Every finding on record at Heights Rehabilitation and Healthcare Center, The

THE FOLLOWING DEFICIENCY REPRESENTS AN INCIDENT OF PAST NON-COMPLIANCE THAT WAS SUBSEQUENTLY CORRECTED PRIOR TO THIS SURVEY. Based on medical record review, review of incident investigations, observations, staff and resident interviews, the facility failed to prevent elopement for two residents (Residents #1 and #3) of three residents reviewed for elopement. The facility census was 98.Findings include:1. Review of the medical record for Resident #3 revealed an admission date of 04/02/25. Diagnoses included sepsis due to methicillin resistant staphylococcus aureus (MRSA), acute pulmonary edema, acute respiratory failure, difficulty walking, major depressive disorder, end stage renal disease, and schizoaffective disorder. The resident had a court appointed guardian. Review of the Quarterly Minimum Data Set (MDS) assessment, dated 06/16/26, revealed Resident #3 had intact cognition. The assessment had not identified Resident #3 to have behaviors of wandering. The resident used a wheeled walker for ambulation. Review of the nurse's note dated 06/21/26 at 2:06 P.M. revealed Resident #3 was observed attempting to leave the building unsupervised and was assisted back to his unit. The Resident's guardian and physician were notified. The elopement assessment was updated, and a wander guard (an electronic safety monitoring device used to protect residents from wandering off or leaving a facility unattended) was put in place. Review of the elopement risk assessment dated [DATE] revealed the resident was at high risk for elopement. Review of physician orders for July 2026 identified orders for a wander guard to Resident #3's right lower extremity, and to check function and placement every shift dated 06/22/26. Review of the plan of care dated 04/17/26 and revised 06/22/26 revealed Resident #3 was at risk for elopement/wandering behavior due to exit seeking behavior. Interventions included calmly redirecting and diverting resident's attention, and offering to take him out to smoke (initiated 04/17/25 and revised on 07/09/26); distracting the resident when wandering/insistent on leaving facility by offering pleasant diversions, structured activities, food, conversation, television, books, etc. (initiated 04/17/25); evaluating for need of wander guard use (initiated 04/17/25); promptly checking when alarm system goes off to ensure the resident was safe and remained in facility (initiated 04/17/25); referring to psychiatrist/psychologist/behavior specialist as needed (initiated 06/22/26); and wearing wander guard to right ankle, monitoring placement/function, and periodically evaluating for continued need initiated 06/22/26 and revised on 07/09/26). Review of the Interdisciplinary team (IDT) note dated 07/02/26 at 12:57 P.M revealed Resident #3's exit seeking was noted. Review of the nurse's note dated 07/09/26 at 10:00 A.M. revealed Resident #3 was returned to the building and was immediately placed on one-to-one staff observation. Review of the elopement investigation dated 07/09/26 revealed Resident#3 was noted to be outside of the building walking on the street by a staff member. The resident was using a rollator to ambulate and was assisted back into the building. Upon re-entering the building, it was discovered the resident's wander guard transmitter was functioning, but the door alarm was not sounding. Resident #3 was immediately placed on one-to-one observation for safety. The service company was contacted for door maintenance. All additional residents were located via face-to-face head count by the Assistant Director of Nursing (ADON) #202. ADON #202 was placed at the facility front door to ensure adequate security was in place. Resident #3 had no injuries, and the guardian and physician were notified. Observation on 07/28/26 at 10:48 A.M. revealed Resident 3 was sitting on the couch in the 200 unit. The wander guard was on the resident's right ankle. Interview at the time of the observation with Resident #3 revealed the resident had wanted to go to the store for some snacks and cigarettes. Resident #3 stated he was not trying to leave the facility and did not realize he was not allowed to go by himself but did now and it was fine. The resident stated it was too far of a walk anyway. Interview on 07/28/26 at 11:01 A.M. with ADON #202 revealed Resident #3 was trying to get cigarettes and snacks at the store nearby. The resident was on dialysis and ambulated with a rollator. On that day he had walked down to the store, bought snacks, and came back. Resident #3 had seen other independent residents sign themselves out. He said he did not know it was a problem. He has not exhibited any additional behaviors. He was alert and oriented but forgetful. The resident did understand that he cannot go out by himself and knew he made a mistake. Once he was told about it, he was fine with not going out by himself. The facility did staff education and an elopement drill after Resident #3's elopement. Interview on 07/28/26 at 11:51 A.M. with Certified Nursing Assistant (CNA) #204 revealed she had found Resident #3 outside after he left the facility. CNA #204 brought Resident #3 back inside and let nursing staff know. The resident had not tried to leave on his own since that day. 2. Review of the medical record for Resident #1 revealed an admission date of 05/26/26. Diagnoses included cerebral infarction, hemiplegia and hemiparesis, cocaine abuse, encephalopathy, major depressive disorder, and anxiety disorder. The resident had a court appointed guardian. Review of the Annual Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #1 had intact cognition. The assessment did not identify the resident to have behaviors of wandering. Resident #1 required a mechanical lift for transfers and used a manual wheelchair for mobility. Review of the social services note dated 07/20/26 at 8:35 P.M. revealed the IDT was informed that Resident #1 was verbalizing exit seeking behavior, and a wander guard was placed to alert staff of resident's whereabouts. The guardian and nurse practitioner were informed and in agreement with the wander guard intervention. Review of the elopement risk assessment dated [DATE] revealed Resident #1 was at high risk for elopement. Review of the plan of care dated 07/20/26 revealed Resident #1 was at risk for elopement/wandering behavior due to verbalizing a desire to leave the facility. Interventions included calmly redirecting and diverting resident's attention (initiated 07/20/26); distracting resident when wandering/insistent on leaving facility by offering pleasant diversions, structured activities, food, conversation, television, books, etc. (initiated 07/20/26); promptly checking when alarm system goes off to ensure resident was safe and remained in facility (initiated 07/20/26); referring to psychiatrist/psychologist/behavior specialist as needed (initiated 07/20/26); wearing wander guard to custom wheelchair, monitoring placement/function, and periodically evaluating for continued need (initiated 07/20/026 and revised on 07/21/26) and a room change as needed for safety measures (initiated 07/22/26). Review of Resident #1's physician orders for July 2026 identified orders for a wander guard to wheelchair, check placement every shift dated 07/21/26, and may have leave of absence with supervision dated 05/26/26. Review of the Change in Condition note dated 07/22/26 at 7:41 P.M. revealed Resident #1 was noted to have left the facility. Upon noticing the resident's absence, the resident was located and brought back to the facility by a staff member. Emotional support and therapeutic communication was provided to Resident #1 about safety risks related to leaving the facility. The physician and guardian were notified of an immediate intervention recommendation to move the resident to Two North (second floor) for increased supervision in addition to a wander guard in place. All parties were in agreement with the plan of care. Review of the social services note dated 07/22/26 at 8:00 P.M. revealed one-to-one intervention was initiated by staff with supervision until a second head count was completed on all residents.Review of the nurse's notes dated 07/22/26 at 8:35 P.M. revealed a head-to-toe assessment was completed. Resident #1 denied any pain or discomfort. No sign or symptoms of any acute distress. Review of the elopement investigation dated 07/24/26 revealed on 07/22/26 at around 7:00 P.M. the delayed egress exit door alarm activated appropriately when Resident #1 exited the building. The resident was found down the sidewalk less than one mile away, and staff escorted the resident back to the facility in his wheelchair. A comprehensive nursing assessment was completed including vital signs and head-to-toe evaluation with no negative outcomes. There were no injuries. The guardian and provider were notified with no new orders. Resident #1's statement revealed that he wanted to leave to go buy cigarettes because he did not have any left. A facility wide head count was completed, and all residents were accounted for. All transmitters/wander guard doors were checked and were all functioning correctly. During the investigation, staff statements confirmed that CNA #206 had silenced the door alarm without visually verifying the resident's location, or ensuring the resident was safely returned to the building. It was determined that the wander guard was in place and that the transmitter functioned as intended. CNA #206 was suspended pending investigation. Observation on 07/28/26 at 10:40 A.M. revealed Resident #1 was lying in bed. A wander guard was attached to the wheelchair next to him. Interview at the time of the observation with Resident #1 revealed he knew he was not supposed to leave the facility, but he wanted cigarettes and no one would get him any, so he went himself. Interview on 07/28/26 at 11:01 A.M. with ADON #202 revealed Resident #1 was found as he was heading to the store for cigarettes. It was around 7:00 P.M. when the receptionist had left for the day. The front door alarmed and was locked, but if pushed for 15 seconds, the door will open for fire safety purposes. CNA #206 was coming in from break and thought she or a smoker had tripped the alarm and turned it off. A lot of smokers sometimes went out front to sit, even knowing they are supposed to smoke in the courtyard. Staff on that evening were all educated. CNA #206 was suspended and brought back after some education. When a door alarms, staff were supposed to check the perimeter for a resident, and call for assist if they cannot get the resident to come in. All units were to do a head count before the alarm gets shut off. The day the incident occurred the faculty educated the staff in the facility and called the remaining staff by phone. The facility had an all staff meeting twice the following day. The nurse did an elopement drill that day and twice following day. Interview on 07/28/26 at 12:02 P.M. with the Administrator revealed Resident #1 was displaying behaviors the evening of 07/20/26 and a wander guard was ordered and placed. He eloped two days later. Interviews on 07/28/26 at 2:52 P.M. and at 3:43 P.M. with the Administrator revealed the aides were coming down the hall and saying Resident #1 was not in his room when they met up with CNA #206, who had just turned off the alarm. After checking the courtyard, a CNA and a nurse went in the aide's car to look for the resident. They found him less than a mile away. The nurse walked him back because he required a mechanical lift and was in a wheelchair. After Resident #3 had eloped the staff education was online. After Resident #1 eloped the facility called an emergency all staff meeting and those who could not make it were personally called. The education included all departments. Administrator emphasized how serious an elopement could be. The deficient practice was corrected on 07/23/26 when the facility implemented the following corrective actions: On 07/09/26 at 10:00 A.M. Resident #3 was safely returned to the facility by CNA #204. Resident was immediately placed on one-to-one by ADON #202.On 07/09/26 at 10:44 A.M. Resident #3 was assessed by ADON #202 for injury, change in condition, and psychosocial distress with no injury identified.On 07/09/26 at 10:46 A.M. the physician/provider was notified by ADON #202 of the unauthorized exit and Resident #3's return to the facility.On 07/09/26 at 11:00 A.M. Resident #3's court-appointed guardian was notified by ADON #202 of the unauthorized exit, Resident #3's safe return, and immediate interventions.On 07/09/26 at 10:15 A.M. a full resident head count was completed by ADON #202, and all residents were accounted for. Administrator and Director of Nursing completed the root cause analysis of Resident #3's incident and determined that the primary root cause was failure of the exit-door wander guard system to detect the resident's transmitter and trigger the alarm/alert response at the time of exit.On 07/09/26 at 10:30 A.M. the exit door used by Resident #3 was secured by placing ADON #202 at the door to prevent other unauthorized exits. All residents with wander guard devices had their transmitters tested for proper functioning by LPN #210 and no other issues were identified. All doors equipped with the wander guard system in the facility were tested for proper functioning by Maintenance Director #208 and no other concerns were identified.On 07/09/26 at 11:00 A.M. Resident #3's wander guard transmitter was tested for proper functioning by Maintenance Director #208. Resident #3's wander guard was functioning appropriately. All residents with orders requiring supervision during leaves of absence were audited by Registered Nurse (RN) #211 to ensure the supervision requirement was accurately reflected in the physician orders, care plan and Kardex (resident information), any identified concerns were immediately corrected.On 07/09/26 at 12:00 P.M. the maintenance staff were educated by the Administrator that the door wander guard system must always function, and the system must be tested weekly.On 07/09/26 at 12:37 P.M., Resident #3's elopement assessment was updated by ADON #202 to high risk for elopement.On 07/09/26 at 12:35 P.M. Resident #3's care plan was revised by LPN #209 to include specific elopement prevention interventions.On 07/09/26 at 12:35 P.M. Resident #3 's Kardex was updated by Licensed Practical Nurse (LPN) #209 to reflect current supervision and specific elopement-prevention interventions.On 07/09/26 at 1:00 P.M. Resident #3's order requiring supervision during leaves of absence was reviewed by RN #211 and verified for accuracy.On 07/09/26 at 1:15 P.M. Resident #3 was placed on the weekly IDT meeting for ongoing monitoring of elopement risk and effectiveness of interventions. On 07/09/26 at 3:30 P.M. Administrator held an Ad Hoc Quality Assurance (QA) meeting to review the elopement and the wander guard system failure. On 07/09/26 by 4:00 P.M. the faulty door wander guard system was repaired/replaced by the providing company.On 07/09/26 by 5:00 P.M. Administrator re-trained all staff on the facility's elopement best practices.Beginning 07/09/26 and weekly thereafter for four weeks, the Administrator or designee will test all doors equipped with the wander guard system to ensure the system is functional and working per the manufacturer's guidelines. Audits will be submitted weekly for those four weeks to the QA committee for tracking trending and recommendations. On 07/22/26 at 7:00 P.M. Resident #1 was safely returned to the facility by RN #212 and Resident #1 remained one-on-one with staff supervision.On 07/22/26 at 7:27 P.M. Resident #1's physician was notified by RN #211. The physician approved relocating the resident to the Two North unit which was located on the second floor and would require elevator access. The elevator was integrated with the wander guard system and would not permit transport of a resident with an active wander guard transmitter without staff intervention, so it would provide an additional layer of protection against unauthorized exit from the facility.On 07/22/26 at 7:33 P.M. Resident #1's court-appointed guardian was notified by RN #211 and agreed to the room change for increased supervision.On 07/22/26 at 7:41 P.M. Resident #1's comprehensive nursing assessment was completed by RN #213, including vital signs and a head-to-toe assessment. No injuries or acute distress was identified.On 07/22/26 at 8:34 P.M. Resident #1's skin assessment was completed by RN #213 with no new injuries identified.On 07/22/26 at 8:57 P.M. Resident #1's pain assessment was completed by RN #213 with no identified pain.On 07/22/26 at 8:59 P.M. Resident #1 received education, emotional support, and therapeutic communication by RN #213 regarding safety and leaving the facility.On 07/22/26 at 9:20 P.M. Social Services Director #205, nurse practitioner, and IDT was notified by RN #211 of Resident #1's guardian confirming agreement with interventions.On 07/22/26 at 9:26 P.M. a facility-wide head count was completed by RN #213. All residents were accounted for. All residents with wander guard devices had their transmitters tested by RN #213 and confirmed proper operation.On 07/22/26 at 9:30 P.M. Resident #1's physician and guardian confirmed Resident #1 would only leave the facility under staff supervision.On 07/22/26 at 10:05 P.M. all residents identified as high risk for elopement were reviewed by RN #211 to ensure current risk assessments and individualized interventions were in place.On 07/22/26 at 10:25 P.M. all residents with court appointed guardians requiring supervised leaves of absence were audited by RN #211 to verify each physician order, care plan and Kardex had accurate and current supervision requirements.On 07/22/26 (no time) Resident #1's elopement risk assessment was completed by RN #211 confirming the resident remained at high risk. Resident #1's care plan and Kardex were updated to contain the new interventions by RN #211. On 07/23/26 at 12:30 P.M. all delayed-egress exit doors and alarm systems were tested by Maintenance Director #208 and confirmed to be functioning properly.On 07/23/26 (no time) Administrator completed a root cause analysis and determined that the wander guard system and delayed-egress door functioned as designed. The primary failure was staff response to the activated alarm. Staff statements confirmed that the exit-door alarm was silenced before staff determined the source of the alarm or verified the resident's location.On 07/23/26 (no time) all staff were re-educated by Administrator or designee that every activated exit-door alarm required immediate investigation, visual confirmation of the resident's location, and assurance that the resident had safely remained within the facility before the alarm was reset.Beginning on 07/22/26 and completed 07/23/26 all staff competency was validated through return demonstration during elopement response drills by Administrator and RN #211 respectively.On 07/23/26 (no time) an ad hoc QA committee meeting was convened to review the event, identify the root cause, evaluate corrective actions, and establish ongoing monitoring to prevent reoccurrence. Beginning 07/23/26 and weekly thereafter for four weeks, Administrator or designee will observe and validate staff response to all activated wander guard/delayed-egress door alarms at least three times per week to ensure staff immediately investigate the alarm, locate the resident, verify resident safety, and do not silence the alarm until the resident was accounted for. Audit results will be submitted for those four weeks to the QA committee for review, tracking, trending, and recommendations.

THE FOLLOWING DEFICIENCY REPRESENTS AN INCIDENT OF PAST NON-COMPLIANCE THAT WAS SUBSEQUENTLY CORRECTED PRIOR TO THIS SURVEY. Based on closed medical record review, review of emergency medical services (EMS) run report, interview, and facility policy review, the facility failed to timely provide basic life support (BLS) including cardiopulmonary resuscitation (CPR) to Resident #123 (a resident with advance directives for a Full Code status). This resulted in Immediate Jeopardy and Actual Harm with subsequent death on [DATE] at approximately 4:20 A.M. when Resident #123 was found not breathing, not moving, unresponsive, and without vital signs. Prior to initiating CPR, Registered Nurse (RN) #439 requested assistance from RN #301. The two nurses attempted to notify the on call Nurse Practitioner (NP) who did not answer and then notified Assistant Director of Nursing (ADON) #419 that the resident was unresponsive and absent of vital signs. ADON #419 instructed them to begin CPR as the resident was a Full Code. CPR was initiated and EMS were contacted. When EMS arrived at the facility at 4:40 A.M., CPR was not in progress, and the resident was only being ventilated by bag valve mask (BVM). When EMS personnel asked facility staff why CPR was stopped, the (unnamed) facility staff member stated, because you guys walked in and my back hurts. EMS re-initiated CPR and life-sustaining efforts which were unsuccessful. After collaboration with an offsite physician, the resident was pronounced deceased by EMS at 5:04 A.M. This affected one resident (#123) of three residents reviewed for death. The facility census was 107.On [DATE] at 11:02 A.M. the Administrator, Director of Nursing (DON), Chief Nursing Officer (CNO) #507, Co-Owner #508, and Regional Clinical Support (RCS) #509 were notified Immediate Jeopardy began on [DATE] at 4:20 A.M. when facility staff failed to provide timely and adequate basic life saving measures (CPR) to Resident #123 who was found unresponsive, per the resident's advance directive. EMS arrived and re-initiated CPR, which was unsuccessful, and pronounced Resident #123 deceased on [DATE].The Immediate Jeopardy was removed on [DATE] and the deficiency continued at a Severity Level 2 (no harm with the potential for more than minimal harm that is not Immediate Jeopardy) until the deficiency was corrected on [DATE], when the facility implemented the following corrective actions:On [DATE] following the incident, the DON removed RN #439 from the schedule and re-educated the nurse on the facility's CPR policy. RN#439 was reinstated on the evening of [DATE]. On [DATE], the DON educated all facility staff, in all departments, on the facility's CPR policy. The training covered the key topics within the policy including initiating CPR, recognizing a change in condition and responsiveness, verifying code status, initiating a code blue, obtaining the crash cart, directing staff to call 911 (emergency medical services) and continuing CPR until EMS arrived and assumed resuscitation efforts. Staff members who were not working were called and made aware of the outstanding training that was due to be completed on [DATE]. Training was verified by review of the electronic staff training confirmations. On [DATE], CNO #507 completed a root cause analysis (RCA). The root cause was determined to be a breakdown in emergency response execution involving delayed CPR initiation, inconsistent clinical competency under stress, and insufficient team-based emergency response activation, resulting in failure to immediately and continuously provide CPR to a resident with full code status until EMS assumed care. The RCA identified corrective actions needed including re-education, CPR drills on different shifts, an audit of all CPR certifications for licensed nurses, and a QA review of drill outcomes and any emergency response events for tracking and trending. On [DATE], an ad hoc Quality Assurance and Performance Improvement (QAPI) meeting was held to discuss Resident #123's CPR initiation and to develop an action plan. The ad hoc QAPI meeting identified the need for staff re-training, ongoing audits of nursing staff CPR certifications, ongoing audits for residents who experienced a code blue, and mock CPR drills to provide enhanced training for staff. Those in attendance included Physician #511 (identified as the co-Medical Director), the DON, the Administrator, and Administrator in Training (AIT) #303. On the evening of [DATE], the DON completed education with the five nurses (RN #301, Licensed Practical Nurse (LPN) #302, RN #319, RN #410, and RN #439) who were working at the time of Resident #123's code. The five nurses had to verbalize the appropriate steps of initiating CPR, including recognizing a change in condition and responsiveness, verifying code status, initiating a code blue, obtaining the crash cart, directing staff to call 911 (emergency medical services) and continuing CPR until EMS arrived and assumed resuscitation efforts. Interviews with RN #301, RN #319, and RN #439 during the survey confirmed the nurses were re-educated on the evening of [DATE] and were knowledgeable of the facility's CPR policy. There were no concerns identified with the training. On the evening of [DATE], the DON completed an audit of all licensed nurses' CPR certifications. All licensed nursing staff employed by the facility, including 22 RNs and 14 LPNs had current CPR certifications with no concerns identified. Beginning on [DATE], the DON began weekly audits for all residents who experienced a code to ensure staff followed the facility's CPR policy, including immediate initiation of CPR when indicated. This audit was completed weekly by the DON or designee for a duration of four weeks, with the last weekly audit completed on [DATE]. There were no concerns identified with the code audits. The results of the audits will be referred to the facility's quality assurance (QA) committee for tracking, trending and additional recommendations. Beginning on [DATE], the DON began weekly CPR drills on varying shifts to ensure staff demonstrated the ability to initiate CPR timely. This was completed weekly by the DON or designee for a duration of four weeks, with the last weekly audit completed on [DATE]. There were no concerns identified with the CPR drills. The results of the audits will be referred to the facility's quality assurance (QA) committee for tracking, trending and additional recommendations. On [DATE], the facility's QAPI team met and reviewed the results of the timeline, corrective action, and ongoing audits and identified no further action was needed. Present at the QAPI meeting was the Administrator, AIT #303, ADON #375, ADON #388, Physician #512, Admissions #427, Minimum Data Set (MDS) Coordinator #315, MDS #323, Business Office Manager (BOM) #307, BOM #396, Environmental Services (EVS) #346, Transporter #353, Central Supply #367, Human Resources (HR) #340, and Social Services (SS) #348.Findings include:Review of the closed medical record for Resident #123 revealed an original admission date of [DATE] and a readmission date of [DATE]. Diagnoses included end stage renal disease, chronic obstructive pulmonary disease, cirrhosis of the liver and congestive heart failure. Resident #123 expired at the facility on [DATE]. Review of Resident #123's care plan dated [DATE] revealed the resident's advance directive was listed as a Full Code (indication for healthcare providers to attempt all possible life-saving measures in the event of a cardiac or respiratory arrest). Interventions included to involve the physician in advanced directive conversations, periodically review advance directives with the resident/family, and record the resident's advance directives in the clinical record.Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #123 had intact cognition. Resident #123 was independent with ambulation, transfers, and bed mobility and was continent of bowel and bladder. Review of the physician orders revealed an order dated [DATE] indicating Resident #123 was a Full Code.Review of a progress note dated [DATE] at 11:05 A.M., authored by SS #348, revealed she had met with Resident #123 to further discuss the resident's plan of care. Resident #123 had declined a hospice referral and stated she wished to remain a Full Code. The interdisciplinary team (IDT) discussed Resident #123's decline and Resident #123 again stated she wished to remain a Full Code with no hospice interventions at that time. The note did not indicate what the resident's decline entailed.Review of progress note dated [DATE] at 5:05 A.M., authored by RN #439, revealed while doing care rounds around 4:20 A.M., an aide noted Resident #123 looked different and did not appear to be breathing. Upon entering Resident #123's room, RN #439 assessed Resident #123 and noted the resident was unresponsive and observed the absence of vital signs, noted the resident's pupils were fixed, dilated, and unresponsive to light, and the resident had a sunken-in appearance. RN #439 noted mottling (patchy, uneven skin discoloration caused by poor blood circulation and decreased oxygen levels; it can be a sign that the body is shutting down) in both of the resident's legs from the feet up to the thighs and noted the resident's skin was patchy red and cool to touch. Resident #123 was noted to have been a Full Code and RN #439 had notified on-call staff (unspecified in the progress note) that CPR was initiated and 911 was called. EMS arrived at 4:40 A.M. and relieved facility staff of performing CPR and continued with CPR until 5:04 A.M. when Resident #123 was pronounced deceased .Review of a linked progress note dated [DATE] at 6:45 A.M. (linked to the prior progress note timed [DATE] at 5:05 A.M.), authored by RN #439, revealed CPR was initiated at 4:30 A.M., with 30 chest compressions and two rescue breaths administered by facility nurses. 911 was called at 4:32 A.M. and CPR continued until EMS arrived and relieved facility staff.Review of an EMS run report dated [DATE] revealed a call was received at 4:34 A.M. and EMS personnel arrived at the patient at 4:40 A.M. The EMS narrative stated upon arrival Resident #123 was found lying supine (on her back) in bed and was unresponsive. CPR was not being administered upon EMS arrival but Resident #123 was being ventilated via bag valve mask (BVM) (device used for manual ventilation). When EMS personnel asked why CPR had stopped the staff member (name not specified) stated because you guys walked in and my back hurts. EMS immediately began manual compressions and after two minutes of CPR a pulse check was conducted and reflected asystole (a state of total cardiac arrest characterized by the complete absence of electrical and mechanical activity in the heart). CPR and life-sustaining interventions were resumed using a [NAME] device (mechanical device used for chest compressions). The EMS personnel's assessment indicated Resident #123 was cyanotic and cool to touch but noted the residents' left and right eyes were both PERRL (indicating pupils were equal, round, and reactive to light). Staff informed EMS during the resuscitative efforts that Resident #123 was last seen well approximately two hours prior. After approximately 23 minutes of resuscitative measures, EMS contacted an offsite collaborating physician and pronounced Resident #123 deceased at 5:04 A.M.Telephone interview on [DATE] at 2:48 P.M. with RN #439 revealed she arrived at the facility at approximately 11:00 P.M. on [DATE] and worked until approximately 7:00 A.M. on [DATE]. RN #439 stated she performed walking rounds at approximately 12:00 A.M. and visualized Resident #123 from the doorway. RN #439 stated she did not enter Resident #123's room but noted the resident appeared to be sleeping at that time. RN #439 stated Resident #123 was continent of bowel and bladder, and she had not provided Resident #123 with any care or medications during her shift. RN #439 stated at approximately 4:20 A.M. she was alerted by a staff member (she could not recall who) that Resident #123 didn't look right. RN #439 stated she immediately entered the resident's and observed Resident #123 in bed and it appeared the resident was not breathing. The resident's pupils were fixed and dilated, and she was stiff and cold. RN #439 stated Resident #123 appeared to have been gone for a while. RN #439 stated she found another RN to come and see the resident and both nurses entered Resident #123's room. RN #439 stated she asked RN #301 if she should begin CPR and RN #439 stated she believed performing CPR at that time would be abuse of a corpse. RN #439 stated she called the on-call NP (she could not recall whom) with no answer and she then called ADON #419 who advised Resident #123 was a Full Code, instructed them to begin CPR, and to call 911. RN #439 stated after speaking with ADON #419, she then initiated a code blue (a common phrase for a critical, life-threatening medical emergency within a hospital system) and chest compressions were started. RN #439 stated CPR was performed until EMS arrived approximately twenty minutes later when EMS assumed care of Resident #123.Telephone interview on [DATE] at 9:54 A.M. with Paramedic #513 revealed he had responded to the facility on [DATE] and upon arrival he observed staff not actively performing CPR on Resident #123. Paramedic #513 stated when the (unnamed in the report) staff member was asked why CPR was not in progress, the staff member stated what the report stated, because you guys walked in and my back hurts. Paramedic #513 stated EMS assumed Resident #123's care and were unable to revive her. Paramedic #513 stated an offsite collaborating physician at a local hospital was contacted and updated and Resident #123 was pronounced deceased at the facility.Interview on [DATE] at 9:27 A.M. with Certified Nursing Assistant (CNA) #431 revealed she cared for Resident #123 during the day of [DATE] and stated the resident did not look well. CNA #431 stated during her shift, Resident #123 did not eat or drink as much as she usually did and stated she informed the nurse (couldn't recall the nurse's name). When CNA #431 arrived for her next shift a few days later, she was informed Resident #123 had passed away. Interview on [DATE] at 11:09 A.M. with ADON #375 revealed she had a conversation with Resident #123 the morning of [DATE] to discuss her code status. During the conversation Resident #123 opted to remain a Full Code and declined hospice services. ADON #375 stated the morning of [DATE], Resident #123 didn't look like herself. ADON #375 stated Resident #123 appeared to be paler and more lethargic at the time of their discussion.Interview on [DATE] at 12:28 P.M. with the DON revealed she had been made aware Resident #123 had passed on [DATE] by ADON #419. At the time of the interview, the DON stated she had not been made aware of any issues or concerns with the nursing staff's response to Resident #123's change in condition or the CPR that was provided to the resident.Interview on [DATE] at 11:55 A.M. with ADON #419 revealed she received a call from RN #439 at approximately 4:30 A.M. and was informed Resident #123 was unresponsive. ADON #419 stated she was aware Resident #123 was a Full Code and instructed RN #439 to begin CPR and to call a code blue and EMS. ADON #419 stated she was not aware CPR had not been started prior to receiving the phone call. ADON #419 verified CPR should have been initiated immediately due to Resident #123 having an advance directive of Full Code status. Telephone interview on [DATE] at 4:41 P.M. with RN #301 revealed she was present on [DATE] when RN #439 approached her and stated she thought Resident #123 had passed away. RN #301 stated she had been working on the downstairs unit and upon being approached immediately went to Resident #123's room on the upstairs unit with RN #439. RN #301 stated upon entering Resident #123's room, the resident appeared to be lifeless, not breathing, her eyes and mouth were closed, and she appeared dusky. RN #301 stated she checked for a pulse and Resident #123 was cold and stiff and without a pulse. RN #301 stated she believed Resident #123 was on hospice and told RN #439 to contact hospice to inform of her passing. RN #301 further stated she checked Resident #123's medical records and then saw Resident #123 was a Full Code. RN #301 revealed RN #439 had stated, she's already gone, however RN #301 stated CPR was to still be done. RN #301 stated RN #439 then proceeded to place calls to the on-call NP as well as ADON #419. RN #301 stated upon speaking with ADON #419, RN #439 had been instructed to initiate a code blue and to begin CPR. RN #301 stated approximately four rounds of CPR had been performed prior to EMS arrival and stated once EMS arrived, they had taken over Resident #123's care. RN #301 stated the code had not been ran correctly as she believed Resident #123 was under hospice care and therefore did not initiate CPR immediately. Interview on [DATE] at 11:41 A.M. with RCS #509, the DON, and the Administrator, confirmed the facility leadership were aware there had been a delay in initiating CPR for Resident #123 on [DATE]. RCS #509 provided the facility's corrective action plan they had begun developing and implementing on [DATE]. RCS #509 indicated upon staff identification of a resident without vital signs, it is the facility's policy and the expectation for CPR to be initiated immediately.Interview on [DATE] at 12:28 P.M. with the DON revealed the DON was shown the EMS report indicating a facility staff nurse was noted to not be performing CPR on Resident #123 upon EMS personnel's arrival at the facility on [DATE] because the staff member's back hurt. The DON read the report and declined to further acknowledge or converse about the details contained within the EMS report.Review of facility policy titled Cardiopulmonary Resuscitation (CPR) revised [DATE] revealed CPR should be initiated immediately when cardiac or respiratory arrest occurs. Once CPR is initiated it will be discontinued only by physician order and/or arrival of rescue personnel.This deficiency represents non-compliance investigated under Complaint Number 2746747.

Based on facility records and staff interviews, the facility failed to ensure the Medical Director attended the quarterly quality assessment and assurance (QAA) committee meetings. This had the potential to affect all 107 residents. Findings include:Review of the facilities Quality Assurance/Performance Improvement Meeting sign-in sheets from 05/2025 to 05/2026 revealed the following:-06/2025, 07/2025, 08/2025 and 09/2025 meetings Medical Director (MD) #512 was listed as Additional Attendees but there was no signature.-Quarter 2025 meeting MD #512 was listed as attending via phone.-02/2026 meeting MD #512 was listed as attending via phone.-03/2026 meeting MD #512 was listed as in attendance and included his signature.-04/2026 meeting MD #512 was listed as attending via phone.-05/2026 meeting MD #512 was listed as in attendance and included his signature.Interview and facility record review on 06/02/26 at 4:49 P.M. with the Administrator and the Administrative Support #303 revealed that the facility QAA committee had met every month to go over the Quality Assurance and Performance Improvement (QAPI) plan. When asked if MD #512 attends the meetings the Administrator revealed that MD #512 did not attend the meetings in-person, by phone or had a designee attend in his place. The Administrator said that MD #512 would not come to the facility during the day shift, so she goes over what they discuss during the meetings with him either by phone or in person.Interview on 06/03/26 at 4:41 P.M. with the Administrator confirmed above observations regarding the sign-in sheets. She confirmed that when MD #512 was listed as via phone that he was not on the phone during the meeting, but that she went over the meeting information with MD #512 over the phone. The Administrator was unsure what additional attendees during the meetings between 06/2025 to 09/2025 meant as she did not start at the facility until after these meetings.

Based on observation and interview, the facility failed to maintain the kitchen in a sanitary manner and failed to dispose of expired foods timely. This had the potential to affect all 102 residents who received food from the kitchen (as Residents #2, #20, #35, #81, and #96 were identified as having orders for nothing by mouth). The facility census was 107. Findings include:1. On 05/17/26 at 8:22 A.M., observations during the initial tour of the kitchen revealed the dry storage room contained a half full case of nectar thick coffee packets that expired on 03/01/26, a case of individual portion peanut butter packets that expired on 03/04/26, a half full case of prune juice cartons that expired on 04/29/26, and four cartons of nectar thick dairy product that expired on 05/01/26; and the reach in cooler contained four cartons of honey thick dairy product that expired on 04/02/26, one carton of prune juice that expired on 04/29/26, and three cartons of nectar thick dairy product that expired on 05/01/26. On 05/17/26 at 8:42 A.M., an interview with Dietary Aide #383 confirmed the expired items in the dry storage area. On 05/17/26 at 8:55 A.M., an interview with [NAME] #405 confirmed the expired items in the reach in cooler. 2. On 05/17/26 at 8:22 A.M., an observation during the initial tour of the kitchen revealed there was a large industrial fan blowing on the clean dishes in the dish area. On 05/19/26 at 11:15 A.M., an observation of the puree preparation in the kitchen revealed the food processor bowl, lid, and blades were washed in the dishwasher and placed in front of the large industrial fan in the clean dish area to dry. The large industrial fan was covered in a layer of dust and positioned to blow on the clean dish area. On 05/19/26 at 11:46 A.M., an interview with Dietary Manager #384 verified the food processor bowl, lid, and blades were placed in front of the large industrial fan to dry. On 05/19/26 at 11:50 A.M., an interview with Registered Dietitian (RD) #500 verified the large industrial fan used to dry the clean dishes was covered in dust. RD #500 said she had an audit form she was supposed to use to conduct kitchen sanitation audits, but she had not completed one because she had only been working in the facility for one month.

Based on observation and interview, the facility failed to maintain resident bathing facilities in proper functioning order. This had the potential to affect all 107 residents in the facility. Findings include: 1. On 05/17/26 at 3:20 P.M., an observation of the shower room by room [ROOM NUMBER] revealed a sign on the door indicating the shower room was closed until further notice and there was no date on the sign. On 05/17/26 at 3:20 P.M., an interview with Licensed Practical Nurse (LPN) #388 confirmed that shower room was out of order and had been for as long as she had been working at the facility, which she stated was about one year. On 05/20/26 at 11:10 A.M., an observation of the shower room by room [ROOM NUMBER] revealed a walk-in tub in the middle of the shower room. An interview at the time of observation with Regional Maintenance Director #503 stated it needed repairs and they were not going to fix it because the census was low. On 05/20/26 at 12:13 P.M., an interview with Director of Nursing (DON) stated the shower room had been out of order since she began working at the facility over one year ago. DON confirmed that shower room was the only shower room in the facility with a tub. On 05/20/26 at 12:19 P.M., an interview with DON said that shower room had been non-functional since the current owner took over the facility. On 05/20/26 at 1:57 P.M., an interview with Administrator confirmed the shower room had been out of order for a while. On 05/26/26 at 11:31 A.M., an interview with Assistant Director of Nursing (ADON) #375 stated she had worked at the facility for 10 years and the shower room containing the tub had been out of order the entire time. ADON #375 said in the 10 years she had been there, she only saw that tub used one time to bathe a dying resident whose last request was to receive a tub bath. 2. On 05/17/26 at 3:32 P.M., an observation of the shower room by room [ROOM NUMBER] revealed displaced tiles at the bottom of the shower and a hole that went all the way into the wall at the bottom of the wall below the shower head. On 05/17/26 at 3:32 P.M., an interview with LPN #390 verified the displaced tiles and hole in the wall in the shower by room [ROOM NUMBER]. This deficiency represents non-compliance investigated under Complaint Number 2746747.

Based on record review, interview, and policy review, the facility failed to accurately document the care for facility residents. This affected five residents (Residents #4, #87, #113, #120, and #121) of nine closed records reviewed and 34 open records reviewed. The facility census was 107. Findings include: 1. Resident #4 was admitted to the facility on [DATE] with diagnoses including hemiplegia and hemiparesis after a stroke affecting the right dominant side, diabetes, a gastrostomy (a surgical incision to the stomach used to provide nutrition to the resident), atrial fibrillation, diabetes, high blood pressure, neuromuscular dysfunction of the bladder, and convulsions. The resident was transferred to the emergency room (ER) on [DATE] and did not return. Review of the quarterly comprehensive Minimum Data Set (MDS) 3.0 assessment, dated [DATE], revealed Resident #4 was rarely/never understood, was dependent on staff for all care, and has a feeding tube. Review of the nursing progress notes revealed on [DATE] at 5:49 A.M. Registered Nurse (RN) #301 documented she assessed Resident #4 around 5:00 A.M. and found the resident's eyes were fixed to the right and her arm was stiff. The resident's blood pressure was 149/99 (normal range 120/80), her heart rate was 135, her respirations were 22, and her oxygen saturation level was 94% on room air (normal is 93% to 100% on room air). The resident did not respond to stimuli. Emergency Medical Services (EMS) were called and the resident was transferred to a local ER. The emergency contact and the nurse practitioner were notified. No further information was documented regarding what happened to the resident after transfer. Interview with the Director of Nursing (DON) on [DATE] at 3:05 P.M. revealed the expectation was for nurses to document whether the resident was admitted to the hospital, transferred elsewhere, or discharged back to the facility, confirming Resident #4's medical record did not contain complete record of what happened to the resident after the hospital transfer. Review of the facility's undated Documentation: Charting policy revealed the clinical record is a legal document and may be used as evidence in law courts. It is essential the record be accurate, legible, and complete. The medical record should have documentation regarding admission, transfer, and discharge as well as any follow up actions to nursing observations. 2. Resident #87 was admitted to the facility on [DATE] with diagnoses including postsurgical malabsorption, chronic kidney disease, major depressive disorder, history of malignant neoplasm of the thyroid, gastric reflux, and hypothyroidism. Review of the quarterly comprehensive Minimum Data Set (MDS) 3.0 assessment, dated [DATE], revealed Resident #87 was cognitively intact, was able to provide his own personal care needs, and has had a significant weight gain over the previous six months. Review of the physician's orders for Resident #87 revealed an order dated [DATE] for Total Parental Nutrition (TPN—an intravenous infusion providing nutrition to keep the body nourished and allow the digestive system to rest) to infuse through a central venous catheter (CVC) to infuse 2280 milliliters (ml) over 12 hours at 165 ml per hour. A registered nurse (RN) was to draw labs from the right CVC prior to administering the TPN on Monday and Thursday evenings. Review of the Medication Administration Record (MAR) for April, May, and [DATE] for Resident #87, revealed numerous dates of the resident's TPN infusion being marked as other/see progress notes. The dates marked as this were [DATE], [DATE], [DATE], [DATE] through [DATE], [DATE] through [DATE], [DATE] through [DATE], [DATE], [DATE] through [DATE], [DATE], [DATE], [DATE] through [DATE], [DATE] through [DATE], and[DATE] through [DATE]. Review of the nursing progress notes from [DATE] through [DATE] revealed Licensed Practical Nurse (LPN) #412 documented Resident #87's TPN infusion was administered by whoever the RN scheduled to work that night was. The RN who hung the TPN infusion did not sign off that they started the infusion. Interview with the DON on [DATE] at 2:27 P.M. revealed LPN # 412 was not able to hang the TPN infusion as it must be administered by an RN. LPN #412 marked the MAR as see progress notes and documented the RN was who started the infusion. When asked why the RN who started the infusion did not sign off the infusion was started, the DON replied she did not know but it should be documented by the RN who administered it. Review of the facility's undated Documentation: Charting policy revealed the clinical record is a legal document and may be used as evidence in law courts. It is essential the record be accurate, legible, and complete. The documentation should record care given including, but not limited to, medications and treatments. 3. Resident #120 was admitted to the facility on [DATE] with diagnoses including chronic obstructive pulmonary disease (COPD), chronic respiratory failure with hypoxia (low oxygen levels in the blood), diabetes, chronic kidney disease, high blood pressure, vascular dementia without behavioral disturbance, prostate cancer, a cerebral aneurysm, a gastrostomy (a surgically placed tube placed into the stomach to allow feeding through a tube), and neuromuscular dysfunction of the bladder. The resident was transferred to the ER on [DATE] and did not return to the facility. Review of the physician's orders revealed Resident #120's head of the bed must be elevated to at least 30 degrees to allow for easier breathing related to his diagnosis of COPD as well as the fact he received a tube feeding for nutrition and elevating the head of the bed assists in preventing aspiration of the tube feeding. Labs were drawn on [DATE] for a blood count, a complete metabolic profile, and blood cultures. Resident #120 also received five liters of oxygen via nasal cannula continuously. The resident also had an order a breathing treatment of Ipratropium-Albuterol 0.5-2.5 milligrams (mg) per three milliliters (ml) via inhalation treatment every four hours as need for shortness of breath or wheezing. The resident also had several wounds for which he received daily dressing changes. Review of the comprehensive quarterly Minimum Data Set (MDS) 3.0 assessment, dated [DATE], revealed Resident #120 was rarely/never understood, was dependent upon staff for all care, exhibited no indicators of pain, and received oxygen continuously. Review of the nursing progress notes revealed Resident #120 was readmitted to the facility on [DATE] with wounds to his sacrum, both heels, and left anterior forearm. The resident also had a peripheral intravenous (IV) line inserted through which he was receiving an IV antibiotic for a urinary tract infection. On [DATE] at 5:00 P.M. Registered Nurse (RN) #350 completed a Change in Condition template indicating Resident #120 was tachypneic (fast respirations) and tachycardic (fast heart rate) starting on [DATE] at night. RN #350 assessed the resident's vital signs. His blood pressure was 114/66 (normal range), a heart rate of 136, a respiratory rate of 28, and a temperature of 97.4 degrees Fahrenheit. His oxygen level was 94% on room air. His blood sugar was 229 which was high. Upon entering the resident's room RN #350 noted Resident #120 was breathing fast and heard crackles (an abnormal, clicking, bubbling, or popping sounds heard during breathing typically indicating the presence of fluid, mucus, or pus in the airways) in the base of his lungs. RN #350 contacted Nurse Practitioner (NP) #506 who said to transfer the resident to the ER for evaluation. No further information was documented on what occurred after transfer. Interview with the DON on [DATE] at 3:05 P.M. revealed the expectation was for nurses to document whether the resident was admitted to the hospital, transferred elsewhere, or discharged back to the facility, confirming Resident #120's record lacked evidence of what transpired after hospital transfer. Review of the facility's undated Documentation: Charting policy revealed the clinical record is a legal document and may be used as evidence in law courts. It is essential the record be accurate, legible, and complete. The medical record should have documentation regarding admission, transfer, and discharge as well as any follow up actions to nursing observations. 4. Resident #121 was admitted to the facility on [DATE] and was transferred to the hospital on [DATE] and did not return to the facility. Admitting diagnoses included acute and chronic respiratory failure, morbid obesity, a peritoneal abscess, diverticulitis of the large intestine with perforation and an abscess with bleeding, high blood pressure, chronic kidney disease, hypothyroidism, lymphedema, and a colostomy (a surgically inserted opening to the bowels to allow for stool to drain from the body). Review of the Medicare 5 Day comprehensive Minimum Data Set (MDS) 3.0, dated [DATE], revealed Resident #121 was cognitively intact, was dependent for toileting, was admitted with a pressure ulcer, had surgical wounds, as well as moisture associated skin damage, and received IV medications, as well as occupational and physical therapy. Review of the nursing progress notes revealed on [DATE] Resident #121 on [DATE] at 2:00 P.M. revealed a change in condition occurred. The resident had low blood pressure and developed chills while in physical therapy. Her blood pressure was 76/50 (normal is 120/80). The resident requested to be transferred to the emergency room (ER) and was transferred as requested. No further information is documented in the chart regarding what happened to the resident after the request for a transfer to the ER was approved. Interview with the DON on [DATE] at 3:05 P.M. revealed the expectation was for nurses to document whether the resident was admitted to the hospital, transferred elsewhere, or discharged back to the facility, confirming Resident #121's record lacked evidence of what transpired after hospital transfer. Review of the facility's undated Documentation: Charting policy revealed the clinical record is a legal document and may be used as evidence in law courts. It is essential the record be accurate, legible, and complete. The medical record should have documentation regarding admission, transfer, and discharge as well as any follow up actions to nursing observations. 5. Review of the medical record for Resident #113 revealed an admission date of [DATE] with diagnoses including chronic respiratory failure, dependence on ventilator, type two diabetes mellitus, dependence on renal dialysis, hypertension, and history of venous thrombosis and embolism. Review of the respiratory therapy progress note dated [DATE] at 1:55 P.M. revealed respiratory therapy responded to Resident #113's vent alarm and found the resident bucking the vent, suctioning produced nothing, the resident had no pulse, and her skin was cold and clammy. Cardiopulmonary resuscitation (CPR) was started within a few minutes while Resident #113 was on a body board flat on her bed. Emergency medical services (EMS) were called, Resident #113's pulse returned, and the resident was transported to the hospital. Review of the nursing progress note dated [DATE] at 3:24 P.M. indicated Resident #113 had a change in condition in the afternoon identified by respiratory therapy, the resident was unresponsive with no pulse, and CPR was initiated. The resident's pulse returned and EMS transported Resident #113 to the hospital. The vital signs recorded regarding the change in condition were as follows: pulse was 98 on [DATE] at 1:26 A.M., oxygen saturation was 98% on [DATE] at 1:26 A.M., blood pressure was 106/59 on [DATE] at 1:29 A.M., respirations were 18 on [DATE] at 1:29 A.M., temperature was 97.6 degrees on [DATE] at 1:29 A.M., and there were no vital signs in the nurse's note documented as obtained in the afternoon when the change in condition occurred. The note indicated Resident #113's daughter was notified of the change in condition on [DATE] at 1:55 A.M. The note also indicated Nurse Practitioner (NP) #506 was notified of the change in condition on [DATE] at 2:00 A.M. On [DATE] at 11:20 A.M., an interview with DON confirmed Resident #113 coded on [DATE] and there were discrepancies in the notes regarding the time of the incident and notifications. On [DATE] at 11:58 A.M., an interview with DON confirmed the nurse inaccurately documented the times for the change in condition and notification times for Resident #113's code blue, stating the documented notifications and vital signs should have been recorded for P.M. and not A.M. This deficiency represents non-compliance investigated under Complaint Number 2746747.

Based on record review, observations, interviews, and facility policy review, the facility failed to ensure wound care orders were updated and treatments had been administered per physician orders for three residents. This affected two residents (#73 and #105) of three reviewed for wound care and one resident (#35) out of three residents reviewed for tube feeding. Additionally, the facility failed to ensure timely and appropriate incontinence care had been completed. This affected one resident (#12) of three observed for incontinence care. The facility also failed to ensure appropriate and timely care provided for a change in condition for one resident (#120) of six residents reviewed for change of condition. The facility census was 107.Findings Include: 1. Record review for Resident #105 revealed resident was admitted on [DATE] with diagnosis that included: cerebral infraction, pyogenic arthritis, type two diabetes, insomnia, essential hypertension, hyperlipidemia, end stage renal disease, carpal tunnel syndrome and generalized anxiety disorder. Review of Care Plan dated 05/15/26 revealed the resident had aggressive behaviors towards staff, verbally aggressive towards others, combative with care, would yell at staff in dialysis, scream and kick at staff and would put on the call-light requesting help and then was combative and resistant to assistance. Resident had behaviors related to refusing wound care, refusing leg wraps, refusing dressing changes and refusing to elevate her legs. Resident had impaired skin as evidenced by vascular wounds. Review of Resident #105's wound care note dated 04/29/26 authored by Wound Nurse Practitioner (WNP) #503 revealed the resident was being seen for a follow up visit for wound care. Resident was evaluated for venous ulcers to bilateral lower extremities. Resident had 10 wounds receiving wound care. Resident was ordered compressions with instructions to lightly wrap bilateral lower extremities with all cotton elastic (ACE) wrap every morning (QAM), remove at bedtime (HS), and to wrap from base of toes to below knee if patient allows. Review of WNP #503 notes from 05/06/26, 05/13/26 and 05/20/26 revealed the same orders for the compressions. Review of physician order dated 05/20/26 revealed orders to lightly wrap bilateral lower extremities (BLE) with ACE wrap QAM, remove at HS, wrap from base of toes to below knee if patient allows. There was no documented evidence of an order for the ACE wraps prior to 05/20/26. Observation on 05/17/26 at 2:56 P.M. of Resident #105 in her room wiping her legs with a tissue and no ACE wraps were present. Interview on 05/20/26 at 5:01 P.M. with WNP #503 revealed she first ordered the ACE wraps on 05/06/26. Interview on 05/21/26 at 12:47 P.M. with Licensed Practical Nurse (LPN) Assistant Director of Nursing (ADON) #375 confirmed the order for the ACE wrap was not added until yesterday and that treatment was originally ordered by WNP #503 in a note on 04/29/26. 2. Review of Resident #73's medical records revealed an admission date of 04/21/26. Diagnoses included left femur fracture, muscle weakness, difficulty walking and need for personal care assistance. Review of Resident #73's admission assessment dated [DATE] revealed a 2 centimeter (cm) by 3 cm skin tear to the left arm. Review of the care plan dated 04/22/26 revealed Resident #73 was at risk for impaired circulatory status. Interventions included administer treatments as ordered. Resident #73 was also at risk for impaired skin integrity. Interventions included complete skin checks every 7 to 10 days and as needed and administer treatments as ordered. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #73 had impaired cognition and required moderate assistance with activities of daily living (ADL) care. Review of Resident #73's physician orders revealed orders dated 04/22/26 to cleanse the left upper extremity skin tear with normal saline, pat dry, apply calcium alginate (absorbent wound dressing) and cover with a silicone foam dressing every day shift and as needed. The order was discontinued on 05/11/26. Review of Medication Administration Record (MAR) and Treatment Administration Record (TAR) for May 2026 revealed the treatment was documented as completed on 05/09/26 and 05/10/26. Observation on 05/17/26 at 10:02 A.M. revealed Resident #73 was seated in a chair in her room with a silicone foam bandage to her left elbow with a date of 05/09/26. Resident #73 was not interviewable. Interview on 05/17/26 at 11:33 A.M. with LPN #390 confirmed Resident #73's dressing date and she stated she was unsure of the orders for her dressing changes. 3. Resident #120 was admitted to the facility on [DATE] with diagnoses including chronic obstructive pulmonary disease (COPD), chronic respiratory failure with hypoxia (low oxygen levels in the blood), diabetes, chronic kidney disease, high blood pressure, vascular dementia without behavioral disturbance, prostate cancer, a cerebral aneurysm, a gastrostomy tube (a surgically placed tube placed into the stomach to allow feeding through a tube), and neuromuscular dysfunction of the bladder. The resident was transferred to the emergency room (ER) on 03/22/26 and did not return to the facility. Review of the care plans for Resident #120 revealed a care plan was initiated on 10/29/25 for impaired respiratory status related to COPD, respiratory failure and sleep apnea. The intervention to assist the resident with breathing was to elevate the head of the bed for comfort and to avoid shortness of breath when lying flat. Review of the physician's orders revealed Resident #120's had an order for a breathing treatment of Ipratropium-Albuterol 0.5-2.5 milligrams (mg) per three milliliters (ml) via inhalation treatment every four hours as need for shortness of breath or wheezing. Review of the comprehensive quarterly Minimum Data Set (MDS) 3.0 assessment, dated 01/19/26, revealed Resident #120 was rarely/never understood, was dependent upon staff for all care, exhibited no indicators of pain, and received oxygen continuously. Review of the nursing progress notes revealed Resident #120 was readmitted to the facility on [DATE] with wounds to his sacrum, both heels, and left anterior forearm. The resident also had a peripheral intravenous (IV) line inserted through which he was receiving an IV antibiotic for a urinary tract infection. On 03/22/26 at 5:00 P.M. Registered Nurse (RN) #350 completed a Change in Condition template indicating Resident #120 was tachypneic (fast respirations) and tachycardic (fast heart rate) starting on 03/22/26 at night. RN #350 assessed the resident's vital signs. His blood pressure was 114/66 (normal was typically noted around 120/80), a heart rate of 136 beats per minute (bpm) (normal ranged from around 60 to 100 bpm), a respiratory rate of 28 breaths per minute (normal ranges from around 12 to 20 breaths per minute), and a temperature of 97.4 degrees Fahrenheit. His oxygen level was 94% on room air (normal ranges from around 93% to 100%). His blood sugar was 229 milligrams per deciliter (mg/dL). Upon entering the resident's room RN #350 noted Resident #120 was breathing fast and heard crackles (an abnormal, clicking, bubbling, or popping sounds heard during breathing typically indicating the presence of fluid, mucus, or pus in the airways) in the base of his lungs. RN #350 contacted Nurse Practitioner (NP) #506 who said to transfer the resident to the ER for evaluation. No further information was documented on what occurred after transfer. Review of the Emergency Medical Service (EMS) run report for Resident #120, dated 03/22/26, revealed EMS dispatch received a call from the facility on 03/22/26 at 5:15 P.M. and EMS was en route to the facility at 5:17 P.M. and arrived on scene at 5:20 P.M. The chief complaint provided by the facility was the resident was tachycardic and they felt he was septic. At 5:21 P.M. Paramedic #600 assessed Resident #120's breathing. The resident's rate of respirations were normal, his respirations were unlabored and his lung sounds were clear bilaterally. His blood pressure was within the normal range of 116/61, his heart rate was rate was 98 bpm, and his oxygen level was 98%. Review of the narrative report revealed the squad was dispatched for a male with a high heart rate. RN #350 told EMS the resident was recently in the hospital for sepsis due to a large sacral wound on the resident's back side. The resident still had a few days of his antibiotic left but did not seem to be responding as fast as the facility believed he should. The resident had audible gargling sounds while breathing and was lying flat in bed. EMS transferred the resident to the stretcher and raised the head of the stretcher in order to facilitate the resident's breathing and placed him on two liters of oxygen via nasal cannula. The gargling sounds decreased and by the time they reached the ER the gargling sounds had stopped. Review of the March 2026 Medication Administration Record (MAR) for Resident #120 revealed the resident's order for a breathing treatment of Ipratropium-Albuterol 0.5-2.5 mg per three ml via inhalation treatment every four hours as need for shortness of breath or wheezing was not administered on 03/22/26 or at any time in March 2026. Interview with the Director of Nursing (DON) on 05/20/26 at 2:30 P.M. confirmed Resident #120 had not been given the as needed breathing treatment per orders for shortness of breath prior to being transferred to the hospital on [DATE]. 4. Review of Resident #12's medical records revealed a readmission date of 03/09/25. Diagnoses included dementia, anxiety and wandering. Review of Minimum Data Set (MDS) assessment dated [DATE] reveled Resident #12 had impaired cognition. Resident #12 was dependent with toileting, bathing and personal hygiene and was incontinent of bowel and bladder. Review of care plan dated 04/30/26 revealed Resident #12 was incontinent of bowel and bladder. Interventions included provide pericare after each incontinence episode. Observation of incontinence care on 05/26/26 at 9:27 A.M. with Certified Nursing Assistant (CNA) #431 revealed Resident #12 was wearing a pull up incontinence brief with a second incontinence brief over top. Further observation revealed Resident #12 was saturated with urine that had soaked through both incontinence briefs, his mattress pad and on to his mattress, along with a strong odor of stale urine being detected. Interview with CNA #431 at time of observation revealed she was not the assigned CNA for Resident #12, and stated there was another aide who had arrived late and likely had not provided Resident #12 with care yet. CNA #431 stated residents should not be wearing more than one incontinence product and confirmed the stale urine odor and Resident #12 having been saturated with urine. CNA #431 stated she was unaware when Resident #12 had last been provided with incontinence care. Resident #12 was not interviewable. 5. Review of Resident #35's medical records revealed an admission date of 03/16/26. Diagnoses included stroke, dysphagia (difficulty swallowing) and gastrostomy (feeding tube). Review of care plan dated 03/13/26 revealed Resident #35 was at risk for altered nutritional status related to a feeding tube. Interventions included treatment to tube site as physician ordered, monitor and report signs of pain or tenderness at tube site to provider and check tube placement as indicated. Review of Minimum Data Set (MDS) assessment dated [DATE] revealed no cognition score due to Resident #35 was rarely understood. Resident #35 was dependent with toileting, bathing and personal hygiene and was incontinent of bowel and bladder. Review of physician orders for May 2026 revealed to cleanse Resident #35's PEG tube site with normal saline every day shift. Review of Treatment Administrator Record (TAR) for May 2026 revealed no documentation of the PEG tube site having been cleaned with normal saline on 05/06/26, 05/07/26, 05/16/26 and 05/17/26. Observation and interview on 05/17/26 at 2:14 P.M. with Licensed Practical Nurse (LPN) #390 revealed Resident #35's PEG tube site had a gauze dressing around it that was undated, had a large amount of dried dark debris and a foul pungent odor. LPN #390 stated she had not cleansed the site today and was unsure when it had last been done. Interview with Resident #35's wife at time of observation revealed she had to ask staff numerous times to cleanse his PEG tube site and it had rarely been cleaned. Interview and observation on 05/20/26 at 1:36 P.M. with Resident #35's wife revealed his PEG tube site had not been cleaned and the dressing had not been changed. At the time of the interview Resident #35's wife had lifted his shirt and a gauze dressing was observed with a date 05/17/26 and the dressing was soiled with dark colored debris and the area continued to have a foul pungent odor. Observation and interview on 05/20/26 at 2:00 P.M. of Resident #35's PEG tube site with Registered Nurse (RN) #391 confirmed the soiled dressing, foul odor and dressing dated 05/17/26. RN #391 stated the dressing changes were supposed to have been done on night shift and she was unaware the dressing had not been done. RN #391 further stated she would inform the physician of the foul odor for Resident #35's PEG tube site. Review of change in condition progress note dated 05/20/26 timed 2:25 P.M. authored by RN #391 revealed Resident #35 had brownish red drainage coming from his PEG tube site. Nurse Practitioner (NP) #506 had been made aware and had given orders for lab work and to start Doxycycline (antibiotic) 100 milligrams (mg) twice a day for seven days. This deficiency represents noncompliance investigated under Complaint Numbers 2980251, 2795193, and 2746747.

Based on record review, observation, and interview, the facility failed to serve meals to meet the nutritional needs of residents requiring double portions at meals. This affected all 24 residents (#1, #5, #7, #8, #14, #18, #28, #37, #38, #46, #47, #50, #56, #63, #69, #74, #84, #89, #90, #94, #95, #106, #108, and #119) identified by the facility as requiring double portions at lunch meals. The facility census was 107. Findings include: 1. Review of the medical record for Resident #1 revealed an admission date of 03/04/26 with diagnoses including type two diabetes mellitus, anemia in chronic kidney disease, hypertension, and anxiety. Review of the dietary assessment note dated 05/06/26 at 4:27 P.M. revealed Resident #1 received a regular diet with regular texture and double entree portions. Review of the nutritional care plan, revised 05/14/26, revealed Resident #1 was at risk for altered nutritional status related to diabetes mellitus, hypertension, hyperlipidemia, anxiety, depression, gastroesophageal reflux disease, anemia, altered nutrition related labs, history of significant weight loss, and refusing supplements. Interventions included provide meals and snacks based on resident preferences and physician orders initiated 12/05/22. 2. Review of the medical record for Resident #5 revealed an admission date of 04/10/25 with diagnoses including end stage renal disease, hypertension, atrial fibrillation, sacral spina bifida, and cerebral palsy. Review of the physician's orders for Resident #5 identified orders for a renal diet with double portions effective 03/13/26. Review of the dietary assessment note dated 05/14/26 at 3:53 P.M. revealed Resident #5 went to dialysis on Mondays, Wednesdays, and Fridays and received a renal diet with regular texture and double portions. The note indicated Resident #5 refused the addition of oral nutrition supplements. Review of the nutritional care plan, revised 05/14/26, revealed Resident #5 was at risk for altered nutritional status related to respiratory failure, atrial fibrillation, heart failure, cerebral palsy, end stage renal disease, dialysis dependent, morbid obesity, increased nutrient needs, and refusal of nutritional supplements. Interventions included provide meals and snacks based on resident food preferences and physician orders initiated 04/15/25. 3. Review of the medical record for Resident #7 revealed an admission date of 09/16/19 with diagnoses including type two diabetes mellitus, cerebral infarction, iron deficiency anemia, and anxiety. Review of the physician's orders for Resident #7 identified orders for a consistent carbohydrate diet with double protein portions effective 12/05/25. Review of the nutritional care plan, revised 03/13/26, revealed Resident #7 was at risk for altered nutritional status related to hemiplegia and hemiparesis, type two diabetes mellitus, morbid obesity, bipolar, schizophrenia, lupus, hypertension, vitamin D deficiency, abnormal labs, increased nutrient needs, and history of significant weight loss. Interventions included provide meals and snacks based on resident food preferences and physician orders initiated 03/07/22. Review of the dietary assessment note dated 04/21/26 at 3:09 P.M. revealed Resident #7 received a consistent carbohydrate diet with double portions of protein. 4. Review of the medical record for Resident #8 revealed an admission date of 02/11/26 with diagnoses including type two diabetes mellitus, dementia, major depressive disorder, anxiety, and hypertension. Review of the nutritional care plan, revised 02/18/26, revealed Resident #8 was at risk for altered nutritional status related to diabetes mellitus, anxiety, depression, dementia, obesity, therapeutic diet needs, and double portions per request. Interventions included provide meals and snacks based on resident food preferences and physician orders initiated 02/18/26. Review of the physician's orders for Resident #8 identified orders for a consistent carbohydrate diet with double entree portions effective 02/19/26. Review of the dietary assessment note dated 05/14/26 at 3:18 P.M. revealed Resident #8 received a regular diet with double portions per request. 5. Review of the medical record for Resident #14 revealed an admission date of 12/09/16 with diagnoses including type two diabetes mellitus, morbid obesity, iron deficiency anemia, vitamin D deficiency, anxiety, and hypertension. Review of the physician's orders for Resident #14 identified orders for regular diet with double entree portions effective 09/15/25. Review of the nutritional care plan, revised 01/07/26, revealed Resident #14 was at risk for altered nutritional status related to depression, type two diabetes mellitus, vitamin D deficiency, hyperlipidemia, anemia, anxiety, gastroesophageal reflux disease, history of significant weight changes, morbid obesity, and hospice care. Interventions included provide meals and snacks based on resident food preferences and physician orders initiated 10/03/23. Review of the dietary assessment note dated 04/08/26 at 3:59 P.M. revealed Resident #14 received a regular diet with double entree portions. 6. Review of the medical record for Resident #18 revealed an admission date of 03/18/22 with diagnoses including chronic obstructive pulmonary disease, morbid obesity, major depressive disorder, hyperlipidemia, anxiety, spinal stenosis, and gastroesophageal reflux disease. Review of the physician's orders for Resident #18 identified orders for a no added salt diet with double entree portions effective 08/05/25. Review of the nutritional care plan, revised 05/03/23, revealed Resident #18 was at risk for altered nutritional status related to spinal stenosis, depression, anxiety, hypertension, congestive heart failure, and gastroesophageal reflux disease. Interventions included provide meals and snacks based on resident food preferences and physician orders initiated 03/22/22. Review of the dietary assessment note dated 05/05/26 at 4:02 P.M. revealed Resident #18 received a no added salt diet with double portions. 7. Review of the medical record for Resident #28 revealed an admission date of 04/02/26 with diagnoses including severe protein calorie malnutrition, respiratory failure, dysphagia, hypertension, and tracheostomy status. Review of the physician's orders for Resident #28 identified orders for a regular diet with double portions effective 04/28/26. Review of the nutritional care plan, revised 05/18/26, revealed Resident #28 was at risk for altered nutritional status related to respiratory failure, dysphagia, hypertension, severe protein calorie malnutrition, underweight status, and requesting double portions at meals. Interventions included provide diet as ordered initiated 04/24/26. Review of the dietary assessment note dated 05/19/26 at 7:26 A.M. revealed weight gain was desirable for Resident #28 due to underweight status and his current diet order was appropriate for meeting nutritional needs. 8. Review of the medical record for Resident #37 revealed an admission date of 11/22/23 with diagnoses including type two diabetes mellitus, morbid obesity, anemia, major depressive disorder, and anxiety. Review of the physician's orders for Resident #37 identified orders for a regular diet with double entree portions effective 02/02/24. Review of the nutritional care plan, revised 01/28/26, revealed Resident #37 was at risk for altered nutritional status related to type two diabetes mellitus, depression, gastroesophageal reflux disease, morbid obesity, history of significant weight changes, and selective eating habits. Interventions included provide meals and snacks based on resident food preferences and physician orders initiated 11/27/23. Review of the dietary assessment note dated 04/28/26 at 6:06 P.M. revealed Resident #37 received a regular diet with regular texture and double entree portions. 9. Review of the medical record for Resident #38 revealed an admission date of 01/11/24 with diagnoses including type two diabetes mellitus, major depressive disorder, adult failure to thrive, hypertension, gastroesophageal reflux disease, and morbid obesity. Review of the physician's orders for Resident #38 identified orders for a consistent carbohydrate diet with double entree portions effective 01/10/24. Review of the nutritional care plan, revised 01/14/26, revealed Resident #38 was at risk for altered nutritional status related to depression, adult failure to thrive, hypertension, gastroesophageal reflux disease, morbid obesity, altered nutrition related lab values, history of weight loss, and increased nutrient needs. Interventions included provide meals and snacks based on resident food preferences and physician orders initiated 01/15/24. Review of the dietary assessment note dated 04/14/26 at 3:50 P.M. revealed Resident #38 received a consistent carbohydrate diet with double portions. 10. Review of the medical record for Resident #46 revealed an admission date of 07/16/25 with diagnoses including type two diabetes mellitus, end stage renal disease, morbid obesity, cancer, major depressive disorder, hypertension, and gastroesophageal reflux disease. Review of the nutritional care plan, revised 08/13/25, revealed Resident #46 was at risk for altered nutritional status related to type two diabetes mellitus, end stage renal disease on hemodialysis, cancer, major depression, hypertension, gastroesophageal reflux disease, and history of weight loss. Interventions included provide meals and snacks based on resident food preferences and physician orders initiated 07/22/25. Review of the physician's orders for Resident #46 identified orders for renal consistent carbohydrate diet with double portions of protein and vegetables effective 12/09/25. Review of the dietary assessment note dated 04/21/26 at 10:53 A.M. revealed Resident #46 was on a renal consistent carbohydrate diet with double portions of protein and vegetables. 11. Review of the medical record for Resident #47 revealed an admission date of 11/22/23 with diagnoses including type two diabetes mellitus, dementia, anxiety, morbid obesity, major depressive disorder, gastroesophageal reflux disease, and hypertension. Review of the physician's orders for Resident #47 identified orders for consistent carbohydrate diet with double protein portions effective 02/03/25. Review of the nutritional care plan, revised 02/11/26, revealed Resident #47 was at risk for altered nutritional status related to type two diabetes mellitus, hyperkalemia, lymphedema, morbid obesity, depression, gastroesophageal reflux disease, hypertension, and history of significant weight changes. Interventions included provide meals and snacks based on resident food preferences and physician orders initiated 11/27/23. Review of the dietary assessment note dated 03/18/26 at 8:33 A.M. revealed Resident #47 received a consistent carbohydrate diet with double protein portions. 12. Review of the medical record for Resident #50 revealed an admission date of 02/18/26 with diagnoses including chronic obstructive pulmonary disease, obesity, chronic respiratory failure, hyperlipidemia, atrial fibrillation, end stage renal disease, dependence on renal dialysis, and type two diabetes mellitus. Review of the physician's orders for Resident #50 identified orders for renal consistent carbohydrate diet with double protein portions effective 04/27/26. Review of the nutritional care plan, revised 04/28/26, revealed Resident #50 was at risk for altered nutritional status related to respiratory failure, obesity, hyperlipidemia, atrial fibrillation, end stage renal disease on hemodialysis, type two diabetes mellitus, gastroesophageal reflux disease, and increased nutrient needs. Interventions included provide meals and snacks based on resident food preferences and physician orders initiated 02/24/26. Review of the dietary assessment note dated 05/25/26 at 10:45 A.M. revealed Resident #50 was on a renal consistent carbohydrate diet with double protein portions. 13. Review of the medical record for Resident #56 revealed an admission date of 01/22/24 with diagnoses including vitamin D deficiency, major depressive disorder, hypertension, cardiomegaly, gastroesophageal reflux disease, and schizophrenia. Review of the physician's orders for Resident #56 identified orders for regular diet with double entree portions effective 01/22/24. Review of the nutritional care plan, revised 10/29/25, revealed Resident #56 was at risk for altered nutritional status related to vitamin D deficiency, depression, hypertension, cardiomegaly, gastroesophageal reflux disease, schizophrenia, and history of significant weight changes. Interventions included provide meals and snacks based on resident food preferences and physician orders initiated 01/28/24. Review of the dietary assessment note dated 04/22/26 at 1:46 P.M. revealed Resident #56 received a regular diet with double entree portions. 14. Review of the medical record for Resident #63 revealed an admission date of 02/17/25 with diagnoses including chronic kidney disease, severe protein calorie malnutrition, dependence on renal dialysis, crohn's disease, major depressive disorder, and dysphagia. Review of the physician's orders for Resident #63 identified orders for a no added salt diet with double entree portions effective 12/02/25. Review of the dietary assessment note dated 03/04/26 at 8:06 A.M. revealed Resident #63 was reliant on dialysis and received a no added salt diet with double entree portions. Review of the nutritional care plan, revised 03/04/26, revealed Resident #63 was at risk for altered nutritional status related to severe protein calorie malnutrition, crohn's disease, chronic kidney disease, underweight status, history of total parenteral nutrition use, history of significant weight loss, and refusing renal diet restrictions. Interventions included provide meals and snacks based on resident food preferences and physician orders initiated 02/18/25. 15. Review of the medical record for Resident #69 revealed an admission date of 01/08/24 with diagnoses including protein calorie malnutrition, chronic obstructive pulmonary disease, type two diabetes mellitus, iron deficiency anemia, vitamin D deficiency, major depressive disorder, and hypertension. Review of the physician's orders for Resident #69 identified orders for regular diet with double entree portions effective 11/08/25. Review of the nutritional care plan, revised 01/14/26, revealed Resident #69 was at risk for altered nutritional status related to protein calorie malnutrition, chronic obstructive pulmonary disease, type two diabetes mellitus, iron deficiency anemia, vitamin D deficiency, depression, hypertension, and history of weight loss. Interventions included provide meals and snacks based on resident food preferences and physician orders initiated 01/09/24. Review of the dietary assessment note dated 04/13/26 at 6:07 P.M. revealed Resident #69 received a regular diet with double entree portions. 16. Review of the medical record for Resident #74 revealed an admission date of 10/07/25 with diagnoses including alcohol dependence, major depressive disorder, gastroesophageal reflux disease, and hypertension. Review of the physician's orders for Resident #74 identified orders for a regular diet with double entree portions effective 10/07/25. Review of the nutritional care plan, revised 02/24/26, revealed Resident #74 was at risk for altered nutritional status related to multiple amputations, depression, gastroesophageal reflux disease, hypertension, alcohol use, and history of weight changes. Interventions included provide meals and snacks based on resident food preferences and physician orders initiated 10/13/25. 17. Review of the medical record for Resident #84 revealed an admission date of 07/24/18 with diagnoses including morbid obesity, schizophrenia, gastroesophageal reflux disease, dementia, major depressive disorder, hypertension, and dysphagia. Review of the physician's orders for Resident #84 identified orders for regular diet with double entree portions effective 08/05/24. Review of the dietary assessment note dated 04/13/26 at 7:13 P.M. revealed Resident #84 received a regular diet with double entree portions. Review of the nutritional care plan, revised 05/18/26, revealed Resident #84 was at risk for altered nutritional status related to schizophrenia, hyperlipidemia, depression, dysphagia, dementia, hypertension, morbid obesity, and significant weight loss. Interventions included provide meals and snacks based on resident food preferences and physician orders initiated 09/08/25. 18. Review of the medical record for Resident #89 revealed an admission date of 01/17/14 with diagnoses including dementia, vitamin D deficiency, chronic obstructive pulmonary disease, schizophrenia, major depressive disorder, hypertension, gastroesophageal reflux disease, and cognitive communication deficit. Review of the physician's orders for Resident #89 identified orders for regular diet with double entree portions effective 01/17/24. Review of the nutritional care plan, revised 10/22/25, revealed Resident #89 was at risk for altered nutritional status related to dementia, chronic obstructive pulmonary disease, depression, schizophrenia, hypertension, vitamin D deficiency, gastroesophageal reflux disease, and obesity. Interventions included provide meals and snacks based on resident food preferences and physician orders initiated 01/22/24. 19. Review of the medical record for Resident #90 revealed an admission date of 04/05/24 with diagnoses including dementia, hypothyroidism, obesity, hyperlipidemia, and altered mental status. Review of the physician's orders for Resident #90 identified orders for regular diet with double entree portions effective 01/22/25. Review of the nutritional care plan, revised 01/14/26, revealed Resident #90 was at risk for altered nutritional status related to hypothyroidism, hyperlipidemia, dementia, altered mental status, obesity, and history of significant weight changes. Interventions included provide meals and snacks based on resident food preferences and physician orders initiated 04/11/24. Review of the dietary assessment note dated 04/13/26 at 3:03 P.M. revealed Resident #90 received a regular diet with double portions. 20. Review of the medical record for Resident #94 revealed an admission date of 02/19/26 with diagnoses including anemia, alcohol abuse, cocaine abuse, rhabdomyolysis, and chronic kidney disease. Review of the physician's orders for Resident #94 identified an order for regular diet with double entree portions effective 02/19/26. Review of the dietary assessment note dated 05/20/26 at 10:59 A.M. revealed Resident #94 received a regular diet with double entree portions. Review of the nutritional care plan, revised 05/20/26, revealed Resident #94 was at risk for altered nutritional status related to chronic kidney disease, anemia, alcohol and drug abuse, and rhabdomyolysis. Interventions included provide meals and snacks based on resident food preferences and physician orders initiated 02/24/26. 21. Review of the medical record for Resident #95 revealed an admission date of 08/06/21 with diagnoses including hyperlipidemia, atrial fibrillation, gastroesophageal reflux disease, major depressive disorder, anemia, vitamin D deficiency, hypertension, and peripheral vascular disease. Review of the physician's orders for Resident #95 identified orders for a regular diet with double entree effective 08/06/21. Review of the nutritional care plan, revised 01/07/26, revealed Resident #95 was at risk for altered nutritional status related to atherosclerosis, anxiety, depression, vitamin D deficiency, peripheral vascular disease, anemia, hypertension, and history of significant weight changes. Interventions included provide meals and snacks based on resident food preferences and physician orders initiated 03/17/22. Review of the dietary assessment note dated 04/08/26 at 4:16 P.M. revealed Resident #95 received a regular diet with double entree portions. 22. Review of the medical record for Resident #106 revealed an admission date of 11/24/21 with diagnoses including parkinson's disease, protein calorie malnutrition, vitamin B12 deficiency anemia, vitamin D deficiency, major depression disorder, and hypertension. Review of the physician's orders for Resident #106 identified orders for a regular diet with double entree portions effective 06/25/23. Review of the nutritional care plan, revised 04/01/26, revealed Resident #106 was at risk for altered nutritional status related to protein calorie malnutrition, parkinson's disease, hyponatremia, hypotension, appetite stimulant use, and history of significant weight changes. Interventions included provide meals and snacks based on resident food preferences and physician orders initiated 11/30/21. Review of the dietary assessment note dated 04/01/26 at 3:52 P.M. revealed Resident #106 received a regular diet with double entree portions. The note indicated Resident #106 had non-significant weight loss at 90 days and 180 days and continued on an appetite stimulant and oral nutritional supplements. 23. Review of the medical record for Resident #108 revealed an admission date of 02/05/26 with diagnoses including end stage renal disease, dependence on renal dialysis, hemiplegia and hemiparesis following cerebral infarction, congestive heart failure, hypotension, and major depressive disorder. Review of the physician's orders for Resident #108 identified orders for a regular diet with double protein portions effective 05/05/26. Review of the dietary assessment note dated 05/13/26 at 4:44 P.M. revealed Resident #108 received a regular diet with double protein portions added since last nutritional review. Review of the nutritional care plan, revised 05/13/26, revealed Resident #108 was at risk for altered nutritional status related to end stage renal disease, cerebral infarction with hemiplegia, congestive heart failure, hyperlipidemia, overweight status, dialysis reliant, and abnormal labs. Interventions included provide meals and snacks based on resident food preferences and physician orders initiated 02/09/26. 24. Review of the medical record for Resident #119 revealed an admission date of 05/16/26 with diagnoses including type two diabetes mellitus, morbid obesity, chronic obstructive pulmonary disease, respiratory failure, dependence on ventilator, major depressive disorder, hypertension, gastroesophageal reflux disease, chronic kidney disease, and long term use of insulin. Review of the physician's orders for Resident #119 identified orders for a consistent carbohydrate diet with double entree portions effective 05/15/26. Review of the nutritional care plan, revised 05/18/26, revealed Resident #119 was at risk for altered nutritional status related to chronic obstructive pulmonary disease, morbid obesity, type two diabetes mellitus, depressive disorder, hyperlipidemia, hypertension, gastroesophageal reflux disease, tachycardia, and insomnia. Interventions included provide meals and snacks based on resident food preferences and physician orders initiated 05/18/26. Review of the dietary assessment note dated 05/18/26 at 10:20 A.M. revealed Resident #119 received a consistent carbohydrate diet. The note indicated double entree portions would be added to meals. On 5/19/26 at 12:16 P.M., an observation of the lunch meal tray line revealed [NAME] #405 used a #16 scoop to serve cheese raviolis and [NAME] #405 counted to ensure residents received 10 raviolis. Further observation of the trayline revealed residents with orders for double portions were served 15 raviolis. On 05/19/26 at 12:16 P.M., interview at the time of observation with [NAME] #405 said the production sheet indicated a #16 scoop was to be used to serve raviolis and a portion size was 10 raviolis. [NAME] #405 confirmed the residents with orders for double portions received 15 raviolis. On 05/19/26 at 12:35 P.M., review of the production sheet with Dietary Manager #384 revealed the #16 scoop was meant for the sauce on top of ravioli and a regular portion serving size was 10 raviolis. Dietary Manager #384 said the production sheet indicated a large portion was 12 raviolis. On 05/19/26 at 3:27 P.M., an interview with the Administrator stated the facility did not have anything like a diet formulary that indicated what each diet meant or define the parameters for each diet. On 05/19/26 at 4:45 P.M., an interview with Registered Dietitian (RD) #500 confirmed double portions meant residents should be served twice as much as the regular portion, not the large portion that was on the production sheets or one-and-a-half portions which is what was served at lunch. This deficiency represents non-compliance investigated under Complaint Number 2746747.

Based on record review, staff interviews and facility policy the facility failed to develop a comprehensive care plan related to Resident #105's dementia. This affected 1 resident (Resident #105) of 3 residents reviewed for dementia care. The facility census was 107.Findings include:Record review for Resident #105 revealed resident was admitted on [DATE] with diagnosis that included cerebral infraction, pyogenic arthritis, type two diabetes, insomnia, essential hypertension, hyperlipidemia, end stage renal disease, carpal tunnel syndrome and generalized anxiety disorder. Review of progress note dated 12/03/25 authored by Nurse Practitioner #506 revealed a diagnosis of vascular dementia. Review of hospital notes dated 12/07/25 revealed resident was admitted on [DATE] for altered mental status and diagnosed with vascular dementia with agitation. Review of Census information revealed resident was initially on the North Wing 1st Floor and was moved to the Memory Unit on 01/08/26.Review of Quarterly Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) was unable to be completed due to resident not being able to be understood. Review of Section 1-Active Diagnoses revealed resident was not marked as having Non-Alzheimer's Dementia. Review of Care Plan dated 05/15/26 revealed resident had aggressive behaviors, impaired cognitive function and impaired communication. Resident's care plan does not list vascular dementia or have interventions related to vascular dementia diagnosis. Confirmed above findings on 06/02/26 at 3:44 P.M. with Licensed Practical Nurse (LPN) Assistant Director of Nursing #375. Review of facility policy titled, Dementia Care dated September 2021 revealed the following: For the individual with confirmed dementia, the Inter-Disciplinary Team (IDT) will identify a resident-centered care plan to maximize remaining function and quality of life.

Based on record review, interview, and policy review, the facility failed to ensure nursing staff called report and sent associated laboratory reports to the emergency room (ER) when a resident sustained a change in condition and was transferred to the ER. This affected one resident (Resident #120) of six residents reviewed for change in condition. The facility census was 107.Findings include:Resident #120 was admitted to the facility on [DATE] with diagnoses including chronic obstructive pulmonary disease (COPD), chronic respiratory failure with hypoxia (low oxygen levels in the blood), diabetes, chronic kidney disease, high blood pressure, vascular dementia without behavioral disturbance, prostate cancer, a cerebral aneurysm, a gastrostomy (a surgically placed tube placed into the stomach to allow feeding through a tube), and neuromuscular dysfunction of the bladder. The resident was transferred to the ER on [DATE] and did not return to the facility.Review of the physician's orders revealed Resident #120's head of the bed must be elevated to at least 30 degrees to allow for easier breathing related to his diagnosis of COPD as well as the fact he received a tube feeding for nutrition and elevating the head of the bed assists in preventing aspiration of the tube feeding. Laboratory tests were drawn on 03/17/26 for a complete blood count, a complete metabolic profile, and blood cultures. Resident #120 also received five liters of oxygen via nasal cannula continuously. The resident had an order for an aerosol breathing treatment of Ipratropium-Albuterol 0.5-2.5 milligrams (mg) per three milliliters (ml) every four hours as need for shortness of breath or wheezing. The resident also had several wounds for which he received daily dressing changes.Review of the comprehensive quarterly Minimum Data Set (MDS) 3.0 assessment, dated 01/19/26, revealed Resident #120 was rarely/never understood, was dependent upon staff for all care, exhibited no indicators of pain, and received oxygen continuously.Review of the nursing progress notes revealed the Director of Nursing (DON) completed a Change of Condition template dated 03/15/26 at 5:04 P.M. Resident #120 was congested and had decreased lung sounds upon assessment. The change in condition started on 03/15/26 in the afternoon. The resident's blood pressure was 98/85 (normal blood pressure is less than 120/80), heart rate of 56 (normal is 60 to 100), respirations were 14 (normal is 12 to 20), his temperature was 101.1 degrees Fahrenheit (elevated), and his oxygen level was 100% on supplemental oxygen. The physician was notified on 03/15/26 at 4:00 P.M. and new orders were given to obtain a complete blood count, a basal metabolic panel, a urinalysis, and a chest x-ray. Resident #120's labs were drawn on 03/16/26 at 6:35 A.M. and were reported to the facility on [DATE] at 5:47 P.M. Resident #120's white blood cell count was high at 25.7 with the normal range being 4.5 to 10.8. His hemoglobin was low at 2.76 with the normal range being 14.0 to 18.0 and his hematocrit was low at 25.0 with the normal range 42.0 to 54.0. On 03/17/26 at 2:18 A.M., the laboratory results were reported to Nurse Practitioner (NP) #506 and additional lab work was ordered. On 03/17/26 at 5:51 A.M., Licensed Practical Nurse (LPN) #335 documented Resident #120 was to be transferred to the emergency room (ER). The resident was admitted with admitting diagnoses of septic arthritis in the left hip, osteomyelitis in the sacral wound, aspiration pneumonia, and a urinary tract infection. No documentation was noted regarding LPN #335 calling report to the ER regarding the resident's condition.Review of the ER medical record dated 03/17/26 revealed at 6:41 A.M. ER Physician (ER MD) #601 documented Resident #120 was sent from the nursing home because of abnormal labs but what labs were abnormal was not provided by the facility. No report from the nursing home was received.Interview with the DON on 06/01/26 at 3:05 P.M. revealed when someone is transferred to the ER due to a change of condition, she would expect the nurse to call report to the ER.Review of the facility's undated Change in a Resident's Condition or Status policy revealed the nurse will notify the physician/nurse practitioner for any significant change in a resident's condition or if there's a need to transfer the resident to the hospital. The nurse will record in the medical record information relative to changes in the resident's condition.Review of the facility's undated Documentation: Charting policy revealed the nurse was to document follow up action to nursing observations.

Based on observation and interview the facility failed to ensure medications were not left unattended at the bedside. This affected one Resident (#1), of three observed for unattended medications. The facility census was 107. Findings include:Review of Resident #1's medical records revealed an admission date of 03/04/26. Diagnoses included diabetes, chronic pain, depression, anxiety and hypertension (high blood pressure).Review of Resident #1's Minimum Data Set (MDS) assessment dated [DATE] revealed no cognition score due to Resident #1 was rarely understood. Resident #1 was dependent with toileting, bathing and personal hygiene and was non-ambulatory.Observation on 05/17/26 at 8:24 A.M. revealed a medication cup on Resident #1's bedside that contained two white tablets and one capsule. Resident #1 was sleeping during observation.Interview on 05/17/26 at 8:31 A.M. with Registered Nurse (RN) #369 confirmed the medication cup in Resident #1's room however she was unable to identify the medications inside the cup. RN #369 stated she had not administered Resident #1's medication yet and stated they may have been left from the evening shift. Interview with Resident #1 at time of observation revealed he was unaware the medication cup was on his bedside table and was unable to state when the medications may have been left. RN #369 proceeded to remove the cup of medications and stated medications were not to be left unattended in residents rooms and stated medications should be monitored to ensure residents consumed them.This deficiency represents non-compliance investigated under Complaint Number 2992281.

Based on record review, observations, interviews, and facility policy review, the facility failed to ensure wound care treatments for a pressure ulcer were administered per physician orders. This affected one resident (#100) of five reviewed for pressure ulcers. The facility census was 107. Findings Include:Record review for Resident #100 revealed an admission date of 12/18/18 with diagnosis that included Alzheimer's disease, type two diabetes, repeated falls, dementia, anxiety disorder, major depressive disorder, hyperlipidemia, disorientation, delusional disorder, essential hypertension and hypothyroidism.Review of the Skin Inspection assessment dated [DATE] revealed Resident #100 did not have any new skin issues. Review of the Wound Evaluation assessment authored by ADON #375 and dated 05/16/26 revealed the resident had a new pressure deep tissue injury (DTI) wound on her left heel that was 5.5 centimeters (cm) in length and 6 cm in width. Review of Resident #100's wound care note dated 05/20/26 authored by Wound Nurse Practitioner #503 revealed the wound size was 9 cm in length and 7.6 cm in width.Review of Resident #100 wound care note dated 05/27/26 authored by WNP #503 revealed the wound size was 9.5 cm in length and 6.2 cm in width. The wound status was listed as improved/healing deep purple non-blanchable discoloration noted, less purple discoloration, more epithelial today. Large intact blister without open areas or skin breakdown. Presentation consistent with a DTI. Plan is to pad and protect, and apply skin prep.Review of the most recent wound care orders dated 05/27/26 revealed the resident was ordered to cleanse left heel with normal saline (NS), pat dry, apply skin prep, cover with abdominal (ABD) gauze pads and loosely wrap with kerlix every dayshift and as needed (PRN). Review of Resident #100's wound care note dated 05/27/26 authored by WNP #503 revealed in addition to the above orders, that resident was to wear offloading boots.Observation and interview on 06/01/26 at 3:03 P.M. with ADON #375 revealed Resident #100 was sitting in a wheelchair in the dining room. ADON #375 brought the resident to her room to complete wound care. Resident #100 was observed with offloading boots on that were not properly attached to the residents' left heel. ADON #375 removed the residents bandage dated 05/31/26 which revealed kerlix was wrapped around residents left foot but there was no ABD bandage applied underneath the kerlix as ordered. Interview with ADON #375 at the time of the observation, confirmed the observations.Review of the undated facility policy titled, Pressure Ulcers/Skin Breakdown-Clinical Policy revealed the following under treatment/management: 1. The physician will authorize pertinent orders related to wound treatments, including wound cleansing and debridement approaches, dressings (occlusive, absorptive, etc.), and application of topical agents if indicated for type of skin alteration.This deficiency represents noncompliance investigated under Complaint Numbers 2980251.

Based on interview and record review, the facility failed to revise care plans to ensure accuracy of the treatment plan. This affected two residents (Residents #48 and #70) of 34 residents reviewed for care plans. The facility census was 107.Findings Include:1. Resident #70 was admitted to the facility on [DATE] with diagnoses including hemiplegia and hemiparesis following a stroke affecting the left nondominant side, diabetes, chronic obstructive pulmonary disease (COPD), end stage renal disease dependent on dialysis, dementia without behavioral disturbance, high blood pressure, chronic pain, major depressive disorder, anxiety disorder, and insomnia.Review of the annual comprehensive Minimum Data Set (MDS) 3.0 assessment, dated 03/25/26, revealed Resident #70 was cognitively intact, had no behaviors, was dependent on staff for all personal care other than eating, was frequently incontinent of urine, had no wounds, and received both oxygen therapy as well as dialysis.Review of Resident #70's care plans revealed the resident demonstrated behavioral disturbances as evidenced by refusing care, refusing ancillary services, noncompliance with diet and dietary recommendations, a history of accusatory behavior and false accusations, refuses showers, refuses continuous oxygen, refuses aerosols, refuses respiratory inhalers, refuses insulin, and refuses foley (a tube inserted into the bladder to drain urine) catheter securement devices. The care plan was last revised on 04/20/26. Review of the physician's orders revealed Resident #70 did not have an order for a foley catheter.Interview with MDS Coordinator Licensed Practical Nurse (LPN) #315 on 06/02/26 at 1:45 P.M. revealed it was not his responsibility to complete or update care plans for either dietary interventions or for behaviors. The responsible party for dietary interventions was the dietician and for behavior related interventions was the Social Services Director.Interview with Social Services Director (SSD) #348 on 06/02/26 at 1:50 P.M. confirmed Resident #70 no longer had a foley catheter and the care plan had not been revised to reflect her current care needs. SSD #348 stated she would revise the care plan.2. Resident #48 was admitted to the facility on [DATE] with diagnoses including a head injury, migraines, anemia, a diaphragmatic hernia, high blood pressure, insomnia, generalized anxiety disorder, and depression.Review of the annual comprehensive MDS 3.0 assessment, dated 03/03/26, revealed Resident #48 was cognitively intact, needed moderate assistance only for toileting and showering, had no difficulty chewing or swallowing, and was receiving occupational and physical therapy.Review of the most recent dietary note for Resident #48 by Dietary #610, dated 03/04/26, revealed the resident feeds himself with no reported issues chewing or swallowing.Review of Resident #48's altered nutritional care plan, last revised on 03/16/26, revealed no information regarding the resident's dietary preferences.Review of the physician's orders dated 04/15/26, Resident #48 was on a regular diet, regular texture, and thin liquids. His dietary preferences were for two hot dogs, mashed potatoes, a chef salad, and vegetables.Interview with Resident #48 on 05/17/26 at 12:45 P.M. revealed he hates the food the facility serves. The meat is so tough he is not able to chew it so he only ends up eating the vegetables. The resident said he has to order food to be delivered in order to have anything to eat.Interview with Registered Dietician (RD) #500 on 06/02/26 at 1:55 P.M. revealed she had only worked for the facility for a few weeks. RD #500 revealed she was unaware Resident #48 found the meat served was to hard for him to chew and was unaware of his food preferences. She confirmed his dietary preferences should be listed on his meal tickets. Resident #48 is due for a review and she will speak with him about his dietary preferences.

Based on interview, record review, and review of facility policy, the facility failed to ensure Total Parenteral Nutrition (TPN) (method of delivering complete nutrition directly into the blood stream through an intravenous (IV) line) was administered per physician orders. This affected one resident (#96) of two reviewed for TPN. The facility census was 107.Findings include:Review of Resident #96's medical records revealed an admission date of 04/24/26. Diagnoses included malnutrition, diverticulitis and encounter for aftercare surgery of the digestive system.Review of physician orders dated 04/25/26 through 05/03/26 revealed Resident #96 was ordered TPN formula to be infused over twelve hours in the evening.Review of the progress note dated 04/25/26 timed 6:17 P.M. authored by Licensed Practical Nurse (LPN) #428 revealed TPN formula was unavailable and pharmacy was notified. TPN was to be delivered to the facility on [DATE].Review of progress note dated 04/25/26 timed 6:19 P.M. authored by LPN #428 revealed the pharmacy had stated TPN was compounded by an outsourced company and was then sent to the pharmacy for delivery. The Nurse Practitioner was notified, and Resident #96 was to receive Lactated Ringers (IV fluids used to replace water and electrolyte losses).Review of progress note dated 04/27/26 timed 6:38 P.M authored by LPN #428 revealed TPN was unavailable, awaiting delivery from pharmacy. Review of the Medication Administration Record (MAR) for April 2026 revealed Resident #96's TPN had not been administered from 04/24/26 through 04/27/26, and an administration was documented as having been given on 04/28/26.Review of the care plan dated 05/05/26 revealed Resident #96 was at risk for altered nutritional status related to receiving TPN. Interventions included administer medication and/or vitamin/mineral supplements per physician orders and provide nutritional supplements as ordered. Interview on 05/26/26 at 7:58 A.M. with Resident #96 revealed there had been a few days she had not been given her TPN, however she was unable to recall dates and stated she was unaware why it had not been administered.Interview on 05/26/26 at 8:11 A.M. with Registered Nurse (RN) #391 revealed she had expressed concerns regarding Resident #96's TPN's having been unavailable when she had first admitted . RN #391 stated she had been made aware Resident #96's TPN had not been administered for several days after her admission and stated she had been told the facility was waiting on pharmacy to send it. RN #391 stated she had been aware Resident #96 had been given Lactated Ringers (LR) instead of TPN and stated the LR had not offered any type of nutrition but rather was for hydration. Interview on 05/26/26 at 12:28 P.M. with Director of Nursing (DON) confirmed Resident #96's TPN had not been available when she was admitted on [DATE]. The DON stated the pharmacy would not send TPN until the resident was physically at the facility. The DON stated the pharmacy had not sent the TPN for several days after Resident #96's admission and stated the physician had been made aware and had ordered LR. The DON further confirmed that the LR solution had not contained any nutritional contents and had been used for hydration.Review of the undated facility policy titled Parenteral Nutrition (PN) revealed PN is the feeding of nutritional products to a person intravenously, bypassing the usual process of eating and digestion.

Based on interview, record review, and policy review, the facility failed to ensure pharmacist recommendations were address by the medical provider. This affected one resident (Resident #105) of five residents reviewed for medication use. The facility census was 107. Findings Include: Resident #105 was admitted to the facility on [DATE] with diagnoses including a stroke, diabetes, high blood pressure, end stage renal disease dependent on dialysis, and generalized anxiety disorder. Review of the physician's orders for Resident #105 revealed she received dialysis every Monday, Wednesday, and Friday. On 02/23/26 an order was written for Ativan (an antianxiety medication) 1 milligram (mg), Benadryl (an antihistamine) 50 mg, and Haldol (an antipsychotic) 1 mg gel. The medication was also referred to as ABH gel. It was to be applied to the right wrist topically three times a day for agitation and combative behaviors related to anxiety. Review of the pharmacist recommendation dated 02/27/26 revealed Resident #105 was receiving ABH gel which contains Haldol 1 mg to be applied to the wrist three times a day for anxiety. The pharmacist noted the resident did not have an appropriate diagnosis to support the use of the medication. The pharmacist noted approved diagnoses for use included schizophrenia, schizoaffective disorder, delusional disorder, mood disorders, psychosis, brief psychotic disorder, dementing illnesses with associated behavioral symptoms, medical illnesses or delirium with manic or psychotic symptoms and/or treatment related psychosis or mania, and major depressive disorder. The pharmacist also requested information regarding behaviors for nursing to monitor. An unidentified person noted the behaviors to be monitored were agitation and combativeness. No date was provided when addressed, no signature was documented, and no diagnosis for the use of ABH gel was provided. Interview with the Director of Nursing (DON) on 05/20/26 at 10:10 A.M. revealed she thought the psychiatric nurse practitioner was probably the one who listed the behaviors to monitor. The DON confirmed there was no signature, no date the recommendation was addressed, and an appropriate diagnosis was not provided for continued use of the ABH gel. Review of the facility's Psychotropics policy, initiated September 2021, revealed the facility will use psychotropic medications appropriately working with the interdisciplinary team to ensure appropriate use, evaluation, and monitoring. The facility will make every effort to comply with state and federal regulations related to the use of psychopharmacological medications. No psychoactive medication will be utilized without a specific physician order or without a diagnoses specific condition. The resident will receive gradual dosage reduction and behavioral interventions, unless clinically contraindicated, in effort to discontinue the medication.

Based on interview and record review the facility failed to ensure Resident #24 and Resident #121 was free from significant medication error. This affected two residents (#24 and #121) of three reviewed for medications as physician ordered. The facility census was 107. Findings include: 1. Review of Resident #24's medical records revealed an admission date of 07/08/21. Diagnoses included high blood pressure and multiple sclerosis. Review of Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #24 had impaired cognition. Resident #24 was dependent with toileting, bathing and personal hygiene and incontinent of bowel and bladder. Review of care plan dated 04/24/26 revealed Resident #24 had impaired cardiovascular status related to hypertension (high blood pressure). Interventions included medications per physicians orders, monitor and report to physician signs/symptoms of hypertension that include headache, lethargy or confusion and monitor vital signs as needed. Review of change in condition progress note dated 03/25/26 timed 1:37 P.M. authored by Assistant Director of Nursing (ADON) #375 revealed Resident #96 had complaints of a headache and abnormal vital signs were taken and resident appeared more confused. Resident #96's blood pressure was recorded at 200/105 (normal range is 120/80). Change in condition further included Resident #96 had been given Tylenol for her complaints of a headache, blood pressure was obtained three times in different positions on different arms and all were within the same range, and resident appeared more confused than baseline. Hospice and Resident #96's representative was notified. Review of progress note dated 03/25/26 timed 4:06 P.M. authored by ADON #375 revealed hospice had given orders for Losartan (blood pressure medication) 50 milligrams (mg) every day. Upon reassessment Resident #24's blood pressure was 188/90. Review of Medication Administration Record (MAR) for March 2026 revealed Resident #24 had received Losartan on the morning of 03/26/26. Interview on 05/26/26 at 11:09 A.M. with ADON #375 revealed she had been made aware of Resident #24's elevated blood pressure reading on 03/25/26 and stated she had contacted hospice and had received the orders to administer Losartan. ADON #375 further confirmed Resident #24 had complaints of a headache and was more confused than her normal and stated the Losartan had not been administered until the following morning. ADON #375 stated the Losartan should have been administered on 03/24/26 when Resident #24 had been exhibiting the symptoms of high blood pressure. 2. Resident #121 was admitted to the facility on [DATE] and was transferred to the hospital on [DATE] and did not return to the facility. Admitting diagnoses included acute and chronic respiratory failure, morbid obesity, a peritoneal abscess, diverticulitis of the large intestine with perforation and an abscess with bleeding, high blood pressure, chronic kidney disease, hypothyroidism, lymphedema, and a colostomy (a surgically inserted opening to the bowels to allow for stool to drain from the body). Review of the physician's orders for Resident #121 revealed an order dated 01/22/25 for the resident to receive the antibiotic Daptomycin 1 gram (gm) intravenously (IV) every 24 hours for an elevated white blood cell count. Review of the Medication Administration Record (MAR) for January and February 2025 revealed the resident did not receive the medication on 01/30/25, 01/31/25, 02/09/25, and 02/10/25. The MAR indicated to see the nursing progress notes for a reason. Review of the nursing progress notes for January and February 2025 revealed no information as to why the resident did not receive her Daptomycin. Review of the physician's orders for Resident #121 revealed an order dated 01/22/25 for Meropenem (an antibiotic)1 gm IV every eight hours for an elevated white blood cell count. Review of the MAR for January and February 2025 revealed the resident did not receive the medication on 02/18/26 at 6:00 A.M. Review of the nursing progress notes for February 2025 revealed no information as to why the resident did not receive her Meropenem. Review of the physician's orders for Resident #121 revealed an order dated 01/22/25 for Mycamine (an antifungal medication) 100 mg IV every 24 hours for an elevated white blood cell count. Review of the MAR for January and February 2025 revealed the resident did not receive the medication on 02/09/25, 02/14/25, and 02/15/25. Review of the nursing progress notes for January and February 2025 revealed no information as to why the resident did not receive her Mycamine. Review of the Medicare 5 Day comprehensive Minimum Data Set (MDS) 3.0, dated 01/29/25, revealed Resident #121 was cognitively intact, was dependent for toileting, was admitted with a pressure ulcer, had surgical wounds, as well as moisture associated skin damage, and received IV medications, as well as occupational and physical therapy. Interview with the Director of Nursing (DON) on 06/02/26 at 10:08 A.M. revealed she did not know why Resident #121 did not receive her IV antibiotics and antifungal medication during the resident's stay. This deficiency represents non-compliance investigated under Complaint 2746747 and 2992281.

Based on record review, interview and facility policy the facility failed to ensure labs were completed as ordered. This affected one resident (Resident #29) of five residents reviewed for lab services. The facility census was 107.Findings include:Review of Resident #29 medical record revealed resident was admitted on [DATE] with diagnosis that included: encephalopathy, spastic hemiplegia, type 2 diabetes mellitus with diabetic neuropathy, dysphagia, major depressive disorder, anxiety, schizoaffective disorder, legal blindness, obstructive sleep apnea, cerebral palsy, essential hypertension, diastolic heart failure, mild intellectual disabilities and anemia. Review of Resident #29's physician orders revealed the resident had an order dated 12/18/24 for HgA1C labs every 3 months (December, March, June, September). There was no evidence of Resident #29's HgA1C for March 2026.Interview on 05/19/26 at 3:30 P.M. with Resident #29 during the Resident Council meeting revealed the resident was ordered labs quarterly to check her HgA1C. She said she had not had lab work completed recently. Interview on 05/19/26 at 5:23 P.M with Registered Nurse (RN) Assistant Director of Nursing (ADON) #419 confirmed Resident #29's A1C levels were not checked quarterly as ordered. Review of medical record revealed original order for lab work was discontinued on 05/19/26 and reordered on 05/19/26.This deficiency represents non-compliance investigated under Complaint Number 2746797.

Based on record review, observations, interviews, review of facility policy, and review of the Center for Disease Control and Prevention (CDC) guidelines for transmission-based precautions, the facility failed to follow infection control standards during wound care, which affected one resident (#9) out of five reviewed for pressure ulcers. In addition, the facility failed to ensure staff wore appropriate personal protective equipment (PPE) while providing care to residents on contact isolation, which affected one resident (#81) out of four identified by the facility as having orders for contact isolation. The facility census was 107. Findings include: 1. Review of the medical record for Resident #81 revealed an admission date of 10/06/25 with diagnoses including hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side, systemic lupus, aphasia, locked-in syndrome, gastrostomy status, and extended spectrum beta lactamase (ESBL) resistance. Review of the physician's orders for Resident #81 identified orders for contact precautions related to multi-drug resistant organism (MDRO) effective 03/29/26. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #81 had severely impaired cognitive skills for daily decision making and required dependence on staff for activities of daily living (ADLs). Review of the ADL care plan, revised 05/06/26, revealed Resident #81 had an ADL self-care deficit related to generalized weakness, impaired mobility, locked-in syndrome, and cerebrovascular accident. Interventions included assist with ADLs as needed initiated 10/07/25, report changes in ADL abilities to the nurse, physician, or therapy initiated 10/07/25, and two person assistance with bed mobility initiated 02/24/26. Review of the infection care plan, revised 05/17/26, revealed Resident #81 had the potential for infection related to a history of ESBL. Interventions included contact isolation precautions initiated 03/11/26, multi-drug resistant organism (MDRO) initiated 03/11/26, and to monitor and report to the physician any worsening signs or symptoms of MDRO infection initiated 03/11/26. Review of the medication administration record (MAR) for May 2026 revealed contact precautions were marked as administered every shift. On 05/17/26 at 10:53 A.M., an observation of Resident #81's room revealed a yellow sign on the door indicating to see the nurse before entering the room and there was a bin of personal protective equipment (PPE) outside the room. On 05/17/26 at 2:40 P.M., an observation of Resident #81's room revealed Registered Nurse (RN) #416 entered Resident #81's room without donning a gown or gloves prior to entering the room. Once in the room, RN #416 applied gloves to her hands and hooked up Resident #81's enteral feeding tube. After hooking up the enteral feeding tube, RN #416 took the gloves off and exited the room without performing hand hygiene. On 05/17/26 at 2:42 P.M., an interview with RN #416 confirmed the observation, stating she thought Resident #81 was only on enhanced barrier precautions for foley catheter care and it was not required for any other care. RN #416 said she did not know Resident #81 was ordered contact isolation. On 05/26/26 at 12:03 P.M., an observation of Resident #81's room revealed Certified Nursing Assistant (CNA) #327 entered Resident #81's room to answer the call light without applying PPE. CNA #327 repositioned Resident #81 in her chair and then entered the in-room bathroom to wash her hands. At 12:04 P.M., CNA #426 entered Resident #81's room without applying PPE and asked CNA #327 what the resident needed. While talking with CNA #327, CNA #426 adjusted the positioning of Resident #81's touch pad call light on her lap. On 05/26/26 at 12:04 P.M., a combined interview with CNA #327 and CNA #426 verified the observation, claiming Resident #81's contact isolation was removed. Neither CNA #327 or CNA #426 was able to state what the yellow sign on the door was for. At 12:05 P.M., CNA #327 asked Licensed Practical Nurse (LPN) #335 if Resident #81 was still on contact isolation and LPN #335 replied no and said it was discontinued. On 05/26/26 at 12:07 P.M., an interview with Assistant Director of Nursing (ADON) #375 verified Resident #81 still had active physician's orders for contact isolation related to MDRO. Review of the facility's policy titled Isolation - Initiating Transmission-Based Precaution, not dated, indicated transmission-based precautions (TBP) would be initiated when there was reason to believe a resident had a communicable infectious disease and types of TBP included contact precautions, droplet precautions, and airborne precautions. The policy indicated TBP would remain in effect until the attending physician or infection preventionist discontinued them, which would only occur after pertinent criteria for discontinuation was met. Review of the Center for Disease Control and Prevention (CDC) guidelines for transmission-based precautions, dated 04/03/24, revealed contact precautions would be used for patients with known or suspected infections that represent an increased risk for contact transmission. The guidelines indicated personal protective equipment would be used, including gloves and gown, for all interactions that may involve contact with the patient or the patient's environment. 2. Review of Resident #9's medical records revealed an admission date of 12/17/25 and a readmission date of 05/09/26. Diagnoses included difficulty walking, muscle weakness, dysphagia (difficulty swallowing) and need for personal care assistance. Review of Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #9 had no cognition score due to resident was rarely understood. Resident #9 was dependent with toileting, bathing, personal hygiene and transfers and was incontinent of bowel and bladder. Review of Resident #9's skin assessment dated [DATE] revealed an unstageable pressure ulcer to the right heel. Review of physician orders for May 2026 revealed to cleanse Resident #9's right heel with normal saline, apply calcium alginate (absorbent wound dressing), Medihoney (wound care ointment), cover with an absorbent dressing, and wrap with kerlix (gauze roll) every dayshift and as needed. Observation of wound care on 05/18/26 at 2:19 P.M. with Registered Nurse (RN) #350 revealed she had gathered Resident #9's wound care supplies and had placed them on the residents bed. RN #350 had obtained a pair of non wound care scissors from her pocket and had proceeded to remove Resident #9's kerlix dressing and had not disinfected the scissors prior to cutting the bandage. RN #350 had removed Resident #9's dressing and had cleansed the wound with normal saline and had then proceeded to place the calcium alginate on Resident #9's wound. RN #350 had then placed the absorbent dressing on Resident #9's right heel and wrapped the area in the kerlix. RN #350 did not change her gloves or perform hand hygiene after cleansing the wound and applying the new dressing. Interview with RN #350 after completion of wound care on 05/18/26 at 2:56 P.M. confirmed the observations and RN #350 stated she should have disinfected the scissors prior to removing the bandage, should not have placed the wound care supplies on the residents bed and should have removed her gloves and performed hand hygiene after cleaning the wound and before applying a new dressing. This deficiency represents non-compliance investigated under Complaint 2992281.

Based on record review, observations, staff interviews, and a review of facility policies, the facility failed to ensure that chemicals and razors were secured and inaccessible to residents. This affected 12 residents (Residents #11, #16, #27, #30, #60, #62, #64, #75, #82, #84, #91, #105, ) and had the potential to affect all 22 residents (Residents #11, #16, #19, #23, #27, #30, #43, #58, #60, #62, #64, #66, #75, #76, #82,# 84, #89, #90, #91, #100, #103, and #105) of 23 residents on the locked memory care unit excluding Resident #12 who was bedbound. The facility census was 107.Findings include: All of the following observations and interviews occurred on 05/19/26 between 10:16 A.M. and 10:42 A.M.Observation and interview with Certified Nursing Assistant (CNA) #403 revealed two disposable razors in Resident #105's bathroom. CNA #403 confirmed the finding. During this same observation period, unsecured shower products were noted in resident rooms for Residents #30, #91, #75, #60, #64, #11, #82, #62, #16, and #84. CNA #403 stated that shower products were either left in resident rooms or placed in unlocked drawers and reported she had not received training on where these products should be stored.During an interview on 5/19/2026 at 10:24 A.M., Licensed Practical Nurse (LPN) #352 stated chemicals and shower products should be locked in the shower room.As observations continued, Resident #27's room was found with the door closed. After knocking, Assistant Director of Nursing (ADON) #375 opened the door while holding multiple disposable razors. Several staff members inside were observed hurriedly emptying drawers and collecting shower supplies and other items into large clear plastic bags.Observation of the unlocked shower room revealed a spray bottle of Bluff Floor Restorer, a disposable razor, an electric razor by the sink, and an overflowing sharps container unattached from its holder and filled with disposable razors. A plastic organizer in front of the shower contained additional shower supplies and disposable razors.Observation of the unlocked linen closet showed staff had placed shower supplies and razors collected from resident rooms into the closet, and multiple razors were observed in unlocked drawers.During an interview and observation on 05/19/26 at 10:56 A.M., ADON #375 confirmed the presence of unsecured razors, the Bluff Floor Restorer spray bottle, and the overflowing sharps container in the shower room. ADON #375 confirmed these items should not be left unlocked. She confirmed there were 23 residents (Residents #11, #12, #16, #19, #23, #27, #30, #43, #58, #60, #62, #64, #66, #75, #76, #82, #84, #89, #90, #91, #100, #103, and #105) and Resident #12 was bedbound. During an interview on 05/19/26 at 11:35 A.M., the Administrator reported the facility did not have a specific policy regarding soaps and bath products in resident rooms. The Administrator stated there were no current residents on the locked unit with ingestion behaviors but confirmed razors and chemical sprays should not be unsecured. She was unsure why staff had begun collecting items into trash bags.Observation and interview on 05/19/26 at 6:22 P.M. on the memory care unit revealed the linen closet and shower room remained unlocked. Registered Nurse (RN) #365 confirmed this finding and then locked both rooms.During an interview on 05/20/26 at 4:54 P.M., ADON #375 stated she would ensure shower supplies were secured and noted that when she first began working as a CNA, these items were always locked.Review of the facility policy titled Hazardous Materials, Areas, Devices and Equipment, dated September 2021, stated that all hazardous areas, devices, and equipment must be identified and addressed to ensure resident safety and mitigate accident hazards. The policy defined hazards as anything with the potential to cause injury or illness and stated that any such item accessible to a vulnerable resident is considered hazardous. Resident vulnerability is based on functional status, medical conditions, cognitive abilities, mood, and treatments.

Based on record review, observations, interviews, and a review of facility policies, the facility failed to provide required activities of daily living (ADL) care by not removing facial hair for one resident (Resident #29) and by not ensuring showers were provided for another resident (Resident #20). This deficiency affected two residents (Residents #20 and #29) who were dependent on staff for care, out of four residents reviewed for ADL services. The facility census was 107.Findings include: 1. Review of the medical record for Resident #29 revealed an admission date of 04/08/24 with diagnoses including encephalopathy, spastic hemiplegia, type II diabetes mellitus with diabetic neuropathy, dysphagia, major depressive disorder, anxiety, schizoaffective disorder, legal blindness, obstructive sleep apnea, cerebral palsy, essential hypertension, diastolic heart failure, mild intellectual disabilities, and anemia. Review of Resident's #29 annual Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed the resident had a Brief Interview for Mental Status (BIMS) score of 14/15, indicating the resident was cognitively intact. Review of functional abilities revealed Resident #29 required set-up assistance for eating and oral hygiene and substantial assistance with upper and lower body dressing and putting on footwear. Resident #29 was dependent on staff for toileting, showering/bathing, and personal hygiene which included combing hair, shaving, applying makeup, washing/drying face and hands. Review of Resident's #29 Care Plan dated 05/14/26 revealed the resident had an ADL self-care performance deficit related to anxiety, congestive heart failure (CHF), depression, history of falls, neuropathy, pain, psychoactive drug use, and seizures. Interventions included assisting with ADL (i.e.: dressing, grooming, personal hygiene, locomotion, oral care, etc.) as needed. During an interview and observation on 05/19/26 at 5:20 P.M., Resident #29 had overgrown chin hair on her face. When asked if she would like her chin hair shaved, she said yes. This was verified during an interview at the time of the observation with Registered Nurse (RN) Assistant Director of Nursing (ADON) #419 who said she would get a certified nursing assistant (CNA) to shave the resident. Review of the undated facility policy titled, Activities of Daily Living (ADL) stated residents will be provided with the care, treatment and services as appropriate to maintain or improve their ability to carry out ADL. Residents who were unable to carry out ADL independently will receive the services necessary to maintain good nutrition, grooming and personal and oral hygiene. 2. Review of Resident #20's medical record revealed an admission date of 09/11/25 with diagnoses including dysphagia (difficulty swallowing), tracheostomy, and gastrostomy (feeding tube). Review of the care plan dated 03/18/26 revealed Resident #20 had ADL deficits. Interventions included assistance with bathing, toileting and transfers via a mechanical lift. Review of the MDS 3.0 assessment dated [DATE] revealed Resident #20 had no cognition score due to resident being rarely understood. Resident #20 was dependent on staff with toileting, bathing and personal hygiene and was incontinent of bowel and bladder. Review of the medical record documentation from April and May 2026 for Resident #20 revealed no documented evidence of bathing. Observation on 05/17/26 at 11:33 A.M. revealed Resident #20 was in bed, and her hair appeared to be greasy, matted and multiple large areas of crusted white debris. At time of observation, interview with Licensed Practical Nurse (LPN) #390 confirmed Resident #20's appearance and stated she was unsure when she had last received a shower or bed bath. Resident #20 was not able to be interviewed due to cognitive impairment. Observation on 05/26/26 at 2:52 P.M. revealed Resident #20's appearance was same as the previous observation on 05/1726. Interview with CNA #355 at the time of the observation verified Resident #20's appearance. She stated she was unsure when Resident #20 had last received a shower or bed bath. During an interview on 05/27/26 at 8:30 A.M., RN #391 revealed she had assisted staff on the evening of 05/26/26 with giving Resident #20 a shower. Observation of Resident #20 at time of interview revealed Resident #20's hair appeared to be clean, unmatted, and without debris. Review of the undated facility policy titled Activities of Daily Living (ADL), stated appropriate care and services will be provided to residents who are unable to care out ADL independently that included hygiene, bathing, and grooming. This deficiency represents non-compliance investigated under Complaint Numbers 2992281 and 2746797.

Based on closed medical record review, review of video/audio camera recordings, review of a fire department cardiopulmonary resuscitation (CPR) report, review of a facility Self-Reported Incident (SRI), review of the facility policy for call lights, review of the facility policy for resident condition change, review of the redcross.org Adult Cardiopulmonary Resuscitation (CPR) Steps reference, and interviews, the facility failed to timely and appropriately respond to Resident #118's calls for assistance and failed to provide adequate assistance/intervention as the resident was experiencing a change in condition/respiratory distress. This resulted in Immediate Jeopardy and serious life-threatening harm/subsequently death beginning on [DATE] at 6:59 A.M. when staff failed to provide timely and appropriate care after Resident #118 pushed her call light and began yelling out for the nurse. Video/audio recording of the resident on [DATE] between 7:13 A.M. and 10:30 A.M. demonstrated a continued lack of adequate and necessary care by multiple staff. This included at 7:13 A.M. when an unidentified staff member entered Resident #118's room, turned off the call light and turned and exited the room stating to Resident #118, You will be fine (Resident #118's name), as she walked away. As the unidentified staff member was walking away, Resident #118 stated she had to pull for air and the unidentified staff member continued to exit the room without addressing Resident #118's concern. At 7:33 A.M. State tested Nurse Aide (STNA) #274 entered Resident #118's room, shut off the call light and said he had to get report then he would be back to help her. There was no further video recording until 9:14 A.M. when Resident #118 began pushing her call light again. (Video footage is recorded following the movement detected by the camera). Between 9:14 A.M. and 9:57 A.M. Resident #118 pushed her call light an additional 11 times and yelled out multiple times for help, with no response from staff. At 9:57 A.M. STNA #274 entered Resident #118's room and asked, What is going on? Resident #118 stated she could not breathe and asked for help sitting up. STNA #274 stated the resident could not sit on the edge of the bed as requested and exited the room. At 9:58 A.M. Licensed Practical Nurse (LPN) #221 and STNA #274 entered Resident #118's room, Resident #118 said she was choking. LPN #221 attempted to suction Resident #118's oral secretions but did not complete an assessment, including vital signs of Resident #118. At 10:01 A.M. LPN #221 called emergency medical services (EMS) via 911. At 10:03 A.M. Resident #118 went unresponsive and at 10:06 A.M. chest compressions were initiated while Resident #118 was lying on an inflated low air loss mattress. A backboard was not used. At 10:08 A.M. an automated external defibrillator (AED) (device that analyzes heart rhythm and delivers shock, if needed, to restore normal heath rhythm) was brought into Resident #118's. However, the AED battery was low and there were no pads to connect the device to Resident #118 to enable detection of heart rhythm and deliver a shock if needed. At 10:10 A.M. staff indicated there was no backboard under the resident, a backboard was not provided for increased effectiveness of CPR. At 10:12 A.M. Emergency Medical Services (EMS) personnel took over care of the resident (a backboard was placed under the resident at that time). Resident #118 was unable to be resuscitated and was pronounced deceased at 10:30 A.M. This affected one resident (#118) of two residents reviewed for death. The facility census was 112. On [DATE] at 12:05 P.M. the Administrator and Administrator in Training (AIT) #401 were notified Immediate Jeopardy began on [DATE] when the facility failed to provide adequate, necessary care and treatment and timely intervention to Resident #118, who was a full code status, for an acute change in condition resulting in Resident #118's death. The Immediate Jeopardy was removed on [DATE] when the facility implemented the following corrective actions. On [DATE] after Resident #118 expired, the identified AED machine was taken out of service and removed from the facility (at 12:00 P.M.) On [DATE] LPN #221 completed Cardiopulmonary Resuscitation (CPR) training and provided the facility a current CPR certification card. On [DATE] the Director of Nursing (DON) reviewed all current resident charts to ensure residents experiencing a change in condition were assessed immediately by the licensed nurse, CPR was performed using a back board appropriately if needed, and the call lights were answered timely. On [DATE] the DON completed training for all facility licensed nurses which included residents with a change in condition were fully assessed and follow up was completed. Additional training was completed for licensed nursing staff to ensure a backboard was used when performing CPR, and that per the facility policy was followed and that the AED was not to be used. Licensed nurses were also educated to check and assure a back board was available for use on the facility crash carts. On [DATE] the DON completed training for all nursing staff to ensure resident call lights were answered timely and care was provided as necessary. On [DATE] the facility held mock CPR code drills during the 7:00 A.M. to 3:00 P.M., 3:00 P.M. to 11:00 P.M., and 11:00 P.M. to 7:00 A.M. shifts for licensed nurses to ensure appropriate procedures were followed. On [DATE] the DON trained Human Resource (HR) #262 to ensure upon hire and monthly thereafter, all licensed nurses had an active CPR card. An audit of licensed nurses was also completed to ensure all CPR cards were current. The facility implemented a plan for weekly audits to be completed for four weeks by the HR #262 to ensure active CPR cards were in personnel files for all licensed nurses. The facility implemented a plan for weekly audits for four weeks by the DON or Assistant Director of Nursing (ADON) to monitor all changes in resident condition and to ensure call lights were answered timely, care was provided as necessary, a full assessment was completed by the licensed nurse, an AED machine was not used, and a backboard was used when CPR was performed. All audits will be submitted to the Quality Assurance (QA) committee weekly for trending, tracking and recommendations. Interviews on [DATE] between 11:30 A.M. and 12:06 P.M. with STNA #204, #233, #271, #232, LPN #235, #311, and #236 confirmed staff were educated by the DON. LPN #311 confirmed she had a mock code completed on [DATE]. Although the Immediate Jeopardy was removed on [DATE], the facility remained out of compliance at Severity Level 2 (no actual harm with potential for more than minimal harm that is not Immediate Jeopardy) as the facility was in the process of implementing their corrective action plan and monitoring to ensure on-going compliance. Findings include: Review of Resident #118's closed medical record revealed an admitted [DATE] and a discharge date of [DATE]. Resident #118 had diagnoses including dysphagia (difficulty swallowing), muscle weakness, hemiplegia and hemiparesis following cerebral infarction affecting right dominant side, chronic congestive heart failure, hypertension, and obstructive sleep apnea. Record review of the care plan for Resident #118 dated [DATE] revealed the resident's advance directives were for a full code status. Record review revealed the resident also had a care plan for impaired respiratory status related to asthma, sleep apnea, and chronic respiratory failure. Interventions included administering medications as ordered, assist with activities of daily living, encourage rest periods, and elevate the head of the bed. Review of a Minimum Data Set (MDS) 3.0 assessment, dated [DATE] revealed Resident #118 was rarely or never understood, required extensive assistance from two staff for bed mobility, transfers, locomotion, dressing, toilet use, personal hygiene, and total dependence (from staff) for eating. The MDS also reflected the resident had medically complex conditions which included cancer, heart failure, and renal failure. Review of Resident #118's physician orders revealed an order dated [DATE] indicating Resident #118 was to have nothing by mouth (NPO). An order dated [DATE] indicated Resident #118 was a full code. Review of Resident #18's (re-admission) Admission Evaluation dated [DATE] timed 12:03 A.M. revealed on [DATE] at 12:00 A.M. Resident #118 was admitted from the hospital, alert and oriented to person and place, on oxygen therapy, and was a full code status. Review of a nurse's note, dated [DATE] timed 12:00 P.M. and completed by LPN #221 revealed during morning medication pass Resident #118 verbalized she felt short of breath and felt that she needed to go to the emergency room . The resident's oxygen saturation level was documented to be 89 % (normal ,d+[DATE]%), blood pressure (BP) was ,d+[DATE] and pulse 62 beats per minute (bpm). The note indicated Resident #118 coded after vital signs with lack of respiration and lack of heartbeat. LPN #221 documented in the note she initiated a Code Blue and EMS was activated. In house staff-initiated CPR, EMS arrived and took over CPR. EMS was in contact with the emergency room physician. Code continued for 20 more minutes. Resident #118 continued to have lack of vitals and was asystole (no heart rhythm) on the heart monitor. The physician discontinued CPR and the resident was pronounced deceased at 10:30 A.M. Family was notified and came in to view the body and staff performed postmortem care. The funeral home was contacted at 11:15 A.M. The note revealed the Nurse Practitioner was also notified. The resident's family provided video/audio footage recording taken from Resident #118's room via a video/audio monitoring camera that was placed in the room that the family had access to and could view dated [DATE] which revealed the following: At 6:59 A.M., Resident #118 pushed her call light and yelled out Nurse. Resident #118 attempted to clear her throat and again yelled out while continuing to push her call light with no response. At 7:13 A.M., an unidentified female staff member entered Resident #118's room, walked directly over to the call light switch located on the wall. Resident #118 spoke to the staff member, the staff did not stop walking, shut off the call light switch on the wall, turned, and as she was walking away from Resident #118, she told her she was fine. Resident #118 stated, I have to pull for air. The staff member continued to walk away and exited the room. At 7:33 A.M., Resident #118 again pushed her call light. STNA #274 entered the room, shut off the call light switch located on the wall and approached Resident #118 asking if she needed something. Resident #118 requested to be pulled up in bed. STNA #274 said he had to get report first then he would come and take care of her, he would be right back. There was no further video recording until 9:14 A.M. when Resident #118 began pushing her call light again. At 9:14 A.M., Resident #118 pushed her call light, coughing and clearing her throat. At 9:16 A.M., Resident #118 pushed her call light with no response from staff. At 9:28 A.M., Resident #118 pushed her call light with no response from staff. At 9:31 A.M., Resident #118 pushed her call light with no response from staff. At 9:43 A.M., Resident #118 pushed her call light with no response from staff. At 9:47 A.M., Resident #118 pushed her call light with no response from staff. Resident #118 began yelling for help. At 9:48 A.M., Resident #118 pushed her call light with no response from staff. Resident #118 was attempting to clear her airway. At 9:49 A.M., Resident #118 pushed her call light with no response from staff. At 9:52 A.M., Resident #118 pushed her call light with no response from staff. Resident #118 was yelling out, Nurse I am sick Resident #118 picked up her phone and attempted to make a phone call unsuccessfully, calling out, Nurse, help. At 9:54 A.M., Resident #118 was observed dropping the phone and heard continuing to call nurse, help. At 9:55 A.M., Resident #118 continued to attempt to use the phone unsuccessfully and continued to yell out repeatedly, Nurse help me, help me, help me while pushing her call light repeatedly without a response. At 9:57 A.M., STNA #274 entered and asked, What's going on? Resident #118 stated, I can't breathe. Resident #118 requested STNA #274 to help her sit up. STNA #274 stated the resident could not sit up on the side of the bed, she had to stay in bed. Resident #118 requested to go to the hospital. At this point Resident #118 was struggling to breathe while making grunting sounds with each breath. Resident #274 left the room at 9:58:23. Resident #118 was observed to continue struggling and called, Nurse. At 9:58 A.M., LPN #221 entered the room with STNA #274. Resident #118, while struggling to speak stated again help me, I am choking. LPN #221 asked what's the matter, are you having a hard time. Resident #118 repeated, I am choking. LPN #221 asked STNA #274 is that thing hooked up (referring to the suction machine). LPN #221 put the tip of the tonsil tip suction device in Resident #118's mouth briefly. Resident #118 indicated there was nothing there. LPN #221 asked Resident #118 if she needed some water. LPN #221 moved from the camera view and stated, Let me see if I can get her some water then asked, Is she NPO? STNA #274 confirmed Resident #118 was NPO. At 10:01 A.M., LPN #221 placed a call on a cell phone while in Resident #118's room to 911 and said Resident #118 was having trouble breathing. A female voice could be heard coming from the video/audio recording camera asking, What's happening? (the voice was confirmed to be Resident #118's daughter). LPN #221 stated Resident #118 was having a hard time, she called 911, the squad was on the way, she could not give her anything to drink because she was NPO, so she was going to have to send her (the resident) out. At 10:03 A.M , another unidentified staff member entered the resident's room. Resident #118 had hand movements toward her chest but offered no response to staff. At 10:03 A.M., Human Resource (HR) #262 (manager on duty) was observed to enter the resident's room and applied gloves. Resident #118 was unresponsive. HR #262 completed a sternal rub and was observed to check the resident for a radial pulse. At 10:04 A.M., LPN #221 placed an automatic wrist blood pressure cuff on Resident #118's left wrist. At 10:05 A.M., STNA #274 was observed attempting to obtain a response from Resident #118 who was unresponsive. No other staff were observed in the room. At 10:06 A.M., Resident #118's bed was positioned flat and manual administration of an ambu bag (for ventilation) was initiated per HR #262. At 10:06:10 A.M., LPN #221 motioned to staff to cover the camera in the resident's room. STNA #204 and #274 were observed to stand in front of the video camera at this time. At 10:06:30 A.M., chest compressions were initiated. No backboard was placed under Resident #118 who was lying on a low air loss mattress. Two staff members were noted to be covering the camera view with their backsides. A crash cart was partially in view. Counting of compressions could be heard. At 10:08:52 A.M., LPN #221 brought an AED into the room and placed it at the foot of Resident #118's bed. At 10:08:56 A.M., audible from the AED could be heard; Battery Low, Check Pads Several staff asked, Where are the pads? The AED repeated, Check Pads as staff looked through the crash cart drawers, pads were not located. Chest compressions continued. The camera view was intermittently blocked. At 10:10:03 A.M. a male voice was heard asking, Where is the back board? A female voice stated, There should be one on there. Three staff members (STNA #274, LPN #221, and LPN #207) went to the crash cart and confirmed a backboard was not on the crash cart nor in the room. No backboard was brought to the resident's room. At 10:10:05 A.M., Environmental Services #239 was providing rescue breaths to Resident #118 using an ambu bag while LPN #280 was doing chest compressions. The low air loss mattress was inflated and Resident #118's body was moving up and down on the mattress during compressions. At 10:11:08 A.M., EMS arrived. At 10:11:32 A.M., LPN #287 took over chest compressions. Environmental Services #239 continued providing respirations/ventilation with the ambu bag. At 10:11:56 A.M., EMS staff can be heard saying they responded for shortness of breath. The team was grabbing what they needed (getting supplies needed to care for a resident requiring cardiopulmonary resuscitation) At 10:12:13 A.M., LPN #221 relieved LPN #287 and continued chest compressions. At 10:12:50 A.M. EMS took over and continued resuscitation efforts through 10:30:57 A.M. Review of the local Fire Department Treatment/CPR report dated [DATE] on page three revealed Resident #118's date and time of death was [DATE] at 10:31 A.M. pronounced per Physician #501. Interview on [DATE] at 3:23 P.M. with HR #262 revealed he was the Manager on Duty on [DATE]. When he walked in the building at 10:00 A.M. he heard a Code Blue. HR #262 was informed Resident #118 was having trouble breathing and went unresponsive. HR #262 stated he was an emergency medical technician (EMT) prior to his employment with the facility in HR and when he entered Resident #118's room, the resident was having agonal (gasping) breathing. HR #262 stated he did a sternal rub, checked for alertness, used a pen to check capillary refill, then tried to obtain a pulse and could not find one. LPN #280 asked for an AED. LPN #221 retrieved the AED which was kept by the receptionist's office on the wall. LPN #280 opened the AED; it said low power and staff could not find the pads. Once the fire department arrived, they brought a [NAME] (provides mechanical chest compressions) device and a cardiac monitor. HR #262 was unaware of the low air loss mattress (on the resident's bed), and the ability to deflate the mattress. HR #262 confirmed the backboard was not in place while staff did CPR on Resident #118. HR #262 revealed the AED was tossed out the next day, the battery was not good enough. The cost of the battery was almost as much as the AED and the reason why the facility had not replaced the battery. On [DATE] at 4:24 P.M. a telephone interview with STNA #274 revealed Resident #118 frequently pushed her call light on (sometimes about 50 times per eight-hour shift) and the majority of the time it was to request to be suctioned. The STNA revealed the resident often needed suctioned (maybe about 10 times per shift) because she had a lot of mucous. Review of employee files and interview with HR #262 on [DATE] at 4:50 P.M. revealed LPN #221 (the nurse assigned to care for Resident #118 on [DATE]) had a hire date of [DATE]. The CPR card on file for LPN #221 was dated [DATE] (following the incident with Resident #118 on [DATE]). There was no evidence the facility had checked or verified LPN #221's CPR certification status at the time of hire. On [DATE] at 5:17 P.M. telephone interview with LPN #221 revealed (on [DATE]) she was outside of Resident #118's door when Resident #118 said nurse can you help me (unable to recall time) but stated this was the first time that morning Resident #118 had called out. LPN #221 stated she went into the room and asked Resident #118 what she needed. Resident #118 said she needed help, she was having a little trouble, but she did not say what kind of trouble. LPN #221 stated she sat Resident #118 up to get her vital signs. Resident #118 had oxygen on, and LPN #221 obtained her vital signs. LPN #118 stated as soon as she got the vital signs, Resident #118 went unresponsive, and LPN #221 called a Code Blue. LPN #221 said STNA #274 was with her, and CPR was initiated. LPN #221 said all equipment was available on the crash cart and 911 was called by another staff member. The squad showed up and took over. LPN #221 said when she assessed Resident #118 that morning (time not provided) she was fine, there were no concerns or complaints expressed by Resident #118. LPN #221 did not recall if there was a suction machine in Resident #118's room but said she did check Resident #118's mouth and there was nothing in her mouth. LPN #221 said there was no AED in Resident #118's room during CPR. On [DATE] at 5:37 P.M. telephone interview with Resident #118's granddaughter revealed the family had placed a camera in the resident's room (date note provided) after the resident reported concerns with care/abuse. The camera was motion detected, the facility was aware of the camera and Resident #118's children would often speak with staff through the camera while the staff would provide care to Resident #118. The granddaughter stated she watched the video from [DATE] and documented the concerns she had from the video, including the resident asking for help and the staff not assisting her, the resident yelling for help and no one coming to check on her, the resident ringing her call light numerous times- attempting to reach staff as she was having trouble breathing and using her phone in an attempt to get help but being unsuccessful. The granddaughter also expressed concerns with the suction machine not working when her grandmother asked to be suctioned and the AED not in working order when it was brought into Resident #118's room for use. On [DATE] from 6:16 P.M. to 7:00 P.M. the video footage (with sound) was reviewed with the Administrator, Administrator in Training #401 and the Director of Nursing. The video footage reviewed began on [DATE] at 6:17 A.M. and continued through the resident's death. On [DATE] at 2:55 P.M. during a follow-up interview and observation of the video footage from [DATE] with LPN #221 (with the Administrator and Administer in Training (AIT) #401 present), LPN #221 revealed she did suction Resident #118 stating, you can see she grabbed it; she likes doing it herself. LPN #221 said the suction machine was working, Resident #118 said there was nothing there (in her mouth). LPN #221 said if a resident was NPO they could still have sips of water to wet the tongue. When asked when Resident #118's vital signs were taken or if a backboard was used during CPR, LPN #221 stated, Well you got the video, you can see what happened. (verifying LPN #221 did not assess the resident's vitals as documented and a backboard was not used during CPR for Resident #118). Interview on [DATE] at 5:08 P.M. with Medical Director/Primary Care Physician #348 revealed expectations were for staff to answer a resident's call light within ,d+[DATE] minutes. If a resident was calling out - staff should respond immediately. When there was a medical concern, the nurse should get vital signs first, assess the resident, then call the physician. If CPR was required and the resident was in bed, a backboard should be used. On [DATE] at 3:39 P.M. a telephone interview with the DON confirmed the facility had a non-functioning AED. It had been decided by the company the AED would not be used and the batteries and pads would not be replaced. However, the AED was never removed from its original location. The DON stated a staff member must have seen the AED and grabbed it mistakenly. The AED had since been removed. On [DATE] at 9:54 A.M. during a telephone interview with the Administrator regarding viewing the video from [DATE] and the unidentified staff member walking into the room, turning off the call light and not addressing Resident #118's needs, he stated he was unable to hear what the unidentified staff member said to the resident after the call light was turned off and the staff member exited the room but he was looking in to it and would report the information in a facility self-reported incident to the State agency. Review of the facility Self-Reported Incident (SRI), tracking number 240091, created on [DATE] with a date of discovery noted to be [DATE] and authored by the Administrator, revealed the facility reported an allegation of neglect involving Resident #118. Information contained in the SRI noted the State agency surveyor showed me several video clips. One of these video clips showed what appeared to be a staff member in blue clothing walking into Resident #118's room at approximately 7:13 A.M. The unidentified staff member exchanged a few words with Resident #118, I could not understand what was said as I only saw the video once, appears to turn off the call light button in the room and exits the room. The staff member never had any physical interaction with Resident #118. However, per the State agency statement received by me on [DATE] at approximately 3:00 P.M., On [DATE] at 7:13 A.M. an unidentified staff member entered Resident #118's room, shut off the resident's call light and turned to leave when Resident #118 was heard telling the staff member she had to pull for air. The staff member said you will be fine and walked away. This was per the State agency statement received on [DATE]. (However, no written statement was provided to the facility or the Administrator regarding this incident by the State agency surveyor). The facility had not submitted a final report of their investigation to the State agency as of [DATE] at 1:15 P.M. Review of information from redcross.org revealed the following CPR Steps/Giving CPR included but were not limited to: Step 4: Kneel beside the person, place the person on their back on a firm, flat surface. Step 7: Use an AED as soon as one is available. Review of the facility's undated Call Light policy and procedure revealed the purpose was to respond to the resident's request and needs. Turn off the signal light. Identify yourself and call the resident by his or her name. Listen to the resident's request. Do what the resident asks of you, if permitted. If uncertain as to whether a request can be fulfilled or if the request cannot be fulfilled, ask the nurse supervisor for assistance. If you have promised the resident you will return with an item or information, do so promptly. Review of the facility undated policy titled, Change in a Resident's Condition or Status revealed the nurse would record in the resident's medical record information relative to changes in the resident's medical/mental condition or status. This deficiency represents non-compliance investigated under Complaint Number OH00147021.

Based on observation, interview, and record review the facility failed to address behavioral symptoms for a resident with dementia. This affected one Resident (#59) of three reviewed for behaviors. The facility census was 114. Actual harm occurred when Resident #59 was involved in a physical altercation with Resident #112. Resident #59 sustained a bloody nose with scratches/bruising to the face and Resident #112 sustained a fractured index finger. Findings include: Review of the open medical record for Resident #59 revealed admission to the facility on [DATE] and diagnoses including dementia with behavioral disturbance, alcohol dependence with alcohol induced persisting dementia, neurocognitive disorder with Lewy bodies, mood disorder, depression, psychosis, and anxiety disorder. Review of the Care Plan dated 01/27/23 revealed Resident #59 had impaired cognitive function related to dementia. Interventions included administer medications as ordered, call resident by name, avoid too many choices, encourage family involvement, keep routine consistent, redirect as needed, and evaluate as needed. Review of the Care Plan dated 01/30/23 revealed Resident #59 had behaviors. Interventions included administer medications as ordered, approach calmly, reapproach as needed, redirect, and offer psychological services as needed. Review of Medicare Admission Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #59 was rarely or never understood, had severely impaired decision making, and had memory problems. Resident #59 exhibited physical and verbal behaviors. Resident #59 was also noted to wander. The assessment indicated the behaviors put Resident #59 at risk for injury, interfering with care/activities/social interaction, intruding on privacy of others, and disruption of living environment. Review of the current physician's orders for February 2023 revealed Resident #59 was on Trazodone (antidepressant) once daily for insomnia, Depakote (anticonvulsant medication often used to treat mania) three times per day for mood disorder, Haldol (antipsychotic) twice daily for psychosis, and Vistaril (antihistamine medication often used to treat anxiety in adults) as needed for mood disorder and psychosis. Review of medication administration records (MARs) for January 2023 and February 2023 revealed one time administration of Ativan (antianxiety) for aggressive behavior and agitation on 02/12/23, one time administration of intramuscular injection Haldol for aggressive behavior on 01/29/23 and 02/12/23. Vistaril was added on 02/23/23 for increased agitation as needed. Review of General Note dated 01/27/23 at 10:03 P.M. revealed Resident #59 was noted to wander in and out of other resident rooms and occasionally undressing in hallway. Review of Nurses Note dated 01/28/23 at 12:42 P.M. revealed Resident #59 was pacing up and down halls, going in and out of others' rooms, laying in other resident beds, and ripping baseboards from walls. Resident #59 was noted to be agitated, confused, and unable to redirect. Resident #59 was given as needed medication to decrease anxiety. Review of Nurses Note dated 01/29/23 at 10:56 A.M. revealed Resident #59 was seen around 7:45 A.M. with blue/green substance around mouth and on tongue. It was noted the baseboards were pulled off wall, plaster was crumbled on ground, and large hole in wall. Resident #59 was noted to take morning medications and was given as needed medication. Additional behaviors including going in others' rooms, spitting on ground, sticking hands in trash, and taking pants off in hallway. Supervision and as needed medications non effective. Resident #59 noted to be agitated and appeared to have hallucinations. Physician gave order for one time dose of intramuscular Haldol and for psychological services to adjust medications. Call to Resident #59's ex-wife revealed Resident #59 had never displayed any of the above behaviors. Review of Nurses Note dated 01/29/23 at 6:20 P.M. revealed Resident #59 continued to have behavioral episodes including going into others' rooms, climbing out of geri chair (medical recliner), taking off clothing, and attempting to kiss another resident that was in bed. Family requested Resident #59 be sent to hospital for psychological evaluation. The progress note indicated Resident #59 had gotten worse since more medications had been added. Review of a Change in Condition Evaluation dated 01/29/23 revealed Resident #59 was having worsening behaviors despite new medication additions. Resident #59 was noted to receive routine and as needed medications for agitation and anxiety. Resident #59 was noted to go into others rooms, hide in closets and under chairs, peeling off baseboards and causing large holes in walls, wrapping self in privacy curtains, spitting on floor, taking off clothing in hallway, laying in others' beds, and trying to have bowel movement in hallway. Physician and responsible party were notified. Physician gave order to send to hospital for psychological evaluation. Review of Admission Note dated 02/09/23 at 4:00 P.M. revealed Resident #59 returned from hospital for exhibited behaviors. Review of Nurses Note dated 02/12/23 at 7:24 P.M. revealed Resident #59 had been arguing with another resident all day. Staff had attempted to keep residents separated however Resident #59 continued to go into the other resident's room. Resident #59 would get into the resident's face and yell at her. At 7:15 P.M. Resident #59 was noted to stand over the other resident in her wheelchair and attempt to hit her in the face. Staff were able to separate the residents before contact was made. Resident #59 then charged at staff attempting to hit them. Staff were able to redirect Resident #59 to room and settle down. Physician was notified and gave order for one time dose of intramuscular Haldol and oral Ativan. Review of General Note dated 02/19/23 at 4:30 P.M. revealed Resident #59 was physically aggressive towards another resident. Resident #59 was striking out towards the other resident and pulled her hair. Residents were separated. Resident #59 was taken to dining room to sit with staff and wait emergency medical services for transport to hospital for evaluation. Review of Nurses Note dated 02/21/23 at 10:01 P.M. revealed Resident #59 was wandering into others' rooms. Resident #59 required constant redirection and one on one supervision. Review of Nurses Note dated 02/22/23 at 4:36 P.M. revealed Resident #59 was involved in physical altercation with roommate resulting in visible injuries to both residents. Resident #59 continued to be agitated and was taken to hospital for psychological evaluation. Review of a Situation, Background, Assessment, and Recommendation (SBAR) - Alleged Abuse Report of Incident dated 02/22/23 revealed Resident #59 had physical altercation with roommate. Resident #59 was noted to be agitated, restless, and pacing/wandering. Review of SBAR- Physical Injury Report of Incident dated 02/22/23 revealed Resident #59 had injury to face including laceration/cut and area of redness. The assessment indicated the event occurred on 02/22/23 at 2:50 P.M. in the resident's room. Resident #59 was displaying restless behaviors resulting in injury during physical altercation with another resident. Physician and responsible party were notified. Physician gave order to send to hospital for psychological evaluation. Review of Self-Report Incident Form dated 02/22/23 revealed Resident #59 and Resident #112 were in a physical altercation. Resident #112 indicated he was startled awake by Resident #59 standing over him and there was an exchange of words. Resident #112 struck Resident #59 knocking him to the floor. Resident #59 sustained a bloody nose with scratches/bruising to face and Resident #112 sustained a broken index finger on right hand. Review of General Note dated 02/22/23 at 11:14 P.M. revealed Resident #59 returned from hospital with superficial scratch on right cheek measuring five centimeters. Resident #59 remained one on one with nursing staff. Review of Physician's Order Note dated 02/23/23 at 12:46 P.M. revealed Resident #59 was evaluated by psychological services nurse practitioner and was given order for Vistaril as needed for agitation. Observation on memory care unit on 02/23/23 at 8:09 A.M. revealed Resident #59 was sitting in chair across from nurse's station. Resident #59 was observed to get up from chair and push on exit door when it did not open, he then walked over to nurse's station door and attempt to go inside. Housekeeper #809 who was cleaning near by re-directed Resident #59 while holding his arm back to chair. Resident #59 again stood from chair and went over to an unmarked door and tried opening door. Housekeeper #809 again redirected him back to chair. There was a bag of trash on floor behind Resident #59's chair. Resident #59 was observed to pull trash bag into lap and start digging through the bag. Housekeeper #809 took bag from Resident #59 and put it on her cart. There was no interaction with Resident #59 by nursing staff on unit and Resident #59 was not provided with any diversional activities to address intrusive behaviors. Interview on 02/23/23 at 2:45 P.M. with the Licensed Nursing Home Administrator (LNHA) confirmed Resident #59 had been involved in multiple incidents with other residents. LNHA indicated only one incident was truly a resident-to-resident abuse situation. Interview on 02/23/23 at 3:26 P.M. with Maintenance Director #803 confirmed Resident #59 had pulled off the baseboard in his room. Maintenance Director #803 indicated there was nothing associated with the baseboards that was blue or green. Maintenance Director #803 indicated the crumbled plaster had been cleaned up however they had not yet replaced the baseboard. Interview on 02/23/23 at 3:55 P.M. with the Director of Nursing (DON) revealed she was not sure of what the green/blue substance was. The DON indicated it was a memory care unit and Resident #59 could have gotten into anything in his or another's room. The DON indicated it was most likely just some candy and Resident #59 was later noted to eat breakfast and was acting fine. Interview on 02/27/23 at 1:18 P.M. with the DON revealed Resident #59 was seen late last week by new psychological services, however she had not received the report yet. Interview on 02/27/23 at 1:43 P.M. with State tested Nursing Assistant (STNA) #811 revealed she had witnessed the resident-to-resident physical altercation with Resident #59 and Resident #112. STNA #811 indicated a female resident was yelling down the hall to come there. STNA #811 indicated she ran down hall and saw next to the foot of Resident #112's bed was Resident #59 down on his knees. Resident #59 was holding on to the front of Resident #112's legs who was standing over him and Resident #112 was hitting down at Resident #59's face with a closed fist. STNA #811 indicated she grabbed Resident #112 from behind and secured his hands to stop him from hitting. STNA #811 indicated when she tried to back Resident #112 from the room Resident #59 stood up and lunged towards them. STNA #811 indicated at that time Resident #112 pulled hands free and hit Resident #59 again in the face with a closed fist. STNA #811 indicated she was finally able to secure Resident #112 and Resident #59 kept coming towards them. STNA #811 indicated help from other staff arrived at this time and they were able to safely separate the two residents. STNA #811 indicated the nurse assessed both residents and they were kept separate. STNA #811 indicated she had observed Resident #112 sleeping in his room [ROOM NUMBER] minutes prior to the altercation. STNA #811 indicated both residents usually got along with others however Resident #59 did not have the mental capacity to understand inappropriate behaviors. STNA #811 indicated Resident #59 went to the hospital and Resident #112 moved rooms. Observation on 02/27/23 at 2:02 P.M. revealed Resident #59 was sleeping on bed in room with a scratch noted to right cheek. Resident #112 was noted to be sitting a chair across from nurses' station with two others. Resident #112 had right hand wrapped with a bandage. Interview on 02/27/23 at 2:21 P.M. with Licensed Practical Nurse (LPN) #800 revealed she only witnessed the end of the altercation between Resident #59 and Resident #112. LPN #800 indicated as she was coming down hallway she saw STNA #811 and STNA #814 between the two residents and they were backing out of the room. LPN #800 indicated Resident #59 was still lunging at Resident #112. LPN #800 indicated she was able to get the attention of Resident #59 and encouraged him to come to her. LPN #800 indicated he turned back to lunge at Resident #112 and she grabbed him by the waist. LPN #800 indicated she directed Resident #59 by the waist to sit in dining room. LPN #800 indicated both residents had injuries. Resident #59's face was bruising and there was scratches and Resident #112 had swollen knuckle on right hand. LPN #800 indicated Resident #112's knuckle was later found to be fractured by X-ray. LPN #800 indicated Resident #59 was sent to emergency room for psychological evaluation. LPN #800 indicated the two residents were moved to separate rooms. LPN #800 indicated there were activities on the memory unit, however in the afternoons the residents were usually left to socialize in hallways or watch television in the dining room. Interview on 02/27/23 at 3:55 P.M. with Licensed Social Worker (LSW) #801 revealed to manage Resident #59's behaviors they have sent him to hospital and redirected him. LSW #801 indicated Resident #59 could not verbalize wants/needs and provided no meaningful information when interviewed. LSW #801 indicated they planned to start using food, music, and toileting to redirect inappropriate behaviors for Resident #59. LSW #801 confirmed these nonpharmacological techniques were not in place until after the physical resident to resident altercation. Interview on 02/27/23 at 3:58 P.M. with Activities Director #812 revealed Resident #59 would not stay for group activities. Activities Director #812 indicated it was hard to keep the residents who wandered away involved in activities. Activities Director #812 indicated she was not sure the status of Resident #59's dementia, where his mind would go to, or what activities would keep him engaged. Activities Director #812 confirmed one on one activities had started after the physical resident to resident altercation. Review of Resident #59's updated care plan provided by the facility revealed changes to interventions were not made until 02/27/23. New interventions included to redirect ambulation, provide snacks, music, and toileting in response to behaviors. This deficiency represents non-compliance investigated under Complaint Number OH00140595.

Based on medical record review, observations, family interview, staff interview, review of the facility policy on visitation, and review of the Department of Health and Human Services, Centers for Medicare & Medicaid (CMS) Memo QSO ,[DATE]-NH, the facility failed to permit family visitation for two residents (Resident #317 and #320) experiencing a significant decline in condition. This resulted in Immediate Jeopardy on [DATE] when a family member of Resident # 317 was notified their mother was significantly declining in health status with end of life changes and requested visitation with their mother (Resident #317). The daughter was denied visitation by the facility. This resulted in the likelihood of serious psychosocial harm when Resident #317 expired on [DATE] without visitation from her daughter. On [DATE] a family member of Resident #320 was notified their mother was significantly declining in health status with end of life changes and the daughter requested visitation with their mother (Resident #320). The daughter was denied visitation by the facility. This resulted in the likelihood of serious psychosocial harm when Resident #320 expired on [DATE] without visitation from her daughter or granddaughter. This affected two (Resident #317 and #320) of 99 residents residing in the facility. On [DATE] at 3:35 P.M., the Administrator was notified Immediate Jeopardy began on [DATE] when a family member requested visitation with her mother (Resident #317) who was experiencing a significant decline in health status, and the family member was not permitted to visit. Resident #317 expired on [DATE] without visitation from her daughter. A second incident of Immediate Jeopardy occurred on [DATE] Resident #320 was experiencing a significant decline in health status, and the family member was not permitted to visit. Resident #320 expired on [DATE] without visitation from her daughter or granddaughter. The Immediate Jeopardy was removed on [DATE] when the facility implemented the following corrective action: · The COVID Unit Best Practice was updated to allow End of Life/[MEDICATION NAME] Care visits on the COVID Unit. Staff will be in-serviced by Management on allowing End of Life Visitors per CMS guidance by [DATE]. Residents on the COVID unit with active COVID will be assessed for active decline/ end of life and allowed to receive visitors per CMS guidance. · The facility will monitor residents on COVID unit daily for changes of condition/end of life status; responsible party will be notified as appropriate and allowed visitation per CMS guidance. The Interdisciplinary Team will collaborate to evaluate the COVID residents and whether potential [MEDICATION NAME] care visits are appropriate. · The Interdisciplinary Team collaborations will be submitted to the Quality Assurance Committee for tracking, trending, and recommendations until sustained compliance is noted. Although the Immediate Jeopardy was removed on [DATE], the facility remained out of compliance at Severity Level 2 (no actual harm with the potential for more than minimal harm that was not Immediate Jeopardy) as the facility was in the process of completing additional staff training and conducting audits to ensure the effectiveness of the staff training and the new processes developed. Findings include: Review of the Department of Health and Human Services, CMS Memo (QSO ,[DATE] NH) dated [DATE] revealed facilities should use the COVID-19 county positivity rate, found on the COVID-19 Nursing Home Data site as additional information to determine how to facilitate indoor visitation: Low (<5%) = Visitation should occur according to the core principles of COVID-19 infection prevention and facility policies (beyond [MEDICATION NAME] care visits) Medium (5% - 10%) = Visitation should occur according to the core principles of COVID-19 infection prevention and facility policies (beyond [MEDICATION NAME] care visits) High (>10%) = Visitation should only occur for [MEDICATION NAME] care situations according to the core principles of COVID-19 infection prevention and facility policies While end-of-life situations have been used as examples of [MEDICATION NAME] care situations, the term [MEDICATION NAME] care situations does not exclusively refer to end-of-life situations. Examples of other types of [MEDICATION NAME] care situations include, but are not limited to: A resident, who was living with their family before recently being admitted to a nursing home, is struggling with the change in environment and lack of physical family support. A resident who is grieving after a friend or family member recently passed away. A resident who needs cueing and encouragement with eating or drinking, previously provided by family and/or caregiver(s), is experiencing weight loss or dehydration. A resident, who used to talk and interact with others, is experiencing emotional distress, seldom speaking, or crying more frequently (when the resident had rarely cried in the past). Allowing a visit in these situations would be consistent with the intent of, [MEDICATION NAME] care situations. However, facilities may not restrict visitation without a reasonable clinical or safety cause, consistent with §483.10(f)(4)(v). Record review for Resident #317 revealed an admission date of [DATE]. Review of the Minimum Data Set (MDS) 3.0 assessment completed on [DATE] revealed Resident #317 required extensive assistance for bed mobility and transfers. Review of the activity assessment dated [DATE] revealed Resident #317 enjoyed watching television, using her laptop, talking on the phone, word puzzles video games and knit/crocheting. Review of the assessment dated [DATE]. revealed Resident #317 tested positive for COVID-19. The resident expired on [DATE] at 8:03 A.M. Interview on [DATE] at 5:20 P.M. with Resident #317's daughter revealed on [DATE] the facility nurse had called to tell her to prepare herself for the worst because her mom (Resident #317) was not doing well. Resident #317's daughter stated she requested to come to the facility to be with her mother, and facility staff denied visitation because of COVID-19. Record review for Resident #320 revealed an admission date of [DATE]. Review of the MDS 3.0 assessment dated [DATE] revealed Resident #320 required limited assistance for bed mobility and supervision to walk in the corridor. Resident #320 ambulated with a walker. Resident #320 continued to attend activities but enjoyed being in her room to relax and read. Resident #320 had weekly virtual visits with her family. Record review of the assessment dated [DATE] revealed Resident #320 tested positive for COVID-19. The resident expired on [DATE] at 5:30 A.M. Interview on [DATE] at 2:28 P.M. with Resident #320's daughter revealed she was notified on [DATE] at 10:30 P.M. that her mother was doing poorly, and the hospice nurse had been called in. She stated the facility nurse told her she could come in to visit. While she was on her way to the facility, the nurse called her back and stated Administration did not allow any visitors into the COVID-19 unit. She stated she was denied visitation but could stand outside and look through the window. She stated she stood outside the window in the cold while she had been sinking in the mud from 11:00 P.M. until 3:30 A.M. She stated she left at 3:30 A.M. due to the cold and received a phone call shortly after 5:30 A.M. that her mother had passed away. Interview on [DATE] at 1:49 P.M. with the Administrator revealed he had received requests from family members to visit with residents who were actively dying. The Administrator verified he had denied visitation due to the company policy. The facility provided no evidence of a clinical or safety reason to prohibit the visitation by Residents #317 or #320's family members. Review of the Company Policy, revised [DATE], revealed end of life visits were not permitted on the COVID-19 unit. This deficiency substantiates Complaint Number OH 212.

Based on interview, record review and policy review, the facility failed to provide ongoing assessment to prevent and treat skin breakdown. Actual Harm occurred when the facility failed to implement interventions for a hand contracture and failed to perform nail care resulting in the fingernails breaking the surface of the skin causing the left-hand fingernails to grow into the palm of the left hand with infection, visible purulent (a thick and milky discharge from a wound that is often a sign of infection) and malodorous (very unpleasant odor) drainage was seeping from the palm. This affected one resident (Resident #305) of three residents (Resident's #305, #306 and #308) residents reviewed for skin breakdown. The facility census was 99. Findings include: Record review of the medical record revealed Resident #305 had an admission date of [DATE] with [DIAGNOSES REDACTED]. Record review of the Minimum Data System (MDS) 3.0 assessment dated [DATE] completed by Registered Nurse (RN) #101 revealed Resident #305 was rarely or never understood. Resident #305 required extensive assistance of two caregivers for bed mobility, dressing, grooming and toilet use. Record review of skin assessment completed on 02/25/19 of pre-existing skin issues, completed by Licensed Practical Nurse (LPN) #103 revealed Resident #305 had pre-existing skin issues which included a skin tear to the right upper back and vascular wounds to the right and left lower extremities. The left lower extremity had measured five centimeters (cm) by three cm and 0.7 cm by 0.7 cm. The right lower extremity measured two centimeters by 1.5 cm. Record review of the care plan dated 10/11/20 completed by RN #101 revealed Resident #305 had impairment to skin integrity to the right side of the back related to abrasion/ maceration and posterior right and left lower extremities secondary to [MEDICAL CONDITION]. Interventions included to change the bed linen every shift, encourage nutrition and hydration and to notify physician promptly of any new skin breakdown. There was no plan of care completed for contractures. Review of Resident #305's medical records revealed a skin assessment was completed weekly to determine new skin issues. The last skin assessment completed on 11/09/20 by Wound Care Nurse #106 at 8:52 A.M. included wounds on the right and left lower leg and right side of his back. The wound to the right lower extremity measured 16.8 cm by 6.2 cm by 0.1 cm depth. The left lower extremity measured 5.6 cm by 4.3 cm by 0.1 cm depth. Resident #305 also had a macerated area to the right side of his back that had measured 14.0 cm by 10.0 cm by 0.1 cm depth. No other wounds were noted. Review of the physician's orders [REDACTED].#305 being transferred to the hospital revealed: · On 02/06/19, a physician's orders [REDACTED].#103 to apply moisturizing cream to the back twice a day and as needed. · On 1/16/20, a physician's orders [REDACTED].#123 for Resident #305 to see Wound Care Physician #102. · On 02/06/20, a physician's orders [REDACTED].#124 for [MEDICATION NAME] powder (antifungal) to apply to the abdominal folds topically every day and evening shift for skin fungus, cleanse with normal saline, pat dry, apply [MEDICATION NAME] powder twice daily and cover with an ABD pad. · On 05/14/20, a physician's orders [REDACTED].#123 to apply zinc oxide to the buttocks and peri area after each incontinent episode and every shift. · On 10/06/20, a physician's orders [REDACTED].#116 which included treatment changes to the right and left lower legs. The new order was to cleanse the areas on the right and left lower extremities with Dakin's (antiseptic) solution, pat dry and apply Alginate silver (highly absorbent antimicrobial dressing) and an abdominal (ABD) pad and wrap with Kerlix (gauze wrap) daily. · On 11/02/20, a physician's orders [REDACTED].#116 which included treatment changes to the right side of the back. The new order was to cleanse the area with Dakin's solution, apply zinc oxide cream (treatment for [REDACTED]. Record review of the treatment records for the month of October 2020 and November 2020 revealed Resident #305 had not refused any medical or wound treatments. Record review of bathing for the month of November 2020 for Resident #305 revealed he had received a bed bath on 11/09/20 at 4:13 P.M. given by STNA #129 and on 11/12/20 given by STNA #127 at 2:49 P.M. and again at 10:46 P.M. Record review for the month of November 2020 revealed Resident #305 received personal hygiene which included washing and drying the face and hands by STNA's #127, #122 and #129 on 11/01/20, 11/02/20, 11/03/20, 11/07/20, 11/08/20, 11/09/20 11/12/20 and 11/14/20. Review of the progress note completed by Licensed Practical Nurse (LPN) #113 revealed on 11/15/20 at 7:35 P.M. Resident #305 was admitted to the local hospital with [DIAGNOSES REDACTED]. Review of the local hospital records revealed on 11/15/20 emergency room Physician #121 stated upon (Resident #305's) arrival to the emergency room revealed the resident's bilateral fingernails were excessively long and dirty. The left-hand fingernails were growing into the palm of the left hand with infection, visible purulent (a thick and milky discharge from a wound that is often a sign of infection) and malodorous (very unpleasant odor) drainage was seeping from the palm. It appeared his fingernails were not cut in a very long time. In addition, the resident was assessed to have a large skin breakdown on the right side of the back from the shoulder to the waist and from the mid spine to the ribs, open sores along the abdominal folds, a coccyx ulcer which had 50 % slough (dead white blood cells, [MEDICATION NAME], cellular debris and liquified devitalized tissue)and was unstageable (full-thickness skin and tissue loss in which the extent of tissue damage within the ulcer cannot be confirmed because it is obscured by slough or eschar), an unstageable ulcer to the left lateral foot with 50% slough and 25 % eschar (dead tissue), large open wounds to the bilateral thighs, a [MEDICAL CONDITION](fungal) like rash to the bilateral axilla (armpits) which was bright red, and his penis had purulent malodorous drainage. Review of the local hospital records dated 11/15/20 revealed Resident #305's admitting [DIAGNOSES REDACTED]. Interview on 12/21/20 at 2:27 P.M. with Wound Nurse #116 revealed he and Wound Care Physician #102 assessed Resident #305's wounds on the bilateral lower extremities and his back weekly. Wound Care Nurse #116 stated he never saw any wounds on Resident #305's palm of the hand and was unaware his hand was contracted. Interview on 12/21/20 at 2:37 P.M. with Wound Care Physician #102 revealed he had been visiting Resident #305 weekly since admission. Wound Physician #102 stated he last visited Resident #305 on 11/09/20 and stated he had not assessed or been notified of any other areas except for Resident #305's bilateral legs and back. Interview on 12/21/20 at 7:35 P.M. with State tested Nurse Aide (STNA) #118 confirmed Resident #305's fingernails were long. She worked with him routinely, and he occasionally would allow her to trim his fingernails. STNA #118 revealed Resident #305's left hand had three fingers which were contracted (permanent tightening of the muscles, tendons, skin and nearby tissues that cause the joints to shorten and become very stiff. This prevents normal movement of the joint) and at times she would roll up a washcloth and place it in his palm. STNA #118 denied seeing cuts on his palms from his nails but stated she went PRN (as needed) and had not worked with Resident #305 during the months of October and November 2020. STNA #118 was unable to recall the last time she worked with Resident #305. Interview on 12/22/20 at 8:15 A.M. with LPN #120 stated Resident #305 held his own cups and fed himself. She did not notice any contracted fingers. LPN #120 confirmed Resident #305's fingernails were long. LPN #120 was unable to recall the last time she had attempted to trim Resident #305's fingernails. Interview on 12/22/20 at 10:20 A.M. with Physician #108 revealed he was the primary physician for Resident #305 while at the nursing home and during his hospital stay. Physician #305 was unaware of the fingernails which were embedded and growing into Resident #305's left palm. Interview on 12/22/20 at 12:00 P.M. with STNA #122 revealed she frequently cared for Resident #305 and verified she noticed the wounds including the nails growing into the palm of his left hand. STNA #122 stated, the nurses knew, and he wouldn't let anyone cut them. I am not a nurse, and I can't treat his wounds. He had a wound doctor. STNA #122 stated Resident #305 was able to feed himself and drink fluids using his right hand. Interview on 12/23/20 at 11:15 A.M. with Physical Therapy Assistant (PTA) #125 revealed Resident #305 received occupational therapy between 07/03/19 and 07/16/19 for bilateral hand range of motion and palm guards. The finger digits three through five on Resident #305's bilateral hands had flexion contractures that were not fixed contractures at that time. Resident #305 refused the palm guards at that time. No further assessments or treatment attempts were completed by therapy for his bilateral hands after 07/16/19. Review of the medical record revealed there was no restorative program initiated for Resident #305. Review of the medical record revealed no documented evidence of assessment or treatment plan for Resident #305's contracted fingers or left-hand wounds. Interview on 12/15/20 at 6:08 P.M. with Resident #305's Responsible Party revealed she had not been made aware of any additional wounds, contractures or embedded fingernails on Resident #305's left hand until she was made aware by the local hospital after admission on 11/15/20. Resident #305's Responsible Party verified she was not able to visit Resident #305 since March 2020 due to the coronavirus outbreak. Record review of the history and physical from the local hospital revealed Resident #305 was admitted on [DATE]. Hospice care was initiated on 11/18/20, and he passed away on 11/20/20. Review of the undated facility policy and procedure titled Guide to Contracture Management revealed: · Monitor during daily care and document any changes taking appropriate action, formally review on a monthly basis. · Encourage participation in personal care and mobility to aid in prevention. · Monitor current range of joint movement daily when providing care. This defieciency substantiates Complaint Number OH 588.