a history of dysphagia related to a stroke in 2017. The Speech Language Pathologist's (SLP1) clinical impression documented the resident presented with severe oral dysphagia and a mild pharyngeal dysphagia. Resident #370 had swallowed whole pieces of soft solid food during the evaluation and was documented as a very high risk for aspiration and occlusion of the airway. SLP1s recommendations included close supervision and the patient may be left alone for less than five minutes at a time when eating. The visit diagnosis was documented as problems with swallowing and mastication and oropharyngeal dysphagia. A care plan with a problem start date of [DATE], revised on [DATE], documented impaired swallowing related to cerebrovascular accident (CVA) with dysphagia. Interventions included observe resident closely for signs of choking and/or aspiration and use aspiration precautions. On [DATE] at 1:22 PM, a Registered Nurse (RN1) explained Resident #370 frequently choked on foods and liquids and was able to self-feed. The RN communicated the CNAs would round on the resident within the hour while the resident was eating for a safety check, but it would not be documented. The CNA would verbally report any issues to the Nurse. On [DATE] at 2:56 PM, a Licensed Practical Nurse (LPN) explained aspiration precautions meant a resident was at risk for choking and should be monitored during meals. The LPN communicated care planned interventions of observe carefully during meals meant someone had to stay with the resident while eating. The LPN confirmed Resident #370 was on aspiration precautions for choking and was not monitored in the resident's room at mealtimes. On [DATE] at 2:59 PM, a CNA explained staff would sit with a resident on aspiration precautions to observe for choking during the meal. On [DATE] at 3:02 PM, RN2 communicated a resident on aspiration precautions should be assisted with feeding, the head of the bed elevated during meals, and an appropriate diet ordered. RN2 explained Resident #370 was on aspiration precautions would need to be monitored closely while eating to prevent choking. On [DATE] at 3:10 PM, the Assistant Director of Nursing (ADON) explained to observe a resident carefully for choking meant a staff member stayed with the resident to observe while eating. The ADON confirmed Resident #370 was not supervised during mealtime because the resident was not identified as requiring a one-on-one meal assist. On [DATE] at 3:19 PM, SLP2 communicated a resident care planned to be observed carefully during meals and had risk of aspiration would mean someone would supervise the resident during meals. SLP2 explained a resident on aspiration precautions should eat in the common area or dining room for observation. The SLP did not recommend the resident to eat in their room due to frequent choking. The SLP had made the recommendation Resident #370 would benefit from a dining program for meal observation, however the ED would not reinstate the dining program due to low staffing during the COVID-19 pandemic. SLP2 communicated a resident with swallowing safety concerns meant the resident should be visible to staff during the meal. SLP2 had proposed removing hot dogs from the facility menu completely due to choking risk and the ED was not receptive to the recommendation. On [DATE] at 4:24 PM, an RN2 communicated Resident #370 could choke easily due to dysphagia and aspiration risk and coughed frequently. On [DATE] at 4:30 PM, the Executive Director (ED) communicated Resident #370 would not have had someone in the room to observe as the resident fed themselves. The ED communicated aspiration precautions meant the resident was sat into an upright position with the meal tray within reach and someone would pop in and check on the resident periodically. The ED confirmed the dining program had not been reinstated since the COVID-19 pandemic. On [DATE] at 5:37 PM, the Director of Nursing (DON) explained Resident #370 was on aspiration precautions due to dysphagia and should have been monitored during meals. The DON confirmed the facility Standard of Practice was [NAME] and [NAME] and had not been followed for aspiration precautions. The facility's Standard of Practice titled [NAME] and [NAME], Clinical Nursing Skills and Techniques: 10th edition, Copyright 2021, page 1114 and ,d+[DATE], documented dysphagia led to disability or decreased functional status, increased likelihood of discharge to institutionalized care, and increased mortality. Staff should be aware of warning signs for dysphagia, which included cough during eating, change in voice tone or quality after swallowing, abnormal gag, delayed swallowing, and incomplete oral clearing. NV00067331

Based on record review, resident and staff interviews and review of payroll time records, the facility failed to implement policies and procedures to prevent the neglect and emotional abuse of 2 of 27 residents (Resident #25 and #26). Findings include: Resident #26 was admitted on [DATE] for rehabilitation due to ischemic [MEDICAL CONDITION], unstable [MEDICAL CONDITION] pectoris, hypertension, post cardiac bypass, and other [MEDICAL CONDITION] disease. Record review revealed a physician's orders [REDACTED]. An additional order dated 8/4/11 was written for the resident to keep a bottle with [MEDICATION NAME] tab 0.4 mg, SL PRN (as needed), in his room. Patient should notify nurse every time he administers a tab. Resident #25 was admitted with general weakness, adult failure to thrive, dementia, paralysis agitans, hypertension, [MEDICAL CONDITION] and a fall at home. She resided in the same room as her husband, Resident #26. On 8/16/11 at 10:00 AM, in the resident group interview, Resident #25 stated that on 8/15/11 in the evening, her husband (Resident #26) had an episode of severe chest pain, unrelieved by his "nitro pills" he put the call light on. Resident #25 stated her husband, told a certified nursing assistant (CNA) (Employee #5), he needed his [MEDICATION NAME] for chest pain. Resident #25 reported Employee #5 stated he would tell the nurse. Resident #25 reported she and her husband waited a very long time while her husband took more nitro. Resident #25 stated her husband then put the call light on again and waited until a second CNA (Employee #6) came to answer. Resident #25 reported, her husband again had asked for his [MEDICATION NAME] and Employee #6 told them that the nurse would be back from her dinner break in about 10 minutes. Resident #25 said she was very worried that no one would come to help her husband. Resident #25 stated "It scared me to death". On 8/16/11 at 1:30 PM, in an interview with Resident #26, the resident stated that on 8/15/11 in the evening, he took 3-4 [MEDICATION NAME] tablets while waiting for the nurse to bring his [MEDICATION NAME] for his severe chest pain. Resident #26 reported he put the call light on after dinner to let the nurse know he had taken a nitro for chest pain without relief and he needed the [MEDICATION NAME]. Resident #26 stated he has been dealing with chest pain for a long time and knows when the nitro isn't working to get the [MEDICATION NAME]. He reported the CNA , Employee #5, stated he would tell the nurse who was on the unit. On 8/17/11 at 11:00 AM, Employee #5 was interviewed and stated when Resident #26 asked for the [MEDICATION NAME], he went immediately to tell the registered nurse (RN-Employee #7) assigned to the unit. Employee #5 indicated the RN (Employee #7) was at the nurses's station next to the medication cart when he reported Resident #26's request for pain medication. Employee #5 reported he told the nurse exactly what the resident said. Employee #5 reported he could not recall what Employee #7 said or did next. In his interview above, Resident #26 reported he waited hoping the pain and anxiety would go away for what seemed like a long time and then put the call light on a second time when no one came back. On 8/16/11 at 2:00 PM, in an interview with the second CNA (Employee #6), the CNA reported she had answered Resident #26's call light, listened to the resident's request for [MEDICATION NAME], and informed the resident the nurse would be back from her break in about 10 minutes. Employee #6 added that she reported Resident #26's request to the RN (Employee #7) as soon as the nurse got back from her break. On 8/16/11 at 2:30 PM in interview, the RN (Employee #7) reported she got the request from Employee #5 and thought Resident #26 was in pain "all over." The RN admitted she was not familiar with the resident, did not check his chart to see why he might need the [MEDICATION NAME], nor did she conduct an assessment of his pain. The RN reported she gave the [MEDICATION NAME] after the second CNA (Employee #6) told her about the resident's request. Review of time records for the RN (Employee #7) revealed she "clocked out" for her break on 8/15/11 at 7:42 PM and checked back in at 8:06 PM. She denied telling anyone but the CNAs on her unit she was leaving for break or telling the charge nurse about Resident #26 request for [MEDICATION NAME] since she thought it was for "general pain." Review of the Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. Review of the 24-hour report for 8/15/11 revealed Employee #7 did not mention Resident #26 chest pain but documented pain management. Review of the daily skilled nurses notes and pain flow sheets in the record revealed no documentation of the chest pain event, his self administration of [MEDICATION NAME], the intensity scale of the pain, the medication intervention, or relief of his pain. Review of the personnel record of Employee #7 revealed she was hired on 1/18/11 and was oriented to the facility's policies and procedures on prevention, recognition, and intervention of abuse and neglect. On 8/17/11 in an interview with the evening shift supervisor (Employee #9) and the unit manager (Employee #3) stated it was the expectation that all nurses check out and give the medication keys for their patient assignment to the supervisor or charge nurse before leaving the unit to for their meals. The evening supervisor added "although no one does it." They both admitted there was no written policy or procedure to require a nurse to check with the supervisor or another nurse before going off for a break. Cross reference Tag F309 On the morning of 8/17/11, at approximately 8:45 AM, in an interview with the Administrator (Employee #1), the administrator indicated when a nurse leaves for her lunch or dinner time, the nurse is expected to give her medication cart/room keys to a fell ow nurse before leaving the nursing unit. The Administrator indicated she did not think there was a written policy in regards to this, but that it was reviewed in orientation. On the afternoon of 8/17/11, in an interview with the Staff Developer (Employee #9), the Staff Developer indicated, during orientation, the nurses are informed that when a nurse leaves their unit for their meal time break, the nurse is to leave her medication keys with a fell ow nurse on the unit so that if a resident should need a medication in the nurse's absence a fell ow nurse can attend to the resident's needs. The Staff Developer indicated she did not think there was a written policy in regards to this procedure and that it was not included on the orientation check list.

Based on record review and interview, the facility failed to provide care and services for 1 of 27 residents to prevent a fecal impaction resulting in hospitalization , surgery, and a permanent [MEDICAL CONDITION] (Resident #15), and to provide pain medication in a timely manner for 1 of 27 residents (Resident #26). Findings include: Resident #15 Resident #15 was originally admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. On 3/19/11 Resident #15 was admitted to the hospital with [REDACTED]. An ultrasound of the lower extremites was negative for blood clot. A computed tomography (CT) scan revealed a large fecal impaction of the sigmoid colon approximately 20 centimeters (approximately 8 inches) in diameter. According to the discharge summary the impaction was compressing the iliac arteries, veins and the ureters, causing the [MEDICAL CONDITION] and the leg swelling. The discharge summary indicated the resident stated his last bowel movement was about 8 days prior to his hospitalization . Resident #15 was taken for emergency surgery where a colectomy (colon removal) and a permanent [MEDICAL CONDITION] were performed. The resident was readmitted to the facility on [DATE]. A review of Resident #15's medical record revealed the following medications prior to the hospitalization : 1. [MEDICATION NAME] acid 500 milligrams (mgs) twice per day (BID). 2. [MEDICATION NAME] 100 mg BID 3. [MEDICATION NAME] XL 10 mg. BID (side effect constipation, dosage increased on 2/1/11) 4. [MEDICATION NAME] 25 mg. BID 5. [MEDICATION NAME] 240 mg. BID 6. Calcium +D 500 mg. three times per day (TID) (may cause constipation) 7. [MEDICATION NAME] solution 10 grams/15 ml 30 cubic centimeters (cc) TID 8. [MEDICATION NAME] 30 mg. 2 tablets every 12 hrs. (slows intestinal motility) 9. [MEDICAL CONDITION] 200 micrograms every day. 10. [MEDICATION NAME] 70 mg. 1/2 hr. before meals every week. 11. Biscacodyl 10 mg. every morning. 12. [MEDICATION NAME] 10 mg. every morning 13. Vitamin formula with minerals daily 14. [MEDICATION NAME] 40 mg. daily 15. [MEDICATION NAME] 2.5 mg. daily A review of the bowel elimination pattern evaluation policy dated 11/2009 indicated that each resident was to monitored for bowel movements and that if none after 3 days Milk of Magnesia was given and results monitored. If no result in 24 hours, then a [MEDICATION NAME] suppository was given and results monitored. If no result in 24 hours, then a Fleets enema was to be administered. A review of the certified nursing assistant- activities of daily living (CNA-ADL) tracking forms for March of 2011 revealed that Resident #15 had no recorded bowel movements for 14 days on the night shift, no recorded bowel movements for 16 days on the evening shift, and no recorded bowel movements for 7 days on the day shift prior to the March 19th hospitalization . There was no evidence recorded in the medication administration forms that Milk of Magnesia, [MEDICATION NAME] suppository or Fleets enema was given during the month of March. There was a late entry on 3/24/11 by a CNA, on the back of the form, indicating Resident #15 had a large bowel movement on March 17th which had not been charted by the CNA. A review of the care plan for Resident #15 revealed the resident had a history of [REDACTED]. If no BM (bowel movement) after three days perform a bowel assessment and report abnormal findings to the physician. Give enemas as ordered by the physician. There was no evidence of recorded amounts or consistency of Resident #15's stools nor was there any evidence of bowel assessments or bowel protocols being initiated during the month of March. An interview was conducted with the alert and oriented Resident #15 on 8/18/11 at 10:15 AM. The resident indicated prior to his hospitalization he was independent in toileting (verified by the unit coordinator Employee #2) and it had been about 7 or 8 days since he had a bowel movement prior to his hospitalization . The resident indicated in the past if he needed a laxative he would tell the nurse. The resident indicated the CNA's never asked him about his daily bowel movements. An interview with the night shift nurse on duty 3/17/11 (Employee #4) revealed she had talked with the CNA after 3/19/11 and the CNA indicated Resident #15 had a bowel movement on 3/17/11 and the CNA had to clean the resident up because of incontinence of bowel, but the CNA had forgotten to chart the event. Resident #25 and #26 Resident #26 was admitted on [DATE] for rehabilitation due to ischemic [MEDICAL CONDITION], unstable [MEDICAL CONDITION] pectoris, hypertension, post cardiac bypass, and other [MEDICAL CONDITION] disease. Record review revealed a physician's orders [REDACTED]. An additional order dated 8/4/11 was written for the resident to keep a bottle with [MEDICATION NAME] tab 0.4 mg, SL PRN (as needed), in his room. Patient should notify nurse every time he administers a tab. Resident #25 was admitted with general weakness, adult failure to thrive, dementia, paralysis agitans, hypertension, [MEDICAL CONDITION] and a fall at home. She resided in the same room as her husband, Resident #26. On 8/16/11 at 10:00 AM, in the resident group interview, Resident #25 stated that on 8/15/11 in the evening, her husband (Resident #26) had an episode of severe chest pain, unrelieved by his "nitro pills" he put the call light on. Resident #25 stated her husband, told a certified nursing assistant (CNA) (Employee #5), he needed his [MEDICATION NAME] for chest pain. Resident #25 reported Employee #5 stated he would tell the nurse. Resident #25 reported she and her husband waited a very long time while her husband took more nitro. Resident #25 stated her husband then put the call light on again and waited until a second CNA (Employee #6) came to answer. Resident #25 reported, her husband again had asked for his [MEDICATION NAME] and Employee #6 told them that the nurse would be back from her dinner break in about 10 minutes. Resident #25 said she was very worried that no one would come to help her husband. Resident #25 stated "It scared me to death". On 8/16/11 at 1:30 PM, in an interview with Resident #26, the resident stated that on 8/15/11 in the evening, he took 3-4 [MEDICATION NAME] tablets while waiting for the nurse to bring his [MEDICATION NAME] for his severe chest pain. Resident #26 reported he put the call light on after dinner to let the nurse know he had taken a nitro for chest pain without relief and he needed the [MEDICATION NAME]. Resident #26 stated he has been dealing with chest pain for a long time and knows when the nitro isn't working to get the [MEDICATION NAME]. He reported the CNA , Employee #5, stated he would tell the nurse who was on the unit. On 8/17/11 at 11:00 AM Employee #5 was interviewed and stated when Resident #26 asked for the [MEDICATION NAME], he went immediately to tell the registered nurse (RN-Employee #7)) assigned to the unit. Employee #5 indicated the RN (Employee #7) was at the nurses's station next to the medication cart when he reported Resident #26's request for pain medication. Employee #5 reported he told the nurse exactly what the resident said. Employee #5 reported he could not recall what Employee #7 said or did next. In his interview above, Resident #26 reported he waited hoping the pain and anxiety would go away for what seemed like a long time and then put the call light on a second time when no one came back. On 8/16/11 at 2:00 PM, in an interview with the second CNA (Employee #6), the CNA reported she had answered Resident #26's call light, listened to the resident's request for [MEDICATION NAME], and informed the resident the nurse would be back from her break in about 10 minutes. Employee #6 added that she reported Resident #26's request to the RN (Employee #7) as soon as the nurse got back from her break. On 8/16/11 at 2:30 PM in interview, the RN (Employee #7) reported she got the request from Employee #5 and thought Resident #26 was in pain "all over." The RN admitted she was not familiar with the resident, did not check his chart to see why he might need the [MEDICATION NAME], nor did she conduct an assessment of his pain. The RN reported she gave the [MEDICATION NAME] after the second CNA (Employee #6) told her about the resident's request. Review of the Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. Review of the 24-hour report for 8/15/11 revealed Employee #7 did not mention Resident #26 chest pain but documented pain management. Review of the daily skilled nurses notes and pain flow sheets in the record revealed no documentation of the chest pain event, his self administration of [MEDICATION NAME], the intensity scale of the pain, the medication intervention, or relief of his pain. On 8/17/11 in an interview with the evening shift supervisor (Employee #11) and the unit manager (Employee #3) stated it was the expectation that all nurses check out and give the medication keys for their patient assignment to the supervisor or charge nurse before leaving the unit to for their meals. The evening supervisor added "although no one does it." They both admitted there was no written policy or procedure to require a nurse to check with the supervisor or another nurse before going off for a break. Cross reference Tag F224