Every finding on record at Highland Pines Rehabilitation Center

Based on interviews and record review, the facility failed to ensure physician orders were followed in a timely manner, related to wound care treatment for one resident (#19) out of three residents sampled. On 10/20/2025 Resident #10 sustained an injury to his right pinky finger. On 10/20/2025 orders were given by the provider for wound care treatment and medications to fight infection. The facility staff failed to enter the orders until 10/22/2025. Resident #10 continued to experience pain and go without medications for the infection for two days. Resident #10 was transferred to a higher level of care and had to have his right pinky finger amputated. Findings Included:During an interview on 02/25/2026 at 10:41 AM, Staff A Licensed Practical Nurse (LPN), stated she went to give Resident #10 medication on 10/20/2025 and noticed the resident had an injury to the right pinky finger. Staff A stated she asked Resident #10 what happened to the finger and was told the finger was caught in his wheelchair spokes. Staff A stated the resident was a brittle diabetic and anything could have caused the injury. Staff A stated It was pretty bad when I saw it. Staff A stated the right pinky was swollen, necrotic, pussy, and had a blister. Staff A said she could tell the finger was infected. Staff A stated it would have taken a few days to develop to the condition it was in. Staff A stated no treatment was provided to Resident #10 until 10/22/2025. Staff A stated the expectations would have been to place the resident on antibiotics. Staff A stated a nurse would have entered the order. Staff A stated she would have immediately notified the provider after seeing the resident's finger like that, and stated I don't know why I didn't.During an interview on 02/25/2026 at 11:39 AM, Staff B, LPN, Unit Manager (UM), stated she was a wound care nurse at the facility. Staff B stated she had seen Resident #10 often due to previously providing wound care for the resident. Staff B stated on 10/21/2025 she provided wound care for Resident #10 for a double below knee amputation. Staff B stated Resident #10 said he had injured his right pinky by getting it caught in his wheelchair. Staff B stated the area was swollen, discolored, with a little drainage, and a blister. Staff B stated Resident #10 did not have neuropathy. Staff B stated there was a late note on 10/22/2025 that the provider had been contacted. Staff B stated the note was created on 10/23/2025. Staff B stated the provider was contacted gave orders for an x-ray. Staff B stated the results of the x-ray were received on 10/23/2025, which suggested osteomyelitis, and recommended an Magnetic Resonance Imaging (MRI) test. Staff B stated the x-ray also revealed subtle bone loss at the fifth DIP (distal interphalangeal joint), with joint swelling. Staff B stated Resident #10's right pinky finger injury should have been identified sooner.During an interview on 02/25/2026 at 01:39 PM, Staff C, Regional Nurse Consultant (RNC), stated having been the Director of Nursing (DON) at the facility in 10/2025. Staff C stated if a resident was observed with an open area, the nurse should have notified the provider immediately. Staff C stated the notification to the provider would have been documented in a progress or evaluation note. Staff C explained being familiar with Resident #10 and stated the resident had a bilateral leg amputations. Staff C stated Resident #10 had a pinky injury on 10/20/2025. Staff C stated according to an evaluation on 10/20/2025, Resident #10 stated his finger was caught in a wheelchair. Staff C stated no treatment was noted at the time. Staff C stated an assessment and evaluation was conducted for Resident #10. Staff C stated an order for Doxycycline was generated for 10 days 100 mg (milligrams) starting 10/22/2025 for Resident #10. Staff C stated the provider was notified of Resident #10's condition on 10/22/2025. Staff C stated not having saw anywhere, that Resident #10 was seen by the provider on 10/22/2025. Staff C stated having expectations for the nurse who found the injury to start a treatment plan, notify the provider, and notify the family immediately. Staff C stated from what she could see, the process was not followed. Staff C stated Resident #10 received an x-ray for his hand on 10/22/2025. Staff C stated Bacitracin was ordered and discontinued on 10/22/2025. Staff C stated staff should have identified the condition of Resident #10's finger prior to 10/20/2025. During a phone interview on 02/27/2026 at 03:43 PM, A family member of Resident #10 stated Resident #10 had injured his finger about a week prior to being sent to the hospital on [DATE]. A family member of resident #10 stated the resident had explained injuring his finger in a wheelchair, by getting it caught in the wheelchair. The family member explained not being notified about Resident #10's pinky injury, until 10/23/2025, and had expectations of being notified prior. The family member stated the resident's finger had to be amputated.During an interview on 03/04/2026 at 11:01 AM, Staff B, LPN, UM, explained not having notified the provider of Resident #10's injury on 10/20/2025 and stated I let the floor nurse do her job. Staff B stated not being aware, the floor nurse had not contacted the provider. Staff B stated the provider saw Resident #10 on 10/20/2025, in person at the facility. Staff B stated not knowing why orders from the provider were not entered into the system until 10/23/2025. Staff B stated Resident #10's right pinky had a white bubble at the top, purple bruising, and dried torn skin. Staff B stated Resident #10's right pinky was so dry that nothing could be put on it. Staff B stated she used normal saline and gauze on the right pinky, on 10/20/2025. During an interview on 03/04/2026 at 11:22 AM, Staff I, Registered Nurse (RN), stated the response process for a skin tear was to notify the family and physician, get orders for care, measure disrupted skin area, make an incident report, notify the unit manager, put in treatment orders from the physician, make post event charting for 72 hours, and notify wound care. Staff I stated the process would have been completed immediately upon discovery of the skin tear.During an interview on 03/04/2026 at 11:25 AM, Staff J stated the response process for a skin tear was to notify the provider and get orders, enter the orders, do a change in condition, notify the family, monitor the area and do daily dressing changes, and notify wound care. Staff J stated the process would have been implemented immediately, upon knowledge of a skin tear.During an interview on 03/04/2026 at 12:09 PM, Resident #10's Primary Care Physician, (PCP), stated she was the primary provider for Resident #10. Resident #10's PCP stated she was rounding at the facility on 10/20/2025 and received a call, related to Resident #10. Resident #10's PCP told staff to order antibiotics and an obtain an x-ray for Resident #10. Resident #10's PCP stated Resident #10 declined the x-ray and she had to go back to the resident's room to insist that the resident receive the x-ray. Resident #10's PCP explained having seen Resident #10 twice on 10/20/2025. Resident #10's PCP stated orders should have went into the system the same day they were given to facility staff. Resident #10's PCP stated orders are supposed to be pulled and completed the same day. Resident #10's PCP explained not knowing the orders given on 10/20/2025 were not put in, the same day they were given. Resident #10's PCP stated the x-ray completed on 10/23/2025, would have revealed suspicions of osteomyelitis, which would have required a higher level of care. Resident #10's PCP stated the treatment for Resident #10 would have been changed, because Doxycycline could not have penetrated the bone. Resident #10's PCP stated IV (intravenous) antibiotics would have been given if the x-ray was received earlier, and hospitalization may have been an option. Resident #10's PCP stated it was not appropriate for the orders to be put in two days later and should have been put in the day she gave the orders.During an interview on 03/04/2026 at 12:35 PM, Staff B, LPN, UM stated not having received orders from the provider on 10/20/2025. Staff B stated there was no reason orders would have been received on 10/20/2025 and not entered until 10/22/2025, unless the nurse entered a later start date and it should have been caught if so.During a phone interview on 03/04/2026 at 02:02 PM, Staff K, LPN, stated having called Resident #10's PCP on 10/22/2025, and stated having explained the condition of Resident #10's right pinky. Staff K stated the resident needed to be sent to the hospital. Staff K stated she received and entered orders for Resident #10, x-rays and antibiotics, on 10/22/2025, the same day she spoke to the PCP. Staff K stated she was not told by the PCP, that orders were given days prior for the same injury. Staff K stated there was no reason she would have waited to enter orders as typically, she entered orders the same day they were given. Staff K stated not knowing about the right pinky injury prior to discovering it on 10/22/2025, while performing a blood pressure check for blood pressure medication.Record review for Resident #10 revealed the resident had been admitted to the facility on [DATE]. Medical diagnosis revealed the following: acquired absence of right leg below knee, acquired absence of left leg below knee, muscle wasting and atrophy, chronic congestive heart failure, Type 2 Diabetes Mellitus with diabetic chronic kidney disease, need for assistance with personal care, altered mental status, and delusion disorder.Review of Resident #10's physician orders revealed:X-ray to the right hand dated 10/22/2025 at 07:45 PM,Bacitracin External Ointment 500 UNIT/GM (Bacitracin (Topical)) Apply to Right 5th digit topically one time a day for Wound Healing Apply cream to 5th digit and cover with dry dressing, dated 10/23/2025 at 09:00 AMDoxycycline Hyclate oral tablet 100 MG, dated 10/23/2025 at 09:00 AMOK to send to ED for assessment and treatment, revised 10/24/2025Review of Resident #10's evaluations revealed a skin evaluation, dated 10/16/2025, which revealed no new areas of skin impairment. A skin evaluation, dated 10/20/2025, reveled bruising to Resident #10's right hand pinky, and an open area.Review of Resident #10's Minimum Data Set, section C revealed the resident had a Brief Interview of Mental Status score of 11, which indicated moderate cognitive impairment. Section GG revealed the resident had impairment on both sides of the lower extremity.Review of progress notes for Resident #10, revealed:10/20/2025 11:11 Skin Issue: #001: Skin issue has not been evaluated. Location: Left rear below knee - amputation site. Issue type: Abrasion. Wound acquired in-house. Wound is new. Undermining: No. Tunneling: No.#002: New skin Issue. Location: Right Dorsum 5th Digit (Small Finger). Laterality / Orientation: Right. Issue type: Skin tear. Wound acquired in-house. Painful: No. Length (cm): 2.23 Width (cm): 2.48 Depth (cm): 0 Area (cm2): 4.19 Undermining: No. Tunneling: No.Skin Issues Note: Resident stated he got finger caught in W/C (wheelchair) no pain noted resident stated he didn't think he needed to tell anyoneAdditional skin issue education documentation: Educated resident that if something else happens like this to alert the nurse when it happens so we can do all necessary actionsA review of the progress notes for Resident #10 revealed: -10/20/2025 15:12 Progress Note (general) Note Text: Writer observed resident with open area noted to right hand pinky finger, UM and wound care team notified. resident stated that his finger accidently became tangled up in wheelchair wheel. No complaints of pain and or discomforts noted at this time.-10/21/2025 08:00 #001: Skin issue has been evaluated. Location: Left rear below knee - amputation site. Issue type: Abrasion. Progress: Monitoring: Wound healed or closed with continued monitoring. Wound acquired in-house. Wound is new. Length (cm): 0.7 Width (cm): 0.56 Depth (cm): 0 Area (cm2): 0.31 Undermining: No. Tunneling: No.#002: Skin issue has not been evaluated. Location: Right Dorsum 5th Digit (Small Finger). Laterality / Orientation: Right. Issue type: Skin tear. Wound acquired in-house. Undermining: No. Tunneling: No-10/22/2025 13:48 Progress Note (general) Note Text: Late entry for 10/22/25: call placed out to Dr, regarding resident right hand pinky finger infectious, swelling, and bruising. Awaiting return call back. Writer spoke with UM regarding the call out. Dr. will be rounding sometime today and will exam resident status. Resident remains alert and oriented x2 with forgetfulness, denies pain and or discomforts at this time.-10/23/2025 11:22 Physician Order Note Text: X-ray to right hand one time only for X-ray for 3 Days D/C once completed-10/23/2025 17:15 Transfer Note Text: Resident and family requested to be sent out to a hospital. Vitals stable, alert and oriented, ambulatory.Review of Resident #10's care plan revealed the following:Focus: WOUND RISK: The resident is at RISK of developing a wound Impaired Mobility, initiated 06/20/2025. The goal was to minimize wounds from developing, initiated: 06/20/2025. The interventions were to: observe for any new areas of skin breakdown: redness, blisters, bruises, discoloration noted during bath or daily care; report to nurse if noted, nurse will report to medical doctor if noted, initiated 06/20/2025.Review of Resident #10's hospital records revealed the resident had presented to the hospital from the facility for evaluation of right small finger injury, on 10/23/2025. The records revealed it was reported the resident injured his finger in a wheelchair as the wheelchair was in motion. The records revealed initial hand x-rays demonstrated signs of cellulitis and osteomyelitis. The records revealed Rocephin and Vancomycin were initiated for Resident #10. The records revealed Resident #10 was taken to an operating room for resection of right small finger on 10/28/2025.Review of Resident #10's medical records showed an untitled document, dated 02/25/2025, for a service date of 10/20/2025. The note revealed Resident #10's primary care provider saw the resident at the facility on 10/20/2025 and gave orders for x-rays, Doxycycline, and topical Bacitracin.Review of Resident #10's medical records showed an untitled document, signed 03/04/2026 by the resident's primary care provider, which revealed a statement: I came to the building and I saw the patient in person on 10.20.2025.Review of a document titled Radiology Report, revealed x-ray results, dated 10/22/2025, as follows:HAND 2 View, RIGHTResults: Subtle bone loss at the 5th DIP joint with swelling. Conclusion: findings suggest osteomyelitis, recommend MRI.Signed 10/23/2025 at 08:52 AM.During an interview on 03/04/2026 at 04:07 PM, the DON stated when nurses respond to reports of resident skin tears, the nurses should contact the provider, get orders, and then implement the orders. The DON stated orders should be added to the system as soon as they are given by the provider. The DON stated Resident #10's primary care provider suspected osteomyelitis related to Resident #10's right pinky finger. The DON stated the x-ray results revealed osteomyelitis for Resident #10's right pinky.Review of a facility policy titled Physician Orders, dated 02/2026, revealed:Policy: Nurses, therapists and pharmacists may take verbal and/or telephone orders as permitted by their state licensure board.Procedures:11. Note Physician's Order (recaps/renewals, telephone/verbal, or fax orders, etc.) by writing noted, dating, and signing with the name and title.12. Confirm the accuracy of orders. Review orders daily in the Clinical meeting to confirm the accuracy in transcription and identify errors of omission.

Based on observations, interviews, and record review, the facility failed to ensure urinary catheter care and services were provided in accordance with professional standards of practice for two residents (#16, #7) out of three residents sampled for catheter care.Findings Include:1. On 03/04/2026 At 9:27 AM Resident #16's urinary catheter bag was observed detached from the bed and resting directly on the floor. Urine appeared slightly cloudy.On 03/04/2026 At 12:32 PM the urinary catheter bag was observed on the floor. On 03/04/2026 At 1:35 PM the urinary catheter bag was observed on the floor.Record review of the March 2026 (Treatment Administration Record) TAR indicated Resident #16 received urinary catheter care as ordered on the day shift of 03/04/2026.Review of Resident #16's admission Record revealed Resident #16 was admitted to the facility on [DATE] with diagnoses to include chronic kidney disease (Stage 4) and obstructive uropathy.The Care Plan for Resident #16, initiated 10/24/2025, directed staff to keep drainage bags below level of bladder and ensure catheter bag is not on the floor.During an interview on 03/04/2025 at 1:03 PM with Staff D, Certified Nursing Assistant (CNA), stated she checks the assigned residents every two hours and ensures the catheter tubing is secured and that the drainage bag is always hanging on the bed frame, kept off the floor to prevent infection.During an interview on 3/4/26 at 2:01 p.m. Staff G, Licensed Practical Nurse (LPN) stated if she has a resident with an indwelling catheter she would check the catheter bag throughout the day to make sure the resident has urine output and what it looks like. She stated the urine should be yellow and clear. She stated if the urine is cloudy or a different color like brown, red or dark she would notify the doctor. She stated if the resident is not having a lot of output, she would notify the doctor. She stated the cnas usually provide care and empty it but will empty the catheter bag when necessary. Upon arriving at Resident #16's room, Resident#16's catheter bag was observed on the floor. Staff G stated the catheter bag was on the floor. She stated the catheter bag should not be on the floor because it could cause an infection.During an interview on 3/4/26 at 4:07 p.m. The Director of Nursing (DON) stated the CNAs are responsible for catheter care. She stated urinary catheter bags should not be on the floor.2. Review of Resident #7's admission record revealed a readmission on [DATE] with diagnoses including obstructive uropathy, renal disease, communicating hydrocephalus, altered mental status, dementia, and acidosis.Review of the Daily Skilled Nursing Notes revealed the following: 10/21/25 urine clear and yellow. Abdomen is non-tender. Bowel sounds presented in all quadrants. 10/23/25 urine is clear and yellow. Abdomen is non-tender. Bowel sounds presented in all quadrants. 10/24/25 urine is clear and yellow. Abdomen is non-tender. Bowel sounds presented in all quadrants.Review of the care plan for Resident #7, initiated 10/21/2025, indicated the resident used a urinary catheter with risk for infection and complications. Staff were directed to change drainage bag routinely and as needed and provide catheter care daily & as needed.Review of a Nursing Progress note dated 10/26/2025 showed Upon entering room [ROOM NUMBER] resident was observed lethargic and not responding to verbal stimuli. 11-7 Nurse called 911 EMS arrived at bedside. Resident sent to ER for evaluation and treatment. On call md was notified. Responsible party called left message to call facility. DON was notified.Review of the Hospital admission record from 10/26/2025 for Resident #7 indicated the resident was admitted with Severe Sepsis secondary to Urinary Tract Infection (UTI), Life-Threatening Hypernatremia (>170), and Acute Kidney Injury. Computed Tomography (CT) scan findings revealed the catheter balloon was inflated in the urethra rather than the bladder, causing a significant distended bladder (1250 mL urine) and bilateral hydroureteronephrosis.During an interview on 02/25/2026 at 10:05 AM with Staff G, Licensed Practical Nurse (LPN), stated she did not specifically recall the resident's catheter status. She noted the resident visually looked clean but remembered he wasn't responding normally prior to transfer. Despite this observed change in condition, no assessment of the urinary catheter patency was documented.During Interviews on 03/04/2026 at 1:42 PM with Staff F, Certified Nursing Assistant (CNA), stated she had no recollection of the resident or whether he had an indwelling catheter. She described her standard care as frequent hourly rounding, reporting urinary catheter related abnormalities to nurses, and emptying the urinary bag every shift.During Interviews on 03/04/2026 at 2:01 PM with Staff E, Certified Nursing Assistant (CNA), stated she had no recollection of the resident having an indwelling catheter. She described her standard care as frequent rounding of every two hours, reporting urinary catheter related abnormalities to nurses, and emptying the urinary bag once to twice a shift.

Based on interviews and record review the facility did not ensure pain management was provided as ordered for two residents (#11 and #13) out of two residents sampled. Findings included:1) An interview on 2/24/2026 at 12:25 P.M with Resident #11 was conducted. Resident #11 said she does not receive her medication as scheduled. Resident #11 said when she does not receive her pain medication as scheduled, she has pain for the rest of the day.A review of Resident #11's admission Record showed she was admitted to the facility on [DATE] with diagnoses including contusion of right knee, muscle weakness, and need for assistance with personal care.A review of Resident #11's Minimum Data Set (MDS), Section C, dated 12/11/2025, revealed a Brief Interview for Mental Status (BIMS) score of 15 indicating intact cognition. A review of Resident #11's MDS Section J, dated 12/11/2025 revealed the resident was experiencing pain with an average pain intensity of 07 over the last five days. The numeric pain rating scale was indicated by asking the resident to rate the pain on a scale of 00-10 over the last five days with zero being no pain and ten as the worst pain imagined.A review of Resident #11's physician orders revealed an order for Hydrocodone-Acetaminophen Tablet 5-325 MG Give 1 tablet by mouth every 8 hours for chronic pain.A review of Resident #11's Medication Administration Record (MAR) for January 2026 revealed the resident did not receive pain medication as ordered on 1/11/2026 at 6:00 A.M. and 1/15/2026 10:00 P.M.2) An interview on 2/24/2026 at 12:31 P.M with Resident #13 was conducted. She said she there are times she does not receive her pain medication leading to her having severe pain. Resident #13 said she is one a schedule pain medication regimen.A review of Resident #13's admission Record showed she was admitted to the facility on [DATE] with diagnoses including generalized anxiety disorder, age-related osteoporosis, and unspecified abdominal pain.A review of Resident #13's Minimum Data Set (MDS), Section C, dated 1/14/2026 revealed a Brief Interview for Mental Status (BIMS) score of 13 indicating cognitively intact. A review of Resident #13's MDS Section J, dated 1/14/2026 revealed the resident was experiencing pain with an average pain intensity of 07 over the last five days. The numeric pain rating scale was indicated by asking the resident to rate the pain on a scale of 00-10 over the last five days with zero being no pain and ten as the worst pain imagined.A review of Resident #13's physician orders revealed an order for monitoring pain every shift and recording pain number on a 0-10 scale. A review of Resident #13's MAR for January 2026 revealed her pain level was not recorded on 1/10/2026 on night shift and Resident #13's pain level on 1/11/2026 on day shift was recorded as 10/10 indicting severe pain. On 1/14/2026 evening shift her pain level as recorded as 5/10 indicting moderate pain.A review of Resident #13's physician orders revealed an order for oxycodone HCl oral tablet 5 MG; Give 1 tablet by mouth every 8 hours for pain.A review of Resident #13's MAR for January 2026 revealed the resident did not receive the medication on 1/29/2026 at 2:00 P.M.A review of Resident #13's physician orders revealed an order for Hydrocodone-Acetaminophen oral tablet 5-325 MG, give 1 tablet via g-tube every 6 hours for pain.A review of Resident #13's MAR revealed the resident did not receive the medication on 1/11/2026 at 12:00 A.M. or 1/11/2026 at 6:00 A.M.A review of Resident #13's physician orders revealed an order for Hydrocodone-Acetaminophen oral tablet 7.5-325 MG, give 1 tablet via g-tube every 6 hours for pain.A review of Resident #13's MAR revealed documentation of NA on 1/14/2026 at 6:00 P.M. and documentation of 9 (indicting to see progress notes) on 1/20/2026 at 12:00 A.M.A review of Resident #13's progress notes on 1/20/2026 revealed no documentation related to the resident receiving pain medication.An interview on 2/25/2026 at 11:00 A.M. with the Activities Director (AD) was conducted. The AD said she remembered a few months ago Resident #11 filed a grievance regarding not receiving her medications. The AD does not know the outcome of that grievance.An interview on 2/25/2026 at 3:25 P.M. with the Regional Nurse Consultant (RNC) was conducted. The RNC said Resident #11 should have received the medication as ordered by the physician. The RNC said Resident #11 does experience a high pain level often and the resident receives scheduled pain medication. The RNC stated the documentation of Resident #13's MAR does not make any sense. The RNC said Resident #13 should have received the medications as ordered by the physician; noting a reason in the progress notes if the medication was not given. A review of the facility policy, dated 2007, titled Medication Administration General Guidelines revealed the following:Medication Administration: 1: Medications are administered in accordance with written orders of the prescriber . 2: Obtain and record any vital signs necessary prior to medication administration. 14: Medications are administered within 60 minutes or scheduled time. Documentation: 1: The individual who administers the medication dose, records the administration on the resident's MAR immediately following the medication being given.

Based on record review and interviews, the facility failed to protect the residents' right to be free from neglect for eleven residents (#1, #2, #3, #4, #5, #6, #7, #8, #9, #10, and #11) out of eleven residents sampled related to seizure medication management and follow-up laboratory orders for seizure medication therapeutic levels. Serious harm occurred when Resident #1's seizure medication levels were not monitored, and neurology consultation was not obtained per the provider's request. Resident #1 experienced a seizure on 7/10/24, 9/28/24, 9/29/24, and 2/27/25. Resident #1 had to be transferred to a higher level of care as a result of the seizure suffered on 2/27/25. This failure created a situation that resulted in a worsened condition and the likelihood for serious injury and/or death to Resident #1 and resulted in the determination of Immediate Jeopardy on 4/16/2025. The findings of Immediate Jeopardy were determined to be removed on 4/17/2025 and the scope and severity was reduced to an E after verification of removal of immediacy of harm. Findings included: 1. Review of Resident #1's Admission Record revealed she was admitted to the facility on [DATE] from an acute care hospital with medical diagnoses of generalized idiopathic epilepsy and epileptic syndromes, not intractable, without status epilepticus, gastrostomy status as of 3/6/25, traumatic subdural hemorrhage with loss of consciousness, hydrocephalus, paraplegia, adult failure to thrive, protein-calorie malnutrition, anxiety disorder, major depressive disorder, lack of coordination, cognitive communication deficit, and Bell's palsy. Review of Resident #1's physician orders revealed the following: -Depakote (Valproic Acid) Sprinkles Oral Capsule delayed release 125 mg (milligrams), give one capsule by mouth two times a day for seizures, start date 5/23/24 and discontinued on 7/5/24. -Depakote Sprinkles Oral Capsule delayed release 125 mg, give one capsule by mouth three times a day for seizures, start date 7/6/24 and discontinued on 4/2/25. Review of Resident #1's July 2024 Medication Administration Record (MAR) revealed she received 125 mg of Depakote three times a day starting on 7/6/24. Review of Resident #1's laboratory (lab) results, dated 7/6/24, revealed her Valproic Acid levels were low at 10 microgram per milliliter (ug/ml). with a reference range of 50-100 ug/mL. Review of Resident #1's progress note, dated 7/7/24 at 8:13 p.m., revealed Hard copy labs called to ARNP (Advanced Registered Nurse Practitioner) . No new orders. Review of Resident #1's ARNP note, dated 7/7/24, revealed: CHIEF COMPLAINTS 7/7/24 fu [follow up] Visit She [Resident #1] has had some seizures in the past and had the recent seizure staff members reporting. Recently she had the seizure and medications were adjusted. Overall, she is very weak and feels like she is de-conditioned. She relies on staff to complete ADL's [activities of daily living] and assist with feeding in general. .ASSESSMENT AND PLAN .Seizure D-[NAME] [disorder] 7/7/24 Neurology consult, check medication levels .increased dose, depakote leve[sic] . Review of Resident #1's Progress note, dated 7/10/24 at 8:19 a.m., revealed Resident had a tonic-clonic seizure [a type of seizure with muscle stiffing followed by rhythmic jerking with a loss of consciousness] for 2 minutes. Resident was contracted and shaking the full time of the seizure. Resident is currently lying in bed. Dr. notified and waiting for a call back. Review of Resident #1's medical record did not reveal evidence the physician called back, or further attempts were made to contact the physician. Review of Resident #1's physician order revealed an order with a start date of 7/12/24, and an end date of 7/12/24 for Depakote Valproic Acid levels one time only for 1 day notify MD [Medical Doctor] of results. Review of Resident #1's lab results, dated 7/12/24, revealed Valproic Acid results were low (12 ug/mL) with a reference range of 50-100 ug/ml. Review of Resident #1's medical record did not reveal evidence the physician was notified of the low Valproic Acid level on 7/12/24. Review of Resident #1's physician orders revealed an order, with a revision date of 7/15/24, a start date of 7/22/24, and an end date of 7/23/24, to recheck Valproic Acid level in one week. Review of Resident #1's progress note, dated 7/22/24 at 3:06 a.m., revealed Resident to have Valproic Acid level rechecked today Review of Resident #1's Treatment Administration Record (TAR) revealed the physician order for Resident to have Valproic Acid level rechecked today was signed off as completed on 7/22/24 at 3:06 a.m. Review of Resident #1's Lab Order History from the lab portal did not reveal a physician's order was in the lab portal for Valproic Acid to be drawn on 7/22/24. Review of Resident #1's medical record did not reveal evidence the Valproic Acid was drawn on 7/22/24 and reported to the physician. Review of Resident #1's Advanced Practice Registered Nurse (APRN) note, dated 9/13/24, revealed CHIEF COMPLAINTS 9/13/24-fu [follow up] Visit .Recently she had the seizure and medications were adjusted. Overall, she is very weak and feels like she is de-conditioned. She relies on staff to complete ADL's [activities of daily living] and assist with feeding in general. . ASSESSMENT AND PLAN .Seizure 9/13/24 Neurology Consult, check medications levels . Review of Resident #1's Physician note, dated 9/20/24 revealed CHIEF COMPLAINTS 9/20/24 fu Visit . Recently she had the seizure and medications were adjusted. Overall, she is very weak and feels like she is de-conditioned. She relies on staff to complete ADL's and assist with feeding in general. .Assessment and Plan .Seizure 9/20/24 Neurology consult, check medications levels . Review of Resident #1's medical record revealed no evidence she received neurology services. Review of Resident #1's progress note, dated 9/28/24 at 5:36 PM, revealed Resident had a seizure while lying in bed at 1730 [5:30PM]. Resident was laying on her side while seizure was occurring. Made sure of resident safety. Seizure was under 5 minutes long and not reoccurring. Resident is now alert and able to speak and move. No discomfort or pain noted. No injuries. MD [Medical Doctor] notified. New order placed for labs. Review of Resident #1's physician orders revealed, an order with an order date of 9/28/24,for Depakote level, Ammonia Level, Levetiracetam (Keppra), and Lacosamide level. There was no start date or end date on the physician order. Review of Resident #1's September 2024 MAR revealed the physician order for Depakote level, Ammonia level, Levetiracetam (Keppra), and Lacosamide level was not documented as completed. Review of Resident #1's Lab Order History on the laboratory portal did not reveal a physician order was placed on 9/28/24 for Depakote level, Ammonia Level, Levetiracetam (Keppra), or a Lacosamide level. Review of Resident #1's progress note, dated 9/29/24 at 7:30AM, revealed Seizure activity noted this am [morning] lasting approximately 3.5 minutes s/p [status post] snoring lasting about 2 minutes then aroused making eye contact with staff alert and orientated to self-97.2 [temperature]-76 [pulse]-20 [respiratory rate]-128/82 [blood pressure]-97% [oxygen saturations] R/A [room air]. Review of the medical record did not reveal the resident's physician was notified of the seizure. Review of Resident #1's lab report with a collection date of 9/30/24 at 5:09 p. m., revealed Valproic Acid was low (14 ug/mL) with a reference range of 50-100 ug/ml. Review of Resident #1's medical record did not reveal evidence the physician was notified of the low Valproic Acid (Depakote) lab results collected on 9/30/24. Review of Resident #1's physicians' orders, revealed an order, with a start date of 2/4/25 and an end date of 2/5/25, for a Complete Blood Count (CBC), Comprehensive Metabolic Panel (CMP), Depakote level, and Ammonia level, every night shift for one day. Review of Resident #1's lab results with a collection date of 2/5/25, revealed abnormal CBC, CMP and Depakote Level results for the following lab values: Glucose: Low (67 milligrams per deciliter (mg/dL)) with a reference range of 70-99 mg/dL BUN: High (24 mg/dL) with a reference range of 6-20 mg/dL BUN /Creatinine Ratio: High (38.6 mg/dL) with a reference range of 6.0-25.0 mg/dL Calcium: Low (3.4 mg/dL) with a reference range of 8.6-10.2 mg/dL RBC: Low (3.93 million per microliter (M/uL)) with a reference range of 4.1-10.9) M/uL HGB: Low (11. grams per deciliter (8g/dL)) with a reference range of 12.0-16.0 g/dL HCT: Low (35.9%) with a reference range of 37.0-47.0% Valproic Acid (Depakote): low (25 ug/mL) with a reference range of 50-100 ug/mL Review of Resident #1's Lab Order History on the laboratory portal revealed the Ammonia order, dated 2/5/25, had a status of collection pending, no results and there was no sample collection date. Review of Resident #1's medical record revealed no evidence the physician was notified of the abnormal lab results collected on 2/5/25. The medical record revealed no Ammonia levels were collected or physician communication related to the Ammonia level lab not being collected. An interview was conducted on 4/15/25 at 12:45 p.m. with the Director of Nursing (DON). She reviewed Resident #1's Lab Order History on the laboratory portal, and she said Collection pending, No Results means the labs were not drawn. Review of Resident #1's progress note, dated 2/27/25 at 9:18 a.m., revealed At approx. [approximately] 7:30am resident was having seizure activity. foaming[sic] at mouth and release of urine and feces noted. resident[sic] moved to[sic] onto her side until seizure ceased. Resident cont [continued] to be slow to wake and is nonverbal at this time. Resident has history of seizure activity. Family and MD aware. Review of Resident #1's change in condition, dated 2/27/25, revealed The change in condition .: Altered mental status The seizure was: New onset seizure activity, OR persistent seizure in someone with known intermittent seizure activity. Provider Notification and Feedback: .send to ER [emergency room ] Review of Resident #1's hospital record revealed a physician note, dated 2/28/25, as: Impressions and Plan Breakthrough seizures due to noncompliance. The patient is currently unresponsive. This could be due to a postictal state, non-convulsive seizure activity or encephalopathy. I spoke to her [Resident #1's] nurse . at the nursing home . the patient has been refusing her medications. Yesterday she had a 4-minute convulsive seizure. Low Keppra level Low Depakote level but her dose of this medication may not be therapeutic. .Plan Prescribe telemetry Neurochecks every 2-4 hours Seizure precautions Lorazepam 2mg IV [intravenous] for convulsive seizure activity lasting more than 100 seconds IV Keppra IV Depakote IV Vimpat. She is also on oxcarbazepine that is not available in IV form, but the other AED's [anti-epileptic drugs] should be adequate. There is not yet clear how her refusal to take p.o. [by mouth] AEDs will get resolved. She may need a PEG [percutaneous endoscopic gastrostomy]. Review of Resident #1's hospital Gastrointestinal Physician note, dated 3/3/25, revealed: The patient presents with 50 yo [year old] f [female] who presented to the ed [emergency department] from her facility after a witnessed seizure. pt [patient] was also in the ed 2 days ago for glf [ground level fall]. I was asked to see the pt for a peg tube. Pt denies abdominal pain, n/v [nausea/vomiting] and dysphagia. Apparently, she frequently refuses to eat and take her medications due to her neurologic and psychiatric issues. Pt did not have issues swallowing during her vss [video swallow study]. per nursing if she is fed she will eat. She does pocket her food and requires verbal reminders. She has no abdominal pain, d/c [discomfort]. She has no gi [gastrointestinal] complaints. .plan Npo[nothing by mouth] after mn [midnight] Egd [esophagogastroduodenoscopy]/peg tomorrow. Review Resident #1's December 2024 through February 2025 Medication Administration Record (MAR) revealed she received 10 ml's of Keppra (100 mg/ml) by mouth twice a day every day for seizures except on 12/12/24 at 5:00 p.m. the documentation revealed 10. Review of the chart codes revealed 10=spit out meds. On 2/25/25 at 9:00 a.m. the documentation revealed 6 review of the chart codes revealed 6= hospitalized . On 2/26/25 at 9:00 a.m. the documentation revealed 2. Review of the chart codes revealed 2=drug refused. The February MAR review revealed Resident #1 received Depakote sprinkles 125 mg three times a day for seizures every day for the month of February until she was discharged on [DATE], except on 2/25/25 at 9:00 a.m. and 1:00 p.m., the documentation revealed Resident #1 was hospitalized . On 2/26/25 at 9:00 a.m. and 1:00 p.m. the documentation revealed Resident #1 refused the drug. Review of Resident #1's progress note, dated 3/6/25 at 2:12 p.m., revealed Resident returned to facility at approx. [approximately] 1;[sic]55pm via stretcher/ EMS [emergency medical services]. resident[sic] had no s/s [signs and symptoms] of distress noted .Resident has PEG tube in place and can eat by mouth. Jevity 1.2 @ 60 FWF [free water flush] 200ml q6 [every 6]. Resident can eat by mouth soft / bite sized. 1400 total in 24 hours. Two boxes a meal. Review of Resident #1's nutrition note, dated 3/7/25 at 9:59 a.m. revealed, Res [Resident] readmitted to facility 3/6/25 s/p [status/post] 7d [day] hospitalization . New Gtube [gastrostomy tube] inserted however res eats 75-100% of meals by mouth and requests snacks frequently. Will d/c [discontinue] enteral feed as res is able to meet needs via po [by mouth] at this time. Flush tube w/ [with] 150cc H20 [water] q [every] shift to maintain patency. Review of Resident #1's progress note, dated 3/7/25 at 10:21 a.m., written by Staff A, Licensed Practical Nurse (LPN), revealed, This writer received order from NP [Nurse Practitioner] stating resident able to take medication by mouth if resident refuses then we may use PEG-Tube for medications; resident is currently eating meals w/o [without] issues or concerns. An interview was conducted on 3/31/25 at 3:10 p.m. with the DON. The DON stated she did not assign a primary person to oversee the labs and review results. She said if labs were not critical staff would put the lab results in the providers' boxes for them to sign. If the labs were critical staff would call the provider to inform them about the critical lab results. The DON stated labs for seizure medications should be drawn every three months, but she does not know why some resident's labs were not being checked. She stated Resident #1's Depakote levels were being monitored by the psychiatric nurse practitioner. The DON stated she was aware that this was a system failure on the facility when it came to their lab process. She stated she would have expected her nurses to fax labs results to the doctor, put follow-up labs in to check the Depakote levels, and monitor the process. The DON stated Resident #1's labs from 9/30/2024 and 2/5/2025 were not signed off by the provider to show they reviewed the resident's lab results. She stated she thought Resident #1 had a neurology consultation while in the hospital, but the facility did not follow up to schedule a neurology appointment for Resident #1. The DON stated Resident #1's and Resident #2's labs were not done because the nurses were not transcribing the information from the orders to the lab reconciliation sheet and putting them in the lab book, so the tech knows which labs to draw for which residents. The DON stated it was her responsibility to ensure the resident's neurology consultation was followed up on. She stated there was a system failure because management did not have anyone assigned to pull labs, review lab results, and ensure all ordered labs were completed. The DON said their process was broken for following up with labs and completing documentation. An interview was conducted on 3/31/2025 at 3:50 p.m. with Resident #1's Psychiatry Physician Assistant (PA). The Psychiatry PA said he does not manage Resident #1's Depakote levels. If a resident is on Depakote for Seizures Psychiatry would not manage the medication; that would be managed by a resident's Primary Care Provider (PCP). An interview was conducted on 3/31/2025 at 4:20 p.m. with Resident #1's Advanced Practice Registered Nurse (APRN). The APRN said he does not monitor residents Depakote because it is managed by Psychiatry. He stated Depakote is not a medication he would prescribe a resident for seizures. He stated that he made a referral to have Resident #1 seen by a Neurologist in September 2024 and then again when Resident #1 came back from her most recent hospital stay (3/6/25), but he is not sure if the facility had followed up on his referral. He stated it is possible the low seizure medication labs could have been caught before the resident had her seizure if the facility had been managing her lab results and followed up with neurology. He stated residents who are on Keppra and Depakote medications for seizures should have labs drawn every three to six months to ensure the medication level are therapeutic for the resident's diagnosis. The APRN confirmed the facility should be doing the labs as ordered by the provider. For abnormal labs the facility should notify him the day the labs resulted and for critical labs the facility should get a hold of him. An interview was conducted on 4/15/25 at 1:50 p.m. with Staff B, LPN, she said she has worked at the facility on and off for four years and is very familiar with Resident #1. She said, Some years ago Resident #1 had a PEG tube for not eating, drinking, or taking her medications but she kept pulling the PEG tube out, so her family decided to just leave it out. She was doing well without it, eating, drinking, and taking her medications without any concerns. Staff B, LPN said for less than one day Resident #1 was not eating, drinking, or taking her medications and when she came in the next morning she had a huge gran-mal seizure, foaming at the mouth, lost control of her bowel and bladder, and then became post ictal (the period immediately following a seizure when the brain recovers, and the body returns to its normal state. During this phase, individuals may experience a range of symptoms, including confusion, drowsiness, headache, and cognitive difficulties.) Staff B, LPN said Resident #1's normal seizures are focal seizures, and she just stares, and they do not last long but this was a big one. Staff B, LPN said she called the physician and had Resident #1 sent to the hospital. Staff B, LPN said when Resident #1 returned the family must have agreed to a PEG tube again because she came back with a PEG tube but all we do is flush it in the morning with water. She said Resident #1 eats by mouth and takes her medications by mouth without any problems. She said since Resident #1 has returned from the hospital after her seizure she is still herself but not quite the same, we definitely fried some brain cells with that seizure. An interview was conducted with the Medical Director on 4/15/25 at 3:11 p.m., she said she was Resident #1's primary physician and she was familiar with the resident. She said, typically Resident #1's seizures are controlled, and she was on multiple seizure medications but, she did go to the hospital for a seizure. The Medical Director said when Resident #1 was admitted to the hospital for the seizure, her Keppra levels were low and her Depakote levels were not therapeutic, because she was not eating and was pocketing her medications [storing medications in her cheek]. She needed intravenous (IV) Keppra and IV Depakote because her levels were very low and it was an emergency. The Medical Director reviewed Resident #1's hospital notes and said Resident #1 had a PEG tube placed in the hospital because she was not eating or taking her medication, so it was life saving for her to have the PEG tube. The Medical Director said she did not remember the staff at the nursing home notifying her Resident #1 was not eating, drinking, or taking her medications. She said the nursing notes will reflect if they notified her or her APRN. The Medical Director said when labs are ordered her expectation is they are collected and once they have resulted the nurses should notify them immediately if any labs are critical. If they aren't critical then the nurses are supposed to put the results in the folder so she or her APRN can check them when they come in three to five times a week. The Medical Director said seizure medication levels should be drawn upon admission and every six months and if the seizure medication labs are abnormal the nursing staff should be notifying the Neurologist because she is not the Physician for the seizure medications, she is just supporting. The Medical Director said if there is an order for a neurology consultation then the facility should coordinate so the resident sees a Neurologist. The Medical Director said the residents had to go out to see a Neurologist because the facility did not have one coming to the facility. But there are transportation problems for bed ridden patients. An interview was conducted on 4/16/25 at 10:37 a.m. with Staff C, LPN she said she would get floated to take care of Resident #1. She said she works two double shifts a week the 3:00 p.m. to 11:00p.m. and 11:00 p.m. to 7:00 a.m. shift. She said before Resident #1 had her big seizure (2/27/25) she didn't have any problems giving her, her medications. She said the nurses knew you had to give her the medications in foods she liked, such as a milk shake. She said Resident #1 used to self-propel herself up and down the hallways yelling cheeseburger and asking for coffee. Staff C, LPN said now she is just not as spunky as she used to be before the seizure. Staff C, LPN said when she returned from the hospital she came back with a PEG tube. She said Resident #1 does not use the PEG tube, it's only there if she refuses to take her medications by mouth. Staff C, LPN said she does not have any issues with Resident #1 taking her medications or eating and drinking. An interview was conducted on 4/16/25 at 10:56 AM with Staff A, LPN 200 hall Unit Manager (UM) and the DON. Staff A, LPN, UM, said she has been a UM since the end of September and did not take over the 200 hall until the end of November. She said she knew Resident #1 for the most part, at the beginning, when Staff A, LPN, UM first started, she had only spit out her medications a couple of times and she was always eating so it was easy to give her medications. Only a day or two before her February seizure she was refusing her medications, But it wasn't long that she was refusing her meds before her seizure. The DON said it's their understanding she had a PEG tube a few years ago for failure to thrive but she had pulled it out and it was left out because she was eating and taking her medications by mouth without issues. The DON said when she came back from the hospital with the PEG tube, she worked with speech therapy and they were able to upgrade her diet right away and she continued to eat, drink, and take her medications without any problems. The DON said, she uses it for nothing and it is there just in case she does not take her medications. An interview was conducted on 4/16/25 at 11:02 a.m. with the DON. She said all the clinical nurses did not have access to the lab portal because they changed to the current lab in June 2024, We didn't push to get everyone access, there was just a push to get the system online. The DON said she had noticed for the past couple of months that lab orders had been cancelled. She said the facility just reordered the labs and didn't question why. The DON said the labs were just reordered and it was not really looked at as a system failure. A phone interview was conducted on 4/17/25 at 1:00 p.m. with Resident #1's Heath Care Proxy and family. They said they were informed Resident #1 went to the hospital in February for a seizure and when she was at the hospital, the hospital had called them and told them Resident #1 was pocketing her food, not drinking and not taking her medications that's why she had the seizure. The family gave the approval to put the PEG tube in and then they had a care plan meeting with the facility, and they were told Resident #1 was eating well and taking her medications by mouth and they were not using the PEG tube. A phone interview was conducted on 4/17/25 at 2:27 p.m. with the Regional Lab Supervisor. She said the Phlebotomist comes to the facility six days a week Monday through Saturday regardless if there are lab orders or not. She said they provide a Phlebotomist for STAT (immediately or without delay) labs as they need it. The Lab Supervisor said the expectation is the facility puts the lab order into the lab portal, print out the reacquisition form, and put the reacquisition form in the lab book. She said if the nurses don not have access to the lab portal, they can hand write the order on a blank reacquisition form, that the lab company provides, and put that in the lab book. The Phlebotomist will not know a lab needs to be drawn on a resident if there is not a reacquisition form in the lab book. The Lab Supervisor said if the nurse has put the order into the lab portal, but they did not print the requisitions form and put it in the lab book then the Phlebotomist will not collect the lab and the order will sit in the portal and have a status of collection pending, no results. If the order is cancelled due to a collection error, then the lab will call the facility and have the nurse re-enter the order in the lab portal and print the reacquisition to put in the lab book so the Phlebotomist can redraw the labs the next day. Once the Phlebotomist has drawn the labs, they take the reacquisition forms with them and when they drop off the lab specimen someone from the lab makes sure the reacquisition was put into the portal because that's the only way the lab can print labels for the specimen. Once the test has resulted, then the result is uploaded into the lab portal and if there is a critical result the lab calls the facility. 2. Review of Admission Records showed Resident #2 was admitted on [DATE] with diagnoses including unspecified injury of head and unspecified convulsions. Review of Resident #2's care plan showed a focus area of Seizure disorder. Interventions included: give seizure medication as ordered by doctor. Monitor/document side effects and effectiveness and obtain and monitor lab/diagnostic work as ordered. Report results to MD and follow up as indicated and monitor labs and report sub therapeutic or toxic results to MD. Dated 10/4/17. Review of Resident #2's order showed the following: -Fasting comprehensive metabolic panel (CMP), lipids, complete blood count (CBC), Valproic Acid level, Ammonia level. One time a day every 4 months starting on the 1st for 1 day for hypertensive atherosclerotic cardiovascular disease (ASCVD), drug monitoring. Schedule routine weekday mornings. Dated 3/9/22. -Fasting CMP, Lipids, CBC, Valproic Acid level, Ammonia level. Every night shift for 1 day. Dated 12/1/24. -Divalproex Sodium HCL capsule delayed release 250 mg (Depakote). Give 250 mg by mouth at bedtime for seizure disorder related to unspecified convulsions. Dated 4/13/22. -Valproic Acid level. Dated 3/31/25. -Ammonia level. Dated 4/1/25. Review of lab results for Resident #2 showed Valproic Acid level and Ammonia level, dated 8/1/24. The Valproic Acid level was low at 23 ug/ml with a reference range of 50-100 ug/ml and the ammonia level was high at 69 ug/ml with a reference range of 11.0-35.0 ug/ml. There were no results found for the labs ordered to be drawn on 12/1/24. The 3/31/25 order for Valproic Acid level was not completed. The labs were reordered and drawn on 4/15/25 with a low result of <13 ug/ml with a reference range of 50-100 ug/ml. The Ammonia level drawn on 4/1/25 was high at 80 umoL/ml with a reference range of 18-72 umoL/ml. Review of Resident #2's progress notes showed no documentation a provider was notified of the abnormal Valproic Acid and Ammonia results on 8/1/24. Review of Resident #2's Lab Order History on the lab portal showed no orders were input in their system for labs to be drawn on 12/1/24. There was an order put in on 3/31/25 for a Valproic Acid level. Review of Resident #2's progress notes, dated 4/15/25, showed obtained orders to redraw Valproic Acid due to alb [albumin] stating uncollected lab and Lab tech out to get STAT Valproic Acid. An interview was conducted on 4/15/25 at 12:40 p.m. with the DON. She confirmed Resident #2 had a Valproic Acid level ordered on 3/31/25 that was not completed. She said they did not realize it was not done until 4/15/25. At 1:56 p.m. the DON reviewed Resident #2's medical record and confirmed there was an active order for labs every 4 months. She said the lab order was one that had fallen through the cracks and labs were not transcribed to the lab portal and lab reconciliation sheets. She confirmed the resident had labs in August 2024 and not again until 3/31/25. A follow-up interview was conducted on 4/17/25 at 5:15 p.m. with the DON. She said somehow Resident #2's lab was cancelled on 4/15/25 by the lab or the nurse. She said the unit manager (UM) had been given this to check on the homework sheet and they should have caught the fact the lab was not completed. 3. Review of Admission Records showed Resident #8 was admitted on [DATE] with diagnoses including epilepsy. Review of Resident #8's physician orders revealed the following: -Levetiracetam (Keppra) Oral Tablet 500 mg. Give 3 tablet by mouth two times a day related to epilepsy. Dated 11/25/24. -Ammonia Level. Every night shift every Wednesday for 4 weeks. Dated 2/5/25. Review of Resident #8's lab results, dated 3/4/25, showed an Ammonia Level results of 118 umol/L (micromole per liter) with a reference range of 18-72 umol/L. This was indicated as a critical result. The lab showed the result was reported on 3/4/25 at 11:38 a.m. Review of Resident #8's progress notes showed no documentation a provider was notified on 3/4/25 of the critically high ammonia level. There was a progress note, dated 3/5/25 at 9:02 a.m.,. showing labs were sent to the Advanced Registered Nurse Practitioner. Review of Resident #8's Treatment Administration Record (TAR) showed the Ammonia level that was scheduled to be rechecked on 3/20/25 was documented as 9 indicating Other/See Nurse Notes. Review of progress notes revealed no nurses' note showing why the lab was not drawn. Review of Resident #8's lab results, dated 4/1/25, showed a Keppra level high at 49.5 ug/mL with a reference range of 6.0-46.0 ug/mL. An interview was conducted on 4/1/25 at 2:35 p.m. with the DON. She reviewed Resident #8's medical record and confirmed documentation showed the provider was not notified of the critical high ammonia level until the day after the results were received. She said her expectation would be the provider to be notified immediately of critical results. The DON confirmed there was no documentation as to why the ammonia level scheduled for 3/20/25 was not completed and said it should have been rescheduled but was not. 4. Review of Admission Records showed Resident #4 was admitted on [DATE] with diagnoses including other seizures. Review of Resident #4's care plan showed a focus area of seizure disorder, dated 8/27/24. Interventions included obtain and monitor lab/diagnostic work as ordered. Report results to MD and follow up as indicated. Review of Resident #4's orders revealed the following active orders: -Depako [TRUNCATED]

Based on interviews and record reviews, the facility failed to provide competent physician services for the treatment and monitoring of seizure diagnoses for eleven residents (#1, #2, #3, #4, #5, #6, #7, #8, #9, #10, #11) out of eleven sampled residents. Serious harm occurred when Resident #1's seizure medication levels were not monitored, and neurology consultation was not obtained per the provider's request. Resident #1 experienced a seizure on 7/10/24, 9/28/24, 9/29/24, and 2/27/25. Resident #1 had to be transferred to a higher level of care as a result of the seizure suffered on 2/27/25. This failure created a situation that resulted in a worsened condition and the likelihood for serious injury and/or death to residents and resulted in the determination of Immediate Jeopardy on 4/16/2025. The findings of Immediate Jeopardy were determined to be removed on 4/17/2025 and the scope and severity was reduced to an E after verification of removal of immediacy of harm. Findings included: 1. Review of Resident #1's Admission Record revealed she was admitted to the facility on [DATE] from an acute care hospital with medical diagnoses of generalized idiopathic epilepsy and epileptic syndromes, not intractable, without status epilepticus, gastrostomy status as of 3/6/25, traumatic subdural hemorrhage with loss of consciousness, hydrocephalus, paraplegia, adult failure to thrive, protein-calorie malnutrition, anxiety disorder, major depressive disorder, lack of coordination, cognitive communication deficit, and Bell's palsy. Review of Resident #1's physician orders revealed the following: -Depakote (Valproic Acid) Sprinkles Oral Capsule delayed release 125 mg (milligrams), give one capsule by mouth two times a day for seizures, start date 5/23/24 and discontinued on 7/5/24. -Depakote Sprinkles Oral Capsule delayed release 125 mg, give one capsule by mouth three times a day for seizures, start date 7/6/24 and discontinued on 4/2/25. Review of Resident #1's July 2024 Medication Administration Record (MAR) revealed she received 125 mg of Depakote three times a day starting on 7/6/24. Review of Resident #1's laboratory (lab) results, dated 7/6/24, revealed her Valproic Acid levels were low at 10 microgram per milliliter (ug/ml). with a reference range of 50-100 ug/mL. Review of Resident #1's progress note, dated 7/7/24 at 8:13 p.m., revealed Hard copy labs called to ARNP (Advanced Registered Nurse Practitioner) . No new orders. Review of Resident #1's ARNP note, dated 7/7/24, revealed: CHIEF COMPLAINTS 7/7/24 fu [follow up] Visit She [Resident #1] has had some seizures in the past and had the recent seizure staff members reporting. Recently she had the seizure and medications were adjusted. Overall, she is very weak and feels like she is de-conditioned. She relies on staff to complete ADL's [activities of daily living] and assist with feeding in general. .ASSESSMENT AND PLAN .Seizure D-[NAME] [disorder] 7/7/24 Neurology consult, check medication levels .increased dose, depakote leve[sic] . Review of Resident #1's Progress note, dated 7/10/24 at 8:19 a.m., revealed Resident had a tonic-clonic seizure [a type of seizure with muscle stiffing followed by rhythmic jerking with a loss of consciousness] for 2 minutes. Resident was contracted and shaking the full time of the seizure. Resident is currently lying in bed. Dr. notified and waiting for a call back. Review of Resident #1's medical record did not reveal evidence the physician called back, or further attempts were made to contact the physician. Review of Resident #1's physician order revealed an order with a start date of 7/12/24, and an end date of 7/12/24 for Depakote Valproic Acid levels one time only for 1 day notify MD [Medical Doctor] of results. Review of Resident #1's lab results, dated 7/12/24, revealed Valproic Acid results were low (12 ug/mL) with a reference range of 50-100 ug/ml. Review of Resident #1's medical record did not reveal evidence the physician was notified of the low Valproic Acid level on 7/12/24. Review of Resident #1's physician orders revealed an order, with a revision date of 7/15/24, a start date of 7/22/24, and an end date of 7/23/24, to recheck Valproic Acid level in one week. Review of Resident #1's progress note, dated 7/22/24 at 3:06 a.m., revealed Resident to have Valproic Acid level rechecked today Review of Resident #1's Treatment Administration Record (TAR) revealed the physician order for Resident to have Valproic Acid level rechecked today was signed off as completed on 7/22/24 at 3:06 a.m. Review of Resident #1's Lab Order History from the lab portal did not reveal a physician's order was in the lab portal for Valproic Acid to be drawn on 7/22/24. Review of Resident #1's medical record did not reveal evidence the Valproic Acid was drawn on 7/22/24 and reported to the physician. Review of Resident #1's Advanced Practice Registered Nurse (APRN) note, dated 9/13/24, revealed CHIEF COMPLAINTS 9/13/24-fu [follow up] Visit .Recently she had the seizure and medications were adjusted. Overall, she is very weak and feels like she is de-conditioned. She relies on staff to complete ADL's [activities of daily living] and assist with feeding in general. . ASSESSMENT AND PLAN .Seizure 9/13/24 Neurology Consult, check medications levels . Review of Resident #1's Physician note, dated 9/20/24 revealed CHIEF COMPLAINTS 9/20/24 fu Visit . Recently she had the seizure and medications were adjusted. Overall, she is very weak and feels like she is de-conditioned. She relies on staff to complete ADL's and assist with feeding in general. .Assessment and Plan .Seizure 9/20/24 Neurology consult, check medications levels . Review of Resident #1's medical record revealed no evidence she received neurology services. Review of Resident #1's progress note, dated 9/28/24 at 5:36 PM, revealed Resident had a seizure while lying in bed at 1730 [5:30PM]. Resident was laying on her side while seizure was occurring. Made sure of resident safety. Seizure was under 5 minutes long and not reoccurring. Resident is now alert and able to speak and move. No discomfort or pain noted. No injuries. MD [Medical Doctor] notified. New order placed for labs. Review of Resident #1's physician orders revealed, an order with an order date of 9/28/24,for Depakote level, Ammonia Level, Levetiracetam (Keppra), and Lacosamide level. There was no start date or end date on the physician order. Review of Resident #1's September 2024 MAR revealed the physician order for Depakote level, Ammonia level, Levetiracetam (Keppra), and Lacosamide level was not documented as completed. Review of Resident #1's Lab Order History on the laboratory portal did not reveal a physician order was placed on 9/28/24 for Depakote level, Ammonia Level, Levetiracetam (Keppra), or a Lacosamide level. Review of Resident #1's progress note, dated 9/29/24 at 7:30AM, revealed Seizure activity noted this am [morning] lasting approximately 3.5 minutes s/p [status post] snoring lasting about 2 minutes then aroused making eye contact with staff alert and orientated to self-97.2 [temperature]-76 [pulse]-20 [respiratory rate]-128/82 [blood pressure]-97% [oxygen saturations] R/A [room air]. Review of the medical record did not reveal the resident's physician was notified of the seizure. Review of Resident #1's lab report with a collection date of 9/30/24 at 5:09 p. m., revealed Valproic Acid was low (14 ug/mL) with a reference range of 50-100 ug/ml. Review of Resident #1's medical record did not reveal evidence the physician was notified of the low Valproic Acid (Depakote) lab results collected on 9/30/24. Review of Resident #1's physicians' orders, revealed an order, with a start date of 2/4/25 and an end date of 2/5/25, for a Complete Blood Count (CBC), Comprehensive Metabolic Panel (CMP), Depakote level, and Ammonia level, every night shift for one day. Review of Resident #1's lab results with a collection date of 2/5/25, revealed abnormal CBC, CMP and Depakote Level results for the following lab values: Glucose: Low (67 milligrams per deciliter (mg/dL)) with a reference range of 70-99 mg/dL BUN: High (24 mg/dL) with a reference range of 6-20 mg/dL BUN /Creatinine Ratio: High (38.6 mg/dL) with a reference range of 6.0-25.0 mg/dL Calcium: Low (3.4 mg/dL) with a reference range of 8.6-10.2 mg/dL RBC: Low (3.93 million per microliter (M/uL)) with a reference range of 4.1-10.9) M/uL HGB: Low (11. grams per deciliter (8g/dL)) with a reference range of 12.0-16.0 g/dL HCT: Low (35.9%) with a reference range of 37.0-47.0% Valproic Acid (Depakote): low (25 ug/mL) with a reference range of 50-100 ug/mL Review of Resident #1's Lab Order History on the laboratory portal revealed the Ammonia order, dated 2/5/25, had a status of collection pending, no results and there was no sample collection date. Review of Resident #1's medical record revealed no evidence the physician was notified of the abnormal lab results collected on 2/5/25. The medical record revealed no Ammonia levels were collected or physician communication related to the Ammonia level lab not being collected. An interview was conducted on 4/15/25 at 12:45 p.m. with the Director of Nursing (DON). She reviewed Resident #1's Lab Order History on the laboratory portal, and she said Collection pending, No Results means the labs were not drawn. Review of Resident #1's progress note, dated 2/27/25 at 9:18 a.m., revealed At approx. [approximately] 7:30am resident was having seizure activity. foaming[sic] at mouth and release of urine and feces noted. resident[sic] moved to[sic] onto her side until seizure ceased. Resident cont [continued] to be slow to wake and is nonverbal at this time. Resident has history of seizure activity. Family and MD aware. Review of Resident #1's change in condition, dated 2/27/25, revealed The change in condition .: Altered mental status The seizure was: New onset seizure activity, OR persistent seizure in someone with known intermittent seizure activity. Provider Notification and Feedback: .send to ER [emergency room ] Review of Resident #1's hospital record revealed a physician note, dated 2/28/25, as: Impressions and Plan Breakthrough seizures due to noncompliance. The patient is currently unresponsive. This could be due to a postictal state, non-convulsive seizure activity or encephalopathy. I spoke to her [Resident #1's] nurse . at the nursing home . the patient has been refusing her medications. Yesterday she had a 4-minute convulsive seizure. Low Keppra level Low Depakote level but her dose of this medication may not be therapeutic. .Plan Prescribe telemetry Neurochecks every 2-4 hours Seizure precautions Lorazepam 2mg IV [intravenous] for convulsive seizure activity lasting more than 100 seconds IV Keppra IV Depakote IV Vimpat. She is also on oxcarbazepine that is not available in IV form, but the other AED's [anti-epileptic drugs] should be adequate. There is not yet clear how her refusal to take p.o. [by mouth] AEDs will get resolved. She may need a PEG [percutaneous endoscopic gastrostomy]. Review of Resident #1's hospital Gastrointestinal Physician note, dated 3/3/25, revealed: The patient presents with 50 yo [year old] f [female] who presented to the ed [emergency department] from her facility after a witnessed seizure. pt [patient] was also in the ed 2 days ago for glf [ground level fall]. I was asked to see the pt for a peg tube. Pt denies abdominal pain, n/v [nausea/vomiting] and dysphagia. Apparently, she frequently refuses to eat and take her medications due to her neurologic and psychiatric issues. Pt did not have issues swallowing during her vss [video swallow study]. per nursing if she is fed she will eat. She does pocket her food and requires verbal reminders. She has no abdominal pain, d/c [discomfort]. She has no gi [gastrointestinal] complaints. .plan Npo[nothing by mouth] after mn [midnight] Egd [esophagogastroduodenoscopy]/peg tomorrow. Review Resident #1's December 2024 through February 2025 Medication Administration Record (MAR) revealed she received 10 ml's of Keppra (100 mg/ml) by mouth twice a day every day for seizures except on 12/12/24 at 5:00 p.m. the documentation revealed 10. Review of the chart codes revealed 10=spit out meds. On 2/25/25 at 9:00 a.m. the documentation revealed 6 review of the chart codes revealed 6= hospitalized . On 2/26/25 at 9:00 a.m. the documentation revealed 2. Review of the chart codes revealed 2=drug refused. The February MAR review revealed Resident #1 received Depakote sprinkles 125 mg three times a day for seizures every day for the month of February until she was discharged on [DATE], except on 2/25/25 at 9:00 a.m. and 1:00 p.m., the documentation revealed Resident #1 was hospitalized . On 2/26/25 at 9:00 a.m. and 1:00 p.m. the documentation revealed Resident #1 refused the drug. Review of Resident #1's progress note, dated 3/6/25 at 2:12 p.m., revealed Resident returned to facility at approx. [approximately] 1;[sic]55pm via stretcher/ EMS [emergency medical services]. resident[sic] had no s/s [signs and symptoms] of distress noted .Resident has PEG tube in place and can eat by mouth. Jevity 1.2 @ 60 FWF [free water flush] 200ml q6 [every 6]. Resident can eat by mouth soft / bite sized. 1400 total in 24 hours. Two boxes a meal. An interview was conducted on 3/31/25 at 3:10 p.m. with the DON. The DON stated she did not assign a primary person to oversee the labs and review results. She said if labs were not critical staff would put the lab results in the providers' boxes for them to sign. If the labs were critical staff would call the provider to inform them about the critical lab results. The DON stated labs for seizure medications should be drawn every three months, but she does not know why some resident's labs were not being checked. She stated Resident #1's Depakote levels were being monitored by the psychiatric nurse practitioner. The DON stated she was aware that this was a system failure on the facility when it came to their lab process. She stated she would have expected her nurses to fax labs results to the doctor, put follow-up labs in to check the Depakote levels, and monitor the process. The DON stated Resident #1's labs from 9/30/2024 and 2/5/2025 were not signed off by the provider to show they reviewed the resident's lab results. She stated she thought Resident #1 had a neurology consultation while in the hospital, but the facility did not follow up to schedule a neurology appointment for Resident #1. The DON stated Resident #1's and Resident #2's labs were not done because the nurses were not transcribing the information from the orders to the lab reconciliation sheet and putting them in the lab book, so the tech knows which labs to draw for which residents. The DON stated it was her responsibility to ensure the resident's neurology consultation was followed up on. She stated there was a system failure because management did not have anyone assigned to pull labs, review lab results, and ensure all ordered labs were completed. The DON said their process was broken for following up with labs and completing documentation. An interview was conducted on 3/31/2025 at 3:50 p.m. with Resident #1's Psychiatry Physician Assistant (PA). The Psychiatry PA said he does not manage Resident #1's Depakote levels. If a resident is on Depakote for Seizures Psychiatry would not manage the medication; that would be managed by a resident's Primary Care Provider (PCP). An interview was conducted on 3/31/2025 at 4:20 p.m. with Resident #1's Advanced Practice Registered Nurse (APRN). The APRN said he does not monitor residents Depakote because it is managed by Psychiatry. He stated Depakote is not a medication he would prescribe a resident for seizures. He stated that he made a referral to have Resident #1 seen by a Neurologist in September 2024 and then again when Resident #1 came back from her most recent hospital stay (3/6/25), but he is not sure if the facility had followed up on his referral. He stated it is possible the low seizure medication labs could have been caught before the resident had her seizure if the facility had been managing her lab results and followed up with neurology. He stated residents who are on Keppra and Depakote medications for seizures should have labs drawn every three to six months to ensure the medication level are therapeutic for the resident's diagnosis. The APRN confirmed the facility should be doing the labs as ordered by the provider. For abnormal labs the facility should notify him the day the labs resulted and for critical labs the facility should get a hold of him. An interview was conducted on 4/15/25 at 1:50 p.m. with Staff B, LPN, she said she has worked at the facility on and off for four years and is very familiar with Resident #1. She said, Some years ago Resident #1 had a PEG tube for not eating, drinking, or taking her medications but she kept pulling the PEG tube out, so her family decided to just leave it out. She was doing well without it, eating, drinking, and taking her medications without any concerns. Staff B, LPN said for less than one day Resident #1 was not eating, drinking, or taking her medications and when she came in the next morning she had a huge gran-mal seizure, foaming at the mouth, lost control of her bowel and bladder, and then became post ictal (the period immediately following a seizure when the brain recovers, and the body returns to its normal state. During this phase, individuals may experience a range of symptoms, including confusion, drowsiness, headache, and cognitive difficulties.) Staff B, LPN said Resident #1's normal seizures are focal seizures, and she just stares, and they do not last long but this was a big one. Staff B, LPN said she called the physician and had Resident #1 sent to the hospital. Staff B, LPN said when Resident #1 returned the family must have agreed to a PEG tube again because she came back with a PEG tube but all we do is flush it in the morning with water. She said Resident #1 eats by mouth and takes her medications by mouth without any problems. She said since Resident #1 has returned from the hospital after her seizure she is still herself but not quite the same, we definitely fried some brain cells with that seizure. An interview was conducted with the Medical Director on 4/15/25 at 3:11 p.m., she said she was Resident #1's primary physician and she was familiar with the resident. She said, typically Resident #1's seizures are controlled, and she was on multiple seizure medications but, she did go to the hospital for a seizure. The Medical Director said when Resident #1 was admitted to the hospital for the seizure, her Keppra levels were low and her Depakote levels were not therapeutic, because she was not eating and was pocketing her medications [storing medications in her cheek]. She needed intravenous (IV) Keppra and IV Depakote because her levels were very low and it was an emergency. The Medical Director reviewed Resident #1's hospital notes and said Resident #1 had a PEG tube placed in the hospital because she was not eating or taking her medication, so it was life saving for her to have the PEG tube. The Medical Director said she did not remember the staff at the nursing home notifying her Resident #1 was not eating, drinking, or taking her medications. She said the nursing notes will reflect if they notified her or her APRN. The Medical Director said when labs are ordered her expectation is they are collected and once they have resulted the nurses should notify them immediately if any labs are critical. If they aren't critical then the nurses are supposed to put the results in the folder so she or her APRN can check them when they come in three to five times a week. The Medical Director said seizure medication levels should be drawn upon admission and every six months and if the seizure medication labs are abnormal the nursing staff should be notifying the Neurologist because she is not the Physician for the seizure medications, she is just supporting. The Medical Director said if there is an order for a neurology consultation then the facility should coordinate so the resident sees a Neurologist. The Medical Director said the residents had to go out to see a Neurologist because the facility did not have one coming to the facility. But there are transportation problems for bed ridden patients. An interview was conducted on 4/16/25 at 10:37 a.m. with Staff C, LPN she said she would get floated to take care of Resident #1. She said she works two double shifts a week the 3:00 p.m. to 11:00p.m. and 11:00 p.m. to 7:00 a.m. shift. She said before Resident #1 had her big seizure (2/27/25) she didn't have any problems giving her, her medications. She said the nurses knew you had to give her the medications in foods she liked, such as a milk shake. She said Resident #1 used to self-propel herself up and down the hallways yelling cheeseburger and asking for coffee. Staff C, LPN said now she is just not as spunky as she used to be before the seizure. Staff C, LPN said when she returned from the hospital she came back with a PEG tube. She said Resident #1 does not use the PEG tube, it's only there if she refuses to take her medications by mouth. Staff C, LPN said she does not have any issues with Resident #1 taking her medications or eating and drinking. An interview was conducted on 4/16/25 at 10:56 AM with Staff A, LPN 200 hall Unit Manager (UM) and the DON. Staff A, LPN, UM, said she has been a UM since the end of September and did not take over the 200 hall until the end of November. She said she knew Resident #1 for the most part, at the beginning, when Staff A, LPN, UM first started, she had only spit out her medications a couple of times and she was always eating so it was easy to give her medications. Only a day or two before her February seizure she was refusing her medications, But it wasn't long that she was refusing her meds before her seizure. The DON said it's their understanding she had a PEG tube a few years ago for failure to thrive but she had pulled it out and it was left out because she was eating and taking her medications by mouth without issues. The DON said when she came back from the hospital with the PEG tube, she worked with speech therapy and they were able to upgrade her diet right away and she continued to eat, drink, and take her medications without any problems. The DON said, she uses it for nothing and it is there just in case she does not take her medications. An interview was conducted on 4/16/25 at 11:02 a.m. with the DON. She said all the clinical nurses did not have access to the lab portal because they changed to the current lab in June 2024, We didn't push to get everyone access, there was just a push to get the system online. The DON said she had noticed for the past couple of months that lab orders had been cancelled. She said the facility just reordered the labs and didn't question why. The DON said the labs were just reordered and it was not really looked at as a system failure. A phone interview was conducted on 4/17/25 at 1:00 p.m. with Resident #1's Heath Care Proxy and family. They said they were informed Resident #1 went to the hospital in February for a seizure and when she was at the hospital, the hospital had called them and told them Resident #1 was pocketing her food, not drinking and not taking her medications that's why she had the seizure. The family gave the approval to put the PEG tube in and then they had a care plan meeting with the facility, and they were told Resident #1 was eating well and taking her medications by mouth and they were not using the PEG tube. A phone interview was conducted on 4/17/25 at 2:27 p.m. with the Regional Lab Supervisor. She said the Phlebotomist comes to the facility six days a week Monday through Saturday regardless if there are lab orders or not. She said they provide a Phlebotomist for STAT (immediately or without delay) labs as they need it. The Lab Supervisor said the expectation is the facility puts the lab order into the lab portal, print out the reacquisition form, and put the reacquisition form in the lab book. She said if the nurses do not have access to the lab portal, they can hand write the order on a blank reacquisition form, that the lab company provides, and put that in the lab book. The Phlebotomist will not know a lab needs to be drawn on a resident if there is not a reacquisition form in the lab book. The Lab Supervisor said if the nurse has put the order into the lab portal, but they did not print the requisition form and put it in the lab book then the Phlebotomist will not collect the lab and the order will sit in the portal and have a status of collection pending, no results. If the order is cancelled due to a collection error, then the lab will call the facility and have the nurse re-enter the order in the lab portal and print the reacquisition to put in the lab book so the Phlebotomist can redraw the labs the next day. Once the Phlebotomist has drawn the labs, they take the reacquisition forms with them and when they drop off the lab specimen someone from the lab makes sure the reacquisition was put into the portal because that's the only way the lab can print labels for the specimen. Once the test has resulted, then the result is uploaded into the lab portal and if there is a critical result the lab calls the facility. 2. Review of Admission Records showed Resident #2 was admitted on [DATE] with diagnoses including unspecified injury of head and unspecified convulsions. Review of Resident #2's care plan showed a focus area of Seizure disorder. Interventions included: give seizure medication as ordered by doctor. Monitor/document side effects and effectiveness and obtain and monitor lab/diagnostic work as ordered. Report results to MD and follow up as indicated and monitor labs and report sub therapeutic or toxic results to MD. Dated 10/4/17. Review of Resident #2's order showed the following: -Fasting comprehensive metabolic panel (CMP), lipids, complete blood count (CBC), Valproic Acid level, Ammonia level. One time a day every 4 months starting on the 1st for 1 day for hypertensive atherosclerotic cardiovascular disease (ASCVD), drug monitoring. Schedule routine weekday mornings. Dated 3/9/22. -Fasting CMP, Lipids, CBC, Valproic Acid level, Ammonia level. Every night shift for 1 day. Dated 12/1/24. -Divalproex Sodium HCL capsule delayed release 250 mg (Depakote). Give 250 mg by mouth at bedtime for seizure disorder related to unspecified convulsions. Dated 4/13/22. -Valproic Acid level. Dated 3/31/25. -Ammonia level. Dated 4/1/25. Review of lab results for Resident #2 showed Valproic Acid level and Ammonia level, dated 8/1/24. The Valproic Acid level was low at 23 ug/ml with a reference range of 50-100 ug/ml and the ammonia level was high at 69 ug/ml with a reference range of 11.0-35.0 ug/ml. There were no results found for the labs ordered to be drawn on 12/1/24. The 3/31/25 order for Valproic Acid level was not completed. The labs were reordered and drawn on 4/15/25 with a low result of <13 ug/ml with a reference range of 50-100 ug/ml. The Ammonia level drawn on 4/1/25 was high at 80 umoL/ml with a reference range of 18-72 umoL/ml. Review of Resident #2's progress notes showed no documentation a provider was notified of the abnormal Valproic Acid and Ammonia results on 8/1/24. Review of Resident #2's Lab Order History on the lab portal showed no orders were input in their system for labs to be drawn on 12/1/24. There was an order put in on 3/31/25 for a Valproic Acid level. Review of Resident #2's progress notes, dated 4/15/25, showed obtained orders to redraw Valproic Acid due to alb [albumin] stating uncollected lab and Lab tech out to get STAT Valproic Acid. An interview was conducted on 4/15/25 at 12:40 p.m. with the DON. She confirmed Resident #2 had a Valproic Acid level ordered on 3/31/25 that was not completed. She said they did not realize it was not done until 4/15/25. At 1:56 p.m. the DON reviewed Resident #2's medical record and confirmed there was an active order for labs every 4 months. She said the lab order was one that had fallen through the cracks and labs were not transcribed to the lab portal and lab reconciliation sheets. She confirmed the resident had labs in August 2024 and not again until 3/31/25. A follow-up interview was conducted on 4/17/25 at 5:15 p.m. with the DON. She said somehow Resident #2's lab was cancelled on 4/15/25 by the lab or the nurse. She said the unit manager (UM) had been given this to check on the homework sheet and they should have caught the fact the lab was not completed. 3. Review of Admission Records showed Resident #8 was admitted on [DATE] with diagnoses including epilepsy. Review of Resident #8's physician orders revealed the following: -Levetiracetam (Keppra) Oral Tablet 500 mg. Give 3 tablet by mouth two times a day related to epilepsy. Dated 11/25/24. -Ammonia Level. Every night shift every Wednesday for 4 weeks. Dated 2/5/25. Review of Resident #8's lab results, dated 3/4/25, showed an Ammonia Level results of 118 umol/L (micromole per liter) with a reference range of 18-72 umol/L. This was indicated as a critical result. The lab showed the result was reported on 3/4/25 at 11:38 a.m. Review of Resident #8's progress notes showed no documentation a provider was notified on 3/4/25 of the critically high ammonia level. There was a progress note, dated 3/5/25 at 9:02 a.m.,. showing labs were sent to the Advanced Registered Nurse Practitioner. Review of Resident #8's Treatment Administration Record (TAR) showed the Ammonia level that was scheduled to be rechecked on 3/20/25 was documented as 9 indicating Other/See Nurse Notes. Review of progress notes revealed no nurses' note showing why the lab was not drawn. Review of Resident #8's lab results, dated 4/1/25, showed a Keppra level high at 49.5 ug/mL with a reference range of 6.0-46.0 ug/mL. An interview was conducted on 4/1/25 at 2:35 p.m. with the DON. She reviewed Resident #8's medical record and confirmed documentation showed the provider was not notified of the critical high ammonia level until the day after the results were received. She said her expectation would be the provider to be notified immediately of critical results. The DON confirmed there was no documentation as to why the ammonia level scheduled for 3/20/25 was not completed and said it should have been rescheduled but was not. 4. Review of Admission Records showed Resident #4 was admitted on [DATE] with diagnoses including other seizures. Review of Resident #4's care plan showed a focus area of seizure disorder, dated 8/27/24. Interventions included obtain and monitor lab/diagnostic work as ordered. Report results to MD and follow up as indicated. Review of Resident #4's orders revealed the following active orders: -Depakote Sprinkles Oral Capsule Delayed Release Sprinkle 125 mg (Divalproex Sodium). Give 2 capsule by mouth every 8 hours related to other seizures. Dated 2/6/25. - CBC, CMP, Depakote, TSH, Ammonia Level. One time a day every 90 day(s) for hypertension, schizophrenia, cholecystitis. Dated 4/29/21. Review of Resident #4's provider note, dated 2/12/25, noted Depakote, check levels and ammonia levels. Review of Resident #4's lab results showed the last Depakote level result was on 7/12/24. 5. Review of Admission Records showed Resident #3 was admitted on [DATE] with diagnoses including hemiplegia and hemiparesis following cerebral infarction, atrial fibrillation, epilepsy, and congestive heart failure. Review of Resident #3's physician orders revealed the following: - Warfarin Sodium Oral Tablet 4 mg . Give 1 tablet by mouth at bedtime related to chronic embolism and

Based on interviews and record review the facility failed to ensure nursing staff were competent in caring for residents with seizure diagnoses to include laboratory monitoring process, following through with orders, processing consultations, and communications with physicians for eleven residents (#1, #2, #3, #4, #5, #6, #7, #8, #9, #10, #11) out of eleven residents sampled. Serious harm occurred when Resident #1's seizure medication levels were not monitored, and neurology consultation was not obtained per the provider's request. Resident #1 experienced a seizure on 7/10/24, 9/28/24, 9/29/24, and 2/27/25. Resident #1 had to be transferred to a higher level of care as a result of the seizure suffered on 2/27/25. This failure created a situation that resulted in a worsened condition and the likelihood for serious injury and/or death to Resident #1 and resulted in the determination of Immediate Jeopardy on 4/16/2025. The findings of Immediate Jeopardy were determined to be removed on 4/17/2025 and the scope and severity was reduced to an E after verification of removal of immediacy of harm. Findings included: 1. Review of Resident #1's Admission Record revealed she was admitted to the facility on [DATE] from an acute care hospital with medical diagnoses of generalized idiopathic epilepsy and epileptic syndromes, not intractable, without status epilepticus, gastrostomy status as of 3/6/25, traumatic subdural hemorrhage with loss of consciousness, hydrocephalus, paraplegia, adult failure to thrive, protein-calorie malnutrition, anxiety disorder, major depressive disorder, lack of coordination, cognitive communication deficit, and Bell's palsy. Review of Resident #1's physician orders revealed the following: -Depakote (Valproic Acid) Sprinkles Oral Capsule delayed release 125 mg (milligrams), give one capsule by mouth two times a day for seizures, start date 5/23/24 and discontinued on 7/5/24. -Depakote Sprinkles Oral Capsule delayed release 125 mg, give one capsule by mouth three times a day for seizures, start date 7/6/24 and discontinued on 4/2/25. Review of Resident #1's July 2024 Medication Administration Record (MAR) revealed she received 125 mg of Depakote three times a day starting on 7/6/24. Review of Resident #1's laboratory (lab) results, dated 7/6/24, revealed her Valproic Acid levels were low at 10 microgram per milliliter (ug/ml). with a reference range of 50-100 ug/mL. Review of Resident #1's progress note, dated 7/7/24 at 8:13 p.m., revealed Hard copy labs called to ARNP (Advanced Registered Nurse Practitioner) . No new orders. Review of Resident #1's ARNP note, dated 7/7/24, revealed: CHIEF COMPLAINTS 7/7/24 fu [follow up] Visit She [Resident #1] has had some seizures in the past and had the recent seizure staff members reporting. Recently she had the seizure and medications were adjusted. Overall, she is very weak and feels like she is de-conditioned. She relies on staff to complete ADL's [activities of daily living] and assist with feeding in general. .ASSESSMENT AND PLAN .Seizure D-[NAME] [disorder] 7/7/24 Neurology consult, check medication levels .increased dose, depakote leve[sic] . Review of Resident #1's Progress note, dated 7/10/24 at 8:19 a.m., revealed Resident had a tonic-clonic seizure [a type of seizure with muscle stiffing followed by rhythmic jerking with a loss of consciousness] for 2 minutes. Resident was contracted and shaking the full time of the seizure. Resident is currently lying in bed. Dr. notified and waiting for a call back. Review of Resident #1's medical record did not reveal evidence the physician called back, or further attempts were made to contact the physician. Review of Resident #1's physician order revealed an order with a start date of 7/12/24, and an end date of 7/12/24 for Depakote Valproic Acid levels one time only for 1 day notify MD [Medical Doctor] of results. Review of Resident #1's lab results, dated 7/12/24, revealed Valproic Acid results were low (12 ug/mL) with a reference range of 50-100 ug/ml. Review of Resident #1's medical record did not reveal evidence the physician was notified of the low Valproic Acid level on 7/12/24. Review of Resident #1's physician orders revealed an order, with a revision date of 7/15/24, a start date of 7/22/24, and an end date of 7/23/24, to recheck Valproic Acid level in one week. Review of Resident #1's progress note, dated 7/22/24 at 3:06 a.m., revealed Resident to have Valproic Acid level rechecked today Review of Resident #1's Treatment Administration Record (TAR) revealed the physician order for Resident to have Valproic Acid level rechecked today was signed off as completed on 7/22/24 at 3:06 a.m. Review of Resident #1's Lab Order History from the lab portal did not reveal a physician's order was in the lab portal for Valproic Acid to be drawn on 7/22/24. Review of Resident #1's medical record did not reveal evidence the Valproic Acid was drawn on 7/22/24 and reported to the physician. Review of Resident #1's Advanced Practice Registered Nurse (APRN) note, dated 9/13/24, revealed CHIEF COMPLAINTS 9/13/24-fu [follow up] Visit .Recently she had the seizure and medications were adjusted. Overall, she is very weak and feels like she is de-conditioned. She relies on staff to complete ADL's [activities of daily living] and assist with feeding in general. . ASSESSMENT AND PLAN .Seizure 9/13/24 Neurology Consult, check medications levels . Review of Resident #1's Physician note, dated 9/20/24 revealed CHIEF COMPLAINTS 9/20/24 fu Visit . Recently she had the seizure and medications were adjusted. Overall, she is very weak and feels like she is de-conditioned. She relies on staff to complete ADL's and assist with feeding in general. .Assessment and Plan .Seizure 9/20/24 Neurology consult, check medications levels . Review of Resident #1's medical record revealed no evidence she received neurology services. Review of Resident #1's progress note, dated 9/28/24 at 5:36 PM, revealed Resident had a seizure while lying in bed at 1730 [5:30PM]. Resident was laying on her side while seizure was occurring. Made sure of resident safety. Seizure was under 5 minutes long and not reoccurring. Resident is now alert and able to speak and move. No discomfort or pain noted. No injuries. MD [Medical Doctor] notified. New order placed for labs. Review of Resident #1's physician orders revealed, an order with an order date of 9/28/24,for Depakote level, Ammonia Level, Levetiracetam (Keppra), and Lacosamide level. There was no start date or end date on the physician order. Review of Resident #1's September 2024 MAR revealed the physician order for Depakote level, Ammonia level, Levetiracetam (Keppra), and Lacosamide level was not documented as completed. Review of Resident #1's Lab Order History on the laboratory portal did not reveal a physician order was placed on 9/28/24 for Depakote level, Ammonia Level, Levetiracetam (Keppra), or a Lacosamide level. Review of Resident #1's progress note, dated 9/29/24 at 7:30AM, revealed Seizure activity noted this am [morning] lasting approximately 3.5 minutes s/p [status post] snoring lasting about 2 minutes then aroused making eye contact with staff alert and orientated to self-97.2 [temperature]-76 [pulse]-20 [respiratory rate]-128/82 [blood pressure]-97% [oxygen saturations] R/A [room air]. Review of the medical record did not reveal the resident's physician was notified of the seizure. Review of Resident #1's lab report with a collection date of 9/30/24 at 5:09 p. m., revealed Valproic Acid was low (14 ug/mL) with a reference range of 50-100 ug/ml. Review of Resident #1's medical record did not reveal evidence the physician was notified of the low Valproic Acid (Depakote) lab results collected on 9/30/24. Review of Resident #1's physicians' orders, revealed an order, with a start date of 2/4/25 and an end date of 2/5/25, for a Complete Blood Count (CBC), Comprehensive Metabolic Panel (CMP), Depakote level, and Ammonia level, every night shift for one day. Review of Resident #1's lab results with a collection date of 2/5/25, revealed abnormal CBC, CMP and Depakote Level results for the following lab values: Glucose: Low (67 milligrams per deciliter (mg/dL)) with a reference range of 70-99 mg/dL BUN: High (24 mg/dL) with a reference range of 6-20 mg/dL BUN /Creatinine Ratio: High (38.6 mg/dL) with a reference range of 6.0-25.0 mg/dL Calcium: Low (3.4 mg/dL) with a reference range of 8.6-10.2 mg/dL RBC: Low (3.93 million per microliter (M/uL)) with a reference range of 4.1-10.9) M/uL HGB: Low (11. grams per deciliter (8g/dL)) with a reference range of 12.0-16.0 g/dL HCT: Low (35.9%) with a reference range of 37.0-47.0% Valproic Acid (Depakote): low (25 ug/mL) with a reference range of 50-100 ug/mL Review of Resident #1's Lab Order History on the laboratory portal revealed the Ammonia order, dated 2/5/25, had a status of collection pending, no results and there was no sample collection date. Review of Resident #1's medical record revealed no evidence the physician was notified of the abnormal lab results collected on 2/5/25. The medical record revealed no Ammonia levels were collected or physician communication related to the Ammonia level lab not being collected. An interview was conducted on 4/15/25 at 12:45 p.m. with the Director of Nursing (DON). She reviewed Resident #1's Lab Order History on the laboratory portal, and she said Collection pending, No Results means the labs were not drawn. Review of Resident #1's progress note, dated 2/27/25 at 9:18 a.m., revealed At approx. [approximately] 7:30am resident was having seizure activity. foaming[sic] at mouth and release of urine and feces noted. resident[sic] moved to[sic] onto her side until seizure ceased. Resident cont [continued] to be slow to wake and is nonverbal at this time. Resident has history of seizure activity. Family and MD aware. Review of Resident #1's change in condition, dated 2/27/25, revealed The change in condition .: Altered mental status The seizure was: New onset seizure activity, OR persistent seizure in someone with known intermittent seizure activity. Provider Notification and Feedback: .send to ER [emergency room ] Review of Resident #1's hospital record revealed a physician note, dated 2/28/25, as: Impressions and Plan Breakthrough seizures due to noncompliance. The patient is currently unresponsive. This could be due to a postictal state, non-convulsive seizure activity or encephalopathy. I spoke to her [Resident #1's] nurse . at the nursing home . the patient has been refusing her medications. Yesterday she had a 4-minute convulsive seizure. Low Keppra level Low Depakote level but her dose of this medication may not be therapeutic. .Plan Prescribe telemetry Neurochecks every 2-4 hours Seizure precautions Lorazepam 2mg IV [intravenous] for convulsive seizure activity lasting more than 100 seconds IV Keppra IV Depakote IV Vimpat. She is also on oxcarbazepine that is not available in IV form, but the other AED's [anti-epileptic drugs] should be adequate. There is not yet clear how her refusal to take p.o. [by mouth] AEDs will get resolved. She may need a PEG [percutaneous endoscopic gastrostomy]. Review of Resident #1's hospital Gastrointestinal Physician note, dated 3/3/25, revealed: The patient presents with 50 yo [year old] f [female] who presented to the ed [emergency department] from her facility after a witnessed seizure. pt [patient] was also in the ed 2 days ago for glf [ground level fall]. I was asked to see the pt for a peg tube. Pt denies abdominal pain, n/v [nausea/vomiting] and dysphagia. Apparently, she frequently refuses to eat and take her medications due to her neurologic and psychiatric issues. Pt did not have issues swallowing during her vss [video swallow study]. per nursing if she is fed she will eat. She does pocket her food and requires verbal reminders. She has no abdominal pain, d/c [discomfort]. She has no gi [gastrointestinal] complaints. .plan Npo[nothing by mouth] after mn [midnight] Egd [esophagogastroduodenoscopy]/peg tomorrow. Review Resident #1's December 2024 through February 2025 Medication Administration Record (MAR) revealed she received 10 ml's of Keppra (100 mg/ml) by mouth twice a day every day for seizures except on 12/12/24 at 5:00 p.m. the documentation revealed 10. Review of the chart codes revealed 10=spit out meds. On 2/25/25 at 9:00 a.m. the documentation revealed 6 review of the chart codes revealed 6= hospitalized . On 2/26/25 at 9:00 a.m. the documentation revealed 2. Review of the chart codes revealed 2=drug refused. The February MAR review revealed Resident #1 received Depakote sprinkles 125 mg three times a day for seizures every day for the month of February until she was discharged on [DATE], except on 2/25/25 at 9:00 a.m. and 1:00 p.m., the documentation revealed Resident #1 was hospitalized . On 2/26/25 at 9:00 a.m. and 1:00 p.m. the documentation revealed Resident #1 refused the drug. Review of Resident #1's progress note, dated 3/6/25 at 2:12 p.m., revealed Resident returned to facility at approx. [approximately] 1;[sic]55pm via stretcher/ EMS [emergency medical services]. resident[sic] had no s/s [signs and symptoms] of distress noted .Resident has PEG tube in place and can eat by mouth. Jevity 1.2 @ 60 FWF [free water flush] 200ml q6 [every 6]. Resident can eat by mouth soft / bite sized. 1400 total in 24 hours. Two boxes a meal. Review of Resident #1's nutrition note, dated 3/7/25 at 9:59 a.m. revealed, Res [Resident] readmitted to facility 3/6/25 s/p [status/post] 7d [day] hospitalization . New Gtube [gastrostomy tube] inserted however res eats 75-100% of meals by mouth and requests snacks frequently. Will d/c [discontinue] enteral feed as res is able to meet needs via po [by mouth] at this time. Flush tube w/ [with] 150cc H20 [water] q [every] shift to maintain patency. Review of Resident #1's progress note, dated 3/7/25 at 10:21 a.m., written by Staff A, Licensed Practical Nurse (LPN), revealed, This writer received order from NP [Nurse Practitioner] stating resident able to take medication by mouth if resident refuses then we may use PEG-Tube for medications; resident is currently eating meals w/o [without] issues or concerns. An interview was conducted on 3/31/25 at 3:10 p.m. with the DON. The DON stated she did not assign a primary person to oversee the labs and review results. She said if labs were not critical staff would put the lab results in the providers' boxes for them to sign. If the labs were critical staff would call the provider to inform them about the critical lab results. The DON stated labs for seizure medications should be drawn every three months, but she does not know why some resident's labs were not being checked. She stated Resident #1's Depakote levels were being monitored by the psychiatric nurse practitioner. The DON stated she was aware that this was a system failure on the facility when it came to their lab process. She stated she would have expected her nurses to fax labs results to the doctor, put follow-up labs in to check the Depakote levels, and monitor the process. The DON stated Resident #1's labs from 9/30/2024 and 2/5/2025 were not signed off by the provider to show they reviewed the resident's lab results. She stated she thought Resident #1 had a neurology consultation while in the hospital, but the facility did not follow up to schedule a neurology appointment for Resident #1. The DON stated Resident #1's and Resident #2's labs were not done because the nurses were not transcribing the information from the orders to the lab reconciliation sheet and putting them in the lab book, so the tech knows which labs to draw for which residents. The DON stated it was her responsibility to ensure the resident's neurology consultation was followed up on. She stated there was a system failure because management did not have anyone assigned to pull labs, review lab results, and ensure all ordered labs were completed. The DON said their process was broken for following up with labs and completing documentation. An interview was conducted on 3/31/2025 at 3:50 p.m. with Resident #1's Psychiatry Physician Assistant (PA). The Psychiatry PA said he does not manage Resident #1's Depakote levels. If a resident is on Depakote for Seizures Psychiatry would not manage the medication; that would be managed by a resident's Primary Care Provider (PCP). An interview was conducted on 3/31/2025 at 4:20 p.m. with Resident #1's Advanced Practice Registered Nurse (APRN). The APRN said he does not monitor residents Depakote because it is managed by Psychiatry. He stated Depakote is not a medication he would prescribe a resident for seizures. He stated that he made a referral to have Resident #1 seen by a Neurologist in September 2024 and then again when Resident #1 came back from her most recent hospital stay (3/6/25), but he is not sure if the facility had followed up on his referral. He stated it is possible the low seizure medication labs could have been caught before the resident had her seizure if the facility had been managing her lab results and followed up with neurology. He stated residents who are on Keppra and Depakote medications for seizures should have labs drawn every three to six months to ensure the medication level are therapeutic for the resident's diagnosis. The APRN confirmed the facility should be doing the labs as ordered by the provider. For abnormal labs the facility should notify him the day the labs resulted and for critical labs the facility should get a hold of him. An interview was conducted on 4/15/25 at 1:50 p.m. with Staff B, LPN, she said she has worked at the facility on and off for four years and is very familiar with Resident #1. She said, Some years ago Resident #1 had a PEG tube for not eating, drinking, or taking her medications but she kept pulling the PEG tube out, so her family decided to just leave it out. She was doing well without it, eating, drinking, and taking her medications without any concerns. Staff B, LPN said for less than one day Resident #1 was not eating, drinking, or taking her medications and when she came in the next morning she had a huge gran-mal seizure, foaming at the mouth, lost control of her bowel and bladder, and then became post ictal (the period immediately following a seizure when the brain recovers, and the body returns to its normal state. During this phase, individuals may experience a range of symptoms, including confusion, drowsiness, headache, and cognitive difficulties.) Staff B, LPN said Resident #1's normal seizures are focal seizures, and she just stares, and they do not last long but this was a big one. Staff B, LPN said she called the physician and had Resident #1 sent to the hospital. Staff B, LPN said when Resident #1 returned the family must have agreed to a PEG tube again because she came back with a PEG tube but all we do is flush it in the morning with water. She said Resident #1 eats by mouth and takes her medications by mouth without any problems. She said since Resident #1 has returned from the hospital after her seizure she is still herself but not quite the same, we definitely fried some brain cells with that seizure. An interview was conducted with the Medical Director on 4/15/25 at 3:11 p.m., she said she was Resident #1's primary physician and she was familiar with the resident. She said, typically Resident #1's seizures are controlled, and she was on multiple seizure medications but, she did go to the hospital for a seizure. The Medical Director said when Resident #1 was admitted to the hospital for the seizure, her Keppra levels were low and her Depakote levels were not therapeutic, because she was not eating and was pocketing her medications [storing medications in her cheek]. She needed intravenous (IV) Keppra and IV Depakote because her levels were very low and it was an emergency. The Medical Director reviewed Resident #1's hospital notes and said Resident #1 had a PEG tube placed in the hospital because she was not eating or taking her medication, so it was life saving for her to have the PEG tube. The Medical Director said she did not remember the staff at the nursing home notifying her Resident #1 was not eating, drinking, or taking her medications. She said the nursing notes will reflect if they notified her or her APRN. The Medical Director said when labs are ordered her expectation is they are collected and once they have resulted the nurses should notify them immediately if any labs are critical. If they aren't critical then the nurses are supposed to put the results in the folder so she or her APRN can check them when they come in three to five times a week. The Medical Director said seizure medication levels should be drawn upon admission and every six months and if the seizure medication labs are abnormal the nursing staff should be notifying the Neurologist because she is not the Physician for the seizure medications, she is just supporting. The Medical Director said if there is an order for a neurology consultation then the facility should coordinate so the resident sees a Neurologist. The Medical Director said the residents had to go out to see a Neurologist because the facility did not have one coming to the facility. But there are transportation problems for bed ridden patients. An interview was conducted on 4/16/25 at 10:37 a.m. with Staff C, LPN she said she would get floated to take care of Resident #1. She said she works two double shifts a week the 3:00 p.m. to 11:00p.m. and 11:00 p.m. to 7:00 a.m. shift. She said before Resident #1 had her big seizure (2/27/25) she didn't have any problems giving her, her medications. She said the nurses knew you had to give her the medications in foods she liked, such as a milk shake. She said Resident #1 used to self-propel herself up and down the hallways yelling cheeseburger and asking for coffee. Staff C, LPN said now she is just not as spunky as she used to be before the seizure. Staff C, LPN said when she returned from the hospital she came back with a PEG tube. She said Resident #1 does not use the PEG tube, it's only there if she refuses to take her medications by mouth. Staff C, LPN said she does not have any issues with Resident #1 taking her medications or eating and drinking. An interview was conducted on 4/16/25 at 10:56 AM with Staff A, LPN 200 hall Unit Manager (UM) and the DON. Staff A, LPN, UM, said she has been a UM since the end of September and did not take over the 200 hall until the end of November. She said she knew Resident #1 for the most part, at the beginning, when Staff A, LPN, UM first started, she had only spit out her medications a couple of times and she was always eating so it was easy to give her medications. Only a day or two before her February seizure she was refusing her medications, But it wasn't long that she was refusing her meds before her seizure. The DON said it's their understanding she had a PEG tube a few years ago for failure to thrive but she had pulled it out and it was left out because she was eating and taking her medications by mouth without issues. The DON said when she came back from the hospital with the PEG tube, she worked with speech therapy and they were able to upgrade her diet right away and she continued to eat, drink, and take her medications without any problems. The DON said, she uses it for nothing and it is there just in case she does not take her medications. An interview was conducted on 4/16/25 at 11:02 a.m. with the DON. She said all the clinical nurses did not have access to the lab portal because they changed to the current lab in June 2024, We didn't push to get everyone access, there was just a push to get the system online. The DON said she had noticed for the past couple of months that lab orders had been cancelled. She said the facility just reordered the labs and didn't question why. The DON said the labs were just reordered and it was not really looked at as a system failure. A phone interview was conducted on 4/17/25 at 1:00 p.m. with Resident #1's Heath Care Proxy and family. They said they were informed Resident #1 went to the hospital in February for a seizure and when she was at the hospital, the hospital had called them and told them Resident #1 was pocketing her food, not drinking and not taking her medications that's why she had the seizure. The family gave the approval to put the PEG tube in and then they had a care plan meeting with the facility, and they were told Resident #1 was eating well and taking her medications by mouth and they were not using the PEG tube. A phone interview was conducted on 4/17/25 at 2:27 p.m. with the Regional Lab Supervisor. She said the Phlebotomist comes to the facility six days a week Monday through Saturday regardless if there are lab orders or not. She said they provide a Phlebotomist for STAT (immediately or without delay) labs as they need it. The Lab Supervisor said the expectation is the facility puts the lab order into the lab portal, print out the reacquisition form, and put the reacquisition form in the lab book. She said if the nurses do not have access to the lab portal, they can hand write the order on a blank reacquisition form, that the lab company provides, and put that in the lab book. The Phlebotomist will not know a lab needs to be drawn on a resident if there is not a reacquisition form in the lab book. The Lab Supervisor said if the nurse has put the order into the lab portal, but they did not print the requisition form and put it in the lab book then the Phlebotomist will not collect the lab and the order will sit in the portal and have a status of collection pending, no results. If the order is cancelled due to a collection error, then the lab will call the facility and have the nurse re-enter the order in the lab portal and print the reacquisition to put in the lab book so the Phlebotomist can redraw the labs the next day. Once the Phlebotomist has drawn the labs, they take the reacquisition forms with them and when they drop off the lab specimen someone from the lab makes sure the reacquisition was put into the portal because that is the only way the lab can print labels for the specimen. Once the test has resulted, then the result is uploaded into the lab portal and if there is a critical result the lab calls the facility. 2. Review of Admission Records showed Resident #2 was admitted on [DATE] with diagnoses including unspecified injury of head and unspecified convulsions. Review of Resident #2's care plan showed a focus area of Seizure disorder. Interventions included: give seizure medication as ordered by doctor. Monitor/document side effects and effectiveness and obtain and monitor lab/diagnostic work as ordered. Report results to MD and follow up as indicated and monitor labs and report sub therapeutic or toxic results to MD. Dated 10/4/17. Review of Resident #2's order showed the following: -Fasting comprehensive metabolic panel (CMP), lipids, complete blood count (CBC), Valproic Acid level, Ammonia level. One time a day every 4 months starting on the 1st for 1 day for hypertensive atherosclerotic cardiovascular disease (ASCVD), drug monitoring. Schedule routine weekday mornings. Dated 3/9/22. -Fasting CMP, Lipids, CBC, Valproic Acid level, Ammonia level. Every night shift for 1 day. Dated 12/1/24. -Divalproex Sodium HCL capsule delayed release 250 mg (Depakote). Give 250 mg by mouth at bedtime for seizure disorder related to unspecified convulsions. Dated 4/13/22. -Valproic Acid level. Dated 3/31/25. -Ammonia level. Dated 4/1/25. Review of lab results for Resident #2 showed Valproic Acid level and Ammonia level, dated 8/1/24. The Valproic Acid level was low at 23 ug/ml with a reference range of 50-100 ug/ml and the ammonia level was high at 69 ug/ml with a reference range of 11.0-35.0 ug/ml. There were no results found for the labs ordered to be drawn on 12/1/24. The 3/31/25 order for Valproic Acid level was not completed. The labs were reordered and drawn on 4/15/25 with a low result of <13 ug/ml with a reference range of 50-100 ug/ml. The Ammonia level drawn on 4/1/25 was high at 80 umoL/ml with a reference range of 18-72 umoL/ml. Review of Resident #2's progress notes showed no documentation a provider was notified of the abnormal Valproic Acid and Ammonia results on 8/1/24. Review of Resident #2's Lab Order History on the lab portal showed no orders were input in their system for labs to be drawn on 12/1/24. There was an order put in on 3/31/25 for a Valproic Acid level. Review of Resident #2's progress notes, dated 4/15/25, showed obtained orders to redraw Valproic Acid due to alb [albumin] stating uncollected lab and Lab tech out to get STAT Valproic Acid. An interview was conducted on 4/15/25 at 12:40 p.m. with the DON. She confirmed Resident #2 had a Valproic Acid level ordered on 3/31/25 that was not completed. She said they did not realize it was not done until 4/15/25. At 1:56 p.m. the DON reviewed Resident #2's medical record and confirmed there was an active order for labs every 4 months. She said the lab order was one that had fallen through the cracks and labs were not transcribed to the lab portal and lab reconciliation sheets. She confirmed the resident had labs in August 2024 and not again until 3/31/25. A follow-up interview was conducted on 4/17/25 at 5:15 p.m. with the DON. She said somehow Resident #2's lab was cancelled on 4/15/25 by the lab or the nurse. She said the unit manager (UM) had been given this to check on the homework sheet and they should have caught the fact the lab was not completed. 3. Review of Admission Records showed Resident #8 was admitted on [DATE] with diagnoses including epilepsy. Review of Resident #8's physician orders revealed the following: -Levetiracetam (Keppra) Oral Tablet 500 mg. Give 3 tablet by mouth two times a day related to epilepsy. Dated 11/25/24. -Ammonia Level. Every night shift every Wednesday for 4 weeks. Dated 2/5/25. Review of Resident #8's lab results, dated 3/4/25, showed an Ammonia Level results of 118 umol/L (micromole per liter) with a reference range of 18-72 umol/L. This was indicated as a critical result. The lab showed the result was reported on 3/4/25 at 11:38 a.m. Review of Resident #8's progress notes showed no documentation a provider was notified on 3/4/25 of the critically high ammonia level. There was a progress note, dated 3/5/25 at 9:02 a.m.,. showing labs were sent to the Advanced Registered Nurse Practitioner. Review of Resident #8's Treatment Administration Record (TAR) showed the Ammonia level that was scheduled to be rechecked on 3/20/25 was documented as 9 indicating Other/See Nurse Notes. Review of progress notes revealed no nurses' note showing why the lab was not drawn. Review of Resident #8's lab results, dated 4/1/25, showed a Keppra level high at 49.5 ug/mL with a reference range of 6.0-46.0 ug/mL. An interview was conducted on 4/1/25 at 2:35 p.m. with the DON. She reviewed Resident #8's medical record and confirmed documentation showed the provider was not notified of the critical high ammonia level until the day after the results were received. She said her expectation would be the provider to be notified immediately of critical results. The DON confirmed there was no documentation as to why the ammonia level scheduled for 3/20/25 was not completed and said it should have been rescheduled but was not. 4. Review of Admission Records showed Resident #4 was admitted on [DATE] with diagnoses including other seizures. Review of Resident #4's care plan showed a focus area of seizure disorder, dated 8/27/24. Interventions included obtain and monitor lab/diagnostic work as ordered. Report results to MD and follow up as indicated. Review of Resident #4's orders revealed the fo [TRUNCATED]

Based on interviews and record review the facility failed to ensure they effectively monitored adverse events to systematically identify, report, track, and analyze the data to prevent potential or serious harm to residents for ineffective management of health care services, and treatment for seizure medication management for eleven residents (#1, #2, #3, #4, #5, #6, #7, #8, #9, #10, #11) out of eleven residents sampled. Serious harm occurred when Resident #1's seizure medication levels were not monitored, and neurology consultation was not obtained per the provider's request. Resident #1 experienced a seizure on 7/10/24, 9/28/24, 9/29/24, and 2/27/25. Resident #1 had to be transferred to a higher level of care as a result of the seizure suffered on 2/27/25. This failure created a situation that resulted in a worsened condition and the likelihood for serious injury and/or death to residents and resulted in the determination of Immediate Jeopardy on 4/16/2025. The findings of Immediate Jeopardy were determined to be removed on 4/17/2025 and the scope and severity was reduced to an E after verification of removal of immediacy of harm. Findings included: 1. Review of Resident #1's Admission Record revealed she was admitted to the facility on [DATE] from an acute care hospital with medical diagnoses of generalized idiopathic epilepsy and epileptic syndromes, not intractable, without status epilepticus, gastrostomy status as of 3/6/25, traumatic subdural hemorrhage with loss of consciousness, hydrocephalus, paraplegia, adult failure to thrive, protein-calorie malnutrition, anxiety disorder, major depressive disorder, lack of coordination, cognitive communication deficit, and Bell's palsy. Review of Resident #1's physician orders revealed the following: -Depakote (Valproic Acid) Sprinkles Oral Capsule delayed release 125 mg (milligrams), give one capsule by mouth two times a day for seizures, start date 5/23/24 and discontinued on 7/5/24. -Depakote Sprinkles Oral Capsule delayed release 125 mg, give one capsule by mouth three times a day for seizures, start date 7/6/24 and discontinued on 4/2/25. Review of Resident #1's July 2024 Medication Administration Record (MAR) revealed she received 125 mg of Depakote three times a day starting on 7/6/24. Review of Resident #1's laboratory (lab) results, dated 7/6/24, revealed her Valproic Acid levels were low at 10 microgram per milliliter (ug/ml). with a reference range of 50-100 ug/mL. Review of Resident #1's progress note, dated 7/7/24 at 8:13 p.m., revealed Hard copy labs called to ARNP (Advanced Registered Nurse Practitioner) . No new orders. Review of Resident #1's ARNP note, dated 7/7/24, revealed: CHIEF COMPLAINTS 7/7/24 fu [follow up] Visit She [Resident #1] has had some seizures in the past and had the recent seizure staff members reporting. Recently she had the seizure and medications were adjusted. Overall, she is very weak and feels like she is de-conditioned. She relies on staff to complete ADL's [activities of daily living] and assist with feeding in general. .ASSESSMENT AND PLAN .Seizure D-[NAME] [disorder] 7/7/24 Neurology consult, check medication levels .increased dose, depakote leve[sic] . Review of Resident #1's Progress note, dated 7/10/24 at 8:19 a.m., revealed Resident had a tonic-clonic seizure [a type of seizure with muscle stiffing followed by rhythmic jerking with a loss of consciousness] for 2 minutes. Resident was contracted and shaking the full time of the seizure. Resident is currently lying in bed. Dr. notified and waiting for a call back. Review of Resident #1's medical record did not reveal evidence the physician called back, or further attempts were made to contact the physician. Review of Resident #1's physician order revealed an order with a start date of 7/12/24, and an end date of 7/12/24 for Depakote Valproic Acid levels one time only for 1 day notify MD [Medical Doctor] of results. Review of Resident #1's lab results, dated 7/12/24, revealed Valproic Acid results were low (12 ug/mL) with a reference range of 50-100 ug/ml. Review of Resident #1's medical record did not reveal evidence the physician was notified of the low Valproic Acid level on 7/12/24. Review of Resident #1's physician orders revealed an order, with a revision date of 7/15/24, a start date of 7/22/24, and an end date of 7/23/24, to recheck Valproic Acid level in one week. Review of Resident #1's progress note, dated 7/22/24 at 3:06 a.m., revealed Resident to have Valproic Acid level rechecked today Review of Resident #1's Treatment Administration Record (TAR) revealed the physician order for Resident to have Valproic Acid level rechecked today was signed off as completed on 7/22/24 at 3:06 a.m. Review of Resident #1's Lab Order History from the lab portal did not reveal a physician's order was in the lab portal for Valproic Acid to be drawn on 7/22/24. Review of Resident #1's medical record did not reveal evidence the Valproic Acid was drawn on 7/22/24 and reported to the physician. Review of Resident #1's Advanced Practice Registered Nurse (APRN) note, dated 9/13/24, revealed CHIEF COMPLAINTS 9/13/24-fu [follow up] Visit .Recently she had the seizure and medications were adjusted. Overall, she is very weak and feels like she is de-conditioned. She relies on staff to complete ADL's [activities of daily living] and assist with feeding in general. . ASSESSMENT AND PLAN .Seizure 9/13/24 Neurology Consult, check medications levels . Review of Resident #1's Physician note, dated 9/20/24 revealed CHIEF COMPLAINTS 9/20/24 fu Visit . Recently she had the seizure and medications were adjusted. Overall, she is very weak and feels like she is de-conditioned. She relies on staff to complete ADL's and assist with feeding in general. .Assessment and Plan .Seizure 9/20/24 Neurology consult, check medications levels . Review of Resident #1's medical record revealed no evidence she received neurology services. Review of Resident #1's progress note, dated 9/28/24 at 5:36 PM, revealed Resident had a seizure while lying in bed at 1730 [5:30PM]. Resident was laying on her side while seizure was occurring. Made sure of resident safety. Seizure was under 5 minutes long and not reoccurring. Resident is now alert and able to speak and move. No discomfort or pain noted. No injuries. MD [Medical Doctor] notified. New order placed for labs. Review of Resident #1's physician orders revealed, an order with an order date of 9/28/24,for Depakote level, Ammonia Level, Levetiracetam (Keppra), and Lacosamide level. There was no start date or end date on the physician order. Review of Resident #1's September 2024 MAR revealed the physician order for Depakote level, Ammonia level, Levetiracetam (Keppra), and Lacosamide level was not documented as completed. Review of Resident #1's Lab Order History on the laboratory portal did not reveal a physician order was placed on 9/28/24 for Depakote level, Ammonia Level, Levetiracetam (Keppra), or a Lacosamide level. Review of Resident #1's progress note, dated 9/29/24 at 7:30AM, revealed Seizure activity noted this am [morning] lasting approximately 3.5 minutes s/p [status post] snoring lasting about 2 minutes then aroused making eye contact with staff alert and orientated to self-97.2 [temperature]-76 [pulse]-20 [respiratory rate]-128/82 [blood pressure]-97% [oxygen saturations] R/A [room air]. Review of the medical record did not reveal the resident's physician was notified of the seizure. Review of Resident #1's lab report with a collection date of 9/30/24 at 5:09 p. m., revealed Valproic Acid was low (14 ug/mL) with a reference range of 50-100 ug/ml. Review of Resident #1's medical record did not reveal evidence the physician was notified of the low Valproic Acid (Depakote) lab results collected on 9/30/24. Review of Resident #1's physicians' orders, revealed an order, with a start date of 2/4/25 and an end date of 2/5/25, for a Complete Blood Count (CBC), Comprehensive Metabolic Panel (CMP), Depakote level, and Ammonia level, every night shift for one day. Review of Resident #1's lab results with a collection date of 2/5/25, revealed abnormal CBC, CMP and Depakote Level results for the following lab values: Glucose: Low (67 milligrams per deciliter (mg/dL)) with a reference range of 70-99 mg/dL BUN: High (24 mg/dL) with a reference range of 6-20 mg/dL BUN /Creatinine Ratio: High (38.6 mg/dL) with a reference range of 6.0-25.0 mg/dL Calcium: Low (3.4 mg/dL) with a reference range of 8.6-10.2 mg/dL RBC: Low (3.93 million per microliter (M/uL)) with a reference range of 4.1-10.9) M/uL HGB: Low (11. grams per deciliter (8g/dL)) with a reference range of 12.0-16.0 g/dL HCT: Low (35.9%) with a reference range of 37.0-47.0% Valproic Acid (Depakote): low (25 ug/mL) with a reference range of 50-100 ug/mL Review of Resident #1's Lab Order History on the laboratory portal revealed the Ammonia order, dated 2/5/25, had a status of collection pending, no results and there was no sample collection date. Review of Resident #1's medical record revealed no evidence the physician was notified of the abnormal lab results collected on 2/5/25. The medical record revealed no Ammonia levels were collected or physician communication related to the Ammonia level lab not being collected. An interview was conducted on 4/15/25 at 12:45 p.m. with the Director of Nursing (DON). She reviewed Resident #1's Lab Order History on the laboratory portal, and she said Collection pending, No Results means the labs were not drawn. Review of Resident #1's progress note, dated 2/27/25 at 9:18 a.m., revealed At approx. [approximately] 7:30am resident was having seizure activity. foaming[sic] at mouth and release of urine and feces noted. resident[sic] moved to[sic] onto her side until seizure ceased. Resident cont [continued] to be slow to wake and is nonverbal at this time. Resident has history of seizure activity. Family and MD aware. Review of Resident #1's change in condition, dated 2/27/25, revealed The change in condition .: Altered mental status The seizure was: New onset seizure activity, OR persistent seizure in someone with known intermittent seizure activity. Provider Notification and Feedback: .send to ER [emergency room ] Review of Resident #1's hospital record revealed a physician note, dated 2/28/25, as: Impressions and Plan Breakthrough seizures due to noncompliance. The patient is currently unresponsive. This could be due to a postictal state, non-convulsive seizure activity or encephalopathy. I spoke to her [Resident #1's] nurse . at the nursing home . the patient has been refusing her medications. Yesterday she had a 4-minute convulsive seizure. Low Keppra level Low Depakote level but her dose of this medication may not be therapeutic. .Plan Prescribe telemetry Neurochecks every 2-4 hours Seizure precautions Lorazepam 2mg IV [intravenous] for convulsive seizure activity lasting more than 100 seconds IV Keppra IV Depakote IV Vimpat. She is also on oxcarbazepine that is not available in IV form, but the other AED's [anti-epileptic drugs] should be adequate. There is not yet clear how her refusal to take p.o. [by mouth] AEDs will get resolved. She may need a PEG [percutaneous endoscopic gastrostomy]. Review of Resident #1's hospital Gastrointestinal Physician note, dated 3/3/25, revealed: The patient presents with 50 yo [year old] f [female] who presented to the ed [emergency department] from her facility after a witnessed seizure. pt [patient] was also in the ed 2 days ago for glf [ground level fall]. I was asked to see the pt for a peg tube. Pt denies abdominal pain, n/v [nausea/vomiting] and dysphagia. Apparently, she frequently refuses to eat and take her medications due to her neurologic and psychiatric issues. Pt did not have issues swallowing during her vss [video swallow study]. per nursing if she is fed she will eat. She does pocket her food and requires verbal reminders. She has no abdominal pain, d/c [discomfort]. She has no gi [gastrointestinal] complaints. .plan Npo[nothing by mouth] after mn [midnight] Egd [esophagogastroduodenoscopy]/peg tomorrow. Review Resident #1's December 2024 through February 2025 Medication Administration Record (MAR) revealed she received 10 ml's of Keppra (100 mg/ml) by mouth twice a day every day for seizures except on 12/12/24 at 5:00 p.m. the documentation revealed 10. Review of the chart codes revealed 10=spit out meds. On 2/25/25 at 9:00 a.m. the documentation revealed 6 review of the chart codes revealed 6= hospitalized . On 2/26/25 at 9:00 a.m. the documentation revealed 2. Review of the chart codes revealed 2=drug refused. The February MAR review revealed Resident #1 received Depakote sprinkles 125 mg three times a day for seizures every day for the month of February until she was discharged on [DATE], except on 2/25/25 at 9:00 a.m. and 1:00 p.m., the documentation revealed Resident #1 was hospitalized . On 2/26/25 at 9:00 a.m. and 1:00 p.m. the documentation revealed Resident #1 refused the drug. Review of Resident #1's progress note, dated 3/6/25 at 2:12 p.m., revealed Resident returned to facility at approx. [approximately] 1;[sic]55pm via stretcher/ EMS [emergency medical services]. resident[sic] had no s/s [signs and symptoms] of distress noted .Resident has PEG tube in place and can eat by mouth. Jevity 1.2 @ 60 FWF [free water flush] 200ml q6 [every 6]. Resident can eat by mouth soft / bite sized. 1400 total in 24 hours. Two boxes a meal. Review of Resident #1's nutrition note, dated 3/7/25 at 9:59 a.m. revealed, Res [Resident] readmitted to facility 3/6/25 s/p [status/post] 7d [day] hospitalization . New Gtube [gastrostomy tube] inserted however res eats 75-100% of meals by mouth and requests snacks frequently. Will d/c [discontinue] enteral feed as res is able to meet needs via po [by mouth] at this time. Flush tube w/ [with] 150cc H20 [water] q [every] shift to maintain patency. Review of Resident #1's progress note, dated 3/7/25 at 10:21 a.m., written by Staff A, Licensed Practical Nurse (LPN), revealed, This writer received order from NP [Nurse Practitioner] stating resident able to take medication by mouth if resident refuses then we may use PEG-Tube for medications; resident is currently eating meals w/o [without] issues or concerns. An interview was conducted on 3/31/25 at 3:10 p.m. with the DON. The DON stated she did not assign a primary person to oversee the labs and review results. She said if labs were not critical staff would put the lab results in the providers' boxes for them to sign. If the labs were critical staff would call the provider to inform them about the critical lab results. The DON stated labs for seizure medications should be drawn every three months, but she does not know why some resident's labs were not being checked. She stated Resident #1's Depakote levels were being monitored by the psychiatric nurse practitioner. The DON stated she was aware that this was a system failure on the facility when it came to their lab process. She stated she would have expected her nurses to fax labs results to the doctor, put follow-up labs in to check the Depakote levels, and monitor the process. The DON stated Resident #1's labs from 9/30/2024 and 2/5/2025 were not signed off by the provider to show they reviewed the resident's lab results. She stated she thought Resident #1 had a neurology consultation while in the hospital, but the facility did not follow up to schedule a neurology appointment for Resident #1. The DON stated Resident #1's and Resident #2's labs were not done because the nurses were not transcribing the information from the orders to the lab reconciliation sheet and putting them in the lab book, so the tech knows which labs to draw for which residents. The DON stated it was her responsibility to ensure the resident's neurology consultation was followed up on. She stated there was a system failure because management did not have anyone assigned to pull labs, review lab results, and ensure all ordered labs were completed. The DON said their process was broken for following up with labs and completing documentation. An interview was conducted on 3/31/2025 at 3:50 p.m. with Resident #1's Psychiatry Physician Assistant (PA). The Psychiatry PA said he does not manage Resident #1's Depakote levels. If a resident is on Depakote for Seizures Psychiatry would not manage the medication; that would be managed by a resident's Primary Care Provider (PCP). An interview was conducted on 3/31/2025 at 4:20 p.m. with Resident #1's Advanced Practice Registered Nurse (APRN). The APRN said he does not monitor residents Depakote because it is managed by Psychiatry. He stated Depakote is not a medication he would prescribe a resident for seizures. He stated that he made a referral to have Resident #1 seen by a Neurologist in September 2024 and then again when Resident #1 came back from her most recent hospital stay (3/6/25), but he is not sure if the facility had followed up on his referral. He stated it is possible the low seizure medication labs could have been caught before the resident had her seizure if the facility had been managing her lab results and followed up with neurology. He stated residents who are on Keppra and Depakote medications for seizures should have labs drawn every three to six months to ensure the medication level are therapeutic for the resident's diagnosis. The APRN confirmed the facility should be doing the labs as ordered by the provider. For abnormal labs the facility should notify him the day the labs resulted and for critical labs the facility should get a hold of him. An interview was conducted on 4/15/25 at 1:50 p.m. with Staff B, LPN, she said she has worked at the facility on and off for four years and is very familiar with Resident #1. She said, Some years ago Resident #1 had a PEG tube for not eating, drinking, or taking her medications but she kept pulling the PEG tube out, so her family decided to just leave it out. She was doing well without it, eating, drinking, and taking her medications without any concerns. Staff B, LPN said for less than one day Resident #1 was not eating, drinking, or taking her medications and when she came in the next morning she had a huge gran-mal seizure, foaming at the mouth, lost control of her bowel and bladder, and then became post ictal (the period immediately following a seizure when the brain recovers, and the body returns to its normal state. During this phase, individuals may experience a range of symptoms, including confusion, drowsiness, headache, and cognitive difficulties.) Staff B, LPN said Resident #1's normal seizures are focal seizures, and she just stares, and they do not last long but this was a big one. Staff B, LPN said she called the physician and had Resident #1 sent to the hospital. Staff B, LPN said when Resident #1 returned the family must have agreed to a PEG tube again because she came back with a PEG tube but all we do is flush it in the morning with water. She said Resident #1 eats by mouth and takes her medications by mouth without any problems. She said since Resident #1 has returned from the hospital after her seizure she is still herself but not quite the same, we definitely fried some brain cells with that seizure. An interview was conducted with the Medical Director on 4/15/25 at 3:11 p.m., she said she was Resident #1's primary physician and she was familiar with the resident. She said, typically Resident #1's seizures are controlled, and she was on multiple seizure medications but, she did go to the hospital for a seizure. The Medical Director said when Resident #1 was admitted to the hospital for the seizure, her Keppra levels were low and her Depakote levels were not therapeutic, because she was not eating and was pocketing her medications [storing medications in her cheek]. She needed intravenous (IV) Keppra and IV Depakote because her levels were very low and it was an emergency. The Medical Director reviewed Resident #1's hospital notes and said Resident #1 had a PEG tube placed in the hospital because she was not eating or taking her medication, so it was life saving for her to have the PEG tube. The Medical Director said she did not remember the staff at the nursing home notifying her Resident #1 was not eating, drinking, or taking her medications. She said the nursing notes will reflect if they notified her or her APRN. The Medical Director said when labs are ordered her expectation is they are collected and once they have resulted the nurses should notify them immediately if any labs are critical. If they aren't critical then the nurses are supposed to put the results in the folder so she or her APRN can check them when they come in three to five times a week. The Medical Director said seizure medication levels should be drawn upon admission and every six months and if the seizure medication labs are abnormal the nursing staff should be notifying the Neurologist because she is not the Physician for the seizure medications, she is just supporting. The Medical Director said if there is an order for a neurology consultation then the facility should coordinate so the resident sees a Neurologist. The Medical Director said the residents had to go out to see a Neurologist because the facility did not have one coming to the facility. But there are transportation problems for bed ridden patients. An interview was conducted on 4/16/25 at 10:37 a.m. with Staff C, LPN she said she would get floated to take care of Resident #1. She said she works two double shifts a week the 3:00 p.m. to 11:00p.m. and 11:00 p.m. to 7:00 a.m. shift. She said before Resident #1 had her big seizure (2/27/25) she didn't have any problems giving her, her medications. She said the nurses knew you had to give her the medications in foods she liked, such as a milk shake. She said Resident #1 used to self-propel herself up and down the hallways yelling cheeseburger and asking for coffee. Staff C, LPN said now she is just not as spunky as she used to be before the seizure. Staff C, LPN said when she returned from the hospital she came back with a PEG tube. She said Resident #1 does not use the PEG tube, it's only there if she refuses to take her medications by mouth. Staff C, LPN said she does not have any issues with Resident #1 taking her medications or eating and drinking. An interview was conducted on 4/16/25 at 10:56 AM with Staff A, LPN 200 hall Unit Manager (UM) and the DON. Staff A, LPN, UM, said she has been a UM since the end of September and did not take over the 200 hall until the end of November. She said she knew Resident #1 for the most part, at the beginning, when Staff A, LPN, UM first started, she had only spit out her medications a couple of times and she was always eating so it was easy to give her medications. Only a day or two before her February seizure she was refusing her medications, But it wasn't long that she was refusing her meds before her seizure. The DON said it's their understanding she had a PEG tube a few years ago for failure to thrive but she had pulled it out and it was left out because she was eating and taking her medications by mouth without issues. The DON said when she came back from the hospital with the PEG tube, she worked with speech therapy and they were able to upgrade her diet right away and she continued to eat, drink, and take her medications without any problems. The DON said, she uses it for nothing and it is there just in case she does not take her medications. An interview was conducted on 4/16/25 at 11:02 a.m. with the DON. She said all the clinical nurses did not have access to the lab portal because they changed to the current lab in June 2024, We didn't push to get everyone access, there was just a push to get the system online. The DON said she had noticed for the past couple of months that lab orders had been cancelled. She said the facility just reordered the labs and didn't question why. The DON said the labs were just reordered and it was not really looked at as a system failure. A phone interview was conducted on 4/17/25 at 1:00 p.m. with Resident #1's Heath Care Proxy and family. They said they were informed Resident #1 went to the hospital in February for a seizure and when she was at the hospital, the hospital had called them and told them Resident #1 was pocketing her food, not drinking and not taking her medications that's why she had the seizure. The family gave the approval to put the PEG tube in and then they had a care plan meeting with the facility, and they were told Resident #1 was eating well and taking her medications by mouth and they were not using the PEG tube. A phone interview was conducted on 4/17/25 at 2:27 p.m. with the Regional Lab Supervisor. She said the Phlebotomist comes to the facility six days a week Monday through Saturday regardless if there are lab orders or not. She said they provide a Phlebotomist for STAT (immediately or without delay) labs as they need it. The Lab Supervisor said the expectation is the facility puts the lab order into the lab portal, print out the reacquisition form, and put the reacquisition form in the lab book. She said if the nurses do not have access to the lab portal, they can hand write the order on a blank reacquisition form, that the lab company provides, and put that in the lab book. The Phlebotomist will not know a lab needs to be drawn on a resident if there is not a reacquisition form in the lab book. The Lab Supervisor said if the nurse has put the order into the lab portal, but they did not print the requisition form and put it in the lab book then the Phlebotomist will not collect the lab and the order will sit in the portal and have a status of collection pending, no results. If the order is cancelled due to a collection error, then the lab will call the facility and have the nurse re-enter the order in the lab portal and print the reacquisition to put in the lab book so the Phlebotomist can redraw the labs the next day. Once the Phlebotomist has drawn the labs, they take the reacquisition forms with them and when they drop off the lab specimen someone from the lab makes sure the reacquisition was put into the portal because that is the only way the lab can print labels for the specimen. Once the test has resulted, then the result is uploaded into the lab portal and if there is a critical result the lab calls the facility. 2. Review of Admission Records showed Resident #2 was admitted on [DATE] with diagnoses including unspecified injury of head and unspecified convulsions. Review of Resident #2's care plan showed a focus area of Seizure disorder. Interventions included: give seizure medication as ordered by doctor. Monitor/document side effects and effectiveness and obtain and monitor lab/diagnostic work as ordered. Report results to MD and follow up as indicated and monitor labs and report sub therapeutic or toxic results to MD. Dated 10/4/17. Review of Resident #2's order showed the following: -Fasting comprehensive metabolic panel (CMP), lipids, complete blood count (CBC), Valproic Acid level, Ammonia level. One time a day every 4 months starting on the 1st for 1 day for hypertensive atherosclerotic cardiovascular disease (ASCVD), drug monitoring. Schedule routine weekday mornings. Dated 3/9/22. -Fasting CMP, Lipids, CBC, Valproic Acid level, Ammonia level. Every night shift for 1 day. Dated 12/1/24. -Divalproex Sodium HCL capsule delayed release 250 mg (Depakote). Give 250 mg by mouth at bedtime for seizure disorder related to unspecified convulsions. Dated 4/13/22. -Valproic Acid level. Dated 3/31/25. -Ammonia level. Dated 4/1/25. Review of lab results for Resident #2 showed Valproic Acid level and Ammonia level, dated 8/1/24. The Valproic Acid level was low at 23 ug/ml with a reference range of 50-100 ug/ml and the ammonia level was high at 69 ug/ml with a reference range of 11.0-35.0 ug/ml. There were no results found for the labs ordered to be drawn on 12/1/24. The 3/31/25 order for Valproic Acid level was not completed. The labs were reordered and drawn on 4/15/25 with a low result of <13 ug/ml with a reference range of 50-100 ug/ml. The Ammonia level drawn on 4/1/25 was high at 80 umoL/ml with a reference range of 18-72 umoL/ml. Review of Resident #2's progress notes showed no documentation a provider was notified of the abnormal Valproic Acid and Ammonia results on 8/1/24. Review of Resident #2's Lab Order History on the lab portal showed no orders were input in their system for labs to be drawn on 12/1/24. There was an order put in on 3/31/25 for a Valproic Acid level. Review of Resident #2's progress notes, dated 4/15/25, showed obtained orders to redraw Valproic Acid due to alb [albumin] stating uncollected lab and Lab tech out to get STAT Valproic Acid. An interview was conducted on 4/15/25 at 12:40 p.m. with the DON. She confirmed Resident #2 had a Valproic Acid level ordered on 3/31/25 that was not completed. She said they did not realize it was not done until 4/15/25. At 1:56 p.m. the DON reviewed Resident #2's medical record and confirmed there was an active order for labs every 4 months. She said the lab order was one that had fallen through the cracks and labs were not transcribed to the lab portal and lab reconciliation sheets. She confirmed the resident had labs in August 2024 and not again until 3/31/25. A follow-up interview was conducted on 4/17/25 at 5:15 p.m. with the DON. She said somehow Resident #2's lab was cancelled on 4/15/25 by the lab or the nurse. She said the unit manager (UM) had been given this to check on the homework sheet and they should have caught the fact the lab was not completed. 3. Review of Admission Records showed Resident #8 was admitted on [DATE] with diagnoses including epilepsy. Review of Resident #8's physician orders revealed the following: -Levetiracetam (Keppra) Oral Tablet 500 mg. Give 3 tablet by mouth two times a day related to epilepsy. Dated 11/25/24. -Ammonia Level. Every night shift every Wednesday for 4 weeks. Dated 2/5/25. Review of Resident #8's lab results, dated 3/4/25, showed an Ammonia Level results of 118 umol/L (micromole per liter) with a reference range of 18-72 umol/L. This was indicated as a critical result. The lab showed the result was reported on 3/4/25 at 11:38 a.m. Review of Resident #8's progress notes showed no documentation a provider was notified on 3/4/25 of the critically high ammonia level. There was a progress note, dated 3/5/25 at 9:02 a.m.,. showing labs were sent to the Advanced Registered Nurse Practitioner. Review of Resident #8's Treatment Administration Record (TAR) showed the Ammonia level that was scheduled to be rechecked on 3/20/25 was documented as 9 indicating Other/See Nurse Notes. Review of progress notes revealed no nurses' note showing why the lab was not drawn. Review of Resident #8's lab results, dated 4/1/25, showed a Keppra level high at 49.5 ug/mL with a reference range of 6.0-46.0 ug/mL. An interview was conducted on 4/1/25 at 2:35 p.m. with the DON. She reviewed Resident #8's medical record and confirmed documentation showed the provider was not notified of the critical high ammonia level until the day after the results were received. She said her expectation would be the provider to be notified immediately of critical results. The DON confirmed there was no documentation as to why the ammonia level scheduled for 3/20/25 was not completed and said it should have been rescheduled but was not. 4. Review of Admission Records showed Resident #4 was admitted on [DATE] with diagnoses including other seizures. Review of Resident #4's care plan showed a focus area of seizure disorder, dated 8/27/24. Interventions included obtain and monitor lab/diagnostic work as ordered. Report results to MD and follow up as indicated. <b [TRUNCATED]

Based on interviews and record reviews, the facility failed to ensure laboratory orders were entered in the electronic medical record and electronic laboratory (lab) portal, labs were completed as ordered, and abnormal results were reported to providers in a timely manner for eleven residents (#1, #2, #3, #4, #5, #6, #7, #8, #9, #10, #11) out of eleven residents sampled. Serious harm occurred when Resident #1's seizure medication levels were not monitored, and neurology consultation was not obtained per the provider's request. Resident #1 experienced a seizure on 7/10/24, 9/28/24, 9/29/24, and 2/27/25. Resident #1 had to be transferred to a higher level of care as a result of the seizure suffered on 2/27/25. This failure created a situation that resulted in a worsened condition and the likelihood for serious injury and/or death to residents and resulted in the determination of Immediate Jeopardy on 4/16/2025. The findings of Immediate Jeopardy were determined to be removed on 4/17/2025 and the scope and severity was reduced to an E after verification of removal of immediacy of harm. Findings included: 1. Review of Resident #1's Admission Record revealed she was admitted to the facility on [DATE] from an acute care hospital with medical diagnoses of generalized idiopathic epilepsy and epileptic syndromes, not intractable, without status epilepticus, gastrostomy status as of 3/6/25, traumatic subdural hemorrhage with loss of consciousness, hydrocephalus, paraplegia, adult failure to thrive, protein-calorie malnutrition, anxiety disorder, major depressive disorder, lack of coordination, cognitive communication deficit, and Bell's palsy. Review of Resident #1's physician orders revealed the following: -Depakote (Valproic Acid) Sprinkles Oral Capsule delayed release 125 mg (milligrams), give one capsule by mouth two times a day for seizures, start date 5/23/24 and discontinued on 7/5/24. -Depakote Sprinkles Oral Capsule delayed release 125 mg, give one capsule by mouth three times a day for seizures, start date 7/6/24 and discontinued on 4/2/25. Review of Resident #1's July 2024 Medication Administration Record (MAR) revealed she received 125 mg of Depakote three times a day starting on 7/6/24. Review of Resident #1's laboratory (lab) results, dated 7/6/24, revealed her Valproic Acid levels were low at 10 microgram per milliliter (ug/ml). with a reference range of 50-100 ug/mL. Review of Resident #1's progress note, dated 7/7/24 at 8:13 p.m., revealed Hard copy labs called to ARNP (Advanced Registered Nurse Practitioner) . No new orders. Review of Resident #1's ARNP note, dated 7/7/24, revealed: CHIEF COMPLAINTS 7/7/24 fu [follow up] Visit She [Resident #1] has had some seizures in the past and had the recent seizure staff members reporting. Recently she had the seizure and medications were adjusted. Overall, she is very weak and feels like she is de-conditioned. She relies on staff to complete ADL's [activities of daily living] and assist with feeding in general. .ASSESSMENT AND PLAN .Seizure D-[NAME] [disorder] 7/7/24 Neurology consult, check medication levels .increased dose, depakote leve[sic] . Review of Resident #1's Progress note, dated 7/10/24 at 8:19 a.m., revealed Resident had a tonic-clonic seizure [a type of seizure with muscle stiffing followed by rhythmic jerking with a loss of consciousness] for 2 minutes. Resident was contracted and shaking the full time of the seizure. Resident is currently lying in bed. Dr. notified and waiting for a call back. Review of Resident #1's medical record did not reveal evidence the physician called back, or further attempts were made to contact the physician. Review of Resident #1's physician order revealed an order with a start date of 7/12/24, and an end date of 7/12/24 for Depakote Valproic Acid levels one time only for 1 day notify MD [Medical Doctor] of results. Review of Resident #1's lab results, dated 7/12/24, revealed Valproic Acid results were low (12 ug/mL) with a reference range of 50-100 ug/ml. Review of Resident #1's medical record did not reveal evidence the physician was notified of the low Valproic Acid level on 7/12/24. Review of Resident #1's physician orders revealed an order, with a revision date of 7/15/24, a start date of 7/22/24, and an end date of 7/23/24, to recheck Valproic Acid level in one week. Review of Resident #1's progress note, dated 7/22/24 at 3:06 a.m., revealed Resident to have Valproic Acid level rechecked today Review of Resident #1's Treatment Administration Record (TAR) revealed the physician order for Resident to have Valproic Acid level rechecked today was signed off as completed on 7/22/24 at 3:06 a.m. Review of Resident #1's Lab Order History from the lab portal did not reveal a physician's order was in the lab portal for Valproic Acid to be drawn on 7/22/24. Review of Resident #1's medical record did not reveal evidence the Valproic Acid was drawn on 7/22/24 and reported to the physician. Review of Resident #1's Advanced Practice Registered Nurse (APRN) note, dated 9/13/24, revealed CHIEF COMPLAINTS 9/13/24-fu [follow up] Visit .Recently she had the seizure and medications were adjusted. Overall, she is very weak and feels like she is de-conditioned. She relies on staff to complete ADL's [activities of daily living] and assist with feeding in general. . ASSESSMENT AND PLAN .Seizure 9/13/24 Neurology Consult, check medications levels . Review of Resident #1's Physician note, dated 9/20/24 revealed CHIEF COMPLAINTS 9/20/24 fu Visit . Recently she had the seizure and medications were adjusted. Overall, she is very weak and feels like she is de-conditioned. She relies on staff to complete ADL's and assist with feeding in general. .Assessment and Plan .Seizure 9/20/24 Neurology consult, check medications levels . Review of Resident #1's medical record revealed no evidence she received neurology services. Review of Resident #1's progress note, dated 9/28/24 at 5:36 PM, revealed Resident had a seizure while lying in bed at 1730 [5:30PM]. Resident was laying on her side while seizure was occurring. Made sure of resident safety. Seizure was under 5 minutes long and not reoccurring. Resident is now alert and able to speak and move. No discomfort or pain noted. No injuries. MD [Medical Doctor] notified. New order placed for labs. Review of Resident #1's physician orders revealed, an order with an order date of 9/28/24,for Depakote level, Ammonia Level, Levetiracetam (Keppra), and Lacosamide level. There was no start date or end date on the physician order. Review of Resident #1's September 2024 MAR revealed the physician order for Depakote level, Ammonia level, Levetiracetam (Keppra), and Lacosamide level was not documented as completed. Review of Resident #1's Lab Order History on the laboratory portal did not reveal a physician order was placed on 9/28/24 for Depakote level, Ammonia Level, Levetiracetam (Keppra), or a Lacosamide level. Review of Resident #1's progress note, dated 9/29/24 at 7:30AM, revealed Seizure activity noted this am [morning] lasting approximately 3.5 minutes s/p [status post] snoring lasting about 2 minutes then aroused making eye contact with staff alert and orientated to self-97.2 [temperature]-76 [pulse]-20 [respiratory rate]-128/82 [blood pressure]-97% [oxygen saturations] R/A [room air]. Review of the medical record did not reveal the resident's physician was notified of the seizure. Review of Resident #1's lab report with a collection date of 9/30/24 at 5:09 p. m., revealed Valproic Acid was low (14 ug/mL) with a reference range of 50-100 ug/ml. Review of Resident #1's medical record did not reveal evidence the physician was notified of the low Valproic Acid (Depakote) lab results collected on 9/30/24. Review of Resident #1's physicians' orders, revealed an order, with a start date of 2/4/25 and an end date of 2/5/25, for a Complete Blood Count (CBC), Comprehensive Metabolic Panel (CMP), Depakote level, and Ammonia level, every night shift for one day. Review of Resident #1's lab results with a collection date of 2/5/25, revealed abnormal CBC, CMP and Depakote Level results for the following lab values: Glucose: Low (67 milligrams per deciliter (mg/dL)) with a reference range of 70-99 mg/dL BUN: High (24 mg/dL) with a reference range of 6-20 mg/dL BUN /Creatinine Ratio: High (38.6 mg/dL) with a reference range of 6.0-25.0 mg/dL Calcium: Low (3.4 mg/dL) with a reference range of 8.6-10.2 mg/dL RBC: Low (3.93 million per microliter (M/uL)) with a reference range of 4.1-10.9) M/uL HGB: Low (11. grams per deciliter (8g/dL)) with a reference range of 12.0-16.0 g/dL HCT: Low (35.9%) with a reference range of 37.0-47.0% Valproic Acid (Depakote): low (25 ug/mL) with a reference range of 50-100 ug/mL Review of Resident #1's Lab Order History on the laboratory portal revealed the Ammonia order, dated 2/5/25, had a status of collection pending, no results and there was no sample collection date. Review of Resident #1's medical record revealed no evidence the physician was notified of the abnormal lab results collected on 2/5/25. The medical record revealed no Ammonia levels were collected or physician communication related to the Ammonia level lab not being collected. An interview was conducted on 4/15/25 at 12:45 p.m. with the Director of Nursing (DON). She reviewed Resident #1's Lab Order History on the laboratory portal, and she said Collection pending, No Results means the labs were not drawn. Review of Resident #1's progress note, dated 2/27/25 at 9:18 a.m., revealed At approx. [approximately] 7:30am resident was having seizure activity. foaming[sic] at mouth and release of urine and feces noted. resident[sic] moved to[sic] onto her side until seizure ceased. Resident cont [continued] to be slow to wake and is nonverbal at this time. Resident has history of seizure activity. Family and MD aware. Review of Resident #1's change in condition, dated 2/27/25, revealed The change in condition .: Altered mental status The seizure was: New onset seizure activity, OR persistent seizure in someone with known intermittent seizure activity. Provider Notification and Feedback: .send to ER [emergency room ] Review of Resident #1's hospital record revealed a physician note, dated 2/28/25, as: Impressions and Plan Breakthrough seizures due to noncompliance. The patient is currently unresponsive. This could be due to a postictal state, non-convulsive seizure activity or encephalopathy. I spoke to her [Resident #1's] nurse . at the nursing home . the patient has been refusing her medications. Yesterday she had a 4-minute convulsive seizure. Low Keppra level Low Depakote level but her dose of this medication may not be therapeutic. .Plan Prescribe telemetry Neurochecks every 2-4 hours Seizure precautions Lorazepam 2mg IV [intravenous] for convulsive seizure activity lasting more than 100 seconds IV Keppra IV Depakote IV Vimpat. She is also on oxcarbazepine that is not available in IV form, but the other AED's [anti-epileptic drugs] should be adequate. There is not yet clear how her refusal to take p.o. [by mouth] AEDs will get resolved. She may need a PEG [percutaneous endoscopic gastrostomy]. Review of Resident #1's hospital Gastrointestinal Physician note, dated 3/3/25, revealed: The patient presents with 50 yo [year old] f [female] who presented to the ed [emergency department] from her facility after a witnessed seizure. pt [patient] was also in the ed 2 days ago for glf [ground level fall]. I was asked to see the pt for a peg tube. Pt denies abdominal pain, n/v [nausea/vomiting] and dysphagia. Apparently, she frequently refuses to eat and take her medications due to her neurologic and psychiatric issues. Pt did not have issues swallowing during her vss [video swallow study]. per nursing if she is fed she will eat. She does pocket her food and requires verbal reminders. She has no abdominal pain, d/c [discomfort]. She has no gi [gastrointestinal] complaints. .plan Npo[nothing by mouth] after mn [midnight] Egd [esophagogastroduodenoscopy]/peg tomorrow. Review Resident #1's December 2024 through February 2025 Medication Administration Record (MAR) revealed she received 10 ml's of Keppra (100 mg/ml) by mouth twice a day every day for seizures except on 12/12/24 at 5:00 p.m. the documentation revealed 10. Review of the chart codes revealed 10=spit out meds. On 2/25/25 at 9:00 a.m. the documentation revealed 6 review of the chart codes revealed 6= hospitalized . On 2/26/25 at 9:00 a.m. the documentation revealed 2. Review of the chart codes revealed 2=drug refused. The February MAR review revealed Resident #1 received Depakote sprinkles 125 mg three times a day for seizures every day for the month of February until she was discharged on [DATE], except on 2/25/25 at 9:00 a.m. and 1:00 p.m., the documentation revealed Resident #1 was hospitalized . On 2/26/25 at 9:00 a.m. and 1:00 p.m. the documentation revealed Resident #1 refused the drug. Review of Resident #1's progress note, dated 3/6/25 at 2:12 p.m., revealed Resident returned to facility at approx. [approximately] 1;[sic]55pm via stretcher/ EMS [emergency medical services]. resident[sic] had no s/s [signs and symptoms] of distress noted .Resident has PEG tube in place and can eat by mouth. Jevity 1.2 @ 60 FWF [free water flush] 200ml q6 [every 6]. Resident can eat by mouth soft / bite sized. 1400 total in 24 hours. Two boxes a meal. An interview was conducted on 3/31/25 at 3:10 p.m. with the DON. The DON stated she did not assign a primary person to oversee the labs and review results. She said if labs were not critical staff would put the lab results in the providers' boxes for them to sign. If the labs were critical staff would call the provider to inform them about the critical lab results. The DON stated labs for seizure medications should be drawn every three months, but she does not know why some resident's labs were not being checked. She stated Resident #1's Depakote levels were being monitored by the psychiatric nurse practitioner. The DON stated she was aware that this was a system failure on the facility when it came to their lab process. She stated she would have expected her nurses to fax labs results to the doctor, put follow-up labs in to check the Depakote levels, and monitor the process. The DON stated Resident #1's labs from 9/30/2024 and 2/5/2025 were not signed off by the provider to show they reviewed the resident's lab results. She stated she thought Resident #1 had a neurology consultation while in the hospital, but the facility did not follow up to schedule a neurology appointment for Resident #1. The DON stated Resident #1's and Resident #2's labs were not done because the nurses were not transcribing the information from the orders to the lab reconciliation sheet and putting them in the lab book, so the tech knows which labs to draw for which residents. The DON stated it was her responsibility to ensure the resident's neurology consultation was followed up on. She stated there was a system failure because management did not have anyone assigned to pull labs, review lab results, and ensure all ordered labs were completed. The DON said their process was broken for following up with labs and completing documentation. An interview was conducted on 3/31/2025 at 3:50 p.m. with Resident #1's Psychiatry Physician Assistant (PA). The Psychiatry PA said he does not manage Resident #1's Depakote levels. If a resident is on Depakote for Seizures Psychiatry would not manage the medication; that would be managed by a resident's Primary Care Provider (PCP). An interview was conducted on 3/31/2025 at 4:20 p.m. with Resident #1's Advanced Practice Registered Nurse (APRN). The APRN said he does not monitor residents Depakote because it is managed by Psychiatry. He stated Depakote is not a medication he would prescribe a resident for seizures. He stated that he made a referral to have Resident #1 seen by a Neurologist in September 2024 and then again when Resident #1 came back from her most recent hospital stay (3/6/25), but he is not sure if the facility had followed up on his referral. He stated it is possible the low seizure medication labs could have been caught before the resident had her seizure if the facility had been managing her lab results and followed up with neurology. He stated residents who are on Keppra and Depakote medications for seizures should have labs drawn every three to six months to ensure the medication level are therapeutic for the resident's diagnosis. The APRN confirmed the facility should be doing the labs as ordered by the provider. For abnormal labs the facility should notify him the day the labs resulted and for critical labs the facility should get a hold of him. An interview was conducted on 4/15/25 at 1:50 p.m. with Staff B, LPN, she said she has worked at the facility on and off for four years and is very familiar with Resident #1. She said, Some years ago Resident #1 had a PEG tube for not eating, drinking, or taking her medications but she kept pulling the PEG tube out, so her family decided to just leave it out. She was doing well without it, eating, drinking, and taking her medications without any concerns. Staff B, LPN said for less than one day Resident #1 was not eating, drinking, or taking her medications and when she came in the next morning she had a huge gran-mal seizure, foaming at the mouth, lost control of her bowel and bladder, and then became post ictal (the period immediately following a seizure when the brain recovers, and the body returns to its normal state. During this phase, individuals may experience a range of symptoms, including confusion, drowsiness, headache, and cognitive difficulties.) Staff B, LPN said Resident #1's normal seizures are focal seizures, and she just stares, and they do not last long but this was a big one. Staff B, LPN said she called the physician and had Resident #1 sent to the hospital. Staff B, LPN said when Resident #1 returned the family must have agreed to a PEG tube again because she came back with a PEG tube but all we do is flush it in the morning with water. She said Resident #1 eats by mouth and takes her medications by mouth without any problems. She said since Resident #1 has returned from the hospital after her seizure she is still herself but not quite the same, we definitely fried some brain cells with that seizure. An interview was conducted with the Medical Director on 4/15/25 at 3:11 p.m., she said she was Resident #1's primary physician and she was familiar with the resident. She said, typically Resident #1's seizures are controlled, and she was on multiple seizure medications but, she did go to the hospital for a seizure. The Medical Director said when Resident #1 was admitted to the hospital for the seizure, her Keppra levels were low and her Depakote levels were not therapeutic, because she was not eating and was pocketing her medications [storing medications in her cheek]. She needed intravenous (IV) Keppra and IV Depakote because her levels were very low and it was an emergency. The Medical Director reviewed Resident #1's hospital notes and said Resident #1 had a PEG tube placed in the hospital because she was not eating or taking her medication, so it was life saving for her to have the PEG tube. The Medical Director said she did not remember the staff at the nursing home notifying her Resident #1 was not eating, drinking, or taking her medications. She said the nursing notes will reflect if they notified her or her APRN. The Medical Director said when labs are ordered her expectation is they are collected and once they have resulted the nurses should notify them immediately if any labs are critical. If they aren't critical then the nurses are supposed to put the results in the folder so she or her APRN can check them when they come in three to five times a week. The Medical Director said seizure medication levels should be drawn upon admission and every six months and if the seizure medication labs are abnormal the nursing staff should be notifying the Neurologist because she is not the Physician for the seizure medications, she is just supporting. The Medical Director said if there is an order for a neurology consultation then the facility should coordinate so the resident sees a Neurologist. The Medical Director said the residents had to go out to see a Neurologist because the facility did not have one coming to the facility. But there are transportation problems for bed ridden patients. An interview was conducted on 4/16/25 at 10:37 a.m. with Staff C, LPN she said she would get floated to take care of Resident #1. She said she works two double shifts a week the 3:00 p.m. to 11:00p.m. and 11:00 p.m. to 7:00 a.m. shift. She said before Resident #1 had her big seizure (2/27/25) she didn't have any problems giving her, her medications. She said the nurses knew you had to give her the medications in foods she liked, such as a milk shake. She said Resident #1 used to self-propel herself up and down the hallways yelling cheeseburger and asking for coffee. Staff C, LPN said now she is just not as spunky as she used to be before the seizure. Staff C, LPN said when she returned from the hospital she came back with a PEG tube. She said Resident #1 does not use the PEG tube, it's only there if she refuses to take her medications by mouth. Staff C, LPN said she does not have any issues with Resident #1 taking her medications or eating and drinking. An interview was conducted on 4/16/25 at 10:56 AM with Staff A, LPN 200 hall Unit Manager (UM) and the DON. Staff A, LPN, UM, said she has been a UM since the end of September and did not take over the 200 hall until the end of November. She said she knew Resident #1 for the most part, at the beginning, when Staff A, LPN, UM first started, she had only spit out her medications a couple of times and she was always eating so it was easy to give her medications. Only a day or two before her February seizure she was refusing her medications, But it wasn't long that she was refusing her meds before her seizure. The DON said it's their understanding she had a PEG tube a few years ago for failure to thrive but she had pulled it out and it was left out because she was eating and taking her medications by mouth without issues. The DON said when she came back from the hospital with the PEG tube, she worked with speech therapy and they were able to upgrade her diet right away and she continued to eat, drink, and take her medications without any problems. The DON said, she uses it for nothing and it is there just in case she does not take her medications. An interview was conducted on 4/16/25 at 11:02 a.m. with the DON. She said all the clinical nurses did not have access to the lab portal because they changed to the current lab in June 2024, We didn't push to get everyone access, there was just a push to get the system online. The DON said she had noticed for the past couple of months that lab orders had been cancelled. She said the facility just reordered the labs and didn't question why. The DON said the labs were just reordered and it was not really looked at as a system failure. A phone interview was conducted on 4/17/25 at 1:00 p.m. with Resident #1's Heath Care Proxy and family. They said they were informed Resident #1 went to the hospital in February for a seizure and when she was at the hospital, the hospital had called them and told them Resident #1 was pocketing her food, not drinking and not taking her medications that's why she had the seizure. The family gave the approval to put the PEG tube in and then they had a care plan meeting with the facility, and they were told Resident #1 was eating well and taking her medications by mouth and they were not using the PEG tube. A phone interview was conducted on 4/17/24 at 2:27 p.m. with the Regional Lab Supervisor. She said the Phlebotomist comes to the facility six days a week Monday through Saturday regardless if there are lab orders or not. She said they provide a Phlebotomist for STAT (immediately or without delay) labs as they need it. The Lab Supervisor said the expectation is the facility puts the lab order into the lab portal, print out the reacquisition form, and put the reacquisition form in the lab book. She said if the nurses do not have access to the lab portal, they can hand write the order on a blank reacquisition form, that the lab company provides, and put that in the lab book. The Phlebotomist will not know a lab needs to be drawn on a resident if there is not a reacquisition form in the lab book. The Lab Supervisor said if the nurse has put the order into the lab portal, but they did not print the requisition form and put it in the lab book then the Phlebotomist will not collect the lab and the order will sit in the portal and have a status of collection pending, no results. If the order is cancelled due to a collection error, then the lab will call the facility and have the nurse re-enter the order in the lab portal and print the reacquisition to put in the lab book so the Phlebotomist can redraw the labs the next day. Once the Phlebotomist has drawn the labs, they take the reacquisition forms with them and when they drop off the lab specimen someone from the lab makes sure the reacquisition was put into the portal because that is the only way the lab can print labels for the specimen. Once the test has resulted, then the result is uploaded into the lab portal and if there is a critical result the lab calls the facility. 2. Review of Admission Records showed Resident #2 was admitted on [DATE] with diagnoses including unspecified injury of head and unspecified convulsions. Review of Resident #2's care plan showed a focus area of Seizure disorder. Interventions included: give seizure medication as ordered by doctor. Monitor/document side effects and effectiveness and obtain and monitor lab/diagnostic work as ordered. Report results to MD and follow up as indicated and monitor labs and report sub therapeutic or toxic results to MD. Dated 10/4/17. Review of Resident #2's order showed the following: -Fasting comprehensive metabolic panel (CMP), lipids, complete blood count (CBC), Valproic Acid level, Ammonia level. One time a day every 4 months starting on the 1st for 1 day for hypertensive atherosclerotic cardiovascular disease (ASCVD), drug monitoring. Schedule routine weekday mornings. Dated 3/9/22. -Fasting CMP, Lipids, CBC, Valproic Acid level, Ammonia level. Every night shift for 1 day. Dated 12/1/24. -Divalproex Sodium HCL capsule delayed release 250 mg (Depakote). Give 250 mg by mouth at bedtime for seizure disorder related to unspecified convulsions. Dated 4/13/22. -Valproic Acid level. Dated 3/31/25. -Ammonia level. Dated 4/1/25. Review of lab results for Resident #2 showed Valproic Acid level and Ammonia level, dated 8/1/24. The Valproic Acid level was low at 23 ug/ml with a reference range of 50-100 ug/ml and the ammonia level was high at 69 ug/ml with a reference range of 11.0-35.0 ug/ml. There were no results found for the labs ordered to be drawn on 12/1/24. The 3/31/25 order for Valproic Acid level was not completed. The labs were reordered and drawn on 4/15/25 with a low result of <13 ug/ml with a reference range of 50-100 ug/ml. The Ammonia level drawn on 4/1/25 was high at 80 umoL/ml with a reference range of 18-72 umoL/ml. Review of Resident #2's progress notes showed no documentation a provider was notified of the abnormal Valproic Acid and Ammonia results on 8/1/24. Review of Resident #2's Lab Order History on the lab portal showed no orders were input in their system for labs to be drawn on 12/1/24. There was an order put in on 3/31/25 for a Valproic Acid level. Review of Resident #2's progress notes, dated 4/15/25, showed obtained orders to redraw Valproic Acid due to alb [albumin] stating uncollected lab and Lab tech out to get STAT Valproic Acid. An interview was conducted on 4/15/25 at 12:40 p.m. with the DON. She confirmed Resident #2 had a Valproic Acid level ordered on 3/31/25 that was not completed. She said they did not realize it was not done until 4/15/25. At 1:56 p.m. the DON reviewed Resident #2's medical record and confirmed there was an active order for labs every 4 months. She said the lab order was one that had fallen through the cracks and labs were not transcribed to the lab portal and lab reconciliation sheets. She confirmed the resident had labs in August 2024 and not again until 3/31/25. A follow-up interview was conducted on 4/17/25 at 5:15 p.m. with the DON. She said somehow Resident #2's lab was cancelled on 4/15/25 by the lab or the nurse. She said the unit manager (UM) had been given this to check on the homework sheet and they should have caught the fact the lab was not completed. 3. Review of Admission Records showed Resident #8 was admitted on [DATE] with diagnoses including epilepsy. Review of Resident #8's physician orders revealed the following: -Levetiracetam (Keppra) Oral Tablet 500 mg. Give 3 tablet by mouth two times a day related to epilepsy. Dated 11/25/24. -Ammonia Level. Every night shift every Wednesday for 4 weeks. Dated 2/5/25. Review of Resident #8's lab results, dated 3/4/25, showed an Ammonia Level results of 118 umol/L (micromole per liter) with a reference range of 18-72 umol/L. This was indicated as a critical result. The lab showed the result was reported on 3/4/25 at 11:38 a.m. Review of Resident #8's progress notes showed no documentation a provider was notified on 3/4/25 of the critically high ammonia level. There was a progress note, dated 3/5/25 at 9:02 a.m.,. showing labs were sent to the Advanced Registered Nurse Practitioner. Review of Resident #8's Treatment Administration Record (TAR) showed the Ammonia level that was scheduled to be rechecked on 3/20/25 was documented as 9 indicating Other/See Nurse Notes. Review of progress notes revealed no nurses' note showing why the lab was not drawn. Review of Resident #8's lab results, dated 4/1/25, showed a Keppra level high at 49.5 ug/mL with a reference range of 6.0-46.0 ug/mL. An interview was conducted on 4/1/25 at 2:35 p.m. with the DON. She reviewed Resident #8's medical record and confirmed documentation showed the provider was not notified of the critical high ammonia level until the day after the results were received. She said her expectation would be the provider to be notified immediately of critical results. The DON confirmed there was no documentation as to why the ammonia level scheduled for 3/20/25 was not completed and said it should have been rescheduled but was not. 4. Review of Admission Records showed Resident #4 was admitted on [DATE] with diagnoses including other seizures. Review of Resident #4's care plan showed a focus area of seizure disorder, dated 8/27/24. Interventions included obtain and monitor lab/diagnostic work as ordered. Report results to MD and follow up as indicated. Review of Resident #4's orders revealed the following active orders: -Depakote Sprinkles Oral Capsule Delayed Release Sprinkle 125 mg (Divalproex Sodium). Give 2 capsule by mouth every 8 hours related to other seizures. Dated 2/6/25. - CBC, CMP, Depakote, TSH, Ammonia Level. One time a day every 90 day(s) for hypertension, schizophrenia, cholecystitis. Dated 4/29/21. Review of Resident #4's provider note, dated 2/12/25, noted Depakote, check levels and ammonia levels. Review of Resident #4's lab results showed the last Depakote level result was on 7/12/24. 5. Review of Admission Records showed Resident #3 was admitted on [DATE] with diagnoses including hemiplegia and hemiparesis following cerebral infarction, atrial fibrillation, epilepsy, and congestive heart failure. Review of Resident #3's physician orders revealed the followi [TRUNCATED]

Based on record review and staff interviews, the facility failed to ensure the Preadmission Screening and Resident Reviews (PASRRs) for residents with a mental disorder and individuals with intellectual disability with qualifying mental health diagnosis, were updated for five (#9, #22, #7, #39 and #23) of six residents sampled. Findings included: Resident #9 was originally admitted to the facility on [DATE] with a primary diagnosis of dementia onset date 10/01/22. Other diagnoses included Schizophrenia, Major depressive disorder with an onset date of 10/10/19. Review of a level I PASRR for Resident #9 dated 10/09/19 revealed page 2 of the PASRR was missing and the qualifying diagnoses were not checked. The level I PASRR showed the primary diagnosis of Dementia was not checked. This diagnosis was initiated after the PASRR was completed. Review of a PASRR level II determination summary report dated 09/13/19 showed this determination was submitted prior to the diagnosis of Dementia becoming primary. The report further showed the diagnosis of Schizophrenia was not considered. On 08/28/24 at 4:43 p.m., an interview was conducted with Staff F, Licensed Practical Nurse, (LPN)/MDS (Minimum Data Set). She stated if the resident acquired a new diagnosis, the PASRR should be updated. She stated a level II PASRR should be updated with diagnosis like Schizophrenia and Dementia. A review of Resident #7's admission record showed an admitted [DATE] with diagnoses to include Major Depressive Disorder, Unspecified Dementia, and Unspecified Psychosis. A review of level I PASRR for Resident #7 dated 5/24/23 showed the qualifying diagnoses were not checked and the need for a level II PASRR was not identified or acted upon. During an interview on 8/28/24 at 3:11 p.m. with the Director of Nursing (DON). The DON said if PASRR revisions were needed, the Social Services Director (SSD) would contact the PASRR people. The DON said she was responsible for completing the PASRRs and she did not have access to the PASRR's web-based submission program. The DON said after admission the Interdisciplinary Team (IDT) reviewed each PASRR for accuracy. During an interview on 8/28/24 at 3:39 p.m. with the SSD and the Nursing Home Administrator (NHA), the SSD said she was unable to access the PASRR web-based submission program and referred revisions to the DON. During an interview on 8/28/24 at 4:40 p.m., the NHA said the facility staff who could complete the level 1 screening, did not have access to the PASRR web-based program. A review of Resident of Resident #22's admission record showed an admitted [DATE] with diagnoses to include Anxiety, Major Depressive Disorder, and Unspecified Dementia with mood disturbance. A review of level I PASRR for Resident #22 dated 6/6/22, showed the qualifying diagnose of Dementia was not checked and the need for a level II PASRR was not identified or acted upon. A review of Resident #39's admission record showed an admitted [DATE] with diagnoses to include Anxiety, Vascular Dementia with other behavioral disturbance, and Major Depressive Disorder. A review of level I PASRR for Resident #39 dated 7/10/19, showed the qualifying diagnoses of Dementia was not checked and the need for a level II PASRR was not identified or acted upon. A review of Resident #23's admission record showed an admitted [DATE] with diagnoses to include Major Depressive Disorder, Parkinsonism, Epilepsy, Traumatic Brain Injury, and cognitive social or emotional deficit following other nontraumatic intracranial hemorrhage. A review of Resident #23's medical record did not reveal a level I PASRR. The facility was not able to locate a PASRR for the resident. Review of the facility's policy and procedure titled PASRR Requirements Level I & Level II, dated effective February 2021 showed: Topic: Pre-Admission Screening & Resident Review (PASRR) pre admission screening will be conducted prior to admission as the PASRR process is federally mandated pre admission screening program (see 42 CFR S483.100) required to be performed on all individuals prior to admission to a nursing home. The screening is reviewed by admissions for suspicion of serious mental illness and intellectual disability to ensure appropriate placement in the least restrictive environment and to identify the need to provide applicants with needed specialized services. PASRR screening applies to all new admissions into a Medicaid certified nursing facility and includes private pay, Medicare, and Medicaid admissions regardless of payer source. * The screening is typically done by discharge planners and hospital staff as a step in the discharge process. It is separate from a medical needs assessment, which most often occurs after a person applies for Medicaid and is required step to qualify for Medicaid long term care assistance. Procedure: 1. During the admission process, business development will communicate with the facility regarding prospective admissions. A level 1 PASRR will be provided prior to admission to the skilled nursing facility. Facility administration will confirm that a level 1 review has been completed prior to transfer to the SNF setting. 2. Determine if a serious mental and/or intellectual disability or related condition exists while reviewing the PASRR form completed by the acute care facility. (Trigger for level 2 completion) 3. If serious mental illness or ID is indicated, determine if the resident/patient will be admitted from a hospital for an acute care stay and the attending physician has certified that the individual is likely to require less than 30 days of nursing facility services. Assure that the certification is signed and dated. 4. If the physician indicates the stay will likely be less than 30 days SNF services, the patient/resident can be admitted to an SNF. If anticipated stay becomes longer than the 30 days a level 2 must be completed prior to day 40. Florida facilities (form 004 part A effective November 2014) assure that sections one through 5 are completed prior to admission. If section IV (provisional admission) this applicable, the form is only valid if the MD has signed and dated the form. If the admission is a provisional admission, the social service director must start a tickler file and assure the level 2 is completed within the state specified time frame. * Delirium - within seven days of admission * caregiver respite within 14 days of admission * emergency placement within seven days of admission * 30 day hospital exemption within 30 to 40 days of admission if the pre admission screening requires a level 2 evaluation submit all required documents to the required agency timely, so that a level 2 can be completed within the required time frames. 49227 48223

Based on observations, interviews, and facility policy review, the facility failed to ensure resident rooms were maintained in a clean and sanitary manner in three (300, 200, 100) of three halls observed, during 4 of 4 days of survey. Findings included: On 08/26/24 at 10:25 a.m., upon entering the secured unit in hall 300, a strong urine odor was noted. On 08/26/24 at 10:26 a.m., an immediate interview was conducted with Staff AA, Certified Nursing Assistant (CNA). She confirmed the smell. She stated this was not the first time. She stated she did not know why the unit had a foul odor. On 08/26/24 at 11:02 a.m., an interview was conducted with Staff L, Regional Housekeeping Manager. He said, Yes, it smells in here. It could be because of soiled depends or a foul wound. He stated some of the residents urinated on the floors which could be the source of the foul smell. On 08/26/24 at 10:49 a.m., room [ROOM NUMBER] was observed with stains and scratches on the walls, stained floors, and dirt and grime along the base boards. On 08/26/24 at 10:57 a.m., room [ROOM NUMBER] was observed with stained privacy curtains, stains and scratches on the walls, grime on the baseboards, and broken dresser and nightstand drawers. On 08/26/24 at 11:06 a.m., room [ROOM NUMBER] was observed with stained walls and raised plastering on the door surface. On 08/26/24 at 11:15 a.m., room [ROOM NUMBER] was observed with wet ,stained floors, bed linens on the floor, stained walls, grime on the baseboards, and a trash can without a bag and a soiled brief in the can. On 08/26/24 at 11:18 a.m., an interview was conducted with Staff AA. She stated resident's linens should not be on the floor. She said, We will pick them up. They should not be on floor. On 08/26/24 at 11:28 a.m., room [ROOM NUMBER] was observed with dirt on the floor corners and chipped missing tiles on the bathroom floor corner by the door. The room's door frame was observed with rusty debris on the bottom corners, stains behind the door and floors, stained walls, and base boards with dirt and grime. A pair of black pants and a book were observed on the floor under bed B. This observation was made during two of four days of survey. The main door was observed without a door knob during 3 of 4 days of survey. On 08/26/24 at 11:23 a.m., an interview was conducted with Staff K, Housekeeping Manager from a sister facility. She stated she was at this facility helping the housekeeper just that day only. She stated she had never been at this facility before but had been asked to come and help out. She observed the unkempt rooms and confirmed the foul odor. She said, No, residents should not live in an unclean environment. It is not acceptable. On 08/26/24 at 11:24 a.m., an observation was made of Staff M, Housekeeping Manager from a sister facility setting up a cleaning cart outside a resident's room. He stated he did not work at this facility but had been asked to come and help. Staff M said, It is not clean and sanitary in here. Yes, it smells. This unit definitely needs cleaning. That is why I came to help. He stated he did not normally come to assist with housekeeping. He stated he was at this location only this day because of the survey. On 08/26/24 at 11:28 a.m., an interview was conducted with Staff L, Regional Housekeeping Manager. He said, We are lacking in accountability. We will clean the unit today. It is not to our standards right now. The residents should be in a sanitary environment. It should be clean. On 08/26/24 at 11:33 a.m., an interview was conducted with Staff J, Housekeeping Manager. He stated the unit smelled like urine. He said, It is not clean in here. Some residents urinate on the floor. The plan is to clean the rooms three times daily. He stated the CNAs should help in the mornings because it smelled like that all the time. On 8/26/24 at 11:36 a.m., Staff N, Housekeeping Aide was observed cleaning a resident's room. She stated she worked at this facility. She stated this was not her regular assignment. She stated the aide who normally cleaned this unit had been out sick. She stated she did not know if anyone had been assigned to clean the secured unit the previous weekend. On 08/27/24 at 2:49 p.m., an observation was made of linens on the floor in room [ROOM NUMBER]. On 8/27/24 at 3:42 p.m., an observation was made of broken nightstands for bed A and B and a broken dresser drawer in room [ROOM NUMBER]. On 8/28/24 at 9:23 a.m., room [ROOM NUMBER] was observed with a bedside table with stains and dried up syrup on the table surface. Observations were made of stains on walls, blinds, floors, and dirt on the baseboards. On 8/28/24 at 9:24 a.m., an interview was conducted with Staff N, Housekeeping Aide. She stated she was assigned to clean both her assignment and the other aide's assignment in halls 200 and 300. She said, The staff who works here is still out sick. I am doing my best working both assignments. On 08/28/24 at 9:30 a.m., room [ROOM NUMBER] was observed with stains on the floor. On 08/28/24 at 9:31 a.m., room [ROOM NUMBER], was observed with stained walls and the handwashing sink without a trim, exposing wood and a white bubbled rough surface. On 08/28/24 at 9:32 a.m., room [ROOM NUMBER] was observed without a door handle. This observation was made three of three days of survey. An immediate interview was conducted with Staff H, CNA. She stated this door had not had a door handle for approximately 3 weeks. She stated it was hard for both staff and residents to push the door open. In a follow -up interview on 08/28/24 at 12:52 p.m., Staff L, Regional Housekeeping Manager stated he had just noticed the door knob missing in room [ROOM NUMBER]. He stated he would get it fixed. He stated the facility's manager should be conducting more rounds. On 08/28/24 9:40 a.m., an interview was conducted with Staff H, CNA. She stated the secured unit had a moldy musty smell. She confirmed it had been an ongoing problem. On 08/28/24 from 9:56 a.m. to 10:08 a.m., a tour of the secured unit's residents smoking area was conducted with the facility's Floor Technician. A portion of the fence was observed fallen, leaving a wide-open space leading outside the facility. The path leading to the resident's smoking area was observed with multiple bees, wasps, and cobwebs on the walls along the pavement. The floor technician stated he would notify maintenance of the observed concerns. On 08/28/24 at 10:05 a.m., an interview was conducted with Staff J, Housekeeping Manager. He stated the aide who cleaned the secured unit was out sick and he had not found a replacement. On 08/29/24 at 2:23 p.m., an interview was conducted with the Director of Maintenance (DOM). He stated he was not sure why there was a musty smell in the secured unit. He stated he had a problem with ventilation in that unit, but he did not know if that was the issue. He said, I know the rooms need painting. They are old. Some rooms need furniture. Especially in the secured unit. He stated he conducted rounds and made a list. He stated he handled emergency concerns first. He stated he did not know room [ROOM NUMBER] did not have a door knob. He stated he was not aware. He said, The residents should have a door knob. I do not know who removed it or how long it had been. He stated he did not know about the bees, wasps problem until the previous day. He stated he was working on the identified concerns. On 08/29/24 at 02:27 p.m., an interview was conducted with the Nursing Home Administrator (NHA). She stated they had one maintenance man on staff (The DOM). She said, Our process is to identify areas of concern and address one issue at a time. Immediate concerns are handled first, and then we go down the list. The NHA confirmed the floors needed to be redone. She stated it was hard to find similar tiles. She said, We scrub and do the best we can. I know some of them need to be replaced. On 8/26/24 at 10:51 a.m., during a tour of room [ROOM NUMBER], the sealant in the front of the bathroom sink appeared rough, missing on the outer edges, and had pale green and rust colored buildup. Rust colored drainage was noted on the sink. There were holes in the shower tile with tan and grey colored buildup between the tiles. The sealant on the base of the shower wall was rough with rust colored buildup. The floor between the bedroom and the bathroom had buildup of dirt and grime. (Photographic Evidence Obtained). On 8/26/24 at 10:54 a.m., during a tour of room [ROOM NUMBER] there was unpainted patch areas in three areas of the wall around the air conditioner unit. There were dry brown colored areas on the floor with buildup of dirt and grime in the crevices. (Photographic Evidence Obtained). On 8/26/24 at 11:11 a.m., during a tour of 200 hall the paint on the hallway wall outside of room [ROOM NUMBER] was peeling. There were depressions in the wall and buildup of dirt and grime in the door jam and base trim crevices. (Photographic Evidence Obtained). On 8/26/24 at 11:44 a.m., during a tour of room [ROOM NUMBER]-2 the wall behind the top of the bed had deep gouges, portions of the paint and the outer dry wall was peeled and white chalk like material was exposed. In the bathroom, the drain was 1/3 covered with debris, and there was a large amount of brown with black speckled biofilm on the gout. The calking between the wall and the toilet stool appeared rough and there was a separation between the toilet and the wall on the side and top. The caulking around the sink was rough with spots of separation from the sink. The faucet's handle, base and spout contain dry, hard, chalky, rust, grey, and tan deposits. (Photographic Evidence Obtained). On 8/26/24 at 12:15 p.m., during a tour of 300 hall, the wall behind the bed headboard in room [ROOM NUMBER]-2 was in disrepair. Deep gouges, portions of the paint and the outer dry wall was peeled and white chalk like material was exposed. There were white particles laying on the floor below. (Photographic Evidence Obtained). An interview was conducted with the Maintenance Director and Nursing Home Administrator (NHA) on 8/29/24 at 2:04 p.m. The Maintenance Director said the facility's management team completes rounds each morning. When maintenance related issues were identified staff members were expected to log the issue in the facility's building management platform. He checked the web-based system daily and address the most immediate first. The Maintenance Director said the facility's current priority was addressing leaks in the facility. He said the building was old and had many ongoing maintenance issues. The facility had one staff member assigned to maintenance duties. An interview was conducted with the Housekeeping Manager and the Housekeeping District Manager on 8/29/24 at 2:36 p.m. The Housekeeping Manager said all resident rooms were cleaned daily. The daily cleaning included emptying the trash, high dusting, clean surfaces of the room, sweep floors, and mop. There were three house keepers assigned to work on weekdays and two on the weekends. The Housekeeping District Manager said the gout between the tiles could be cleaned, and he planned to retrain staff. A review of the facility's policy and procedure titled physical environment, effective August 2024. The policy statement is a safe, clean, comfortable, and homelike environment is provided for each resident, allowing the use of personal belongings to the greatest extent possible. Sufficient space and equipment in dining, health services, recreation, and program areas are provided to enable staff to provide residents with needed services. All essential mechanical, electrical, and resident care equipment is maintained in safe operating condition through the facilities preventative maintenance program. The procedure showed 1) Encourage residents to bring their individual possessions within the limits of the safety of the resident and others. 2) Maintain sufficient space and equipment in dining, health services, recreation, and program areas. Remove unnecessary clutter. 3) Assure flame proof cubicle curtains are available and in place at all times to assure resident privacy. 4) Assure an applicable working system is in place and within reach for residents to summon assistance, including, but not limited to typical call light with cord, manual call bell, specialty call bell as needed A review of the facility's policy, titled housekeeping procedures, revised 9/5/ 2017. The section titled bathroom cleaning showed material needed includes a cart, dust mop, damp mop, dustpan, dust brush, high duster, bucket and ringer, quat disinfectant, three spray bottles, 3 pals, rags, sponges, scraper, johnny mop, wet floor sign, paper towels, toilet tissue, plastic trash bags. Use a seven-step method. Dry steps 3) Pick up trash, use dust mop. Wet steps: 4) sanitize sinks, light, mirror, sink, fixtures and pipes. 5) sanitize commode, tank, bowl and base. Use brush for inside of bowl. 6) Spot clean-walls, partitions, light switches. 7) Damp mop. Start in far corner get behind commode, move trash can, mop out the door. The section titled daily patient room cleaning B) Do a quick straighten up. C) Follow five step room cleaning method: 1) empty trash. 2) Horizontal Dusting. 3) Spot clean. 4) Dust mopped floor; pick up with dustpan. 5) damp mop floor . the section titled Complete Room Cleaning showed A) set up calendar outlining what rooms are to be cleaned on certain days. B) Coordinate with charge nurse at the start of shift to have the room ready. F) Follow 5-Step room cleaning method: 1) Empty Trash, 2) Horizontal dusting, 3) Spot Nurse, 4) Dust mop floor, 5) Damp mop floor. 49227

Based on observations and interviews, the facility failed to maintain an effective infection prevention and control program by failing to ensure staff members donned appropriate personal protective equipment (PPE) before entering the rooms of residents with transmission based precaution signage on the door for four (#2, #86, #104, #38) of four residents and two (#102 and #217) of four rooms sampled in the secure unit. Findings included: 1. On 08/26/24 at 10:15 a.m., a tour of the secure unit was conducted which revealed three residents (#86, #104, #38) had contact isolation signage posted on the door to their rooms. The signs showed everyone must: Put on gloves and gown before room entry, discard gloves and gown before room exit. An interview was conducted with Staff Z, Certified Nursing Assistant (CNA) on 08/26/24 at 10:35 a.m. She stated there was no one on isolation in the unit. An interview was conducted with Staff AA, CNA on 08/26/24 at 10:37 a.m. She stated there was no one on isolation in the unit and was unsure why Resident #86 was on contact isolation. An interview was conducted with Staff D, Registered Nurse (RN) on 08/26/24 at 10:40 a.m. She stated Residents #86, and #38 were on isolation for Covid precautions. She was unsure why the contact isolation signage was posted on the door. An observation was conducted on 08/26/24 at 11:21 a.m. outside Resident #86's room. A contact isolation sign was present on the door with instructions to put on gloves and gown before room entry, discard gloves and gown before room exit. A caddy containing isolation gowns, gloves, and one N95 mask was observed inside the room to the left of the doorway. Staff M, Housekeeping Manager from a sister facility, entered Resident #86's room wearing a Kn95 mask. Resident #86 was observed in bed dressed in day clothes with no mask on. The Housekeeping Manger emptied the trash inside the room and exited the room to put the trash on his cart located outside of the room. He entered and exited the room multiple times without donning or doffing PPE. On 08/26/24 at 11:23 a.m., Staff J, Housekeeping Manager was observed entering Resident #86's room without donning or doffing PPE and began cleaning the bed by the window. Resident # 86 was observed in bed dressed in day clothes with no mask on. On 08/26/24 at 11:25 a.m., an interview was conducted with Staff J. He stated for him to know which resident was on transmission-based precautions he would look at the sign on the resident's door. Upon looking at the contact isolation sign located on the door of Resident #86's room, he stated I am not sure what I need to put on. On 08/26/24 at 1:15 p.m., a review of Resident #86's physician's orders revealed an order for Isolation precaution for COVID . with an order date of 08/19/24 and completed date of 08/24/24. On 08/26/24 at 10:45 a.m., Staff D, RN was observed assisting Resident #104 without using PPE. On 08/26/24 at 10:46 a.m., Staff Z, CNA was observed assisting resident #104 without using PPE. On 08/26/24 at 2:00 p.m., a review of Resident #104's physician's orders revealed an order for Isolation precaution for COVID . with an order date of 08/19/24 and completed date of 08/25/24 On 08/26/24 at 12:53 p.m., Resident #38 was observed in the dining room eating lunch at a table with two other residents with no PPE On 08/26/24 at 2:00 p.m., a review of Resident #38's physician's orders revealed an order for Isolation precaution for COVID . with an order date of 08/19/24 and completed date of 08/24/24. On 08/26/24 at 1:40 p.m., a Transmission Based Precaution List was provided by the Nursing Home Administrator which revealed Residents #104, and #38 were Covid positive. On 08/27/24 at 9:43 a.m., no isolation signs were present on any rooms in the secure unit. On 08/27/24 at 9:45 a.m., Staff C, Licensed Practical Nurse (LPN) stated there was no isolation on the secure unit. On 08/27/24 at 3:35 p.m., an isolation sign Special Contact/Droplet isolation was present on Residents #104's, and #38's door to their rooms in the secure unit. The sign indicated the use of gown, gloves, N95 respirator and eye protection before entering and exiting the room. On 08/27/24 at 3:40 p.m., an interview was conducted with Staff E, Licensed Practical Nurse/Unit Manager (LPN/UM). He stated he thinks Resident #104 is off isolation for Covid and the only resident on isolation is Resident #104. 20311 Observations of the 100 hall on 08/27/24 at 9:51 a.m., revealed room [ROOM NUMBER] had a isolation sign posted on the door indicating droplet precautions. Staff X was noted to enter room [ROOM NUMBER] with a mask, gown and gloves. Continued observations revealed Staff X exited room [ROOM NUMBER] discarding her gloves and gown, but kept her mask on and proceeded to walk to other resident rooms. Observations on 08/27/24 at 10:03 a.m. of room [ROOM NUMBER], revealed a droplet isolation sign and caddy were mounted on the room door. The caddy was noted to only have gloves and gowns in it. It was noted there were no masks or eye protection in the caddy. Continued observation at this time revealed Staff Y walked into room [ROOM NUMBER] and did not don gloves, mask, gown, or eye protection. Photographic evidence obtained. An interview on 08/27/24 at 10:13 a.m. with Staff X, Certified Nursing Assistant, CNA, revealed the resident in room [ROOM NUMBER] was on droplet precautions due to being COVID positive. She said to enter this room she must don a gown, gloves, and wash her hands. She said she did not need the use of eye protection and she kept the same mask on when exiting the room. She said she was trained to keep the mask on. An interview with Staff Y, CNA on 08/27/24 at 10:17 a.m., revealed she was aware of entering an isolation room and knew she should have put on a gown and gloves because there was a caddy on the door. She reported she was not sure if there was a sign on the door so she was not sure what type of isolation was in place for room [ROOM NUMBER]. Observations on 08/27/24 at 10:24 a.m., revealed Staff D, Registered Nurse (RN) entered room [ROOM NUMBER] and donned a mask, gown, and gloves. Continued observations revealed when Staff D exited the isolation room she kept the same surgical mask on her face. Interview with Staff D at this time revealed room [ROOM NUMBER] was on droplet precautions due to a COVID positive resident. She reported she should have donned a gown, eye protection, done hand hygiene, and wore gloves and a mask. She confirmed that she did not wear eye protection and used the same mask after exiting the room. She reported that she should have had goggles on and she should have changed the mask. 48223 On 8/26/24 at 12:33 p.m., Staff DD, CNA was observed wearing a KN95 mask, removed a tray from the meal cart and entered room [ROOM NUMBER], which had a droplet isolation sign on the door. Staff DD, CNA did not don any PPE. Staff DD, CNA was observed touching the over the bed table and setting up the resident's meal tray. Staff DD, CNA exited the room at 12:35 p.m., no hand hygiene was performed nor was any doffing of PPE. An interview was conducted with Staff DD, CNA on 08/26/24 at 12:36 a.m. Staff DD, CNA confirmed entering room [ROOM NUMBER] and acknowledged the droplet isolation sign on the door. Staff DD stated, I don't need to wear a gown or any other PPE to drop off the meal tray and I have my mask on. Staff DD, CNA continued to state not having to change the mask upon exiting the room. An interview was conducted with Staff V, LPN on 08/26/24 at 12:40 p.m. Staff V, LPN stated the resident in room [ROOM NUMBER] was on droplet isolation. Staff should be following the signage, which stated to wear a gown, gloves, N95 mask, and eye protection to enter the room, even if just dropping off the tray. During an interview on 8/27/24 at 4:06 p.m., the DON said staff were expected to wear a mask, shield, gown, and gloves when entering the room with a resident on COVID/ droplet precautions. The appropriate mask could be found in the caddy outside of the resident's room. Staff were expected to replace masks with a new one prior to caring for the resident. Staff were expected to remove PPE including the mask upon existing the resident's room. The approved mask for Covid is a N95, not a KN95. On 8/26/24 at 10:35 a.m. an Enhanced Barrier sign was present on Residents #2's door. Review of Resident #2's progress notes, dated 8/25/24 showed urine culture results received and Resident #2 has Extended-spectrum beta-lactamase (ESBL). Review of Resident #2's physician orders did not reveal any active order for contact precautions. During an interview on 8/29/24 at 10:57 a.m. the Infection Control Preventionist (ICP) stated if a resident has ESBL in the urine the protocol is to place the resident on Contact Precautions. The ICP confirmed that Resident #2 should be on contact precautions, no enhanced barrier. Prior to this week no one oversaw the PPE supply nor the signage. Review of the facility's policy and procedures titled Infection Prevention and Control Program dated Effective October 2021 revealed: Policy: The infection prevention and control program is comprehensive program that addresses detection, prevention and control of infections and communicable diseases among residents, visitors, volunteers, and those individuals providing services under contractual agreements and personnel. The infection prevention and control program, in addition, will facilitate activities to improve antibiotic use to reduce adverse events, prevent emergence of antibiotic resistance, and promote better outcomes for residents. Goals: The goals of the infection prevention and control program are to: a. Provision of a safe sanitary, and comfortable environment b. Decrease the risk of infection and communicable disease development and transmission to residents, volunteers, visitors, individuals providing services under a contractual agreement and personnel. Review of the facility's policy and procedure titled Barrier Precautions revealed: Policy: . Contact Precautions are used when the employee expects to be in direct or indirect contact with a patient and/or his or her environment including a person's room or objects in contact with the person, that has an infection with an organism transmitted fecal-orally, such as colostrum difficile, or wound and skin infections, or multidrug resistant bacteria such as methicillin resistant staphylococcus aureus (MRSA). PPE required before entering a contact precaution designated room is always gloves and a gown. Mask and eye protection are additionally required if contact with bodily secretions is possible. Enhanced Barrier precautions (EBP) refers to an infection control intervention designed to reduce transmission of multidrug resistant organisms that employ targeted gown and glove use during high contact resident activities. EBP are used in conjunction with standard precautions and expand the use of PPE to donning of gown and gloves during high contact resident care activities that provide opportunities for transfer of MDROs to staff hands and clothing. EBP is indicated for residents with any of the following: . Droplet precautions are necessary when an employee is within three to six feet of a resident infected with a pathogen, such as influenza. Infections are transmissible through air droplets by coughing, sneezing, talking, and close contact with an infected patients breathing period patient should be placed in an individualized room, if possible.

Based on observation, interview, and record review, the facility failed to ensure the medication error rate was less than 5.00%. 32 medication administration opportunities were observed, and six errors were identified for two residents (#110 and #107) of six residents observed. These errors constituted a 18.75% medication error rate. Findings Included: On 8/28/24 at 10:08 a.m., a medication administration observation was conducted with Staff U, Registered Nurse (RN) for Resident #110. Staff U, RN administered insulin subcutaneously and Cyanocobalamin (Vitamin B 12) intramuscularly. Resident #110's electronic medication administration record (eMAR) was highlighted in red. Staff U, RN, confirmed the medications were late. Review of Resident #110's August 2024 MAR showed insulin administration was due at 0800 with meal and Cyanocobalamin was scheduled to be given at 9:00 a.m. On 8/28/24 at 10:13 a.m., a medication administration observation was conducted with Staff U, RN for Resident #107. Staff U, RN prepared and administered Amlodipine 10 milligrams (mg) for high blood pressure, Naloxegol Oxalate 625mg for irritable bowel syndrome (IBS), Mirabegron ER 50 mg for bladder, Fluticasone-Salmeterol inhalation 250/50 for chronic obstructive pulmonary disease (COPD), Guaifenesin 10 milliliters (ml) for sore throat, and Percocet 10/325 mg for pain. Resident #107's (eMAR) was highlighted in red. Staff U, RN, confirmed Amlodipine, Naloxegol Oxalate, Mirabegron ER and Fluticasone/Salmeterol were due at 9:00 a.m. and were administered late. Review of Resident #107's August 2024 MAR showed Amlodipine, Naloxegol Oxalate, Mirabegron ER and fluticasone/salmeterol were due at 9:00 a.m. During an interview on 8/28/24 at 10:39 a.m., Staff U, RN said, I always have medications to administer after 10:00 a.m. During an interview on 8/28/24 at 1:40 p.m., the Director of Nursing (DON) said medications should be administered one hour before and one hour after the time the medication was scheduled to be administered. During an interview on 8/29/24 at 8:19 a.m., the DON said she was told by the facility's corporate nurse. Late medication administration orders were obtained from Resident #110's and #107's physician on 8/28/24. Review of Resident #107's progress note, dated 8/28/24 at 3:07 p.m. showed, Md was notified of meds being late. MD stated it was okay to give late. Review Resident #107's orders on 8/29/24 did not show an order to administer Amlodipine, Naloxegol Oxalate, Mirabegron ER and Fluticasone/Salmeterol late. Review of Resident #110's progress note, dated 8/28/24 at 3:05 p.m. showed, Md was notified of meds being late. MD stated it was okay to give late. Review of Resident #107's orders on 8/29/24 did not show an order to administer insulin and Cyanocobalamin (Vitamin B 12) late. Review of the facility's policy titled, Medication Administration, General Guidelines, dated 05/16. Policy: Medications are administered as prescribed in accordance with manufacturers' specifications, good nursing principles and practices only by persons legally authorized to do so. Personnel authorized to administer medications do so only after they have familiarized themselves with the medication. Procedures: Medication Administration: 1) medications are administered in accordance with written orders of the prescriber 3) Medication administration time in parameters include the following: b) Medications to be given with meals are to be scheduled for administration at the resident's meal times. 13) medications are administered within 60 minutes of scheduled time, except before or after mail orders, which are administered based on mealtimes. Unless otherwise specified by the prescriber, routine medications are administered according to the established medication administration schedule for the nursing care center. Documentation: 2) if a dose of regularly scheduled medication is withheld, refused, or given at other than the scheduled time . The space provided on the front of the MAR for that dosage administration is initialed and circled. And explanatory node is entered on the reverse side of the record provided for PRN documentation 4) The resident's MAR/TAR is initialed by the person administering the medication, in the space provided under the date, and on the line for that specific medication dose administration end time. Initials on each MAR/TAR are verified with a full signature in the space provided or on the nursing care centers master employee signature log .

Based on interview and record review, the facility failed to maintain an ongoing antibiotic stewardship program for two out of three months reviewed. Findings included: Review of the facility's infection prevention documentation did not reveal any documentation related to an ongoing surveillance of resident infections and antibiotic orders for the months of July and August of 2024. During an interview on 8/26/2024 at 3:30 p.m., the Nursing Home Administrator (NHA) stated the Infection Control Preventionist (IPC) was the Staff R, Registered Nurse (RN) Unit Manager (UM). During an interview on 8/27/2024 at 10:30 a.m., Staff R, RN stated she was not responsible for Infection Control. Staff R, RN stated she was hired as the UM. During an interview on 8/27/2024 at 1:40 p.m., the NHA confirmed there was confusion as to who was the ICP but Staff R, RN UM was the designated IPC. During an interview on 8/29/2024 at 10:57 a.m., the Director of Nursing (DON) and the IPC who was also the Unit Manager stated they were both new to the building and not currently working on any surveillance or audits in relations to Infection Control Practices. Neither were able to discuss any information for past practice or provide any information from prior months. During the interview, the ICP and DON were unable to produce their monthly antibiotic stewardship program reports for the month of July and August to date for this year. The ICP stated the goal was to run weekly reports with the attempt to concurrently review the use of current residents' antibiotic orders and based on the McGreer's criteria to meet the criteria for an infection and the appropriate antibiotic was ordered with an end date. Neither the DON or the ICP knew who the contact was for the Department of Health in case of an outbreak. They said they would have to get with the NHA. A review of the facilities policy and procedure titled: Infection Prevention and Control Program effective October 2021 showed: Procedure: The Major Activities of the Program are: a. Surveillance of infections and communicable disease There is on-going monitoring for infections and communicable diseases among residents, visitors, volunteers, and those individuals providing services under a contractual arrangement and personnel and subsequent documentation of infections that occur b. Antibiotic Stewardship Ongoing tracking of antibiotic prescribing, antibiotic use, and developing antibiotic resistance patterns with documentation and education. Tracking of antibiotic will include: antifungals, antivirals, and all formulations of the antibiotics used. c. Implementation of infection control and prevention measures Prevention of spread of infections is accomplished by use of Standard Precaution, organism specific precautions, and other barriers, appropriate treatment and follow-up, and employee work restrictions for illness. d. Prevention of Infection and Communicable Diseases Staff, volunteers, visitor, those individuals providing services under contractual bases and resident education is done to focus on risk of infection and practices to decrease risk. Policies, procedures and aseptic practices are followed by personnel in performing procedures and in disinfection of equipment, if indicated. Immunizations are offered as appropriate to residents and personnel to decrease the incidence of vaccine preventable infections diseases. * Exposure Control

Based on observations interviews, and record review, the facility failed to ensure call lights were within reach in eight resident rooms (207A/B, 206B, 210A/B, 214B, 305, 307, 312 and 314) in two (200 and 300) of four halls. Findings included: During multiple facility tours of halls 200 and 300, call lights were observed on the floors as follows: On 08/26/24 at 10:52 a.m., a call light was observed on the floor in room [ROOM NUMBER]. On 08/26/24 at 10:57 a.m., a call light was observed on the floor in room [ROOM NUMBER]. On 08/26/24 at 11:06 a.m., a call light was observed on the floor in room [ROOM NUMBER]. On 08/28/24 at 12:08 p.m., and on 08/29/24 at 9:36 a.m., a call light was observed on the floor in room [ROOM NUMBER]. On 08/28/24 at 9:32 a.m., an interview was conducted with Staff H, Certified Nursing Assistant (CNA). She stated she made sure the call lights are within reach during her rounds. She said, If I see them on the floor or under the bed, I pick them up. On 08/29/24 at 10:03 a.m., an interview was conducted with Staff C, Licensed Practical Nurse (LPN). She stated the residents should have access to their call lights. She said, Yes, even if they have cognition challenges, they should have it. We have a few residents who are alert and use their call lights. She stated they educated the CNAs to ensure they place them within reach. During multiple facility tours of the 200 hall, call lights were observed on the floors as follows: On 08/26/24 at 10:58 a.m., a call light was observed on the floor in room [ROOM NUMBER] B. On 08/26/24 at 11:04 a.m., a call light was observed on the floor in room [ROOM NUMBER] A and B. On 08/26/24 at 11:10 a.m., a call light was observed on the floor in room [ROOM NUMBER] A and B. On 08/26/24 at 11:20 a.m., a call light was observed on the floor in room [ROOM NUMBER] B. On 08/27/24 at 9:41 a.m., a call light was observed on the floor in room [ROOM NUMBER] A and B. On 08/27/24 at 9:43 a.m., a call light was observed on the floor in room [ROOM NUMBER] B. On 08/27/24 at 9:45 a.m., an interview was conducted with Staff CC, CNA. Staff CC, CNA stated call lights should be within reach for the residents. Staff CC, CNA said, I didn't notice them on the floor, I will put them within reach now. During an interview on 8/27/24 at 4:55 p.m., Staff BB, LPN stated the residents should have access to their call light, in case they need assistance. I didn't notice they were not within the residents reach. During an interview on 8/28/24 at 9:30 a.m., the Director of Nursing (DON) stated the facility did not have a policy and procedure for call light placement, although the call light should be within the reach of the resident. 48223

Based on observations, interviews, and record review, the facility failed to ensure a resident had privacy in his room for one (#9) of two residents sampled. Findings included: Resident #9 was readmitted to the facility on [DATE] with a primary diagnosis of dementia. Other diagnoses included Schizophrenia, major depressive disorder and age-related cognitive decline. Review of a quarterly MDS (Minimum Data Set) dated 07/16/24, section C showed Resident #9 had a Brief Interview for Mental Status (BIMS) score of 00 that indicated severe cognitive impairment. During facility tours of the secured unit on 08/26/24 at 10:54 a.m., and 12:32 p.m., Resident #9 was observed in his room, laying on his bed performing sexual acts on himself. The resident's privacy curtain was not enclosed. The resident was in Bed A, which was closer to the door, leaving him exposed to other residents, visitors, and employees. This resident was also fully exposed to his roommate. On 08/27/24 at 3:42 p.m., Resident #9 was observed wandering in halls. He was observed heading to his room and pulling his pants down. The resident's body was visible from the hallway. Review of a care plan initiated on 04/06/20 showed a behavioral focus, Resident #9 has, a behavior problem related to publicly disrobes, publicly masturbates and gropes, wandering, and insinuates he would like sexual favors from staff. Interventions included to administer medications as ordered, monitor/document for side effects and effectiveness, approach in a calm manner, caregivers to provide opportunity for positive interaction, attention. Stop and talk with him when passing by and to document behaviors and resident's response to interventions. An activities focus in the care plan initiated on 07/17/24 showed Resident #9 required staff's assistance with involvement of activities related to severe cognitive impairment, non-verbal, behavioral symptoms that may affect participation-has inappropriate sexual behavior of touching himself. The interventions section showed when behavior is exhibited, remove him from situation and take to alternate location as needed. The care plan did not address dignity and privacy concerns for Resident #9 and his roommate. On 08/27/24 at 3:51 p.m., an interview was conducted with Staff G, CNA (Certified Nursing Assistant). She said, Resident #9 [acts out sexually] all the time. We redirect him. As soon as you tell him to stop, he starts all over again. She stated the roommate did not say anything about the behavior. She said, I know, it's kind of unfair. We try and make sure the curtain is pulled. On 08/28/24 at 9:28 a.m., an observation was made of resident #9 displaying sexual behaviors as he laid on his bed. The privacy curtain was wide open, exposing him to the public. His roommate could be seen from the hallway trying to pull the privacy curtain so he could not see what his roommate was doing. On 08/28/24 9:38 a.m., a fell ow resident in the secured unit was observed standing outside Resident #9's window with the blinds open. He was observed shaking his head to the left and right in a disagreeing movement. Resident #9 was in his bed uncovered performing sexual acts on himself. On 08/28/24 at 9:40 a.m., an interview was conducted with Staff H, CNA. She stated when they observe Resident #9 engaging in the sexual behavior, they tell him to cover up. She stated he did this 24/7. She said, He only comes out of the room during meals and then he is back at it. It's an ongoing thing. It has been like this for at least seven months . She stated they tried to cover him and redirect the roommate out of the room when possible. She stated the roommate did not like it. On 08/28/24 at 9:46 a.m., an interview was conducted with Staff C, Licensed Practical Nurse (LPN). She observed Resident #9 in his bed acting out sexually as another Resident was watching through the blind that was open. She said, I agree this is not good. The blind should not be open. We should provide him privacy. She stated the resident should not be observed by others. He should have privacy in his room. On 08/28/24 at 10:05 a.m., an interview was conducted with Staff E, LPN/ Unit Manager. He stated Resident #9 acts out sexually all the time. When they see him doing that, they pull the curtain to provide him privacy. He stated sometimes he walks by, and the curtain is not pulled. Sometimes it's open. On 08/28/24 at 10:12 a.m., an interview was conducted with the Social Services Director (SSD). The SSD stated behavioral care plans are completed by the facility's MDS nurse. She stated Resident #9 was care planned related to [performing sexual acts on himself]. She stated the resident saw psychiatry. She said, He has the right to do that, but he should not be seen from the hallway. She stated the staff should ensure dignity and privacy was provided for those residents. She stated the residents in the secured unit were confused and needed constant redirection. She said, The CNAs should close the curtain or door if they observe the behavior. On 08/28/24 at 10:31 a.m., an interview was conducted with Staff F, LPN/MDS nurse. She stated the Resident #9 was cognitively impaired and he acted out sexually. She stated this resident should have privacy when engaged in the sexual acts. On 08/28/24 at 11:01 a.m., an interview was conducted with the Nursing Home Administrator (NHA). The NHA stated the expectation was for staff to close the curtain and remove the roommate from the room. She stated if the CNAs observed Resident #9 performing the behavior, they should immediately intervene and give him privacy. She stated both Resident #9 and his roommate had a right to privacy and dignity. On 08/29/24 at 11:50 a.m., an interview was conducted with Resident #9's guardian. She stated the resident was known for sexually inappropriate behaviors. She said, He should be provided privacy. It is his right. The other residents should be protected. I know he has not acted out on other people, but he propositions staff and other residents. She stated she expected the residents to be treated with dignity. On 08/29/24 at 10:59 a.m., an interview was conducted with Resident #9's Psychiatric Physician Assistant (PA). He stated he was aware of this resident's sexual behaviors, and he was receiving medications. He stated if this resident had displayed increased sexual activity, he should be evaluated. He stated the resident should be monitored to see if the medications were working or not. He stated staff should be ensuring he had privacy. He said, If he starts acting out sexually the curtain should be pulled for his privacy. Review of a facility policy titled, Resident Rights, effective February 2021, showed the facility strives to assure that each resident has a dignified existence . The facility will protect and promote the rights of each resident. The facility must ensure that the resident can exercise his or her rights without interference, coercion, discrimination, or reprisal from the facility. Each resident/or representative will be presented with a copy of the Federal and/or State-specific [NAME] of Resident Rights. Review of the Resident [NAME] of Rights showed: Our facility will protect and promote each of the following rights: Exercise of Rights: 1. You have the right to exercise your rights as a resident of the facility and as a citizen, or resident of the United states 2. You have the right to be free of interference, coercion, discrimination or reprisal from the facility in exercising your rights. 6. The facility must provide equal access to quality of care regardless of diagnosis, severity, condition or payor source. 19. You have the right to personal privacy and confidentiality of your personal and clinical records. Personal privacy includes privacy in accommodations . 37. Dignity/self-determination and participation: You have the right to receive care from the facility in a manner and in an environment that promotes, maintains or enhances your dignity and respect in full recognition of your individuality.

Based on observation, interview, and record review, the facility failed to ensure accommodations were in place for two (#25 and #61) of two sampled residents with limited English proficiency. Findings Included: On 8/26/24 at 4:09 p.m. during observation and interview, Resident #61 used their personal cell phone to translate from English to Vietnamese to communicate with staff. Review of the admission record showed Resident #61 was admitted on [DATE] with diagnoses including paraplegia, depression, anxiety, and heart failure. Review of Resident #61's quarterly Minimum Data Set (MDS), dated [DATE], Section A, Identification Information showed the resident's preferred language is Vietnamese. Section C- Cognitive Pattern revealed a Brief Interview for Mental Status (BIMS) score of 15, which indicated intact cognition. Review of Resident #61's care plans showed a focus plan in place for communication related to a problem with communication: Primary Language other than English: Vietnamese. The care plan interventions included, [Resident #61] uses his cell phone with a translation app for communication. Review of the admission record showed Resident #25 was admitted on [DATE], with diagnoses including Alzheimer's Disease, dementia, and visual disturbance. Review of Resident #25's quarterly MDS, dated [DATE], Section C- BIMS Score of 5, which indicated severe cognitive impairment. Review of Resident #25's care plans showed a focus plan in place for communication related to Alzheimer's, Spanish speaking, . blind. Resident #25's care plan's interventions Utilize Spanish staff to assist in communication. During an interview on 8/29/24 at 8:27 a.m., Staff P, Certified Nursing Assistant (CNA) said she writes on a paper and show it to them (residents) to assist with communicating. She taught herself Spanish to be able to communicate with Resident #25. During an interview on 8/29/24 at 8:42 a.m., Staff E, Licensed Practical Nurse (LPN), Unit Manager (UM) said Resident #61 used his personal phone to communicate with staff. He said the facility's therapy department had a communication board for residents who's preferred language was not English. Staff E, LPN, UM, said staff anticipates resident's needs and there are Spanish speaking staff who communicates with Resident #25. He said he did not know if Spanish speaking staff were always available in the facility. During an interview on 8/28/24 at 4:15 p.m., the Director of Nursing (DON) said the facility's staff have access to a language [translation] line. During an interview on 8/28/24 at 6:00 p.m., the Nursing Home Administrator (NHA) said Resident #61 used their own phone to communicate with staff. Currently staff did not have access to interpreting services for the residents. Review of a facility policy titled, Policy and Procedures for Communications with Persons with Limited English proficiency (LEP) Office for Civil Rights, effective August 2024. The policy showed [name of facility]will take reasonable steps to ensure that persons with limited English proficiency have meaningful access and an equal opportunity to participate in our services, activities, programs, and other benefits. The policy of the [name of facility] is to ensure meaningful communication with LEP residents and their authorized representatives regarding their medical care and treatment. The policy also provides for communication of information contained in vital documents, including but not limited to, waivers of rights, consent to treatment forms, financial and insurance benefit forms, etc. Interpreters, translators, and other aids needed to comply with this policy shall be provided without cause to the person being served, and residents and their representatives will be informed of the availability of such free assistance. Language assistance will be provided through the use of qualified translators technology and telephonic interpretation services. Staff will be provided with notice of policy and procedure, and staff that may have direct contact with LEP individuals will be trained in effective communication techniques, including the use of qualified interpreters. The [name of facility] will review and update the facility assessment annually to identify the language access needs of our resident population, as well as update and monitor the implementation of this policy and these procedures, as necessary. Procedure 1) process to identify individuals who need sign language interpreters or assistive services: the [name of facility] will promptly identify the language and communication needs of the LEP person. Language identification cards (or I speak cards and posters are available online In addition, when records are kept of past interactions with residents or resident representatives, the language used to communicate with the LEP person will be included as part of the record.

Based on observation, interview, and record review, the facility failed to address a change in condition for one (#46) of two residents reviewed. Findings included: Resident #46 was admitted to the facility on [DATE] with diagnoses to include unspecified Dementia, Major depressive disorder and Anxiety among other diagnoses. Review of a care plan for Resident #46 showed a psychotropic medication focus, the resident uses psychotropic medications related to antidepressant to manage depression, anticonvulsant to manage behavior management, anti-anxiety to manage anxious behaviors, an anti-psychotic to manage bipolar. Interventions included psychotropic side effects monitoring such as: confusion, disturbed gait, drooling, and drowsiness. Administer medications as ordered, observe/document for side effects and effectiveness. Report to physician negative outcomes associated with use of drug. A quarterly Minimum Data Set (MDS) dated [DATE] showed Resident #46 had a Brief Interview for Mental Status (BIMS) score of 99 which indicated severe cognitive impairment. On 08/26/24 at 9:32 a.m., Resident #46 was observed in his bed. His eyes were closed. The resident did not respond to greeting. Staff A, CNA was in the room providing 1:1 supervision. She stated the resident previously had multiple falls. She said, He is much sleepier today. On 08/26/24 at 1:04 p.m., an observation was made of Resident #46 being assisted with meal. He did not eat. Staff A, CNA stated he ate some during breakfast. She said, He will not open his eyes now. The nurse is going to check his vitals. On 08/26/24 at 1:08 p.m. the resident was observed unresponsive, not easily aroused. Staff D, Registered Nurse (RN) stated the CNA had notified her the resident was lethargic and difficult to arouse. She stated she obtained his vitals. His blood pressure was 107/65 She stated she had notified the physician and had received orders to transfer the resident to the Emergency Department (ED). Review of a document titled Name of Hospital, ED Nursing Documentation dated 08/26/24, showed reason for visit, Patient from [name of facility] for AMS (Altered Mental Status), he has a history of dementia, however he is acting more altered than normal. Review of a document titled Name of Hospital, ED Physician Notes dated 08/26/24, showed under HPI (History of Present illness) showed, the patient is a [AGE] year-old male presents for AMS per SNF (skilled nursing facility) staff at [name of facility]. Staff reports patient was at his baseline this morning however seemed altered today around lunchtime when he became completely unresponsive. CBG (Capillary Blood Glucose) at that time was reportedly around 90. Report dementia at baseline. Is somewhat ambulatory with staff, however, mainly sits in bed and requires frequent assistance. Staff states he's usually verbal, however cannot form words clearly at his baseline. Staff denies any recent falls trauma to the head, vomiting and fevers. On 08/27/24 at 9:36 a.m., Resident #46 was observed outside his room, sitting in his wheelchair with Staff B, CNA providing 1:1 supervision. The resident was observed nodding to sleep and unable to keep his head up. Staff B stated he was doing much better today. On 08/27/24 at 10:26 a.m., an interview was conducted with Staff C, Licensed Practical Nurse (LPN). She stated Resident #46 went to the hospital the previous day and returned around 6:40 p.m. without new orders. She stated the resident continued with some sleepiness. On 08/27/24 at 4:19 p.m., Resident #46 was observed in bed, sleeping. Staff B, CNA was observed sitting at his bedside. She stated the resident appeared to be drowsy. She stated he was not conversing. On 08/28/24 at 9:45 a.m. and 12:50 p.m., Resident #46 was observed in his room, in bed with Staff B CNA providing 1:1 supervision at his bedside. Staff B stated the resident was on 1:1 supervision for aggressive behaviors. She stated he had not been aggressive lately but had behaviors in the past. She confirmed he had been sleeping a lot, not getting out of bed. On 08/28/24 at 1:59 p.m., an interview was conducted with Staff C, LPN she stated the resident was back at a new baseline. She said, He is in bed now mostly. That is a recent change. He is typically out and about. Very aggressive. He has slowed down. Review of August 2024 physician orders for Resident #46 showed newly added orders: Quetiapine Fumarate Oral Tablet 200 MG (Milligrams), Give 200 mg by mouth two times a day for bipolar, 8/23/24. Ativan Oral Tablet 0.5 MG (Lorazepam) *Controlled Drug* Give 1 tablet by mouth three times a day for Anxiety, 8/22/24 Trazodone HCl Oral Tablet 100 MG (Trazodone HCl), Give 1 tablet by mouth at bedtime for depression, 7/31/24. Melatonin Oral Tablet 3 MG (Melatonin), 7/4/24. On 08/28/24 at 5:10 p.m., an interview was conducted with Staff E, LPN/ Unit Manager. He stated the resident was moved to the secured unit due to exit seeking behaviors. He stated his baseline was wandering, multiple falls, impulsive, always rocking, chewing all kinds of stuff, aggressive behaviors such as throwing coffee at others, hitting, kicking, He stated he had suffered falls due to trying to get up or pick up things off the floor. The unit manager stated the significant change started about a couple weeks prior. He said, He is in bed more. Yesterday he was up in his chair, his 1:1 assisted him with his dinner. He used to feed himself but was now requiring staff to feed him. Staff E stated he had observed the resident mellow, low key, almost sedated all the time. He said, The doctor changed his Seroquel to 200 mg twice a day, previously it was 50 mg twice daily His Ativan is now 0.5 mg three times a day, and he is also taking Trazodone 100 mg at bedtime. He weighs 145 lbs. Staff E stated he did not know if the resident was sedated. He said, He is definitely sleeping more. I don't know if he is sedated. The PA (Physician Assistant) comes monthly. I have not notified him of this change. The UM stated he had worked with the resident the day before. He said, Yes, he was sleepy a lot. I do think that is a heavy Seroquel dose. I thought it was more like 100 mg. I will call the doctor. Staff E, LPN stated the resident went to the ED on Monday for sedation, he was not easy to arouse and had returned without orders. Staff E stated if they did not find anything wrong with the resident at the ED on Monday, then he should have been seen by a doctor yesterday or today to figure out what was causing him to be sedated. He stated he would find out if he saw the ARNP (Advanced Registered Nurse Practitioner. Review of record revealed no documentation of the doctor's visit. On 08/28/24 at 5:27 p.m., an interview was conducted with the Director of Nursing. The DON stated the resident should be reviewed for appropriate medications dosage and response. The DON said, it sounds like he is lethargic. I think that is a significant dose increase. I will let the doctor know. During this interview, the DON reviewed the August 2024 Medical Administration Record (MAR) for this resident and stated the nurses were documenting a check mark under side effects monitoring. She stated the check mark denoted administered. The DON stated the monitoring should show if the behavior or side effect was present or not, and document a response with a Yes or No. She stated a Yes response should be followed by a note describing the behavior or side effect which was observed. On 08/29/24 at 9:55 a.m., an interview was conducted with Staff C, LPN. She stated the resident was more alert today and was needing redirection unlike the past few days. She stated related to the increased dose of Seroquel, there was an order to hold the Ativan if the resident was sedated. She stated she did not know if any of doses were held. She stated the order had been changed to PRN (as needed). She stated the nurses monitored behaviors related to medications. The behaviors should be documented in the progress notes. She sated they were in constant communication with the Nurse Practitioner. She said, I understand nothing is documented. Review of the Electronic Medical Record (EMR) showed there were no Ativan doses held. Review of the EMR showed there were no notes related to concerns of sedation and drowsiness. Review of the EMR showed the PA was not notified of the side effects or behaviors in relation to the increased medication doses. On 08/29/24 at 11:10 a.m., an interview was conducted with Resident #46's PA. He stated staff should be monitoring the resident for sedation. He said, I put in an order for them to hold the Ativan if sedated. I expect them to let me know how he is doing. The PA stated the previous Friday he had increased the resident's medications. He stated he needed an aggressive response to the aggressive behaviors. He stated he was notified the previous day he was a little more sedated. He said, The nurses should let me know when there is a change. I am trying to reduce the agitation, but we also don't want to send him to the other extreme. He should be closely monitored for sleep, meal intake and other behaviors to confirm the efficacy of the medications and make changes as needed. I will try to back off the meds. The PA stated the medication response such as sedation should be monitored. He stated he did not typically put in orders to monitor behaviors. He said, It is a facility-by-facility basis on how they handle the monitoring of medications' side effects and behaviors. I expect a call if there is a change in mood or behavior. If I don't hear anything, I assume the resident okay, They should communicate with the physician and keep me informed of any changes. On 08/29/24 at 01:46 p.m., The Regional Nurse Consultant (RNC) stated a change in condition (CIC) should be documented if the resident has had any kind of change that requires a response. She stated the facility had no CIC policy. She said, We follow the EINTERACT CIC evaluation form.

Based on observations, interview and record review the facility failed to ensure that services were provided to address resident vision needs for one (#105) of 48 residents sampled. Findings included: Review of Resident #105's face sheet revealed he was admitted to the facility on [DATE]. Review of the resident's MDS dated [DATE] revealed a BIMS score of 15 which indicated intact cognition. During an interview with Resident #105 on 08/26/24 at 12:08 p.m., the resident said he had been waiting since June for transportation to go the eye doctor. He said he had not seen an eye specialist since admission to the facility. A review of the progress note showed on 6/21/24 3:16 p.m., General-the resident brought to the writer's attention that he has a detached retina to his left eye, requested lubricating eye drops to help with the discomfort in the right eye. Per MD needs medical attention ASAP (As Soon As Possible). Ophthalmology consult is in place. Care plan remains ongoing for the resident at this time. Review of the resident's care plan initiated on 7/11/24 revealed the following: The resident has impaired visual function r/t detached retina, The interventions includes Vision consult as needed. Review of the progress notes revealed the following: -6/22/24 08:46 [8:46 a.m.] General-Order for ophthalmology/eye appt asap for L retinal detachment per MD. -6/22/24 13:08 [1:08 p.m.] General- A/O x 3 OOB ambulating around in room denies any type discomfort no s/s distress noted refused pneuovac (sic) despite education voiced understanding continues to c/o unable to see out of lt [left] eye -6/28/24 00:33 [12:33 a.m.] Schedule an Ophthalmology Consultation for detached retina ASAP every shift for 30 Days REFERRED TO S.S. TO SCHED: -6/29/24 00:38 [12:38 a.m.] emar [electronic medication administration record] note-Schedule an Ophthalmology Consultation for detached retina ASAP. every shift for 30 Days social services to schedule consultation -6/30/24 15:39 [3:39 p.m.] emar note: Schedule an Ophthalmology Consultation for detached retina ASAP. every shift for 30 Days weekend -7/1/24 18:27 [6:27 p.m.] Social Service Note: SSD spoke with resident regarding Ophthalmology consult needed. Unit manager aware and has been assisting resident with appointment. Resident stated that he was in no pain and did not want to go to the hospital. Resident is alert and oriented X 4 with a BIMS score of 15. He is able to make his needs and wants to be known. Resident was calm and eating dinner. SSD will update resident when appointment is set. The ophthalmologist is scheduled to see resident at the facility on July 3rd if needed. SSD will continue to assist. -7/2/24 12:49 [p.m.] General-Writer was informed by social services that resident was to be transferred out of facility to Hospital ER for further evaluation of Detached Retinal. Resident aware of transfer. Call placed out to ARNP and made aware of arrangements. ambulance non-emergency called, awaiting arrival. -7/2/24 14:32 2:32 [p.m.] General- ambulance non-emergency transport to ER for possible admission for surgery due to Retinal detachment. Awaiting arrival. -7/3/24 00:45 [12:45 a.m.] emar note-Schedule an Ophthalmology Consultation for detached retina ASAP. every shift for 30 Days ATTEMPTED TO SEND TO E.R. FOR TX. , E.R. SENT RESIDENT BACK TO FACILITY WITHOUT TREATING. -7/3/24 13:51 [1:51 p.m.] General-Scheduled exam with The Eye vendor on 7/16/24 at 10 am for f/u Left retinal detachment and possible cataract removal -7/4/24 02:01 [a.m.] emar note-Schedule an Ophthalmology Consultation for detached retina ASAP. every shift for 30 Days S.S. working on Appt. -7/14/24 07:22 [a.m.] emar note-Schedule exam with The Eye vendor ASAP for f/u Left retinal detachment and possible cataract removal every day shift for eye appt asap for OS retinal detachment Weekend -7/14/24 15:10 [3:10 p.m.] emar note- Schedule an Ophthalmology Consultation for detached retina ASAP. every shift for 30 Days Weekend -7/16/24 11:23 [a.m.] Social Service note-SSD called The Eye vendor and scheduled a new appointment for Monday July 22th at 2:10 PM. SSD called and arranged transportation for appointment with physician. Resident is scheduled to be picked up for appointment at 11:05 PM Reservation number 80265. If transportation has not arrived by 11:05 staff needs to call transportation vendor. -7/16/24 14:51 [2:51 p.m.] General-Transportation did not arrive for eye appointment. Appointment was missed. -7/21/24 08:55 [a.m.] Emar note-Schedule an Ophthalmology Consultation for detached retina ASAP. every shift for 30 Days weekend -7/21/24 17:28 [5:28 p.m.] emar note-Schedule an Ophthalmology Consultation for detached retina ASAP. every shift for 30 Days weekend -7/23/24 11:44 [a.m.] Social Service note-SSD called The Eye vendor and scheduled a new appointment for Monday July 29th at 12:55 PM. SSD called vendor Ambulance and arranged transportation for resident to go to appointment. Transportation vendor will arrive at our facility on Monday 7/29/24 at 11:15 AM. Resident needs to be reminded the night before appointment 7/28/24 and the morning of the appointment. RETURN TRIP NEEDS TO BE ARRANGED. -8/13/24 12:47 [p.m.] Social Service Note-SSD called The Eye vendor and scheduled a new appointment for Friday August 30th at 12:00 PM. Round trip transportation needs to be arranged. -8/14/24 05:51 [a.m.] general scheduled appt The Eye vendor Friday August 30th at 12:00 PM Review of the physician order revealed the following: -6/20/24 14:41 [2:41 p.m.] phone order-Ophthalmic, Auditory, Psychological, Psychiatric, Dental, Physiatry, and Podiatry services as needed -6/21/24 23:52 [11:52 p.m.] verbal order-Schedule an Ophthalmology Consultation for detached retina ASAP. -6/22/24 08:39 [a.m.] written order-Schedule exam with The Eye vendor ASAP for f/u Left retinal detachment and possible cataract removal -7/3/24 13:49 [1:39 p.m.] phone order-Scheduled exam with The Eye vendor on 7/16/24 at 10 am for f/u Left retinal detachment and possible cataract removal -7/24/24 09:15 [a.m.] phone order-scheduled a new appointment for Monday July 29th at 12:55 PM with eye vendor. Transport Ambulance at pickup time 1115 am -8/14/24 05:38 [a.m.] phone order-scheduled appt The Eye vendor Friday August 30th at 12:00 PM During an interview on 08/29/24 at 9:13 a.m. with the SSD, she said now if transportation did not come for the resident's 8/30/24 appointment, the facility would pay for a ride share vendor.

Based on observation, interview, and record review, the facility failed to monitor for medication related side effects and behaviors for two (#10 and #73) of five residents reviewed for unnecessary medications. Findings Included: 1. Review of Resident #10's admission record showed he was admitted on [DATE] with diagnoses including epilepsy, mood disturbance, dementia, cognitive communication deficit, schizoaffective disorder, seizures, and anxiety. Review of Resident #10's orders showed, Levetiracetam tablet 500 milligrams (mg) every 12 hours for seizures, Escitalopram Oxalate tablet 20 mg daily for depression, and Olanzapine tablet 20 mg at bedtime for schizoaffective disorder. Review of care plans showed Resident #10 has a behavior problem related to yelling out in the hallway, refuses to go to bed, places self on the floor, .combative with staff. The care plan interventions include document behaviors and resident response to interventions. Review of Resident #10's medication administration and treatment administration records, dated 8/1/24 to 8/31/24 does not show documentation of Resident #10's behaviors. During an interview on 8/28/24 at 8:23 a.m., Staff C, Licensed Practical Nurse (LPN) said resident's behaviors were documented by exception in the progress notes. 2. Resident #73 was admitted to the facility on [DATE] with diagnoses to include unspecified dementia unspecified severity, with other behavioral disturbance and anxiety disorder among other diagnoses. Review of August 2024 Physician Orders for Resident #73 showed Donepezil HCl Oral Tablet 10 MG (Milligram), Give 1 tablet by mouth at bedtime for dementia. Trazodone HCl Oral Tablet 50 MG, Give 1 tablet by mouth at bedtime for sedative. Review of the MAR (Medication Administration Record) dated August 2024 showed, Resident #73 was admitted with Risperdal 0.5 MG, Give 1 tablet by mouth at bedtime for antipsychotic discontinued on 08/02/24. Review of the MAR showed there were no orders for behavior monitoring. Review of psychotropic progress notes dated 07/26/24, 08/02/24, 08/09/24 and 08/23/24 showed under care plan recommendations to continue to monitor for mood sedation, sedation, medication side effects and behaviors. Staff was educated on communication, redirection and non-pharmacological techniques to redirect patient as needed. Review of the August 2024 MAR showed there was no behavior monitoring documented. The MAR showed side effects monitoring without indication of the presence of side effects or response thereof. On 08/28/24 at 5:27 p.m., an interview was conducted with the Director of Nursing. The DON stated the resident should be reviewed for appropriate medications dosage and response. The DON said, it sounds like he is lethargic. I think that is a significant dose increase. I will let the doctor know. During this interview, the DON reviewed the August 2024 Medical Administration Record (MAR) for this resident and stated the nurses were documenting a check mark under side effects monitoring. She stated the check mark denoted administered. The DON stated the monitoring should show if the behavior or side effect was present or not, and document a response with a Yes or No. She stated a Yes response should be followed by a note describing the behavior or side effect which was observed. Review of a facility policy titled, Behavior Monitoring Record, dated October 2021, showed: To quantitatively document the frequency of identified behavioral symptoms. To document the type of interventions used to reduce or eliminate the behavior and the effectiveness of the intervention. To document side effects of psychoactive medications in the EMR. The behavior monitoring record will be initiated on residents taking psychoactive medications that require behavior monitoring. It will also be used to track behavior symptoms that interfere with the ability to function or receive care. Procedure: 1. Enter the following information into electronic medical record. 2. Describe the specific behavior to be monitored. 3. Called the interventions determined to address the specific behavior. 4. Enter the frequency of the behavior on each shift. 5. Enter the letter code (or #code) of the intervention(s) chosen to address the behavior. 6. Enter the outcome code of the intervention(s). 43453

Based on observations, interviews and record review, the facility failed to ensure the resident's living environment promoted, maintained and enhanced dignity and respect for three (#56, #265, #264) of four residents sampled. Findings included: 1. Resident #56 was admitted to the facility on [DATE] with diagnoses to include dementia, and developmental disorders of scholastic skills. Review of an annual MDS (Minimum Data Set) dated 05/31/24, section C showed Resident #56 had a Brief Interview for Mental Status (BIMS) score of 00 which indicated severe impairment. On 08/26/24 10:54 a.m. and 12:32 p.m., Resident #56 was observed in his room laying on his bed. His roommate was performing sexual acts on himself exposed to Resident #56. The privacy curtain was partially drawn. Review of a care plan dated 06/09/21 showed a cognition focus. Resident has impaired cognitive function/dementia or impaired thought processes related to developmental disability. Interventions included to promote dignity, talk with resident and ensure privacy . Report to nurse any changes in cognitive function, specifically changes in: decision making ability, memory, recall, awareness of surroundings and others, difficulty expressing self and difficulty understanding others. A communication focus in the care plan showed the resident has a problem with communication. He is usually understood, usually expresses ideas or wants, he is able to verbalize his needs or wants, make decisions in regards to routine daily care and decline what he doesn't want. Review of the care plan did not show interventions related to Resident #56's exposure to his roommate's sexual activities. On 08/27/24 at 3:51 p.m., an interview was conducted with Staff G, CNA (Certified Nursing Assistant). She said, Resident #56's roommate [acts out sexually] all the time. We redirect him. As soon as you tell him to stop, he starts all over again. She stated Resident #56 did not say anything about the behavior. She said, I know, it's kind of unfair. We try and make sure the curtain is pulled. On 08/28/24 at 9:28 a.m., an observation was made of Resident #56's roommate displaying sexual behaviors as he laid on his bed. The privacy curtain was wide open exposing him to the public. Resident #56 could be seen from the hallway trying to pull the privacy curtain so he could not see what his roommate was doing. The resident was observed lifting his left hand to cover his eyes and pointing with his right hand to his roommate on the bed. The resident repeatedly said, I don't like it. I don't like this. He continued to attempt to pull the privacy curtain which was stuck. Staff I, Personal Care Attendant (PCA) was observed down the hallway. Staff I came to the door and walked into the room and observed this resident's roommate performing sexual acts on himself. She said, Oh no! and immediately walked out. She did not immediately assist Resident #56 who was trying to pull the curtain. She stated this resident's roommate did this all the time. After waiting for approximately 5 minutes, Staff I returned to the room and without asking Resident #56 escorted him out of the room. On 08/28/24 at 9:40 a.m., an interview was conducted with Staff H, CNA. She stated when they observe Resident #56's roommate engaged in the sexual behavior, they tell him to cover up. She stated he did this 24/7. She said, Resident #56's roommate only comes out of the room during meals and then he is back at it. It's an ongoing thing. It has been like this for at least seven months . She stated they try to cover him and redirect Resident #56 out of the room when possible. She stated this resident did not like it. On 08/28/24 at 9:46 a.m., an interview was conducted with Staff C, Licensed Practical Nurse (LPN). She observed Resident #56's roommate in his bed acting out sexually. She stated Resident #56 spent most of his time outside the room. She said, I spoke to this resident regarding his roommate's behavior. He has mental retardation he does not always give a clear answer. The nurse was observed walking into the room in wheeling Resident#56 to the dining room without asking him. On 08/28/24 at 10:05 a.m., an interview was conducted with Staff E, LPN/ Unit Manager. He stated he had never spoken to Resident #56 about his roommate's behavior. He said, I don't know why I have never thought about this resident and his thoughts about this issue. All residents deserve to be treated with dignity. He stated he didn't know if they could move him or not. On 08/28/24 at 10:12 a.m., an interview was conducted with the Social Services Director (SSD). The SSD stated behavioral care plans were completed by the facility's Minimum Data Set (MDS) nurse. She stated the staff should ensure dignity and privacy was provided for both residents. She said, The CNAs should close the curtain or door if they observe the behavior. She said regarding Resident #56, I would not like that. I don't know what to do it is over my head. I have never received a concern. It is not appropriate for him. We can definitely assess the roommate situation it is a dignity issue. On 08/28/24 at 10:31 a.m., an interview was conducted with Staff F, LPN/MDS and the Regional Clinical Reimbursement Consultant. Staff F stated Resident #56 had never said anything about the roommate's behavior. She said, I mean they are cognitively impaired. When asked if other residents should be subjected to the sexual behavior against their will, both the MDS and RNC stated they could not answer that question. Staff F stated she could not speculate how Resident #56 felt. She stated it was the first time she heard about the concern. She said, should have his dignity. On 08/28/24 at 11:01 a.m., an interview was conducted with the Nursing Home Administrator (NHA). She stated the expectation was for staff to close the curtain and remove Resident #56 from the room. She stated both Resident #56 and his roommate had a right to privacy and dignity. On 08/29/24 at 10:59 a.m., an interview was conducted with Resident #56's Psychiatric Physician Assistant (PA). He stated he had not spoken with this resident regarding exposure to his roommate's sexual behaviors. He said, I have not been notified he was verbalizing concerns. I just know it would not be his favorite thing to watch the behavior. He stated if the resident was verbalizing concerns, he needed to be evaluated and see if the facility would do something about it or maybe they could move him. He stated they should protect other residents from this behavior. 2. On 8/26/2024 at 10:58 a.m., Resident #264's urinary catheter bag was visible from the hallway, hanging on the frame of the bed closest to the door. No cover was seen. On 8/26/2024 at 11:20 a.m., Resident #266's urinary catheter bag was visible from the hallway, hanging on the frame of the bed closest to the door. No cover was seen. On 8/26/2024 at 4:15 p.m., Resident #264's urinary catheter bag was visible from the hallway, hanging on the frame of the bed closest to the door. No cover was seen. On 8/26/2024 at 4:20 p.m., Resident #266's urinary catheter bag was visible from the hallway, hanging on the frame of the bed closest to the door. No cover was seen. On 8/27/2024 at 9:31 a.m., Resident #264's urinary catheter bag was visible from the hallway, hanging on the frame of the bed closest to the door. No cover was seen. On 8/27/2024 at 9:40 a.m., Resident #266's urinary catheter bag was visible from the hallway, hanging on the frame of the bed closest to the door. No cover was seen. During an interview on 8/27/2024 at 4:55 p.m., Staff BB, Licensed Practical Nurse (LPN) stated, there was usually a cover on the urinary catheter bags. I'm not sure why there isn't one on these two catheters. During an interview on 8/28/2024 at 10:04 a.m.,, Staff R, Registered Nurse (RN) stated, the urinary catheter bags should have been covered, did not understand why they were not. Review of a facility policy titled, Resident Rights, effective February 2021, showed the facility strives to assure that each resident has a dignified existence . The facility will protect and promote the rights of each resident. The facility must ensure that the resident can exercise his or her rights without interference, coercion, discrimination, or reprisal from the facility. Each resident/or representative will be presented with a copy of the Federal and/or State-specific [NAME] of Resident Rights. Review of the Resident [NAME] of Rights showed: Our facility will protect and promote each of the following rights: Exercise of Rights: 1. You have the right to exercise your rights as a resident of the facility and as a citizen, or resident of the United states 2. You have the right to be free of interference, coercion, discrimination or reprisal from the facility in exercising your rights. 6. The facility must provide equal access to quality of care regardless of diagnosis, severity, condition or payor source. 19. You have the right to personal privacy and confidentiality of your personal and clinical records. Personal privacy includes privacy in accommodations . 37. Dignity/self-determination and participation: You have the right to receive care from the facility in a manner and in an environment that promotes, maintains or enhances your dignity and respect in full recognition of your individuality. 48223

Based on observation, interview, record review and facility policy review, the facility failed to protect the resident's right to be free from neglect by not preventing staff to resident abuse for one resident (#1) out of 3 residents reviewed for allegations of abuse. Resident #1 was harmed by a facility staff member during activities of daily living (ADL) care when Resident #1,who had known behaviors, became combative towards a staff member, the staff member continued to perform ADL care and when Resident #1 continued having behaviors, the staff member made contact with Resident #1's face which resulted in Resident #1 sustaining a swollen nose, two bruised eyes, and a swollen lip with a laceration to the top lip. Findings included: Review of Resident #1's admission record revealed he was an [AGE] year-old male resident readmitted to the facility on [DATE]. Resident #1 had medical diagnoses which included but are not limited to dementia with mood disturbances, chronic pain, difficulty in walking, unsteadiness on feet, muscle wasting and atrophy, dysphagia, major depressive disorder, anxiety disorder, and lack of coordination. Review of Resident #1's progress note revealed a late entry Post Event Note dated 5/31/2023 at 1:37 p.m. revealed This is an Initial Event Note for: [Resident #1] The following event had occurred: resident noted with facial swelling. The noted date and time of the event are as follows: 5/31/23 9:00 p.m. The event took place in the following location: [resident room] Mental status was evaluated and the resident is noted to be oriented to the following: Oriented to person .The resident displayed active ROM [range of motion]. The body parts ROM was completed to include the following: upper and lower extremities. On a scale of 0-10, the residents pain level is reported to be a 6 The resident is cognitively impaired and evaluation of facial expression indicates there is substantial pain. The resident's response to pain is described as: Appropriate. The findings of the Skin Check that was completed include the following: facial swelling Treatment [sic] as follows was provided to the area or areas of concern: facial x-ray The description of the event as provided by licensed staff is as follows: observed facial swelling The resident has provided the following description of the event: unable to describe Anger, agitation, distress causing increased or new onset of aggression Fear/anxiety 9e.g., trembling, cowering, flinching) diminished ability to think or concentrate [sic] The following type of event is noted: skin alteration Details of the event are as follows: observed facial swelling Preventative interventions related to this event include: pain mediation[sic] changed, x-ray The name of the practitioner notified is: [Resident #1's primary Physician] The date and time of practitioner notification: 5/31/23 10:00p.m. Please note the following new orders: facial x-ray The name of the Resident Representative notified: family The date and time of the Resident's Representative was notified: 5/31/2023 11:00 PM. Review of Resident #1's progress notes revealed a progress note dated 6/1/23 at 6:07 a.m. revealed Received order for Nasal Xray (3view) STAT d/t facial discoloration and c/o [complaints of] pain. Bedside xray needed d/t [due to] res [resident] dementia diagnosis. Review of Resident #1's physician orders revealed an order dated 6/1/23 Nasal X-Ray STAT. Review of the Nasal X-ray dated 6/1/23 revealed Results: No acute fracture or dislocation. Nasal septum intact and midline. Soft tissue normal. Sinuses clear. Conclusion: Normal nasal bone series. Review of Resident #1's Lab/Diagnostics Note dated 6/1/23 at 9:21 a.m. revealed Nasal x-ray completed and reviewed with ARNP. NNO [no new orders] at this time. No acute FX [fracture] or dislocation. Nasal septum intact and midline. Soft tissues normal. Sinuses clear. Normal nasal bone series. RP made aware. Review of Resident #1's Progress Note (general) dated 6/2/23 at 12:03 p.m. revealed Resident oob [out of bed] with normal routine, no complaints of facial pain noted at this time. Skin lacerations to facial area remains bluish purple bilateral eyes with swelling to nose area. No apparent drainage noted. Condition stable. Further review of Resident #1's Post event note dated 6/2/23 at 4:36 p.m. revealed the following event has occurred: facial bruising The noted date and tome of the event are as follows: 5/31/23 9:30 AM the event took place in the following location: [resident's room] .On a scale of 0-10, the resident's pain level is reported to be a 8 The resident is cognitively impaired and evaluation of facial expression indicates there is substantial pain. The resident's response to pain is described as: Appropriate. The findings of the Skin Check that was completed include the following: redness to nose, lip eyes Treatment as follows was provided to the area or areas of concern: Assessment done, facial x-rays neg [negative]. Resident #1 was observed on 6/19/23 at 12:18 p.m. The resident was observed to be in the facility's secured unit, dressed in day clothes self-propelling in his wheelchair out of his room asking when he was going home. The staff were observed to interact with the resident by saying [Resident #1] this is your home. The resident stated I am going home call [family member]. The staff said okay we will call [family member] for you. The resident's face was observed to be free of bruising or swelling or open areas. Resident #1 was observed to be comfortable. In Spanish, the resident stated I'm good when asked how he was doing. In English he stated, can you call [family member] for me, I have to go home. An interview was conducted on 6/19/23 at 10:46 a.m. with Staff A, Licensed Practical Nurse (LPN) she stated I was here for [AGE] years then I left for a year then came back and I have been back now for two years. I normally work on the secured unit, and I am familiar with [Resident #1]. I was the one who reported. The CNA [Certified Nursing Assistant], Staff B, CNA, he came out of [Resident #1's] room and shut the door behind him. He [Staff B, CNA] was sweating and I heard a muffled sound that alarmed me. When I got up we both met each other outside of [Resident #1's] room and I asked him what is going on and he said [Resident #1] spat in his face and I said okay so I opened the door [Resident #1] was alert, he was sitting up in his wheelchair, he wasn't wearing a shirt and I saw specks of blood on his chest, his face, the floor, and the clothing that [Staff B, CNA] had taken off of him. I'm guessing he was trying to put the gown on him because the gown was on the floor and the shirt was on the floor and that had blood on it. I guess he tried to put the gown on but I'm not going to speculate but, I did see there was blood on the gown as well. I did not see the event I just saw the after math. I helped clean [Resident #1] up and I cleaned up his face and put the gown on him and I helped him into bed. [Staff B, CNA] got all the stuff off of the floor and bagged it up. Then I told [Staff B, CNA] to just leave the room and go get off of the floor. I made sure [Resident #1] was comfortable and safe because he seemed frightened. I reported it to the RN [Registered Nurse] supervisor and the DON [Director of Nursing] and [Nursing Home Administrator [NHA]] . [Resident #1]'s face, and his nose was swollen. His eyes were puffy and the swelling was starting. There were scratches on the bridge of his nose, not lacerations, more like scratches. I have no idea where he was bleeding from. I asked [Staff B, CNA] where all the blood came from and he said it was from his nose. I did not see any indications of open areas, cuts, lacerations. After everyone was called, we got orders to get an x-ray. This happened about around 9 in the evening. [Resident #1] did not say he was in any pain. [DON] called [Staff B, CNA] to get his side of the story and [NHA] told him to leave the premises. After that event I have not seen [Staff B, CNA] back working with other residents .He [Resident #1] had an x-ray done and that was negative. He has chronic pain, but his pain was the same pain that he normally voices but we did give him a stronger pain medication. He never mentioned anything with his face or his head hurting it is always his back, but we did get pain management involved and they gave him a stronger pill for his pain. He is acting the same as he always acts, he does not seem fearful. He developed bruising from the bridge of his nose, and around the orifice of both his eyes, there was swelling to the nose. The mid part of the top lip was kind of puffed out a bit, it was mainly the eyes and the nose. I was surprised the bruising on his face only lasted for about a week .I always tell all the CNA' s let two or three CNA's help out with [Resident #1] especially with the residents who fight. But [Staff B, CNA] would get agitated really easily being back on the secured unit just dealing with that patient population . [Resident #1] has the violent type of dementia, all he thinks about is going home . He can be violent with ADL care. He likes to spit, pinch, kick, scratch and sometimes he picks up objects to try and throw them at you. Further interview was conducted with Staff A, LPN on 6/19/23 at 12:28p.m. she stated when [Staff B, CNA] came out of the residents room I asked him what happened and he said the resident spit on him and [Staff B,CNA] hit him. When I walked into the room and saw all the blood I was overwhelmed, and I asked him how hard did you hit him? [Staff B, CNA] did not answer me and he did not indicate if he hit him with a closed or open hand. He [Staff B, CNA] started to help me clean up, but the resident said he tried to kill me, and I just told [Staff B, CNA] you need to go, leave. And he left. I made sure the resident was safe and then I immediately went and reported it. A phone interview was conducted with Staff B, CNA on 2/19/23 at 3:34 p.m. he said I was in the middle of getting his [Resident #1] dirty clothes off and into his night clothes, he became agitated and he didn't want to go to bed. He started to hit me and then when he started to spit I turned and trying to block his spit and I don't know if he tried to lean in right when I did but my hand made contact with his face and it isn't intentional. After that I went and got the nurse, and I didn't notice any blood coming from his nose until after the fact and I went and got the nurse and she helped clean it up and she contacted the supervisor and the supervisor contacted the DON. Usually, I don't have a problem getting him [Resident #1] undressed and usually I get him a snack and that usually works but that day I guess he was overally agitated. I don't normally have that problem with [Resident #1]. The nurse was wiping his nose because there was some blood coming down, there wasn't a lot. I was helping while she was cleaning his nose and I guess the DON wanted to talk to me and they told me to wait in the break room after that .I would never do anything intentional to a resident. When that happened, I was in shock. The police came and talked to me that night and I told them the same exact story and they walked me out. I did not get arrested. I have never really experienced anything like this. Yeah, he'll try and hit here and there but I have never seen him that agitated I tried to reassure him that he wasn't going to bed but there is a big language barrier .I am a newer CNA and he is usually on my assignment. I'm still learning, I just usually approach in a calming way. The resident was sitting in the chair and I was standing beside him and I was bent down trying to put his arm in the gown. Then he tried to hit me but him trying to hit me that don't phase me but then he tried to spit on me and that's when I tried to block the spit and that's when I made contact with his face. My hand was open and I had a glove on when I tried to block his spit. An interview was conducted with Staff C, CNA on 6/19/23 at 12:20 p.m. he indicated he has worked at the facility for ten plus years and his normal assignment includes Resident #1. Staff C, CNA stated [Resident #1] keeps to himself, he usually stays in his room or he is out asking to go home, or asked for food. During care he will spit, hit, scratch, kick at you. When that happens, I remove myself, I reapproach and after the second attempt he's still combative I will remove myself and reapproach with another staff member and if he still doesn't want to do it I can't force him. He stated his approach is to walk away and retry. An interview was conducted with Staff D, CNA on 6/19/23 at 12:22 p.m. She indicated she has worked on the secured unit for 4 years. She said [Resident #1] is not on her typical assignment but she will help out with care if the assigned CNA needs it. [Resident #1] can be combative but we walk away and reapproach him later. We cannot force him to receive care. We just give him space and reapproach later. Review of Resident #1's behavioral care plan revised on 6/6/23 revealed The resident is noted with the following behaviors: places self on floor, may become combative at times 5.31.23 spitting at caregivers. Goals: Will be informed of the risk/outcomes associated with preference of choice. Will not harm themselves. Will not harm staff. Interventions included, speak softly and clearly when communicating. Allow time to communicate effectively. Discuss procedures and mediations [sic] prior to administration. Give clear explanation of all care activities prior to an as they occur during each contact. Provide resident with opportunities for choice during care provision. Do Not Corner if agitated. Provide space, remove other Residents, remain calm and Call [sic] for assistance. Psych Services as needed. Review of Resident #1's ADL (activities of daily living) care plan revised on 5/15/23 revealed The resident has an ADL Self Care Performance Deficit. Goals included, will prevent decline in ADL self-performance through next review . Will Improve level of self performance by next review. Interventions include but are not limited to AM/PM [morning/evening] Routine Care: Resident will be able to independently or sometimes independently perform ADL functions including but not limited to Bed Mobility, Personal Hygiene, Oral Care, Bathing, Dressing, Transferring, Feeding, Toileting, Encourage to perform at highest functional level. Res [Resident] can help with some ADLs, but need Physical Help from Staff to help complete task. Encourage resident to participate at highest level. Provide assistance required to complete task and document. Anticipate needs. Locomotion: Wheel Chair [sic] propels self. Personal Hygiene: assistance X [times] 1 as needed. Dressing: Assist of 1 An interview was conducted with the Nursing Home Administrator (NHA) and the DON on 6/19/23 at 1:33 p.m. The NHA said on 5/31/23 at approximately 9:30 p.m. [Staff A, LPN], the nurse on the unit, she called [DON] and [DON] called me. And she [Staff A, LPN], said she heard yelling coming from [Resident #1's room] and she said [Staff B, CNA] was coming out of the room. She [Staff A, LPN], opened the door the resident was sitting in his wheelchair with his shirt off and he had some blood on his face[Staff A, LPN], said she asked the CNA what happened and the CNA had said he was spitting on him and he [Staff B, CNA] reacted , trying to keep him [Resident #1] from spitting on him. So, [DON] called and told me I told [DON] I would call [Staff B, CNA] and we told him to go in the break room and not leave and I told him that I had to call the police and report it and the police would have to come to the facility and talk to him. So, I called the police and reported it and I reported it to DCF [Department of Children and Families] right then too. And I asked him what happened and he told me the resident was spitting in his face and he was trying to get him to stop and he wouldn't and he said he smooshed him. I asked him what smooshing meant and he said 'you know, I smooshed him to try and keep him from spitting in my face.' And after I talked to the police and I asked them to tell me what he said to them and the police called me and they said that he told them the same thing he told me. The police officer told me that he smooshed him too .I told [Staff B, CNA] he had to come in and do a reenactment with me too so I can see exactly what happened. He came into my office to show me and I had someone else witness it to. The NHA reenacted what she was shown by [Staff B, CNA]. The NHA acted as the resident sitting in the wheelchair, and said, [Staff B, CNA] took off the residents shirt off, [Staff B, CNA] was standing off to the side of the resident and when the resident was spitting he [Staff B, CNA], turned and put his hand out and he must've accidently made contact with the residents face. [Staff B, CNA] is about 7 foot tall. We train the staff when a resident gets combative to walk away and come back. The residents' eyes were discolored, both eyes under his eyes and up and around them. The NHA said we [NHA and DON] did not come in that night but we did not see any blood the next day when we looked at [Resident #1]. [Staff A, LPN] said she did see some blood. I did have [Staff D, Registered nurse [RN]] go and look at the resident. I started the investigation that night over the phone. The DON said based on the statements, there was a small amount of blood around the resident's nose that she had cleaned up. [Staff D, RN] said she did not see any blood and there were no open areas. We did the nasal 3 views of the whole face and that showed no fractures . The DON said [Staff B, CNA] started on 10/4/22 as a PCA [Patient Care Technician]. He worked until 2/2/23. He was termed [terminated] because his 180 days to get his CNA license was up so we had to term him and told him to let us know when he gets his license. So, he returned back to us on 2/16/23 after he got his CNA license. When he worked here as a PCA he worked on the secured unit. When he was hired back as a CNA his designated area was the secured unit. The NHA said .This was not substantiated because no one had seen it and he said he just put his hand . The NHA stopped talking then said, and that's what the police told me to. The NHA said . After [Staff A, LPN] wrote her statement that night, I had [Staff A, LPN] come to me and I talked to her on 6/7/23. She said he [Resident #1] has behaviors and we usually use 2 people when he punches, scratches, hits. It calms him down if you say you'll call the [family member]. She said she asked him [Staff B, CNA] what happened and he said he [Resident #1] spit in his face and I asked [Staff A, LPN] what exact words did he [Staff B, CNA] use? he spat in my face and his reaction, he smooshed . The NHA corrected herself and said it [statement documentation] says 'and hit him [Resident #1]. I went into the room and saw a little blood on his chest and clothes and saw a little bit on the floor. And I said did you ever see him [Staff B, CNA] get aggressive like this before? She said she saw him get anxious but not aggressive . it also says in the statement that [Staff B, CNA] said to her 'can you just write it up and say he fell and she said no I can't do that.' The DON said we did change his [Resident #1's] pain medication around with the facial bruising because he had been grimacing during therapy and he has chronic pain and was on tramadol so we called pain management and got him on hydrocodone. The NHA confirmed Staff B, CNA has not worked in the facility since the incident occurred, and is currently in the termination process. Review of the facility's Abuse Prevention Program with a effective date of 2012 and a change date of August 2022. Revealed Policy The facility has designated and implemented processes, which strive to reduce the risk of abuse, neglect, exploitation, mistreatment and misappropriation of resident's property. These policies guide the identification, management and reporting of suspected, or alleged, abuse, neglect, mistreatment and exploitation. It is expected that these policies will assist the facility with reducing the risk of abuse, neglect, exploitation and misappropriation of resident's property through education of staff and residents, as well as early identification of staff burnout, or resident behavior which may increase the likelihood of such events. Definitions: Abuse-Includes Verbal, Physical, Sexual, and Mental/Emotional Abuse Abuse Willful infliction of injury upon a resident by a staff member, another resident, a vendor, a visitor, or other individual. . Note: Willful is defined as meaning the individual must have acted deliberately, not that the individual must have intended to inflict injury or harm. .Physical Abuse Includes hitting, slapping, pinching, scratching, spitting, holding roughly, etc . . Serious Bodily Injury An injury involving extreme physical pain; involving substantial risk of death; involving protracted loss of impairment of the function of a bodily member, organ, or mental faculty; requiring medical intervention such as surgery, hospitalization , or physical rehabilitation; or an injury resulting from criminal sexual abuse. .Procedure the facility has implemented the following processes in an effort to provide residents, visitors and staff with a safe and comfortable environment. The Administrator is responsible for designating an Abuse Coordinator The designated shift supervisor is identified as responsible for immediate initiation of the reporting process. The Administrator, DON and/or designated individual are responsible for the investigation and reporting of suspected, or alleged, abuse, neglect, and exploitation and misappropriation. The Administrator, DON and/or designated individual are also ultimately responsible for the following: Implementation Ongoing Monitoring Investigation Reporting Tracking and Trending . Training Facility orientation program and ongoing training programs will include, but may not be limited to: 483.95(c): Freedom from abuse, neglect, & exploitation requirements in 483.13. .483.95(c): Dementia management & resident abuse prevention . Utilization of appropriate interventions to manage resident behaviors that might result in harm to the resident or staff, aggressive &/or catastrophic reactions of residents. . How to provide protection for residents. . Methods to reduce the risk of abuse, neglect, mistreatment, misappropriation, and exploitation that may include, but may not be limited to, recognizing signs of burnout, frustration and stress, stress management and relaxation techniques

Based on observation, interview, and record review, the facility failed to implement interventions, including adequate supervision, consistent with the resident's needs, goals, and care plan in order to eliminate or reduce the risk of accidents and injuries for one (Resident #44) of five residents sampled for accidents. Resident #44 was admitted to the facility in September of 2020 with a [DIAGNOSES REDACTED].#44 sustained five falls since admission between 10/8/20 and 2/27/21 with no documented evidence of analysis of hazards and risks to prevent further accidents. Resident #44 was placed on 15 minute checks on 1/20/21 with no documentation of safety checks maintained. On 3/10/2021 scans revealed Resident #44 had bilateral fractures in the hip area thought to be associated with the fall on 2/27/21. Observations and interviews with staff during the survey revealed staff continued to be unaware of Resident #44's [MEDICAL CONDITION] and interventions to prevent further injuries from occurring. Findings included: During a tour of the facility conducted on 3/15/2021 at approximately 10:00 a.m., Resident #44 was observed in her room, in bed, awake, and responsive. The resident's bed was in the high position and a floor mat was on the left side of the resident's bed. On 3/16/2021 at 3:24 p.m., Resident #44 was observed in the dining room sitting up in a geri-chair wearing rubber soled shoes. A review of the Facility's Incident Log from 10/1/2020 through 3/16/2021 indicated Resident #44 fell on [DATE], 12/17/2020, 1/2/2021, 1/16/2021, and 2/27/2021. A review of Resident #44's record was conducted. Resident # 44 was admitted in the facility on 9/2/2020 with [DIAGNOSES REDACTED]. The admission Minimum Data Set (MDS - an assessment tool) dated 9/8/2020 indicated a BIMS (Brief Interview for Mental Status), an evaluation of cognition, score of 7 (0-7 severe cognitive impairment). The assessment also indicated the following: - supervision for eating -one person limited assistance with bed mobility, transfers and dressing -one person extensive assistance with toilet use and personal hygiene -dependent on one staff for bathing -no functional limitation or impairment in both upper and lower extremity range of motion Review of Resident #44's progress notes indicated: 3/10/2021, Resident returned from (name of hospital) via stretcher resident had CT (Computerized Tomography) scans showing bilateral fractures of symphysis pubis (joint between the left and right pubis of the hip bones, located in front of and below the urinary bladder) on the left extending to the anterior aspect of the acetabulum on the right and [MEDICAL CONDITION] inferior pubic ramus (bones). Resident is no weight bearing on the LLE (left lower extremity) and may toe touch weight bear as tolerated on the RLE (right lower extremity) . There was no other documentation in the resident's record addressing the change in Resident #44's weight bearing status. There was no documentary evidence in the physician's orders or Resident #44's care plans addressing the resident's [MEDICAL CONDITION] and new weight bearing status. 3/2/2021, Resident is wincing in pain and moaning when rolling from side to side, when asked where her pain was she motioned towards her left leg .new orders for pelvis, left hip and left femur x-rays. 2/27/2021, Writer came out into hallway from another room and Resident was in hallway lying on right side directly in front of wheelchair. head to toe assessment completed. No injuries observed. Right side forehead with pink/red, dime sized non raised area. AROM (active range of motion) WNL's (within normal level) to BUE/BLE's (bilateral upper extremity/bilateral lower extremity). resident with no expressions of pain or discomfort. Denies pain .Shoes only half on with heels hanging out backside of shoes . 1/16/2021, .CNA (certified nurse assistant) pushing resident in wheelchair. While in motion resident attempted to stand up by placing feet to floor .she fell forward on face front height of chair to floor .large hematoma covering left side of forehead and eyebrow .EMS called . Review of Resident #44's fall care plan indicated: 9/2/2020, The resident is at risk for falls or fall related injury because of history of falls, Goal: Will minimize the risk for fall. -initiated 2/27/2021, Resident to wear non-skid socks at all times. -initiated 1/20/2021, q (every) 15 min safety checks -initiated 9/9/2020. Ensure Non-Skid socks/shoes in place at all times Review of other care plans initiated for of Resident #44 indicated: -2/8/2021, CANCELED:TRANSFER -- decline in ability -2/8/2021, CANCELED:DRESSING & GROOMING -- decline in ability On 3/16/2021 at 3:30 p.m., the Unit Manager (UM) was interviewed regarding Resident #44's fall incidents. The UM stated, All the other Unit Managers are all gone .were suppose to have three, now it's only me, the education person is also gone the DON has been working on the floor too . The UM stated, We have had to work the floor because we have insufficient staff. The UM stated As unit manager my responsibility is auditing orders for medication, new treatments, follow up on labs, x-ray .there's no oversight because we have been working the floor. On 3/16/2021 at 4:37 p.m., the MDS Nurse was interviewed. The MDS nurse stated she complete a significant change in status MDS on 2/2/2021 for Resident #44 because She had so many falls .with all of her falls her functional status has really declined including her cognition. On 3/16/21 at 5:12 p.m. Resident #44's record was reviewed with the Director of Nursing (DON). The DON stated fall risk was assessed on admission and reassessed by the Interdisciplinary Team after fall incidents and then the care plan was updated. The DON reviewed Resident #44's fall incidents: -10/8/2020 - witnessed, slipped from her wheelchair and fell backwards, hit her head -12/17/2020 - unwitnessed fall, complained of left wrist pain -1/2/2021 - unwitnessed, found sitting on the floor in the dining room, bump on left side of the head -1/16/2021 - witnessed, attempted to stand up while being wheeled by CNA, subdural hematoma -2/27/2021 - found in the hallway lying on her right side Review of the IDT notes provided by the DON indicated the following: -10/9/2020, IDT review of fall 10/8. Resident fell in her room. Psych services to assess resident and medication review sent to pharmacy. -12/22/2020, IDT review of fall on 12/17. resident reported fall in the night, unwitnessed. Reports pain in her thumb .Medication review sent over to pharmacy. -1/6/2021, IDT review of fall on 1/2. Labs UA (urinalysis) to r/o (rule out) medical concerns for fall. -3/1/2021, IDT review of fall on 2/27. Resident not wearing shoes correctly. the back of her heels were hanging out of her shoes. resident states she doesn't know what happened. She states she was tired .Labs and UA obtained .UA still pending -There was no documentary evidence in Resident #44's record of the IDT evaluation and analysis of hazards and risks to prevent further accidents. - There was no documentary evidence in Resident #44's record of implementation, monitoring for effectiveness and modification of interventions from the IDT. During the 3/16/21 5:12 p.m. record review and interview with the DON, she indicated that there was no documented evidence in the resident's record addressing the cause of Resident #44's recent fractures and, there was no documented evidence the resident's treatment and care plans were updated to reflect the recent fractures and new weight bearing status. The DON stated they surmised the fractures were related to the resident's fall incident on 2/27/2021. The DON also confirmed there was no documentary evidence to indicate that the every 15 minutes safety checks were conducted for Resident #44. On 3/16/2021 at 6:06 p.m., Staff F was interviewed. Staff F was the CNA assigned to the resident. Staff F stated she was an agency nurse and this was first time she was assigned to Resident #44. Staff F stated she did not know about the resident's fracture and weight bearing status. Staff F stated, Usually around this time there are only agency nurses .I just try to figure it out .I only look at the shower book . On 3/16/2021 at 6:17 p.m. Staff G was interviewed. Staff G was the nurse assigned to the resident. Staff G stated the CNA would not know about the resident's fracture and weight bearing status because It's not there (in the Kardex) there is no instructions for transfers. On 3/17/2021 at 4:04 p.m., the significant change in status MDS dated [DATE] was reviewed with the MDS nurse. The MDS nurse stated Resident #44's functional status has declined as evidenced by the following assessed changes: -Cognition BIMS from 7 to 2 -Eating from supervision with one person assist to limited assistance with two persons assisting -One person limited assistance with bed mobility, transfers and dressing to extensive assistance with two person assist -One person extensive assistance with toilet use and personal hygiene to extensive assistance with two person assist -Bathing from total dependence one person assist to dependence with two persons assist -Balance During Transition and Walking from not steady able to stabilize with staff assistance to activity did not occur, stated the resident was not able to perform the task anymore -Functional limitation in Upper Extremity Range of Motion from no limitation to impairment on one side Review of the hospital Emergency Department Documents for Resident #44 dated 3/10/2021 indicated: -History of Present Illness: Hip Injury-Pain. The patient presents with bilateral hip pain. The onset was one week ago . -Diagnosis: [REDACTED]. -Plan: .non weight bearing on the left lower extremity. May toe touch weight bear as tolerated on the right lower extremity . On 3/30/2021 at 3:56 p.m., a telephone interview was conducted with Advance Practice Registered Nurse (APRN) who was following Resident #44. The APRN stated he was not informed of the resident's status upon returning from the hospital to the facility on [DATE]. The APRN stated the multiple falls the resident has had in the facility contributed to her significant functional and cognitive decline. Review of the facility policy and procedure, Fall and Injury Reduction Policy, effective February 2021 indicated The facility strives to reduce the risk for falls and injuries by promoting the implementation of the Falls and Injury Reduction Policy. Resident data is collected to identify fall risk factors. The interdisciplinary team works with the resident and family to identify and implement appropriate interventions to reduce the risk for falls or injuries while maximizing dignity and independence .4. Implement plan of care based on individual needs. 5. Communicate interventions during shift report, daily clinical rounds and/or entry on electronic care communication tool to the care giving team. 6. Provide training to staff as needed. 7. Review and revise the plan of care as needed to reflect the resident's current needs .

Based on record review and interviews, the facility failed to ensure that it implemented an care plan for 1 (#1) of 5 sampled residents who needed assistance with transfers as evidenced by the improper use of a sit to stand lift during transfer, non- use of a 2 person transfer and non- reporting of a bruise in keeping with the care plan. Approximately six hours elapsed between the first sighting of the bruise and assessment by licensed personnel to determine the appropriate interventions. The resident was determined to have sustained a fracture to the femur. Findings include: 1. A review of Resident #1's clinical chart, documented that the resident admitted to the facility in 10/09, with relevant [DIAGNOSES REDACTED]. The resident was [AGE] years old. 2. A review of Resident #1's Care Plan was completed. The goal area of "minimize wounds from developing," was initiated 03/15/13 with target date of 10/01/13. The relevant interventions described were as follows: "Support surface to bed; Support surface to chair ...and as of 07/03/13: observe for any new areas of skin breakdown: Redness, Blisters, Bruises, discoloration noted during bath or daily care; report to nurse if noted, Nurse will report to MD if noted." A review of the Focus area determined: "The Resident has an ADL Self Care Performance Deficit as evidenced by: Impaired Cognition, Activity Intolerance, Self-Performance level may fluctuate throughout the course of the day, dependent on staff for ADL's." Relevant interventions, initiated 03/15/13 included: "Resident is Total Dependent upon staff for ADL's. Encourage resident to participate at highest functional ability. Bed Mobility: Assist of One of staff participation to reposition and turn in bed. Transfer: Total Mechanical Lift to Chair of 2." 3. An Interview was conducted on 09/03/13 at approximately 1:30 p.m., with Staff member C, Certified Nursing Assistant (CNA). She stated that Resident #1 does not get out of bed by herself; she is total care; in her Kardex, they do not have her as a 2 person transfer; so you can use the sit stand machine "Sera Lift." If you move her to the edge of the bed and it cris crosses between her legs; the machine stands them up (pulling action)." She further stated that she utilized the sit to stand lift for the resident because she was assisted with eating and "I have to get her up to eat in the Cafe in the morning. That morning I transferred her by my-self with the sit to stand. The sit-to stand does not need a second person." The CNA further stated: "I was putting her back to bed, and when I moved her pants down, she had bruising on her upper thigh; cannot remember the exact color; probably the size of my palm; saw the bruise before breakfast; put information in the kiosk; I documented that I saw a bruise; I did not tell the nurse, the son came in a little after lunch; he saw the bruise and he told the nurse and asked her if she could come look at it." A review of the Kiosk for skin observations was conducted for Resident #1 for 08/10 thru 08/12. The first entry made by Staff member C, was on 08/12/13 at 14:41, "skin observation=discoloration." An interview conducted on 09/04/13 at 1:00 with the Certified Dietary Manager who confirmed that Resident #1 usually ate breakfast between 7:15 a.m. and 8:45 a.m. Approximately 6 hours elapsed before Staff member C, inputted information regarding a skin discoloration. 4. An interview was conducted on 09/03/13 at 2:54 p.m. with Staff member B, Licensed Practical Nurse, who stated: At the end of my shift, the son approached my unit manager, Staff member A. She came to me and said that she had gone an looked at the bruise with the son, the she had assessed the bruise; she had called the physician. I looked at the bruise, it looked faded; not fresh; she agreed that it was approximately 4 " x 4 " circle. The edges yellowing; not like a fresh bruise, which would be a darker purple in color. She further stated that the CNA did not report any bruising to her. The L.P.N. (staff member B) stated, "I could tell something was wrong. the leg was under the cover but, I could see that it was inverted. I went to take the covers down to look and she made a pained expression and face. Usually, she is giggly and this was very different for her. I knew it was broken when I looked at it at that time (8/12/13)." 5. The Progress Notes timed 14:58 for 08/12/2013 indicated: "Xray ordered for left knee [MEDICAL CONDITION] and bruising." At 23:31 on 08/12/13, the notes reflected "MD gives order to send patient to ER for further treatment. Son aware." On 08/13/2013, a "LATE ENTRY" for 08/12/2013 @ 2:35 pm" provided that "Unit Manager informed this writer while on break that CNA reported to her a moderate size bruise located to resident left leg. Family member (son) present at time. Unit Manager spoke with family and call physician, orders obtained for xrays, resident assisted to bed. Assessments made earlier by unit manager, this writer examined resident leg on return from break, notice a moderate size light purple bruise to left leg mid section. Leg slightly inverted. Reported to on-coming nurse of orders obtained." 6. Record review of Chart summary for a hospital admission that occurred on 08/13/13 for Resident #1 found: "The patient presents with ... a history of severe dementia and [MEDICAL CONDITION], presenting with the chief complaint of having a left distal femur fracture. The patient has severe dementia and is bedridden and nonverbal. Apparently, the (family member) was visiting her this afternoon and noticed that she had ecchymosis and swelling to her left thigh region. An x-ray was performed and found that she had a left distal femur fracture. There was no known trauma. The patient has been at her baseline mental status. The son states that the last time he may have seen her leg and it was normal was last Thursday. There are no other complaints." Record review of a Chart Summary, dated 08/17/13, documented an admission date of [DATE], orthopedic consultation: "This [AGE] year old patient suffered a fall which resulted in a spiral [MEDICAL CONDITION] distal femur. ...Following open reduction internal fixation this will take approximately 2 months to heal and the patient will be during that period of time non weight bearing on the left lower extremity." The D.O. summary of 8/20/2013 explains that the resident is a "high [MEDICAL CONDITION] risk with concurrent [MEDICAL CONDITION] and progressive disability." 7. An interview was conducted on 09/03/13 at 5:40 p.m. with Staff Member D, a Physical Therapist, who confirmed that she was familiar with Resident #1. Staff member D confirmed that if staff were to use a " sit to stand " lift for transferring a resident, the care plan would specify a " sit to stand." She further stated that Resident #1, prior to her transfer to the hospital, was a mechanical lift that would be the kind that lifted her off the bed. She stated that she knew this because Resident #1 was dependent on transfer, she could probably bear weight, but it would be unsafe because of the risk of her buckling. Totally dependent means that the resident is not assisting with the transfer at all; the CNAs are doing all the work." A 1/9/2012 "PT Therapist Progress Report and Discharge Summary "stated under "clinical Impression," that "pt. continues to be dependent for all transfers. She has not progressed since being on PT services. This is largely due to pt. being unable to understand instructions or the actions being asked or performed on her when attempting sit to stand for example, pt. does not appear to recognize that she is being assisted to a standing position and makes no effort to assist in the action. Exercise intervention in an attempt to make pt's Legs strong to better assist have produced little functional results. Pt will need to use mechanical means of transfers as she is dependent." 8. Review of the March 7, 2013 Minimum Data Set for Cognitive Patterns described the resident's "Cognitive Skills for Daily Decision Making " as a "3" meaning "Severely impaired." Under "Signs and symptoms of [MEDICAL CONDITION]," the resident scored a "2" for "inattention" as to the question of "Did the resident have difficulty focusing attention (easily distracted, out of touch or difficulty following what was said?)." Under coding, a score of "2" referred to "Behavior present, fluctuates (comes and goes, changes in severity." Under "Activities of Daily Living," for "Transfer," the resident scored a "4" for self-performance meaning total dependence and a "3" for "Two plus persons physical assist."

Based on record review and interview, the facility failed to ensure that the observance of a bruise, approximately 4 " x 4," was reported in a "prompt" manner to nursing staff and the resident's physician in order that a timely assessment for needed treatment could be conducted for 1 (#1) of 5 sampled residents. Approximately six hours elapsed between the discovery of the resident's bruise to the assessment for injury which identified a [MEDICAL CONDITION]. Findings include: 1. A review of Resident #1's clinical chart, documented that the resident was admitted to the facility in 10/09 and is currently [AGE] years old. Relevant [DIAGNOSES REDACTED]. 2 In an Interview conducted on 09/03/13 at approximately 2:30 p.m., with Staff member C, Certified Nursing Assistant (CNA) in regards to events that occurred on 08/12/13 with Resident #1, she stated that Resident #1 "does not get out of bed by herself; she is total care. In her Kardex, they do not have her as a 2 person transfer; so you can use the sit to stand machine "Sera Lift." If you move her to the edge of the bed and it cris crosses between her legs; the machine stands them up (pulling action)." She further stated that she utilized the sit to stand lift for the resident for her because she "was assisted with eating and I have to get her up to eat in the Cafe in the morning. That morning I transferred her by my-self with the sit to stand. The sit-to stand does not need a second person." The CNA further stated: "I was putting her back to bed, and when I moved her pants down, she had bruising on her upper thigh; cannot remember the exact color; probably the size of my palm; saw the bruise before breakfast; put information in the kiosk; I documented that I saw a bruise; I did not tell the nurse, the son came in a little after lunch; he saw the bruise and he told the nurse and asked her if she could come look at it." 3. Review of the March 7, 2013 Minimum Data Set for Cognitive Patterns described the resident's "Cognitive Skills for Daily Decision Making " as a "3" meaning "Severely impaired." Under "Signs and symptoms of [MEDICAL CONDITION]," the resident scored a "2" for "inattention" as to the question of "Did the resident have difficulty focusing attention (easily distracted, out of touch or difficulty following what was said?)." Under coding, a score of "2" referred to "Behavior present, fluctuates (comes and goes, changes in severity." Under "Activities of Daily Living," for "Transfer," the resident scored a "4" for self-performance meaning total dependence and a "3" for "Two plus persons physical assist." 4. A review of the Kiosk, skin observations, was conducted for Resident #1 for 08/10 thru 08/12. The first entry made by Staff member C, was on 08/12/13 at 14:41, "skin observation=discoloration." 5. During an interview conducted on 09/04/13 at 1:00 with the Certified Dietary Manager, she confirmed that Resident #1 usually ate breakfast between 7:15 a.m. and 8:45 a.m. Approximately 6 hours elapsed before Staff member C, inputted information regarding a skin discoloration into the kiosk. 6. The Progress Notes timed 14:58 for 08/12/2013 indicated: "Xray ordered for left knee [MEDICAL CONDITION] and bruising." At 23:31 on 08/12/13, the notes reflected "MD gives order to send patient to ER for further treatment. Son aware." On 08/13/2013, a "LATE ENTRY" for 08/12/2013 @ 2:35 pm" provided that "Unit Manager informed this writer while on break that CNA reported to her a moderate size bruise located to resident left leg. Family member (son) present at time. Unit Manager spoke with family and call physician, orders obtained for xrays, resident assisted to bed. Assessments made earlier by unit manager, this writer examined resident leg on return from break, notice a moderate size light purple bruise to left leg mid section. Leg slightly inverted. Reported to on-coming nurse of orders obtained." 7. An interview was conducted on 09/03/13 at 2:54 p.m., with Staff member B, Licensed Practical Nurse in regards to events that occurred on 08/12/13 with Resident #1. She stated: "At the end of my shift, the son had approached my unit manager, Staff member A. She came to me and said that she had gone and looked at the bruise with the son, she had assessed the bruise; she had called the physician. I looked at the bruise, it looked faded; not fresh; she agreed that it was approximately 4 " x 4 " circle. The edges were yellowing; not like a fresh bruise, which would be a darker purple in color. She further stated that the CNA did not report any bruising to her." 8. Record review of Chart summary for a hospital admission that occurred on 08/13/13 for Resident #1 found the following information regarding the resident's condition on arrival: "The patient presents with ... a history of severe dementia and [MEDICAL CONDITION], presenting with the chief complaint of having a left distal femur fracture. The patient has severe dementia and is bedridden and nonverbal. Apparently, the (family member) was visiting her this afternoon and noticed that she had ecchymosis and swelling to her left thigh region. An x-ray was performed and found that she had a left distal femur fracture. There was no known trauma. The patient has been at her baseline mental status. The (family member) states that the last time he may have seen her leg and it was normal was last Thursday. There are no other complaints." 9. Interviews conducted with Certified Nursing Assistants were conducted on 09/04/13 at approximately 10:45 a.m. to determine the facility expectation for reporting a change in skin condition: 10. Staff member E: "If I saw a bruise on a resident, I would let the nurse know as soon as I see it." Staff member F: "If I saw a bruise, I would report to the nurse, as soon as I see it." Staff member G: "If I saw a bruise on a resident, I would report it to the nurse, immediately, as soon as I saw it."