Every finding on record at Homeplace Manor Healthcare Center

Based on interview and record review, the facility failed to implement written policies and procedures that prohibit and prevent abuse, neglect, and exploitation of residents, and misappropriation of resident property for 2 of 3 employees (RN and DON) reviewed for employability. The facility failed to ensure evidence that the criminal history was checked prior to the DON and RN being hired or having access to the residents. The facility failed to ensure evidence that the Employee Misconduct Registry or Nurse Aide Registry was checked prior to RN being hired or having access to the residents. The failure could place residents at risk of receiving care from someone who was unemployable, which increased the risk of abuse, neglect, and exploitation. Findings included: Record review of the personnel file for the RN revealed a hire date of 05/06/2026. Further review of the personnel file provided by the BOM reflected the RN had no evidence the facility ran a Criminal History Check prior to her hire date. The BOM provided a document that the RN's criminal history was checked on 05/28/2026 at 10:35 a.m., during the on-site investigation. Further review revealed the Employee Misconduct Registry and Nurse Aide Registry document located in the RN's file reflected the EMR and NAR registries were checked on 05/07/2026, which was after her hire date. Record review of the personnel file for the DON reflected a hire date of 04/28/2026. Further review of personnel record provided by the Business of Manager reflected the DON had no evidence the facility ran a Criminal History Check prior to her hire date. The BOM provided a document that the DON's criminal history was checked on 05/28/2026 at 10:16 a.m., during the on-site investigation. During an interview on 05/28/2026 at 1:22 p.m., the RN said she had been employed at the facility approximately three (3) weeks. During an interview on 05/28/2026 at 2:17 p.m., the DON said she had been employed at the facility approximately a month. During an interview on 05/28/2026 at 3:54 p.m., the BOM said she had been employed at the facility for approximately nine (9) years and in her current position for approximately 11 months. The BOM said she was in housekeeping prior to being hired into her new position. The Business Office Manager said she was trained on her job duties by the corporate trainer, but she did not feel like she received the training she needed to perform her job efficiently. The Business Office Manager said she received training on the new employee process, which included checking the applicants' criminal history and misconduct registry. The Business Office Manager said the main problem was that the facility switched over to a new payroll company and she was overwhelmed within the month of May 2026. The Business Office Manager said the change in software to complete payroll for the facility and her overwhelmed state was the reason the RN's and the DON's criminal history was not conducted and the RN's EMR and NAR were not checked. The Business Office Manager said she fully understood the registries and criminal history of each person that applied for employment were to be checked prior to being hired and having access to the residents. The Business Office Manager said the purpose was to ensure the facility knew the person was safe to work at the facility and would not cause harm to the residents or put the residents in harm. During an interview on 05/28/2026 at 4:12 p.m., the Administrator said the fact that the RN and the DON did not have a criminal history check prior to their hire date did not meet her expectation. The Administrator said the facility had to know if a person had anything in his or her background prior to letting them work in the facility with the residents. The Administrator said her expectation was the registries and back-grounds were checked prior to the hire date. The Administrator said this could have a negative effect on the residents and could adversely affect the staff and residents if someone was hired and put the residents in danger. The Administrator said that the lack of following procedures could increase the residents' risk of abuse and neglect. Record review of the facility's policy, Background Screening Investigations, dated March 2019, revealed the facility would conduct employment background screening checks and criminal conviction investigation checks on all applicants for positions with direct access to residents. Further record review revealed, For any individual applying for the position of certified nursing assistant, nurse, or direct contact with residents, the state nurse aide registry is contacted to determine if any findings of abuse, neglect, mistreatment of individuals, and/or theft of property have been entered into the applicant's file. For any licensed professional applying for a position that may involve direct contact with residents, his/her respective licensing board is contacted to determine if any sanctions have been assessed against the applicant's license.

Based on interview and record review, the facility failed to ensure the Pre-admission Screening and Resident Review (PASRR) Level I assessment accurately reflected the resident's status for one (Resident #1) of 3 residents reviewed for PASRR Level 1 screenings. The facility failed to ensure the accuracy of the PASRR Level 1 Screening for Resident #1. The PASRR Level 1 Screening dated 11/13/25 did not indicate a diagnosis of mental illness, although the diagnosis post-traumatic stress was present upon Resident #1's admission on [DATE]. This failure could place residents with mental illness at risk of not receiving a PASRR Evaluation, individualized care, or special services to meet their needs. Findings included: A record review on 4/25/2026 of the face sheet dated 4/25/2026 revealed Resident #1 admitted on [DATE] and was [AGE] year-old female. A record review on 4/25/2026 of Resident #1's Physician Progress note dated 3/18/2026 revealed diagnoses of generalized anxiety disorder (persistent, excessive and uncontrollable worry about everyday things), panic disorder (sudden episode of intense fear that triggers severe physical reactions when there is no real danger or apparent cause), PTSD (a mental and behavioral disorder that can develop because of exposure to a traumatic event including symptoms of disturbing thoughts, mental or physical distress, and alterations in the way a person thinks or feels). Under the assessment and plan section of this progress note it stated PTSD on multiple meds. A record review of Resident #1's quarterly MDS assessment dated [DATE], revealed a BIMS score of 15 which indicated Resident #1's cognition was intact. Resident #1's active diagnoses included anxiety, depression, and post-traumatic stress disorder. A record review of Resident #1's PASRR Level 1 Screening completed on 11/13/2025 by the referring entity revealed Resident #1 did not have a primary diagnosis of dementia and no indicator of mental illness. During an interview on 4/25/2026 at 11:00am with Resident #1, she stated she had been at the facility since November 2025. Resident #1 stated she had anxiety with panic disorder, PTSD, and depression. Resident #1 stated she has not received any services for mental health. During an interview on 4/25/2026 at 2:07pm, the MDS Coordinator stated Resident #1 had a mental illness diagnosis, thus the PASRR screening was positive, not negative as reflected on the screening form. She stated a corrected screening should have been completed and sent to the local authority for evaluation. The MDS Coordinator stated PASRR was her responsibility, and she would correct the issue. She stated the risk of PASRR not being accurate could be a lack of services for the resident. During an interview on 04/25/26 at 3:49pm, the Administrator stated she expected the PASRRs to be accurate and timely. She stated if an error in a PASRR was later found, a corrected form was sent. The Administrator stated the MDS Coordinator was responsible for the accuracy of PASRR documents. She stated residents may not have received the benefits or treatments they needed, or were entitled to, if the PASRR screening was inaccurate. During a record review of the facility's policy dated November 2023 titled PASRR revealed:6. Follow Texas PASRR Policy for all mandatory meetings and care coordination including any changes that may require a change in residents PASRR status. Review of the Texas Health and Human Services Detailed Item by Item Guide for Local Authorities and Nursing Facilities to Complete the PASRR Level 1 Screening Form, revised June 2023, and accessed at PASRR Forms and Instructions | Texas Health and Human Services revealed in part, The PASRR Level I (PL1) Screening Form is designed to identify individuals who are suspected of having mental illness (MI), intellectual disability (ID) or a developmental disability (DD). Developmental disabilities are also referred to as related conditions. If documentation entered on the PL1 Screening Form indicates a suspicion of MI, ID, or DD, a PASRR Evaluation (PE) must be completed to confirm PASRR eligibility. The PE is designed to confirm the suspicion of MI, ID or DD and ensure an individual is placed in the most integrated residential setting receiving the specialized services needed to improve and maintain an individual's level of functioning. Examples of MI diagnoses are:SchizophreniaMood Disorder (Bipolar Disorder, Major Depressive Disorder, or other mood disorder)Paranoid DisorderSevere Anxiety DisorderSchizoaffective DisorderPost-Traumatic Stress SyndromeWhat is not considered an MI:Neurocognitive Disorders, such as Alzheimer's disease, other types of dementia, Parkinson's disease, and Huntington's. (DSM-5*), Depression, unless diagnosed as Major Depression; and Anxiety, unless diagnosed as severe anxiety disorder.*Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition

Based on interviews and record review, the facility failed to provide the appropriate treatment and facility services to correct the assessed problem or to attain the highest practicable mental and psychosocial well-being for a resident with Post Traumatic Stress Disorder (PTSD) for 1 (Resident #1) of 3 residents reviewed for behavioral health care services. The facility failed to ensure Resident #1, who was diagnosed with depression, anxiety, and post-traumatic stress disorder (PTSD), received the care and services needed in the most appropriate setting, after the resident began to display increased behaviors on 4/15/2026 and requested outpatient psychiatric services. This failure could place a resident with PTSD at risk of not receiving specialized services which would enhance their highest level of functioning and could contribute to residents' decline in physical, mental, and psychosocial well-being.Findings included: A record review on 4/25/2026 of the face sheet dated 4/25/2026 revealed Resident #1 admitted on [DATE] and was a [AGE] year-old female. A record review on 4/25/2026 of Resident #1's Physician Progress note dated 3/18/2026 revealed diagnoses of generalized anxiety disorder (persistent, excessive and uncontrollable worry about everyday things), panic disorder (sudden episode of intense fear that triggers severe physical reactions when there is no real danger or apparent cause), PTSD (a mental and behavioral disorder that can develop because of exposure to a traumatic event including symptoms of disturbing thoughts, mental or physical distress, and alterations in the way a person thinks or feels. Under assessment and plan section of this progress note, it stated PTSD on multiple meds, probably needs psych follow up. A record review on 4/25/2026 of Resident #1 Quarterly MDS assessment dated [DATE] revealed a BIMS score of 15 indicating intact cognition. Resident #1 had clear speech, was understood by others and understood others. Mood section indicated Resident #1 had little interest or pleasure in doing things and feeling down, depressed, or hopeless. Section E revealed no behaviors. Functional abilities reveal Resident #1 was independent with ADLs. Section I Active Diagnoses reveal Resident #1 had anxiety disorder, depression, and PTSD. A record review on 4/25/2026 of Resident #1 Care plan revealed a focus area initiated on 12/11/2025 that resident had behavior problems; verbal aggression, crying, and isolation related to PTSD, depression, and panic disorder. The goal indicated resident will have no evidence of behavior problems by review date. Interventions included administering medications as ordered, anticipating resident's needs, providing opportunity for positive interaction, discussing the resident's behavior and reinforce why behavior is inappropriate, intervene as necessary to protect the rights and safety of others. A record review on 4/25/2026 of Resident #1 physician's orders dated 4/25/2026 revealed behavior monitoring orders, psychoactive medication monitoring, and Psych services to evaluate and treat with order date of 11/17/2025. Resident #1's physician orders also revealed Resident #1 received medication duloxetine and bupropion to treat depression with a start date of 11/17/2025. Resident #1 received alprazolam to treat anxiety with a start date of 12/12/2025. Resident #1 also received temazepam to treat insomnia with a start date of 12/4/2025. A record review on 4/25/2026 of Resident #1 progress notes dated 4/22/2025 written by LVN S revealed Resident #1 made her own appointment with psychiatrist and administrator said to inform Resident #1 that she can't schedule her own appointments and must coordinate with nursing when appointment needs to be scheduled. Resident #1 appointment is on May 12th at 9:30am with Psychiatrist. During an interview on 4/25/2026 at 11:00am with Resident #1, she stated she had been at the facility without psychiatrist services since admission. She stated she has been requesting a psychiatrist for her PTSD and depression and voiced her concerns to the Social Worker and Administrator, and they have not done anything. She stated she made her own appointment with psychiatrist and the Administrator got mad at her for making her own appointment. Resident #1 stated a counselor was coming to the facility to talk to her, but then he stopped coming. Resident #1 stated the counselor was unable to make any medication adjustments and was basically just there to talk to her. During an interview on 4/25/2026 at 12:51pm with the MD, he stated Resident #1 was high functioning and independent with most things. Resident #1 had multiple medical issues and trauma from her past. He stated the biggest reason for Resident #1 being in the facility was because of mental health issues. MD stated he had been recommending mental health services for Resident #1. MD stated he did not know the risk to her not receiving these services because he was not sure there would be a big improvement in her psychological status. MD stated he does not believe Resident #1 has had a negative outcome from not receiving psych services, but he does think she could benefit from them. During an interview on 4/25/2026 at 2:13pm with the Social Worker, he stated Resident #1 was receiving counseling services, but the counselor relocated, and they have not had one in a while. Social Worker stated he comes to the facility once a week and visits Resident #1. Social worker stated he does not believe Resident #1 was at risk of hurting herself or others at this point. During an interview on 4/25/2026 at 3:00pm with the Administrator, she stated Resident #1 refused to see the psychiatrist NP that comes to the facility since admission. Administrator was unable to produce documentation that verified she refused. She stated she does not know why facility has not attempted to seek Resident #1 services with a different mental health entity. Administrator stated Resident #1 made her own appointment for May and will be going to that appointment. Administrator stated Resident #1 had no negative outcome due to not having mental health services, but the risk could include isolation, depression and worsening in mental health status. A record review of the facility's policy dated February 2019 titled Behavioral Health Services revealed .Policy StatementThe facility will provide and residents will receive behavioral health services as needed to attain or maintain the highest practible physical, mental, and psychosocial well-being in accordance with the comprehensive assessment and care plan.Policy Interpretation and ImplementationBehavioral health services are provided to residents as needed as part of the interdisciplinary, person-centered approach to care.Residents who exhibit signs of emotional/psychosocial distress receive services and support that address their individual needs and goals for care.6. Behavioral health services are provided by staff who are qualified and competent in behavioral health and trauma- Informed care.

Based on interviews and record reviews, the facility failed to utilize the services of a RN for 8 consecutive hours 7 days a week and designate a RN as a DON on a full-time basis for 1 of 1 facility reviewed for nursing services.The facility failed to ensure an RN worked for 8 consecutive hours for 28 of 79 days reviewed in October and November 2025 until December 18th 2025.The facility failed to designate an RN as a DON on a full-time basis for 2 of 3 months reviewed in October and November 2025 until December 18th 2025.These failures placed all residents at risk for their clinical needs not being met.Findings includedDuring an interview on 12/16/2026 at 10:16 a.m., the AIT stated the facility did not have a DON or RN coverage for eight consecutive hours a day seven days a week.Record review of Monthly Nursing Attendance Calendar for 2025 revealed: RN/DON last date worked was on 11/06/2025. RN/DON hired on 11/04/2025 and her last day worked was on 11/10/2025. 10/01/2025-10/31/2025 had 2 days (10/11/2025 & 10/12/2025) with no RN for 8 consecutive hours. 11/01/2025-11/30/2025 had 3 weeks (the week of 11/10/2025, the week of 11/17/2025, and the week of 11/24/2025) of 4 weeks with no DON. 11/01/2025-11/30/2025 had 11 days (11/13/025, 11/17/2025-11/23/2025, 11/25/2025, 11/27/2025 & 11/29/2025) of 30 days with no RN for 8 consecutive hours. 12/01/2025-12/18/2025 had 2 weeks (the week of 12/01/2025 and the week of 12/08/2025) of 3 weeks with no DON. 12/01/2025-12/18/2025 had 15 days (12/01/2025-12/15/2025) of 18 days with no RN for 8 consecutive hours.During an interview on 12/17/2025 at 1:10 p.m., the AIT stated her expectation would be for the facility to have a RN on shift at least eight hours a day seven days a week. She stated she expected the facility to have a DON at least forty hours a week. She stated the facility had a DON but could not find another DON after her last day on 11/10/2025. She stated she had been attempting to get another DON to fill the position with no applicants. She stated on Monday 12/15/2025, they redid their DON position opportunity on the internet and added incentives to try and get more interest in the position. She stated she did not know why there was no RN coverage prior to her starting to work at the facility. She stated her first day was on 11/3/2025. She stated she had corporate oversight, and he was in the building at that time. She stated he had been onsite for 4 days since she had been working as the AIT but had been available by telephone to her.During an interview on 12/18/2025 at 8:14 a.m., the RDO stated he was aware the facility did not have RN coverage or an acting DON. He stated he expected the facility to have an RN working eight consecutive hours a day every day of the week. He stated he expected there to be an acting DON in the facility. He stated the facility had been attempting to hire RN staff and a DON, and just recently added incentives to make those positions more desirable. He stated they had one application as of that morning for DON. He stated turnover in management staff led to the failure of those positions not be filled. He stated the AIT was an LVN and the facility had corporate oversight from an RN, but that RN had not worked forty hours a week at the facility. He stated it was the ADMIN who was responsible for making sure there was a DON and the facility had RN coverage. He stated it was his responsibility to monitor the ADMIN filled those positions. He stated he had worked for the corporation for two months and the ADMIN was new as well. He stated there was improvement to be made and the management was aware of the issue prior to today.Record review of facility's policy titled, Nursing Services-Registered Nurse (RN), revised on 01/01/2025 reflected 1. The facility will utilize the services of a Registered Nurse for at least 8 consecutive hours per day, 7 days per week. 2. The facility will designate a Registered Nurse to serve as the Director of Nursing on a full time basis.

Based on observations, interviews, and record reviews, the facility failed to properly store, prepare, distribute, and serve food in accordance with professional standards for food service safety for 1 of 1 kitchen reviewed. 1. The facility failed to ensure freezer and refrigerator temperatures were tracked daily2. The facility failed to ensure foods were labeled properly. 3. The facility failed to ensure food temperatures were taken before serving. These failures could place residents that eat out of the kitchen at risk for food borne illnesses. The findings included: During an observation on 12/16/2025 at 9:37 AM of the refrigerator revealed: 1. 1 package of food that resembled corn tortillas was in an unopened package, but not in the original box and did not have a label of what the item was, or the date opened or use by date.2. current temperature showed 33 Fahrenheit. Freezer:1. 3 slices of food item that appeared to be garlic toast in an opened/unsealed package without label of what it was or a date of when received, date opened, or use by date. 2. 1 opened bag of food items that appeared to be mixed fruit without label or date of when received, date opened, or use by date.3. 1 opened bag of food items that appeared to be frozen biscuits without date of when received, date opened, or use by date or label. 4. Current temp showed 31 Fahrenheit on external freezer thermometer. Record review of the temperature log of the refrigerator revealed the last documented temperature was on 12/07/2025 in the afternoon of 40 degrees Fahrenheit. There was no further evidence of the temperature logs documented since 12/07/2025.Record review of temperature log of the freezer revealed the last documented temperature was on 12/07/2025 in the afternoon of -2 degrees Fahrenheit. There was no further evidence of temperature logs documented since 12/07/2025.During an interview on 12/16/25 at 9:45 AM, the DM stated temperatures were to be taken from the freezer and refrigerator twice a day and logged by kitchen staff. DM stated she and dietary assistant had been trying to get the kitchen cleaned and corrected from previous dietary staff that had left since the management change. DM stated food temperatures were to be checked before being served by cook and logged on food temperature logs. DM stated foods that were not in original packaging and opened, are to be placed in a sealed container or baggie with the opened date, use by date, and description of what the item is.During an observation of 12/16/2025 at 12:15 pm, Dietary Assistant began taking food temperatures with separate food thermometers on the stove; Lima Beans 125 degrees Fahrenheit; gravy 100 degrees Fahrenheit; carrots 120 degrees Fahrenheit; and chicken 140 degrees Fahrenheit. Dietary staff were not observed documenting the temperatures.During an interview on 12/18/24 8:06 AM, Admin stated the food temperatures should be taken by dietary staff while being prepared and at the time of serving. Her expectation was the food temperatures were completed and logged during each meal. She stated there was a risk to residents of foodborne illness if temps were not within appropriate range for service. ADMIN stated the dietary staff were to check the temperatures inside freezers and refrigerators daily using the thermometer on the inside of the appliance, not the external thermometer. The Admin stated the food temperatures were to be documented on the log completed that was located on the outside of the appliance. The Admin stated the dangers of not having correct food storage temperatures could lead to food spoilage and foodborne illnesses and waste. DMIN stated her expectation for the storage of opened food in refrigerator and freezer was to put food in a baggie or container with a lid with date opened, and date use by, description of the item. Admin stated the dangers of not having the food labeled and dated properly was the possibility of using spoiled or expired food or incorrect food and causing an allergic reaction or a foodborne illness.Record review of the facility's policy titled, Refrigerators and Freezers undated revealed: -Food service supervisors or designated employees will check and record refrigerators and freezer temperatures daily with first opening and at closing in the evening. All food shall be appropriately dated to ensure proper rotation by expiration dates. Received dates will be marked on cases and on individual items removed from cases for storage. use by dates will be completed with expiration dates on all prepared food in refrigerators. Expiration dates on unopened food will be observed and use by dates indicated once food is opened.Record review of the facility's policy titled, Pureed Foods Guidelines undated revealed: - For Hot Foods: CCP Reheat to an internal temperature of >165F held for 15 seconds. Maintain at an internal temperature of >140F for only 4 hours.Record review of the facility's policy titled, Food Preparation and Service - The following internal cooking temperatures/times for specific foods must be reached to kill or sufficiently inactivate pathogenic microorganisms:a. Poultry and stuffed foods - 165 F. b. Ground meat, ground fish and eggs held for service - at least l I 5 F.c. Fish and other meats - 145 F for 15 seconds.d. Fresh, frozen or canned fruits/vegetables - 135 F.e. Foods cooked in a microwave - 165 in all parts of the food. It is critical to measure the food temperature at multiple sites and allow the food to stand covered for two (2) minutes after microwave beating.Previously cooked food must be reheated to an internal temperature of 165 for at least 15 seconds. Reheated foods that are not consumed within 2 hours will be discarded.Record review of the facility's policy titled, Food Receiving and Storage undated revealed: -All foods stored in refrigerator or freezer will be covered, labeled and dated ( use by date); Refrigerated food must be stored at or below 40F unless otherwise specified by law. Functioning of the refrigeration and food temperatures will be monitored at designated intervals throughout the day by the Food Service Manager or designee and documented according to state-specific requirements.Review of the FDA Food Code 2022 https://www.fda.gov/food/guidance-regulation-food-and-dietary-supplements/retail-food-protection reviewed 12/22/2025 revealed: 3 602.11 Food Labels. (A) FOOD PACKAGED in a FOOD ESTABLISHMENT, shall be labeled as specified in LAW, including 21 CFR 101 Food labeling, and 9 CFR 317 Labeling, marking devices, and containers. (B) Label information shall include: (1) The common name of the FOOD, or absent a common name, an adequately descriptive identity statement; (2) If made from two or more ingredients, a list of ingredients and sub ingredients in descending order of predominance by weight, including a declaration of artificial colors, artificial flavors and chemical preservatives, if contained in the FOOD; (3) An accurate declaration of the net quantity of contents; (4) The name and place of business of the manufacturer, [NAME], or distributor; and (5) The name of the FOOD source for each MAJOR FOOD ALLERGEN contained in the FOOD unless the FOOD source is already part of the common or usual name of the respective ingredient. (6) Except as exempted in the Federal Food, Drug, and Cosmetic Act S 403(q)(3) (5), nutrition labeling as specified in 21 CFR 101 Food Labeling and 9 CFR 317 Subpart B Nutrition Labeling. (7) For any salmonid FISH containing canthaxanthin or astaxanthin as a COLOR ADDITIVE, the labeling of the bulk FISH container, including a list of ingredients, displayed on the retail container or by other written means, such as a counter card, that discloses the use of canthaxanthin or astaxanthin. Time/temperature control for safety refrigerated foods must be consumed, sold or discarded by the expiration date.

Based on interviews and record reviews, the facility failed to implement written policies and procedures that prohibit and prevent abuse, neglect, exploitation of residents and misappropriation of resident property for 14 of 45 employees (AIT, SW, DM, Maint D, ADON, AD, DOR, RN A, LVN B, LVN C, LVN D, CNA E, CNA F, and CNA G) reviewed for employability. The facility failed to ensure evidence that the criminal history was checked prior to the AIT, SW, DM, Maint D, ADON, AD, DOR, RN A, LVN B, LVN C, CNA E, CNA F, and CNA G being hired or having access to the residents. The facility failed to ensure evidence that the EMR was checked prior to the AIT, AD, DM, Maint D, CNA E, CNA F, and CNA G being hired or having access to residents. The facility failed to ensure evidence that the NAR was checked prior to CNA E, CNA F, and CNA G being hired or having access to the residents. These failures placed residents at risk of receiving care from someone who was unemployable, which increased the risk of abuse, neglect, and exploitation risk.Findings included Record review of the personnel record for the AIT reflected a hire date of 10/17/2025. Further review of personnel record provided by the BO reflected the AIT had no evidence the facility ran a CHC or an EMR check on her prior to her hire date.Record review of the personnel record for the ADON reflected a hire date of 1/04/1994. Further review of personnel record provided by the BO reflected the ADON had no evidence the facility ran a CHC on her prior to her hire date.Record review of the personnel record for the SW reflected a hire date of 3/01/2025. Further review of personnel record provided by the BO reflected the SW had no evidence the facility ran a CHC on her prior to her hire date.Record review of the personnel record for the AD reflected a hire date of 9/29/2025. Further review of personnel record provided by the BO reflected the AD had no evidence the facility ran a CHC or an EMR check on her prior to her hire date.Record review of the personnel record for the DM reflected a hire date of 11/19/2025. Further review of personnel record provided by the BO reflected the DM had no evidence the facility ran a CHC or an EMR check on her prior to her hire date.Record review of the personnel record for the Maint D reflected a hire date of 9/19/2023. Further review of personnel record provided by the BO reflected the Maint D had no evidence the facility ran a CHC or EMR check on him prior to his hire date.Record review of the personnel record for the DOR reflected a hire date of 5/08/2025. Further review of personnel record provided by the BO reflected the DOR had no evidence the facility ran a CHC on her prior to her hire date.Record review of the personnel record for RN A reflected a hire date of 4/21/2025. Further review of personnel record provided by the BO reflected RN A had no evidence the facility ran a CHC on her prior to her hire date.Record review of the personnel record for LVN B reflected a hire date of 9/05/2022. Further review of personnel record provided by the BO reflected LVN B had no evidence the facility ran a CHC on her prior to her hire date.Record review of the personnel record for LVN C reflected a hire date of 2/25/1987. Further review of personnel record provided by the BO reflected LVN C had no evidence the facility ran a CHC on her prior to her hire date.Record review of the personnel record for LVN D reflected a hire date of 8/01/2025. Further review of personnel record provided by the BO reflected LVN D had no evidence the facility ran a CHC on her prior to her hire date.Record review of the personnel record for CNA E reflected a hire date of 11/06/2025. Further review of personnel record provided by the BO reflected CNA E had no evidence the facility ran a CHC, an EMR check, or a NAR check on her prior to her hire date.Record review of the personnel record for CNA F reflected a hire date of 1/09/2023. Further review of personnel record provided by the BO reflected CNA F had no evidence the facility ran a CHC, an EMR check, or a NAR check on her prior to her hire date.Record review of the personnel record for CNA G reflected a hire date of 8/10/2017. Further review of personnel record provided by the BO reflected CNA G had no evidence the facility ran a CHC, an EMR check, or a NAR check on her prior to her hire date.During an interview on 12/17/2025 at 1:10 p.m., the AIT stated her expectation would be for all staff to have background checks prior to being allowed to have contact with the residents. She stated there had been a changeover in BO managers that occurred approximately two months ago. She stated the BO manager now was hired from her position as housekeeper with the understanding that corporate BO manager would train her. She stated she was told by the BO manager that training did not occur. The AIT stated she could not reach out to the corporate BO manager because she quit working for the company yesterday. She stated the corporate BO manager was also supposed to load the employee background checks and employee training into the payroll database for the company because of the change in ownership that occurred in March of 2025. She stated the previous company's employee background checks and previous company's employee training was not found in the payroll database. She stated prior to yesterday, she was not aware that the facility did not have background checks, NAR/EMR checks, employee training, and nurse aide annual competency checkoffs on their employees. During an interview on 12/17/2025 at 2:38 p.m., the BO manager stated she had been in the position of the BO since the end of July. She stated she had one day when a person sat next to her and trained her. She stated since then, she has had several Team's trainings that she had attended on the computer. She stated she was the housekeeping manager prior to this position. She stated she remembered looking at some of the new hires' background checks but did not know she should have printed them out and could not show proof the background checks had been reviewed.During an interview on 12/18/2025 at 8:14 a.m., the RDO stated he expected all staff to have background checks prior to being hired along with EMR / NAR checks to unlicensed employees prior to hire. He stated the failure occurred due to change in ownership and change in management. He stated the Admin position had a change over and the facility was currently looking for a DON. He stated it was the Administrator's responsibility to make sure background checks were implemented per regulation and it was his job to monitor that the ADMIN was ensuring those background checks had been done. He stated he was relatively new to the company and did not know why the background checks were not stored in the employee files. He stated he had worked for the company for two months and knew there was improvement to be made.During an interview on 12/18/2025 at 2:45 p.m., the AIT stated the BO manager had run all the employees in question CHCs, EMRs, and NARs and there were no unemployable employees found. Record review of the facility's policy titled, Background Screening Investigations revised on March 2019 reflected, The director of personnel, or designee, conducts background checks, reference checks and criminal conviction checks (including fingerprinting as may be required by state law) on all potential direct access employees and contractors. Background and criminal checks are initiated within two days of an offer of employment or contract agreement, and completed prior to employment. For any individual applying for a position as a certified nursing assistant, the state nurse aide registry is contacted to determine if any findings of abuse, neglect, mistreatment of individual, and/or theft of property have been entered into the applicant's file.Should the background investigation disclose any misrepresentation on the application form or information indicating that the individual has been convicted of abuse, neglect, mistreatment of individuals, and/or misappropriation of property, the applicant is not employed or contracted.Record review of facility's policy titled, Abuse, Neglect and Exploitation revised on 1/01/2025 reflected, Potential employees will be screened for a history of abuse, neglect, exploitation, or misappropriation of resident property. 1. Background, reference, and credentials' checks shall be conducted on potential employees, contracted temporary staff, students affiliated with academic institutions, volunteers, and consultants. 2. Screenings may be conducted by the facility itself, third-party agency or academic institution. 3. The facility will maintain documentation of proof that the screening occurred.

Based on interviews and record reviews, the facility failed to ensure staff members were educated on the rights of the resident and the responsibilities of a facility to properly care for its residents. for all new and existing staff for 9 of 15 (the AIT, the SW, the AD, the DM, the DOR, RN A, LVN D, CNA E, and HK H) staff reviewed for training on resident's rights. The facility failed to ensure that the AIT, the SW, the AD, the DM, the DOR, RN A, LVN D, CNA E, and HK H were educated on the rights of the resident, and the responsibilities of the facility to properly care for its residents upon hire.This failure could place residents at risk of their rights not being honored by uninformed staff. Findings includedRecord review of personnel record for the AIT reflected a hire date of 10/17/2025. Further review of personnel record provided by the BO reflected the AIT had no evidence she had completed required resident rights training upon hire or while working at the facility.Record review of personnel record for the SW reflected a hire date of 3/01/2025. Further review of personnel record provided by the BO reflected the SW had no evidence he had completed required resident rights training upon hire or while working at the facility. Record review of personnel record for the AD reflected a hire date of 9/29/2025. Further review of personnel record provided by the BO reflected the AD had no evidence she had completed required resident rights training upon hire or while working at the facility.Record review of personnel record for the DM reflected a hire date of 11/19/2025. Further review of personnel record provided by the BO reflected the DM had no evidence she had completed required resident rights training upon hire or while working at the facility.Record review of personnel record for the DOR reflected a hire date of 5/08/2025. Further review of personnel record provided by the BO reflected the DOR had no evidence she had completed required resident rights training upon hire or while working at the facility.Record review of personnel record for RN A reflected a hire date of 4/21/2025. Further review of personnel record provided by the BO reflected RN A had no evidence she had completed required resident rights training upon hire or while working at the facility.Record review of personnel record for LVN D reflected a hire date of 8/01/2025. Further review of personnel record provided by the BO reflected LVN D had no evidence she had completed required resident rights training upon hire or while working at the facility.Record review of personnel record for CNA E reflected a hire date of 11/06/2025. Further review of personnel record provided by the BO reflected CNA E had no evidence she had completed required resident rights training upon hire or while working at the facility.Record review of personnel record for HK H reflected a hire date of 11/24/2025. Further review of personnel record provided by the BO reflected HK H had no evidence she had completed required resident rights training upon hire or while working at the facility.During an interview on 12/17/2025 at 1:10 p.m., the AIT stated her expectation would be for staff to have appropriate training during orientation and annual per regulation. She stated there had been a changeover in BO managers that occurred approximately two months ago. She stated the BO manager now was hired from her position as housekeeper with the understanding that corporate BO manager would train her. She stated she was told by the BO manager that her job duty training did not occur. The AIT stated she could not reach out to the corporate BO manager because she quit working for the company yesterday. She stated the corporate BO manager was also supposed to load the employee training into the payroll database for this company because of change in ownership that occurred in March of 2025. She stated the previous company's employee training was not found in the payroll database. She stated prior to yesterday, she was not aware that the facility did not have employee training. During an interview on 12/17/2025 at 2:22 p.m., CNA E stated she had worked at the facility in the past and had just started back working in the facility on 11/06/2025. She stated she remembered getting some training through in-services but thought those happened prior to her re-hire. She stated she thought that she had training on resident rights prior to her re-hire.During an interview on 12/17/2025 at 2:38 p.m., the BO manager stated she had been in the position of the BO since the end of July 2025. She stated she had one day when she had a person sit next to her and train her and had attended several training meetings on the computer. She stated prior to being in the BO role, she had worked as the HK supervisor for the facility. She stated she had not been aware of orientation training requirements until now.During an interview on 12/18/2025 at 8:14 a.m., the RDO stated he expected all staff to have orientation with appropriate education on required topics including resident rights to understand the rights each resident had. He stated he had worked for the company for two months and knew there was improvement to be made. He stated the failure occurred due to change in ownership and change in management in both the DON and the ADMIN. He stated it was the ADMIN's job to make sure all training was implemented per regulations. He stated he was responsible for monitoring those trainings had occurred. During an interview on 12/18/2025 at 9:38 a.m., the AIT stated she had not received any orientation training on resident's rights but thought she had been trained on resident's rights from a previous employer.Record review of facility policy titled Orientation, with revision date of 1/02/2025, reflected 1. The facility has designated the Staff Development Coordinator, or designee, as the contact person for the facility's orientation program. This person works closely with each department head for scheduling orientation sessions and developing orientation plans. 2. Orientation plans are maintained by the Staff Development Coordinator. a. General orientation plans reflect the onboarding process for all newly hired employees, and reflect content that is applicable to all staff. b. Departmental orientation plans reflect the skills and competencies that each new employee will require to fulfill his or her job responsibilities. 3. General orientation must be completed prior to the employee's formal contact with facility residents. 4. Departmental orientation will continue until the employee has demonstrated competency in all the skills necessary for performing his/her job and to meet resident needs.10. When an employee changes roles or departments, he/she will go through a departmental orientation specific to that new role or department. 11. All documentation to support completion of the orientation process shall be maintained in the employee's personnel file.Record review of the staff list provided by the facility with no date reflected no staff member titled Staff Development Coordinator.The facility did not provide a policy that specifically required staff to be trained on resident rights.

Based on interviews and record reviews, the facility failed to provide behavioral health training consistent with the requirements at 483.40 (behavioral health services) and as determined by the facility assessment for 8 of 15 (the AIT, the SW, the DM, the DOR, RN A, LVN D, CNA E, and HK H) staff reviewed for training on behavioral health. The facility failed to ensure that the AIT, the SW, the DM, the DOR, RN A, LVN D, CNA E, and HK H were educated on behavioral health upon hire. This failure could place residents diagnosed with a mental, psychosocial, or substance use disorder at risk of not receiving the care specific to their individual needs.Findings were:Record review of personnel record for the AIT reflected a hire date of 10/17/2025. Further review of personnel record provided by the BO reflected the AIT had no evidence she had completed behavioral health training upon hire or while working at the facility.Record review of personnel record for the SW reflected a hire date of 3/01/2025. Further review of personnel record provided by the BO reflected the SW had no evidence he had completed behavioral health training upon hire or while working at the facility.Record review of personnel record for the DM reflected a hire date of 11/19/2025. Further review of personnel record provided by the BO reflected the DM had no evidence she had completed behavioral health training upon hire or while working at the facility.Record review of personnel record for the DOR reflected a hire date of 5/08/2025. Further review of personnel record provided by the BO reflected the DOR had no evidence she had completed behavioral health training upon hire or while working at the facility.Record review of personnel record for RN A reflected a hire date of 4/21/2025. Further review of personnel record provided by the BO reflected RN A had no evidence she had completed behavioral health training upon hire or while working at the facility.Record review of personnel record for LVN D reflected a hire date of 8/01/2025. Further review of personnel record provided by the BO reflected LVN D had no evidence she had completed behavioral health training upon hire or while working at the facility.Record review of personnel record for CNA E reflected a hire date of 11/06/2025. Further review of personnel record provided by the BO reflected CNA E had no evidence she had completed behavioral health training upon hire or while working at the facility.Record review of personnel record for HK H reflected a hire date of 11/24/2025. Further review of personnel record provided by the BO reflected HK H had no evidence she had completed behavioral health training upon hire or while working at the facility.During an interview on 12/17/2025 at 1:10 p.m., the AIT stated her expectation would be for staff to have appropriate training during orientation and annual per regulation. She stated there had been a changeover in BO managers that occurred approximately two months ago. She stated the BO manager now was hired from her position as housekeeper with the understanding that corporate BO manager would train her. She stated she was told by the BO manager that her job duty training did not occur. The AIT stated she could not reach out to the corporate BO manager because she quit working for the company yesterday. She stated the corporate BO manager was also supposed to load the employee training into the payroll database for this company because of change in ownership that occurred in March of 2025. She stated the previous company's employee training was not found in the payroll database. She stated prior to yesterday, she was not aware that the facility did not have employee training. During an interview on 12/17/2025 at 2:22 p.m., CNA E stated she had worked at the facility in the past and had just started back working in the facility on 11/06/2025. She stated she remembered getting some training through in-services but thought those happened prior to her re-hire.During an interview on 12/18/2025 at 8:14 a.m., the RDO stated he expected all staff to have orientation with appropriate education on required topics including behavioral health to understand behavioral health. He stated he had worked for the company for two months and knew there was improvement to be made. He stated the failure occurred due to change in ownership and change in management in both the DON and the ADMIN. He stated it was the ADMIN's job to make sure all training was implemented per regulations. He stated he was responsible for monitoring those trainings had occurred. During an interview on 12/18/2025 at 9:38 a.m., the AIT stated she had not received any orientation training on behavioral health.Record review of facility policy titled Orientation, with revision date of 1/02/2025, reflected 1. The facility has designated the Staff Development Coordinator, or designee, as the contact person for the facility's orientation program. This person works closely with each department head for scheduling orientation sessions and developing orientation plans. 2. Orientation plans are maintained by the Staff Development Coordinator. a. General orientation plans reflect the onboarding process for all newly hired employees, and reflect content that is applicable to all staff. b. Departmental orientation plans reflect the skills and competencies that each new employee will require to fulfill his or her job responsibilities. 3. General orientation must be completed prior to the employee's formal contact with facility residents. 4. Departmental orientation will continue until the employee has demonstrated competency in all the skills necessary for performing his/her job and to meet resident needs.10. When an employee changes roles or departments, he/she will go through a departmental orientation specific to that new role or department. 11. All documentation to support completion of the orientation process shall be maintained in the employee's personnel file.Record review of facility's document titled Facility Assessment Tool dated 6/12/2025 reflected 3.4. Staff/training/education and competencies: Annual education upon hire and competencies are developed for all staff based on their job title. 3.5. Policies and procedures for provision of care and facility operations: Policies are reviewed and updated on an on-going basis to ensure current professional standards of practice Events that may trigger a policy review or update include but are not limited to the following: Change in regulation; change in interpretative guidance, case by case review. 3.6. Working with medical practitioners: The facility works closely with its affiliated hospitals and community-based service providers to ensure adequate medical practitioners (including physicians and nurse practitioners) who are trained and knowledgeable in the care of the facility's resident population. The facility is affiliated with the following hospitals: N/A. A list of actively credentialed physicians is maintained and available for print on demand. 3.7. Expectations of medical staff: The facility follows and provides medical practitioners (attending physicians, consultant physicians and other licensed independent practitioners) with federal guidelines and regulations on resident visits, frequency, documentation, and communication with clinical staff.Record review of the staff list provided by the facility with no date reflected no staff member titled Staff Development Coordinator.The facility did not provide a policy that specifically required staff to be trained on behavioral health.

Based on interviews and record reviews, the facility failed to include as part of its compliance and ethics program (1) an effective way to communicate the program's standards, policies, and procedures through a training program or in another practical manner which explains the requirements under the program; (2) annual training if the operating organization operates 5 or more facilities for all new and existing staff for 8 of 15 (the AIT, the SW, the DM, the DOR, RN A, LVN D, CNA E, and HK H) reviewed for training on compliance and ethics.The facility failed to ensure that the AIT, the SW, the DM, the DOR, RN A, LVN D, CNA E, and HK H were educated on compliance and ethics upon hire.This failure could affect residents and place them at risk of being uninformed of compliance and ethics program due to lack of staff training.Findings includedRecord review of personnel record for the AIT reflected a hire date of 10/17/2025. Further review of personnel record provided by the BO reflected the AIT had no evidence she had completed compliance and ethics training upon hire or while working at the facility.Record review of personnel record for the SW reflected a hire date of 3/01/2025. Further review of personnel record provided by the BO reflected the SW had no evidence he had completed compliance and ethics training upon hire or while working at the facility.Record review of personnel record for the DM reflected a hire date of 11/19/2025. Further review of personnel record provided by the BO reflected the DM had no evidence she had completed compliance and ethics training upon hire or while working at the facility.Record review of personnel record for the DOR reflected a hire date of 5/08/2025. Further review of personnel record provided by the BO reflected the DOR had no evidence she had completed compliance and ethics training upon hire or while working at the facility.Record review of personnel record for RN A reflected a hire date of 4/21/2025. Further review of personnel record provided by the BO reflected RN A had no evidence she had completed compliance and ethics training upon hire or while working at the facility.Record review of personnel record for LVN D reflected a hire date of 8/01/2025. Further review of personnel record provided by the BO reflected LVN D had no evidence she had completed compliance and ethics training upon hire or while working at the facility.Record review of personnel record for CNA E reflected a hire date of 11/06/2025. Further review of personnel record provided by the BO reflected CNA E had no evidence she had completed compliance and ethics training upon hire or while working at the facility.Record review of personnel record for HK H reflected a hire date of 11/24/2025. Further review of personnel record provided by the BO reflected HK H had no evidence she had completed compliance and ethics training upon hire or while working at the facility.During an interview on 12/17/2025 at 1:10 p.m., the AIT stated her expectation would be for staff to have appropriate training during orientation and annual per regulation. She stated there had been a changeover in BO managers that occurred approximately two months ago. She stated the BO manager now was hired from her position as housekeeper with the understanding that corporate BO manager would train her. She stated she was told by the BO manager that her job duty training did not occur. The AIT stated she could not reach out to the corporate BO manager because she quit working for the company yesterday. She stated the corporate BO manager was also supposed to load the employee training into the payroll database for this company because of change in ownership that occurred in March of 2025. She stated the previous company's employee training was not found in the payroll database. She stated prior to yesterday, she was not aware that the facility did not have employee training. During an interview on 12/17/2025 at 2:22 p.m., CNA E stated she had worked at the facility in the past and had just started back working in the facility on 11/06/2025. She stated she remembered getting some training through in-services but thought those happened prior to her re-hire. During an interview on 12/17/2025 at 2:38 p.m., the BO manager stated she had been in the position of the BO since the end of July 2025. She stated she had one day when she had a person sit next to her and train her and had attended several training meetings on the computer. She stated prior to being in the BO role, she had worked as the HK supervisor for the facility. She stated she had not been aware of orientation training requirements until now.During an interview on 12/18/2025 at 8:14 a.m., the RDO stated he expected all staff to have orientation with appropriate education on required topics including compliance and ethics to understand compliance and ethics. He stated he had worked for the company for two months and knew there was improvement to be made. He stated the organization operated more than 5 facilities. He stated the failure occurred due to change in ownership and change in management in both the DON and the ADMIN. He stated it was the ADMIN's job to make sure all training was implemented per regulations. He stated he was responsible for monitoring those trainings had occurred. During an interview on 12/18/2025 at 9:38 a.m., the AIT stated she had not received any orientation training on compliance and ethics.Record review of facility policy titled Orientation, with revision date of 1/02/2025, reflected 1. The facility has designated the Staff Development Coordinator, or designee, as the contact person for the facility's orientation program. This person works closely with each department head for scheduling orientation sessions and developing orientation plans. 2. Orientation plans are maintained by the Staff Development Coordinator. a. General orientation plans reflect the onboarding process for all newly hired employees, and reflect content that is applicable to all staff. b. Departmental orientation plans reflect the skills and competencies that each new employee will require to fulfill his or her job responsibilities. 3. General orientation must be completed prior to the employee's formal contact with facility residents. 4. Departmental orientation will continue until the employee has demonstrated competency in all the skills necessary for performing his/her job and to meet resident needs.10. When an employee changes roles or departments, he/she will go through a departmental orientation specific to that new role or department. 11. All documentation to support completion of the orientation process shall be maintained in the employee's personnel file.Record review of the staff list provided by the facility with no date reflected no staff member titled Staff Development Coordinator.The facility did not provide a policy that specifically required staff to be trained on compliance and ethics.

Based on interviews and record reviews, the facility failed to include as part of its infection prevention and control program mandatory training that includes the written standards, policies, and procedures for the program for all new and existing staff for 8 of 15 (the AIT, the SW, the DM, the DOR, RN A, LVN D, CNA E, and HK H) staff reviewed for training on infection control. The facility failed to ensure the AIT, the SW, the DM, the DOR, RN A, LVN D, CNA E, and HK H were educated on infection control upon hire. This failure could place residents at risk of contracting facility acquired infections from staff not being informed on proper infection prevention and control practices when performing resident care activities that pertain to that staff member's role.Findings includedRecord review of personnel record for the AIT reflected a hire date of 10/17/2025. Further review of personnel record provided by the BO reflected the AIT had no evidence she had completed infection control training upon hire or while working at the facility.Record review of personnel record for the SW reflected a hire date of 3/01/2025. Further review of personnel record provided by the BO reflected the SW had no evidence he had completed infection control training upon hire or while working at the facility.Record review of personnel record for the DM reflected a hire date of 11/19/2025. Further review of personnel record provided by the BO reflected the DM had no evidence she had completed infection control training upon hire or while working at the facility. Record review of personnel record for the DOR reflected a hire date of 5/08/2025. Further review of personnel record provided by the BO reflected the DOR had no evidence she had completed infection control training upon hire or while working at the facility.Record review of personnel record for RN A reflected a hire date of 4/21/2025. Further review of personnel record provided by the BO reflected RN A had no evidence she had completed infection control training upon hire or while working at the facility.Record review of personnel record for LVN D reflected a hire date of 8/01/2025. Further review of personnel record provided by the BO reflected LVN D had no evidence she had completed infection control training upon hire or while working at the facility.Record review of personnel record for CNA E reflected a hire date of 11/06/2025. Further review of personnel record provided by the BO reflected CNA E had no evidence she had completed infection control training upon hire or while working at the facility.Record review of personnel record for HK H reflected a hire date of 11/24/2025. Further review of personnel record provided by the BO reflected HK H had no evidence she had completed infection control training upon hire or while working at the facility.During an interview on 12/17/2025 at 1:10 p.m., the AIT stated her expectation would be for staff to have appropriate training during orientation and annual per regulation. She stated there had been a changeover in BO managers that occurred approximately two months ago. She stated the BO manager now was hired from her position as housekeeper with the understanding that corporate BO manager would train her. She stated she was told by the BO manager that her job duty training did not occur. The AIT stated she could not reach out to the corporate BO manager because she quit working for the company yesterday. She stated the corporate BO manager was also supposed to load the employee training into the payroll database for this company because of change in ownership that occurred in March of 2025. She stated the previous company's employee training was not found in the payroll database. She stated prior to yesterday, she was not aware that the facility did not have employee training. During an interview on 12/17/2025 at 2:22 p.m., CNA E stated she had worked at the facility in the past and had just started back working in the facility on 11/06/2025. She stated she remembered getting some training through in-services but thought those happened prior to her re-hire.During an interview on 12/17/2025 at 2:38 p.m., the BO manager stated she had been in the position of the BO since the end of July 2025. She stated she had one day when she had a person sit next to her and train her and had attended several training meetings on the computer. She stated prior to being in the BO role, she had worked as the HK supervisor for the facility. She stated she had not been aware of orientation training requirements until now.During an interview on 12/18/2025 at 8:14 a.m., the RDO stated he expected all staff to have orientation with appropriate education on required topics including infection control to understand how to prevent infections. He stated he had worked for the company for two months and knew there was improvement to be made. He stated the failure occurred due to change in ownership and change in management in both the DON and the ADMIN. He stated it was the ADMIN's job to make sure all training was implemented per regulations. He stated he was responsible for monitoring those trainings had occurred. During an interview on 12/18/2025 at 9:38 a.m., the AIT stated she had not received any orientation training on infection control.Record review of facility policy titled Orientation, with revision date of 1/02/2025, reflected 1. The facility has designated the Staff Development Coordinator, or designee, as the contact person for the facility's orientation program. This person works closely with each department head for scheduling orientation sessions and developing orientation plans. 2. Orientation plans are maintained by the Staff Development Coordinator. a. General orientation plans reflect the onboarding process for all newly hired employees, and reflect content that is applicable to all staff. b. Departmental orientation plans reflect the skills and competencies that each new employee will require to fulfill his or her job responsibilities. 3. General orientation must be completed prior to the employee's formal contact with facility residents. 4. Departmental orientation will continue until the employee has demonstrated competency in all the skills necessary for performing his/her job and to meet resident needs.10. When an employee changes roles or departments, he/she will go through a departmental orientation specific to that new role or department. 11. All documentation to support completion of the orientation process shall be maintained in the employee's personnel file.Record review of the staff list provided by the facility with no date reflected no staff member titled Staff Development Coordinator.The facility did not provide a policy that specifically required staff to be trained on infection control.

Based on interviews and record reviews, the facility failed to include as part of its QAPI program mandatory training that outlines and informs staff on the elements and goals of the facility QAPI program for all new and existing staff for 9 of 15 (the AIT, the SW, the AD, the DM, the DOR, RN A, LVN D, CNA E, and HK H) staff reviewed for training on QAPI. The facility failed to ensure that the AIT, the SW, the AD, the DM, the DOR, RN A, LVN D, CNA E, and HK H were educated on the facility's QAPI program upon hire. This failure could place residents at risk of their quality of care not being improved upon when a known issue had occurred from staff not being informed on the goals and various elements of the QAPI program. Findings includedRecord review of personnel record for the AIT reflected a hire date of 10/17/2025. Further review of personnel record provided by the BO reflected the AIT had no evidence she had completed QAPI training upon hire or while working at the facility.Record review of personnel record for the SW reflected a hire date of 3/01/2025. Further review of personnel record provided by the BO reflected the SW had no evidence he had completed QAPI training upon hire or while working at the facility.Record review of personnel record for the AD reflected a hire date of 9/29/2025. Further review of personnel record provided by the BO reflected the AD had no evidence she had completed QAPI training upon hire or while working at the facility. Record review of personnel record for the DM reflected a hire date of 11/19/2025. Further review of personnel record provided by the BO reflected the DM had no evidence she had completed QAPI training upon hire or while working at the facility. Record review of personnel record for the DOR reflected a hire date of 5/08/2025. Further review of personnel record provided by the BO reflected the DOR had no evidence she had completed QAPI training upon hire or while working at the facility.Record review of personnel record for RN A reflected a hire date of 4/21/2025. Further review of personnel record provided by the BO reflected RN A had no evidence she had completed QAPI training upon hire or while working at the facility.Record review of personnel record for LVN D reflected a hire date of 8/01/2025. Further review of personnel record provided by the BO reflected LVN D had no evidence she had completed QAPI training upon hire or while working at the facility.Record review of personnel record for CNA E reflected a hire date of 11/06/2025. Further review of personnel record provided by the BO reflected CNA E had no evidence she had completed QAPI training upon hire or while working at the facility.Record review of personnel record for HK H reflected a hire date of 11/24/2025. Further review of personnel record provided by the BO reflected HK H had no evidence she had completed QAPI training upon hire or while working at the facility.During an interview on 12/17/2025 at 1:10 p.m., the AIT stated her expectation would be for staff to have appropriate training during orientation and annual per regulation. She stated there had been a changeover in BO managers that occurred approximately two months ago. She stated the BO manager now was hired from her position as housekeeper with the understanding that corporate BO manager would train her. She stated she was told by the BO manager that her job duty training did not occur. The AIT stated she could not reach out to the corporate BO manager because she quit working for the company yesterday. She stated the corporate BO manager was also supposed to load the employee training into the payroll database for this company because of change in ownership that occurred in March of 2025. She stated the previous company's employee training was not found in the payroll database. She stated prior to yesterday, she was not aware that the facility did not have employee training. During an interview on 12/17/2025 at 2:22 p.m., CNA E stated she had worked at the facility in the past and had just started back working in the facility on 11/06/2025. She stated she remembered getting some training through in-services but thought those happened prior to her re-hire. She stated she thought that she had training on resident rights prior to her re-hire.During an interview on 12/17/2025 at 2:38 p.m., the BO manager stated she had been in the position of the BO since the end of July 2025. She stated she had one day when she had a person sit next to her and train her and had attended several training meetings on the computer. She stated prior to being in the BO role, she had worked as the HK supervisor for the facility. She stated she had not been aware of orientation training requirements until now.During an interview on 12/18/2025 at 8:14 a.m., the RDO stated he expected all staff to have orientation with appropriate education on required topics including the QAPI program to understand the QAPI process. He stated he had worked for the company for two months and knew there was improvement to be made. He stated the failure occurred due to change in ownership and change in management in both the DON and the ADMIN. He stated it was the ADMIN's job to make sure all training was implemented per regulations. He stated he was responsible for monitoring those trainings had occurred. During an interview on 12/18/2025 at 9:38 a.m., the AIT stated she had not received any orientation training on the QAPI program.Record review of facility policy titled Orientation, with revision date of 1/02/2025, reflected 1. The facility has designated the Staff Development Coordinator, or designee, as the contact person for the facility's orientation program. This person works closely with each department head for scheduling orientation sessions and developing orientation plans. 2. Orientation plans are maintained by the Staff Development Coordinator. a. General orientation plans reflect the onboarding process for all newly hired employees, and reflect content that is applicable to all staff. b. Departmental orientation plans reflect the skills and competencies that each new employee will require to fulfill his or her job responsibilities. 3. General orientation must be completed prior to the employee's formal contact with facility residents. 4. Departmental orientation will continue until the employee has demonstrated competency in all the skills necessary for performing his/her job and to meet resident needs.10. When an employee changes roles or departments, he/she will go through a departmental orientation specific to that new role or department. 11. All documentation to support completion of the orientation process shall be maintained in the employee's personnel file.Record review of the staff list provided by the facility with no date reflected no staff member titled Staff Development Coordinator.The facility did not provide a policy that specifically required staff to be trained on QAPI.

Based on interviews and record reviews, the facility failed to provide training to their staff that at a minimum educates staff on (1) activities that constitute ANE and misappropriation of resident property: (2) procedures for reporting incidents of ANE or misappropriation of resident property; (3) dementia management and resident abuse prevention for all new and existing staff for 9 of 15 (the AIT, the SW, the AD, the DM, the DOR, RN A, LVN D, CNA E, and HK H) staff reviewed for training on abuse, neglect, and exploitation and training for dementia management. The facility failed to ensure the AIT, the SW, the AD, the DM, the DOR, RN A, LVN D, CNA E, and HK H were educated on abuse, neglect and exploitation & dementia management upon hire. These failures could place residents at risk of being abused, neglected, or exploited by uninformed staff and could delay the facility's investigation of abuse, neglect, or exploitation. Findings includedRecord review of personnel record for the AIT reflected a hire date of 10/17/2025. Further review of personnel record provided by the BO reflected the AIT had no evidence she had completed either the abuse, neglect, and exploitation training or the dementia management training upon hire or while working at the facility.Record review of personnel record for the SW reflected a hire date of 3/01/2025. Further review of personnel record provided by the BO reflected the SW had no evidence he had completed either the abuse, neglect and exploitation training or the dementia management training upon hire or while working at the facility.Record review of personnel record for the AD reflected a hire date of 9/29/2025. Further review of personnel record provided by the BO reflected the AD had no evidence she had completed either the abuse, neglect and exploitation training or the dementia management training upon hire or while working at the facility.Record review of personnel record for the DM reflected a hire date of 11/19/2025. Further review of personnel record provided by the BO reflected the DM had no evidence she had completed either the abuse, neglect and exploitation training or the dementia management training upon hire or while working at the facility.Record review of personnel record for the DOR reflected a hire date of 5/08/2025. Further review of personnel record provided by the BO reflected the DOR had no evidence she had completed either the abuse, neglect, and exploitation training or the dementia management training upon hire or while working at the facility. Record review of personnel record for RN A reflected a hire date of 4/21/2025. Further review of personnel record provided by the BO reflected RN A had no evidence she had completed either the abuse, neglect and exploitation training or the dementia management training upon hire or while working at the facility.Record review of personnel record for LVN D reflected a hire date of 8/01/2025. Further review of personnel record provided by the BO reflected LVN D had no evidence she had completed either the abuse, neglect and exploitation training or the dementia management training upon hire or while working at the facility.Record review of personnel record for CNA E reflected a hire date of 11/06/2025. Further review of personnel record provided by the BO reflected CNA E had no evidence she had completed either the abuse, neglect and exploitation training or the dementia management training upon hire or while working at the facility.Record review of personnel record for HK H reflected a hire date of 11/24/2025. Further review of personnel record provided by the BO reflected HK H had no evidence she had completed either the abuse, neglect and exploitation training or the dementia management training upon hire or while working at the facility During an interview on 12/17/2025 at 1:10 p.m., the AIT stated her expectation would be for staff to have appropriate training during orientation and annual per regulation. She stated there had been a changeover in BO managers that occurred approximately two months ago. She stated the BO manager now was hired from her position as housekeeper with the understanding that corporate BO manager would train her. She stated she was told by the BO manager that her job duty training did not occur. The AIT stated she could not reach out to the corporate BO manager because she quit working for the company yesterday. She stated the corporate BO manager was also supposed to load the employee training into the payroll database for this company because of change in ownership that occurred in March of 2025. She stated the previous company's employee training was not found in the payroll database. She stated prior to yesterday, she was not aware that the facility did not have employee training. During an interview on 12/17/2025 at 2:22 p.m., CNA E stated she had worked at the facility in the past and had just started back working in the facility on 11/06/2025. She stated she remembered getting some training through in-services but thought those happened prior to her re-hire. She stated she thought that she had training on abuse, neglect, and exploitation prior to her re-hire.During an interview on 12/17/2025 at 2:38 p.m., the BO manager stated she had been in the position of the BO since the end of July 2025. She stated she had one day when she had a person sit next to her and train her and had attended several training meetings on the computer. She stated prior to being in the BO role, she had worked as the HK supervisor for the facility. She stated she had not been aware of orientation training requirements until now.During an interview on 12/18/2025 at 8:14 a.m., the RDO stated he expected all staff to have orientation with appropriate education on required topics including abuse, neglect, and exploitation to ensure employees knew what those were and how to protect residents from them. He stated dementia management was important to help staff understand how to care for residents diagnosed with dementia. He stated he had worked for the company for two months and knew there was improvement to be made. He stated the failure occurred due to change in ownership and change in management in both the DON and the ADMIN. He stated it was the ADMIN's job to make sure all training was implemented per regulations. He stated he was responsible for monitoring those trainings had occurred. During an interview on 12/18/2025 at 9:38 a.m., the AIT stated she had not received any orientation training on abuse, neglect, and exploitation. She stated she did not get orientation on dementia management. She stated she had been trained on these topics from a previous employer.Record review of facility policy titled Orientation, with revision date of 1/02/2025, reflected 1. The facility has designated the Staff Development Coordinator, or designee, as the contact person for the facility's orientation program. This person works closely with each department head for scheduling orientation sessions and developing orientation plans. 2. Orientation plans are maintained by the Staff Development Coordinator. a. General orientation plans reflect the onboarding process for all newly hired employees, and reflect content that is applicable to all staff. b. Departmental orientation plans reflect the skills and competencies that each new employee will require to fulfill his or her job responsibilities. 3. General orientation must be completed prior to the employee's formal contact with facility residents. 4. Departmental orientation will continue until the employee has demonstrated competency in all the skills necessary for performing his/her job and to meet resident needs.10. When an employee changes roles or departments, he/she will go through a departmental orientation specific to that new role or department. 11. All documentation to support completion of the orientation process shall be maintained in the employee's personnel file.Record review of the staff list provided by the facility with no date reflected no staff member titled Staff Development Coordinator.The facility did not provide a policy that specifically required staff to be trained on abuse, neglect, and exploitation and training for dementia management.

Based on interview and record review, within 14 days after a facility completes a resident's assessment, the facility failed to electronically transmit encoded, accurate, and complete MDS data to the CMS System for 14 (Residents #1, #4, #5, #7, #10, #11, #13, #14, #16, #19, #20, #21, #23, and #24) of 24 reviewed for resident assessments, in that: 1. Resident #1's admission MDS assessment, dated 03/11/2025 and Quarterly MDS's, dated 05/29/2025, 08/26/2025,09/11/2025, and 11/10/2025 were completed but not transmitted to CMS as of 12/18/2025. 2. Resident #4's admission MDS, dated [DATE] and Quarterly MDS's, dated 05/29/2025, 08/26/2025,09/11/2025, and 11/10/2025 were completed but not transmitted to CMS as of 12/18/2025. 3. Resident #5's Entry MDS, dated [DATE], admission MDS dated [DATE] and Quarterly MDS's, dated 06/02/2025, 08/25/2025, and 11/24/2025 were completed but not transmitted to CMS as of 12/18/2025. 4. Resident #7's Entry MDS, dated [DATE], admission MDS dated [DATE], and Quarterly MDS's, dated 05/30/2025, 08/19/2025, and 09/08/2025 were completed but not transmitted to CMS as of 12/18/2025. 5. Resident #10's admission MDS, dated [DATE] and Quarterly MDS's, dated 05/29/2025, 08/22/2025, 12/10/2025 and Discharge Return Anticipated dated 09/07/2025 were completed but not transmitted to CMS as of 12/18/2025. 6. Resident #11's Entry MDS, dated [DATE], Admission/Medicare - 5-Day MDS dated [DATE] and Quarterly MDS's, dated 07/25/2025, 07/31/2025, and 10/28/2025 were completed but not transmitted to CMS as of 12/18/2025. 7. Resident #13's Entry MDS, dated [DATE], admission MDS dated [DATE] and Quarterly MDS dated [DATE] were completed but not transmitted to CMS as of 12/18/2025. 8. Resident #14's Entry MDS dated [DATE] and admission MDS, dated [DATE], were completed but not transmitted to CMS as of 12/18/2025. 9. Resident #16's Entry MDS's dated 08/02/2025 and 10/20/2025, admission MDS, dated [DATE], Discharge Return Anticipated dated 10/13/2025 and Significant Change MDS dated [DATE] were completed but not transmitted to CMS as of 12/18/2025. 10. Resident #19's Quarterly MDS's dated 05/28/2025 and 09/20/2025, and Significant Change MDS dated [DATE] were completed but not transmitted to CMS as of 12/18/2025. 11. Resident #20's Entry MDS dated [DATE], admission MDS, dated [DATE] and Quarterly MDS's, dated 06/03/2025, 08/15/2025, and 11/14/2025 were completed but not transmitted to CMS as of 12/18/2025. 12. Resident #21's Entry MDS dated [DATE], admission MDS, dated [DATE] and Quarterly MDS's, dated 05/26/2025, 08/25/2025, and 11/12/2025 were completed but not transmitted to CMS as of 12/18/2025. 13. Resident #23's Entry MDS dated [DATE], admission MDS, dated [DATE] and Quarterly MDS's, dated 08/26/2025, and 12/03/2025 were completed but not transmitted to CMS as of 12/18/2025. 14. Resident #24's Entry MDS dated [DATE], admission MDS, dated [DATE] and Quarterly MDS's, dated 04/11/2025, 07/11/2025, and 10/11/2025 were completed but not transmitted to CMS as of 12/18/2025. These failures could place residents at risk of not having their assessments completed timely, which could result in denial of services and or denial of payment for services.The findings were: 1. Record review of Resident #1's face sheet revealed a [AGE] year-old male admitted to the facility on [DATE] with medical diagnoses including Alzheimer's disease, non-insulin dependent diabetes. History of falls, obesity, schizoaffective disorder (a combination of symptoms of schizophrenia and a major mood disorder), major depressive disorder, anxiety, insomnia, high blood pressure, heartburn, difficulty swallowing, stroke, and high cholesterol. Review of Resident #1's MDS assessments list revealed his admission MDS dated [DATE] and Quarterly MDS's, dated 05/29/2025, 08/26/2025,09/11/2025, and 11/10/2025 had been completed but not transmitted to CMS with a status of export ready. 2. Record review of Resident #4's face sheet revealed a [AGE] year-old male admitted to the facility on [DATE] with medical diagnoses including chronic obstructive pulmonary disease (a progressive lung condition), weakness, anxiety, mood disorder, schizoaffective disorder, heartburn, low back pain, arthritis, difficulty walking, dementia, and need for assistance with personal care.Review of Resident #4's MDS assessments list revealed his admission MDS, dated [DATE] and Quarterly MDS's, dated 05/29/2025, 08/26/2025,09/11/2025, and 11/10/2025 had been completed but not transmitted to CMS with a status of export ready.3. Record review of Resident #5's face sheet, dated 05/16/2025, revealed a [AGE] year-old female admitted to the facility on [DATE] with medical diagnoses including epilepsy, intellectual disabilities, malnutrition, depression, anxiety, schizoaffective disorder, obsessive-compulsive disorder, pain, heartburn, multiple contractures (a permanent tightening and stiffening of tissues that cause restriction of movement or deformity in joints), tremors, difficulty walking, and difficulty with speech.Review of Resident #5's MDS assessments list revealed her Entry MDS, dated [DATE], admission MDS dated [DATE] and Quarterly MDS's, dated 06/02/2025, 08/25/2025, and 11/24/2025 had been completed but not transmitted to CMS with a status of export ready.4. Record review of Resident #7's face sheet revealed an [AGE] year-old female admitted to the facility on [DATE] with medical diagnoses including weakness, dementia, epilepsy, low blood calcium, low blood potassium, anxiety, insomnia, stroke, difficulty with speech, pain, amnesia, nausea with vomiting, and urgency of urination.Review of Resident #7's MDS assessments list revealed her Entry MDS, dated [DATE], admission MDS dated [DATE], and Quarterly MDS's, dated 05/30/2025, 08/19/2025, and 09/08/2025 had been completed but not transmitted to CMS with a status of export ready.5. Record review of Resident #10's face sheet revealed an [AGE] year-old male initially admitted to the facility on [DATE] and re-admitted on [DATE] with medical diagnoses including Alzheimer's disease, atrial fibrillation (irregular heart rhythm), chronic obstructive pulmonary disease, weakness, difficulty walking, low heart rate, Parkinson's disease, depression, epilepsy, chronic pain, heartburn, tremor, and abdominal aortic aneurysm (a weakened or building swelling of the aorta, the main artery in the body located in the abdominal cavity). Review of Resident #10's MDS assessments list revealed his admission MDS dated [DATE] and Quarterly MDS's dated 05/29/2025, 08/22/2025, 12/10/2025 and Discharge Return Anticipated dated 09/07/2025 had been completed but not transmitted to CMS with a status of export ready.6. Record review of Resident #11's face sheet revealed an [AGE] year-old female admitted to the facility on [DATE] with medical diagnoses including difficulty walking, high blood pressure, heartburn, weakness, constipation, and pneumonia.Review of Resident #11's MDS assessments list revealed her Entry MDS, dated [DATE], Admission/Medicare - 5-Day MDS dated [DATE] and Quarterly MDS's, dated 07/25/2025, 07/31/2025, and 10/28/2025 had been completed but not transmitted to CMS with a status of export ready.7. Record review of Resident #13's face sheet revealed a [AGE] year-old female admitted to the facility on [DATE] with medical diagnoses including heart failure, difficulty walking, overactive bladder, weakness, high cholesterol, anxiety, high blood pressure, mitral valve disorder, rheumatoid arthritis (an autoimmune disease that attacks the joints), gout (inflammatory arthritis), systemic lupus erythematosus (an autoimmune disease that causes inflammation and damage to joints, skin, kidney, brain, and other tissues), and chronic kidney disease. Review of Resident #13's MDS assessments list revealed her Entry MDS, dated [DATE], admission MDS dated [DATE] and Quarterly MDS dated [DATE] had been completed but not transmitted to CMS with a status of export ready.8. Record review of Resident #14's face sheet revealed a [AGE] year-old female admitted to the facility on [DATE] with medical diagnoses including panic disorder, chronic pain, opioid dependence, depression, and low back pain.Review of Resident #14's MDS assessments list revealed her Entry MDS dated [DATE] and admission MDS, dated [DATE] had been completed but not transmitted to CMS with a status of export ready.9. Record review of Resident #16's face sheet revealed a [AGE] year-old female initially admitted to the facility on [DATE] and re-admitted on [DATE] with medical diagnoses including osteomyelitis (a bone infection), difficulty walking, insomnia, heartburn, weakness, methicillin resistant staphylococcus aureus infection (an infection resistant to multiple antibiotics), constipation, obstructive and reflux uropathy (disease of the urinary tract), high blood pressure, and foot ulcer.Review of Resident #16's MDS assessments list revealed her Entry MDS's dated 08/02/2025 and 10/20/2025, admission MDS, dated [DATE], Discharge Return Anticipated dated 10/13/2025 and Significant Change MDS dated [DATE] had been completed but not transmitted to CMS with a status of export ready.10. Record review of Resident #19's face sheet revealed a [AGE] year-old female admitted to the facility on [DATE] with medical diagnoses including dementia, heart failure, shoulder pain, high cholesterol, edema (swelling), low blood potassium, difficulty walking, and constipation.Review of Resident #19's MDS assessments list revealed her Quarterly MDS's dated 05/28/2025 and 09/20/2025, and Significant Change MDS dated [DATE] had been completed but not transmitted to CMS with a status of export ready.11. Record review of Resident #20's face sheet revealed a [AGE] year-old female admitted to the facility on [DATE] with medical diagnoses including Alzheimer's disease, high blood pressure, weakness, edema, low blood potassium, insomnia, constipation, knee pain, anxiety, slow heart rate, and history of falls.Review of Resident #20's MDS assessments list revealed her Entry MDS dated [DATE], admission MDS, dated [DATE] and Quarterly MDS's, dated 06/03/2025, 08/15/2025, and 11/14/2025 had been completed but not transmitted to CMS with a status of export ready.12. Record review of Resident #21's face sheet revealed an [AGE] year-old female admitted to the facility on [DATE] with medical diagnoses including Alzheimer's disease, weakness, repeated falls, malnutrition, low blood potassium, dementia, delusional disorder, schizoaffective disorder, major depressive disorder, transient cerebral ischemic attacks (temporary blockage of blood flow in the brain, mini stroke), high blood pressure, heart disease, contracture, myalgia (muscle pain), difficulty swallowing, edema, and abnormal posture. Review of Resident #21's MDS assessments list revealed her Entry MDS dated [DATE], admission MDS, dated [DATE] and Quarterly MDS's, dated 05/26/2025, 08/25/2025, and 11/12/202 had been completed but not transmitted to CMS with a status of export ready.13. Record review of Resident #23's face sheet revealed an [AGE] year-old female admitted to the facility on [DATE] with medical diagnoses including neurocognitive disorder with Lewy bodies (abnormal clumps of protein that forms in the brain), fracture of her left upper arm, weakness, diarrhea, high cholesterol, depression, atrial fibrillation, and fibromyalgia (widespread body pain).Review of Resident #23's MDS assessments list revealed her Entry MDS dated [DATE], admission MDS, dated [DATE] and Quarterly MDS's, dated 08/26/2025, and 12/03/2025 had been completed but not transmitted to CMS with a status of export ready.14. Record review of Resident #24's face sheet revealed a [AGE] year-old female admitted to the facility on [DATE] with medical diagnoses including Alzheimer's disease, atrial fibrillation, gout, heartburn, high blood pressure, weakness, anemia, low blood potassium, major depressive disorder, panic disorder, insomnia, sleep apnea, and shortness of breath, .Review of Resident #24's MDS assessments list revealed her Entry MDS dated [DATE], admission MDS, dated [DATE] and Quarterly MDS's, dated 04/11/2025, 07/11/2025, and 10/11/2025 had been completed but not transmitted to CMS with a status of export ready.During an interview on 12/18/2025 at 8:10 a.m., the RCN stated the reason the MDS's had not been transmitted was due a change of ownership in progress. He stated the facility was waiting for a new number to be assigned before transmission would be possible. RNC provided the name and contact information for the person at corporate that was responsible for monitoring the MDS's. During an interview on 12/18/2025 at 09:56 a.m., the corporate DOMDS stated she was responsible for oversight of MDS completion for 8 facilities. She stated the delay in transmitting MDS's for the facility was due to waiting for a new contract number and was almost there in receiving the number. She explained the process of transmitting was to upload the completed MDS into an online program which then transmitted the data to CMS. She stated without the contract number the system would not recognize the transmittal. She stated CMS was familiar' with the process therefore she anticipated no penalties will be levied by CMS. The DOMDS stated the ADON at the facility was responsible for completing the MDS and preparing for transmission. She stated all MDS's for the facility were completed on time. The DOMDS was unable to state any adverse effect failure to transmit the MDS's may have on the residents. During an interview on 12/18/2025 at 11:22 a.m., the ADON stated her understanding of the reason for the delay in transmitting was because corporate was waiting for notification that the new provider number had been assigned. She stated when corporate received the number, she would be able to transmit the MDS's. The ADON was unable to state an adverse effect on residents from failing to transmit the MDS's.During an interview on 12/18/2025 at 11:20 a.m., the AIT stated the reason the MDS's had not been transmitted was because the change of ownership was not complete until about a week ago. She stated the ADON was not able to transmit completed MDS's during the change. Record review of the facility's policy, MDS Completion and Submission Timeframes, dated 2001, revealed, Our facility will conduct and submit resident assessments in accordance with the current federal and state submission timeframes.

Based on interviews and record reviews, the facility failed to complete a performance review of each CNA at least once every 12 months, for 2 of 3 (CNA F & CNA G) reviewed for nursing services.The facility failed to complete annual CNA competency evaluations for CNA F and CNA G, based on the personnel file review results.This failure could affect residents by placing them at risk of not receiving consistent, appropriate interventions necessary to meet the residents' needs.Findings includedRecord review of the Personnel File Review completed on 12/18/2025, reflected CNA F was hired on 1/09/2023. Further review reflected CNA F did not have a competency evaluation on file. Record review of the Personnel File Review completed on 12/18/2025, reflected CNA G was hired on 8/10/2017. Further review reflected CNA F did not have a competency evaluation on file.During an interview on 12/17/2025 at 2:38 p.m., the BO manager stated she did not have any annual competencies on record for CNA F and CNA G.During an investigation on 12/18/2025 at 9:20 a.m., the RCN stated he would not know where the CNA competencies would be filed if not in CNA F and CNA G's employee files. He stated he was going through the DON's office to look to see if there was any documentation of those somewhere else. He stated CNAs should have training and competency checkoffs per regulation. He stated he had not been working for the company for long, but that would be the DON's responsibility. He stated that he had reached out to the previous DON to see if she would respond on where training and competencies may be if not in their employee files. He stated that CNAs should have training and competencies, and he would monitor that the DON was providing those per requirements. He stated the facility did not have a DON at that time and was actively attempting to hire one. Record review of the Facility Assessment Tool, dated 6/12/2025, reflected Staff training/education and competencies: Annual education, education upon hire and competencies are developed for all staff based on their job title.

Based on interview and record review, the facility failed to collaborate with hospice representatives and coordinate the hospice care planning process for each resident receiving hospice services, to ensure quality of care for the resident, ensuring communication with the hospice medical director, the resident's attending physician and others participating in the provision of care for 5 (Resident #9, Resident #10, Resident #19, Resident #20, and Resident #23) of 5 residents reviewed for hospice services. 1. The facility failed to maintain the required hospice forms and documentation, that included the Hospice Election Form, for Resident #10, Resident #19, and Resident #20 Resident #23 were. 2. The facility failed to have a communication process, including how the communication will be documented between the facility and the hospice provider, for Resident #9, Resident #10, Resident #19, Resident #20, and Resident #23. 3. The facility failed to ensure a staff member was designated to communicate with hospice agencies. This failure could place the residents who receive hospice services at-risk of receiving inadequate end-of-life care due to a lack of documentation, coordination of care, and communication of resident needs. The findings included: Resident #9 Review of Resident #9's electronic face sheet accessed on 12/18/2025, revealed a [AGE] year-old female admitted to the facility on [DATE] with diagnoses to include: depression, anxiety, and pain. Review of Resident #9's Quarterly MDS assessment dated [DATE], revealed a BIMS score of 03 which indicated severe cognitive impairment. Review of Section O revealed Resident #9 was on hospice care. Review of Resident #9's Comprehensive Care Plan last revised 10/23/2025, revealed: The resident has a termina prognosis related too being admitted to hospice. Review of Resident #9's electronic Physicians Orders revealed: Admit to hospice services for diagnosis of severe protein-calorie malnutrition, dated 11/28/2025. Review of Resident #9's clinical records revealed no evidence of communication between the facility and the hospice provider for Resident #9. Resident #10 Review of Resident #10's electronic face sheet accessed on 12/18/2025, revealed an [AGE] year-old male readmitted to the facility on [DATE] with diagnoses to include: Alzheimer's disease, fracture of vertebra, adjustment disorder. Review of Resident #10's Quarterly MDS dated [DATE], revealed a BIMS score of 06 which indicated severe cognitive impairment. Review of Section O: revealed Resident #10 was on hospice care. Review of Resident #10's Comprehensive Care Plan last revised 12/15/2025, revealed no evidence of Resident #10 being on hospice services and no evidence of code status. Review of Resident #10's electronic Physicians Orders revealed: Admit to hospice services, dated 09/11/2025. Review of Resident #10's clinical records revealed no evidence of the required hospice forms and documentation, that included the Hospice Election Form or any form of communication between the facility and the hospice provider for Resident #10. Resident #19 Review of Resident #19's electronic face sheet accessed on 12/18/2025, revealed a [AGE] year-old female admitted to the facility on [DATE] with diagnoses to include: Alzheimer's disease, mild protein-calorie malnutrition, and heart surgery. Review of Resident #19's Quarterly MDS dated [DATE], revealed no BIMS score completed. Review of Section O: revealed Resident #19 was on hospice care. Review of Resident #19's Comprehensive Care Plan last revised 06/23/2025, revealed: The resident has a terminal prognosis and has been admitted to hospice services for Alzheimer's disease. Review of Resident #19's electronic Physicians Orders revealed: Admit to hospice services for diagnosis of Alzheimer's disease, dated 06/19/2025. Review of Resident #19's clinical records revealed no evidence of the required hospice forms and documentation, that included the Hospice Election Form or any form of communication between the facility and the hospice provider for Resident #19. Resident #20 Review of Resident #20's electronic face sheet accessed on 12/18/2025, revealed a [AGE] year-old female admitted to the facility on [DATE] with diagnoses to include: Alzheimer's disease, mild protein-calorie malnutrition, and heart failure. Review of Resident #20's Quarterly MDS dated [DATE], revealed a BIMS score of 02 which indicated severe cognitive impairment. Review of Section O: revealed Resident #20 was on hospice care. Review of Resident #20's Comprehensive Care Plan last revised 04/21/2025, revealed: Focus: The resident has a terminal prognosis related to Alzheimer's disease. Interventions: consult with physician and social services to have hospice care for resident in the facility. Review of Resident #20's electronic Physicians Orders revealed: Admit to hospice services for diagnosis of Alzheimer's disease, dated 03/07/2025. Review of Resident #20's clinical records revealed no evidence of the required hospice forms and documentation, that included the Hospice Election Form or any form of communication between the facility and the hospice provider for Resident #20. Resident #23 Review of Resident #23's electronic face sheet accessed on 12/18/2025, revealed an [AGE] year-old female admitted to the facility on [DATE] with diagnoses to include: fracture of arm, depression, and disorders of bone and structure. Review of Resident #23's Quarterly MDS dated [DATE], revealed a BIMS score of 07 which indicated severe cognitive impairment. Review of Section O: revealed Resident #20 was on hospice care. Review of Resident #23's Comprehensive Care Plan last revised 06/23/2025, revealed: Focus: The resident has a terminal prognosis and is on hospice services for end stage dementia. Review of Resident #23's electronic Physicians Orders revealed: Admit to hospice services for diagnosis of dementia, dated 05/29/2025. Review of Resident #23's clinical records revealed no evidence of the required hospice forms and documentation, that included the Hospice Election Form or any form of communication between the facility and the hospice provider for Resident #23. During an interview on 12/18/2025 at 12:53 PM, the Administrator stated that there was no designated facility staff member to work with and communicate with hospice. She stated that communication was just done verbally with the charge nurses. She stated there was no documented communication. She stated that she was not aware that was a regulation. She stated that the DON was responsible for ensuring that all hospice documents were in the facility but since there currently was no DON it would be the ADON. Review of facility's policy titled, Hospice Program, revised July 2017, revealed in part: Policy Statement: Hospice services are available to residents at the end of life. Policy Interpretation and Implementation . 10. In general, it is the responsibility of the facility to meet the resident's personal care and nursing needs in coordination with the hospice representative and ensure that the level of care provided is appropriately based on the individual residents' needs. These responsibilities include the following .d. Communicating with the hospice provider (and documenting such communication) to ensure that the needs of the resident are addressed and met 24 hours per day .12. Our facility is responsible for a. Collaborating with hospice representatives and coordinating facility staff participation in the hospice care planning process. B. Communicating with hospice representatives and other healthcare providers participating on the provision of care .d. Obtaining the following information from the hospice . 3.) Physician certification of the terminal illness specific to each resident.

Based on observations, interviews, and record reviews, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 2 of 2 (CNA-E and CNA-I) staff observed during incontinent care, and the storage of ice scoop for 1 of 1 ice chest reviewed for infection control. 1. The facility failed to ensure CNA E and CNA I performed appropriate hand hygiene during peri-care for Resident #24. 2. The facility failed to ensure the ice scoop for the ice chest was stored outside of the ice chest. These failures placed residents of the facility at risk of infection spread from cross contamination of ice in ice chest and improper hand hygiene. Findings includedRecord Review of the Resident #24's electronic face sheet, dated 12/18/2025, revealed she was a [AGE] year-old female admitted on [DATE] with diagnoses including Alzheimer's disease a progressive brain disorder that slowly destroys memory and thinking skills, eventually making it difficult to perform simple tasks. Record review of Resident #24's quarterly MDS assessment dated [DATE] reflected a BIMS score of 5 indicating severe cognitive impairment. Further review of the MDS reflected that she was dependent on staff for toileting hygiene, and Resident #24 always had bowel and bladder incontinence.Record review of Resident #24's comprehensive care plan accessed on 12/18/2025 reflected she had self-care performance deficit related to confusion and needed extensive assistance by staff for toileting initiated on 5/14/2025. Further review of the comprehensive care plan reflected she had a urinary tract infection (bladder infection) and antibiotic therapy was ordered with intervention to include caregiver teaching should include good hygiene practices initiated on 11/17/2025.During an observation and interview on 12/16/2025 at 10:59 a.m., the ice chest sitting in front of the nurses' station with the lid closed had the ice scoop sitting inside of the chest in the ice. The ADON/IP was sitting behind the nurses' station and stated that it was the only ice chest for the whole facility. She stated the ice scoop should not be left inside of the chest. She stated she would get the ice dumped and refilled due to having the scoop inside which could cause infection from cross contamination. During an observation on 12/17/2025 at 9:02 a.m., CNA E and CNA I performed incontinent care on Resident #24. Both CNA E and CNA I placed the gloves on their hands after performing hand hygiene using soap and water. They positioned Resident #24 in the bed on a draw mat (mat that lays under a resident to help with positioning in bed). CNA E and CNA I both assisted Resident #24 with lowering her pants and removing them. Resident #24's brief was then folded back in between her legs after the tabs were unsecured on both sides by CNA E. CNA E asked Resident #24 to spread her legs so she could clean her skin, and Resident #24 clinched her legs together. CNA E then assisted Resident #24 to roll toward CNA I with CNA I's assistance, stating she would have to clean her once the brief was removed. CNA E removed the urine soiled brief from Resident #24 when she was positioned on her left side. Resident #24 was assisted back to her back by both CNA E and CNA I without cleaning her skin. Resident #24's skin was cleaned with disposable wipes by CNA E disposing of the wipes into a plastic bag after each use. CNA E wiped the right inner fold, the left inner fold, then down the labia. Resident #24 was then assisted onto her left side again by CNA E and CNA I and the back of her skin was cleaned with disposable wipes three times disposing of the wipes into a plastic bag after each use. CNA E then placed a clean brief under the resident's left side and on top of the soiled draw sheet. CNA E put some of the cream on her right hand and applied that to Resident #24's skin. CNA E removed the gloves from both her hands. After closing and sitting the multiuse skin protectant cream bottle on the bed, CNA E placed new gloves onto both her hands without performing hand hygiene. CNA E then helped CNA I reposition Resident #24 on her back. Both CNAs fastened the brief together after pulling the front through Resident #24's legs. Both CNAs removed their gloves and threw them away in the plastic bag with other trash. Both CNAs helped Resident #24 to cover up with her bed sheet and cover. CNA E then positioned the bed using the bed control and gave Resident #24 her call light. CNA I had stopped to help Resident #24's roommate find the sink and soap to wash her hands as the roommate was asking where she could wash her hands as she entered the room. CNA I grabbed a paper napkin to hand to Resident #24's roommate out of the dispenser next to the sink. Both CNAs washed their hands with soap and water before they left Resident #24's room.During an interview on 12/17/2025 at 9:15 a.m., both CNA E and CNA I stated they should have put a pad down over the draw mat if they were putting a resident's uncleaned skin after incontinence on it. They stated they should have washed hands after removal of their gloves and prior to touching other items in the room. They stated they were both nervous from being watched perform the task which led to them failing to perform hand hygiene when moving from a dirty task to a clean task. CNA E stated she should have taken her soiled gloves off and performed hand hygiene prior to reaching into the drawer and removing clean supplies. They stated not performing hand hygiene, removing gloves, and placing unclean skin on bedding could cause infection from contaminating clean surfaces. CNA E stated she had been trained by other CNAs when she started to work at the facility and had training during CNA certification on hand hygiene. CNA E stated she had just returned to working in the facility and did not remember getting infection prevention training when she was re-hired. CNA I stated she believed she was also trained by other CNAs during orientation, but that was over a year ago. She stated she wasn't sure but thought she had a skills checkoff after she had been working in the facility.During an interview on 12/17/2025 at 1:37 p.m., the ADON stated she was the IP of the facility. She stated the DON quit working for the facility back in September 9th or 10th of 2025. She stated the facility hired a new DON but she only worked for 3 days then left. The ADON stated the RCN had worked in the facility about 3 weeks ago and then again this week. She stated she could reach out to the RCN with any issues via the telephone when he was not onsite. She stated staff had not received any in-services since the DON quit in September. She stated she attempted to monitor that staff were following infection control prevention, but she had been working the floor and did not have time to monitor them lately. She stated her expectation would be for staff to not place resident's unclean skin on a clean draw mat without changing that draw mat out. She stated she expected for all staff to take off gloves and clean their hands prior to reaching into a drawer. She stated she expected for staff to perform hand hygiene after taking their gloves off prior to touching anything else. She stated the staff needed more education on infection control, and the DON had provided the training in the past. She stated not performing hand hygiene and other infection prevention during incontinent care could lead to residents getting an infection and could spread infection to other residents through cross contamination. Record review of the personnel file for CNA E reflected the facility had no evidence that she had been trained in infection control and her hire date was 11/06/2025.During an interview on 12/18/2025 at 9:20 a.m., the RCN stated he expected the ice scoop not to be stored in the ice chest. He stated he expected what was dirty to remain dirty and not be cross contaminated with a clean environment. He stated he would expect for staff to wash hands with soap and water or use ABHR when changing gloves. He stated staff should not have reached into a drawer with a gloved hand after using that hand to wipe incontinent substances. He stated he expected the draw mat to be changed from the bed if it came in contact with soiled skin during incontinent care. He stated all those failures could cause infection spread from cross contamination. He stated he had coached those CNAs prior to them providing incontinent care and did not feel the facility not being able to show required onboarding and annual training in infection control would have prevented staff from not following infection control. He stated he was told by CNA E and CNA I they were nervous and that led to the failure. He stated he was available to the staff by phone and in person but verified that he does not work at the facility for forty hours a week.Review of facility's policy titled Handwashing/Hand Hygiene, dated October 2023, reflected Hand hygiene is indicated: a. immediately before touching a resident; b. before performing an aseptic task; after contact with blood, body fluids, or contaminated surfaces; d. after toughing a resident; e. after touching the resident's environment; f. before moving from work on a soiled body site to a clean body site on the same resident; and g. immediately after glove removal.

Based on interviews and record reviews, the facility failed to develop, implement, and maintain an effective training program for all new and existing staff for 9 of 15 (the AIT, the SW, the AD, the DM, the DOR, RN A, LVN D, CNA E, and HK H) staff reviewed for training on HIV, restraint reduction and prevention of falls. The facility failed to implement and maintain a training program that ensured the AIT, the SW, the AD, the DM, the DOR, RN A, LVN D, CNA E, and HK H received required HIV training upon hire. The facility failed to implement and maintain a training program that ensured the AIT, the SW, the AD, the DM, the DOR, RN A, LVN D, CNA E, and HK H received required restraint reduction training upon hire.The facility failed to implement and maintain a training program that ensured the AIT, the SW, the AD, the DM, the DOR, RN A, LVN D, CNA E, and HK H received required prevention of falls training upon hire. These failures could place residents at risk of being cared for by staff who had been insufficiently trained on the mode of HIV transmission, HIV prevention, behaviors related to substance abuse, precautions, rights of an infected individual and behaviors associated with HIV transmission, reduction of restraint use, and prevention of falls. Findings includedRecord review of personnel record for the AIT reflected a hire date of 10/17/2025. Further review of personnel record provided by the BO reflected that the AIT had no evidence she had completed required orientation HIV training, restraint reduction training or fall prevention training.Record review of personnel record for the SW reflected a hire date of 3/01/2025. Further review of personnel record provided by the BO reflected the SW had no evidence he had completed required orientation HIV training, restraint reduction training or fall prevention training.Record review of personnel record for the AD reflected a hire date of 9/29/2025. Further review of personnel record provided by the BO reflected the AD had no evidence she had completed required orientation HIV training, restraint reduction training or fall prevention training.Record review of personnel record for the DM reflected a hire date of 11/19/2025. Further review of personnel record provided by the BO reflected the DM had no evidence she had completed required orientation HIV training, restraint reduction training or fall prevention training.Record review of personnel record for the DOR reflected a hire date of 5/08/2025. Further review of personnel record provided by the BO reflected that the DOR had no evidence she had completed required orientation HIV training, restraint reduction training or fall prevention training.Record review of personnel record for RN A reflected a hire date of 4/21/2025. Further review of personnel record provided by the BO reflected RN A had no evidence she had completed required orientation HIV training, restraint reduction training or fall prevention training.Record review of personnel record for LVN D reflected a hire date of 8/01/2025. Further review of personnel record provided by the BO reflected LVN D had no evidence she had completed required orientation HIV training, restraint reduction training or fall prevention training.Record review of personnel record for CNA E reflected a hire date of 11/06/2025. Further review of personnel record provided by the BO reflected CNA E had no evidence she had completed required orientation HIV training, restraint reduction training or fall prevention training.Record review of personnel record for HK H reflected a hire date of 11/24/2025. Further review of personnel record provided by the BO reflected HK H had no evidence she had completed required orientation HIV training, restraint reduction training or fall prevention training.During an interview on 12/17/2025 at 1:10 p.m., the AIT stated her expectation would be for staff to have appropriate training during orientation and annual per regulation. She stated there had been a changeover in BO managers that occurred approximately two months ago. She stated the BO manager now was hired from her position as housekeeper with the understanding that corporate BO manager would train her. She stated she was told by the BO manager that her job duty training did not occur. The AIT stated she could not reach out to the corporate BO manager because she quit working for the company yesterday. She stated the corporate BO manager was also supposed to load the employee training into the payroll database for this company because of change in ownership that occurred in March of 2025. She stated the previous company's employee training was not found in the payroll database. She stated prior to yesterday, she was not aware that the facility did not have employee trainings. During an interview on 12/17/2025 at 2:22 p.m., CNA E stated she had worked at the facility in the past and had just started back working in the facility on 11/06/2025. She stated she remembered getting some training through in-services but thought those happened prior to her re-hire. She stated she thought that she had training on HIV, fall prevention and restraint reduction prior to her re-hire.During an interview on 12/17/2025 at 2:38 p.m., the BO manager stated she had been in the position of the BO since the end of July 2025. She stated she had one day when she had a person sit next to her and train her and had attended several training on the computer. She stated prior to being in the BO role, she had worked as the HK supervisor for the facility. She stated she had not been aware of orientation training requirements until now.During an interview on 12/18/2025 at 8:14 a.m., the RDO stated he expected all staff to have orientation with appropriate education on required topics including HIV to understand the disease and how to prevent spread, restraint reduction training to understand how to reduce restraint use, and prevention of falls to understand how to prevent falls. He stated he had worked for the company for two months and knew there was improvement to be made. He stated the failure occurred due to change in ownership and change in management in both the DON and the ADMIN. He stated it was the ADMIN's job to make sure all training was implemented per regulations. He stated he was responsible for monitoring those trainings had occurred. During an interview on 12/18/2025 at 9:38 a.m., the AIT stated she had not received any orientation training on HIV, restraint reduction, or fall prevention.Record review of facility policy titled Orientation, with revision date of 1/02/2025, reflected 1. The facility has designated the Staff Development Coordinator, or designee, as the contact person for the facility's orientation program. This person works closely with each department head for scheduling orientation sessions and developing orientation plans. 2. Orientation plans are maintained by the Staff Development Coordinator. a. General orientation plans reflect the onboarding process for all newly hired employees, and reflect content that is applicable to all staff. b. Departmental orientation plans reflect the skills and competencies that each new employee will require to fulfill his or her job responsibilities. 3. General orientation must be completed prior to the employee's formal contact with facility residents. 4. Departmental orientation will continue until the employee has demonstrated competency in all the skills necessary for performing his/her job and to meet resident needs.10. When an employee changes roles or departments, he/she will go through a departmental orientation specific to that new role or department. 11. All documentation to support completion of the orientation process shall be maintained in the employee's personnel file.Record review of the staff list provided by the facility with no date reflected no staff member titled Staff Development Coordinator.The facility did not provide a policy that specifically required staff to be trained on HIV, restraint reduction and prevention of falls.

Based on interviews and record reviews, the facility failed to include effective communications as mandatory training for direct care staff all new and existing staff for 8 of 15 (the AIT, the SW, the DM, the DOR, RN A, LVN D, CNA E, and HK H) staff reviewed for training on effective communication. The facility failed to ensure communication training was provided to the AIT, the SW, the DM, the DOR, RN A, LVN D, CNA E, and HK H upon hire. This failure could place residents at risk of not understanding their total health status and not effectively being provided notice of rights and services both orally and in writing in a manner that the resident understands.Findings includedRecord review of personnel record for the AIT reflected a hire date of 10/17/2025. Further review of personnel record provided by the BO reflected the AIT had no evidence she had completed required effective communication training upon hire or while working at the facility.Record review of personnel record for the SW reflected a hire date of 3/01/2025. Further review of personnel record provided by the BO reflected the SW had no evidence he had completed required effective communication training upon hire or while working at the facility.Record review of personnel record for the DM reflected a hire date of 11/19/2025. Further review of personnel record provided by the BO reflected the DM had no evidence she had completed required effective communication training upon hire or while working at the facility. Record review of personnel record for the DOR reflected a hire date of 5/08/2025. Further review of personnel record provided by the BO reflected the DOR had no evidence she had completed required effective communication training upon hire or while working at the facility. Record review of personnel record for RN A reflected a hire date of 4/21/2025. Further review of personnel record provided by the BO reflected RN A had no evidence she had completed required effective communication training upon hire or while working at the facility.Record review of personnel record for LVN D reflected a hire date of 8/01/2025. Further review of personnel record provided by the BO reflected LVN D had no evidence she had completed required effective communication training upon hire or while working at the facility.Record review of personnel record for CNA E reflected a hire date of 11/06/2025. Further review of personnel record provided by the BO reflected CNA E had no evidence she had completed required effective communication training upon hire or while working at the facility.Record review of personnel record for HK H reflected a hire date of 11/24/2025. Further review of personnel record provided by the BO reflected HK H had no evidence she had completed required effective communication training upon hire or while working at the facility. During an interview on 12/17/2025 at 1:10 p.m., the AIT stated her expectation would be for staff to have appropriate training during orientation and annual per regulation. She stated there had been a changeover in BO managers that occurred approximately two months ago. She stated the BO manager now was hired from her position as housekeeper with the understanding that corporate BO manager would train her. She stated she was told by the BO manager that her job duty training did not occur. The AIT stated she could not reach out to the corporate BO manager because she quit working for the company yesterday. She stated the corporate BO manager was also supposed to load the employee training into the payroll database for this company because of change in ownership that occurred in March of 2025. She stated the previous company's employee training was not found in the payroll database. She stated prior to yesterday, she was not aware that the facility did not have employee training. During an interview on 12/17/2025 at 2:22 p.m., CNA E stated she had worked at the facility in the past and had just started back working in the facility on 11/06/2025. She stated she remembered getting some training through in-services but thought those happened prior to her re-hire. She stated she thought that she had training on communication prior to her re-hire.During an interview on 12/17/2025 at 2:38 p.m., the BO manager stated she had been in the position of the BO since the end of July 2025. She stated she had one day when she had a person sit next to her and train her and had attended several training meetings on the computer. She stated prior to being in the BO role, she had worked as the HK supervisor for the facility. She stated she had not been aware of orientation training requirements until now.During an interview on 12/18/2025 at 8:14 a.m., the RDO stated he expected all staff to have orientation with appropriate education on required topics including effective communication to understand how to communicate with residents effectively. He stated he had worked for the company for two months and knew there was improvement to be made. He stated the failure occurred due to change in ownership and change in management in both the DON and the ADMIN. He stated it was the ADMIN's job to make sure all training was implemented per regulations. He stated he was responsible for monitoring those trainings had occurred. During an interview on 12/18/2025 at 9:38 a.m., the AIT stated she had not received any orientation training on effective communication but thought she had received training on effective communication from a previous employer.Record review of facility policy titled Orientation, with revision date of 1/02/2025, reflected 1. The facility has designated the Staff Development Coordinator, or designee, as the contact person for the facility's orientation program. This person works closely with each department head for scheduling orientation sessions and developing orientation plans. 2. Orientation plans are maintained by the Staff Development Coordinator. a. General orientation plans reflect the onboarding process for all newly hired employees, and reflect content that is applicable to all staff. b. Departmental orientation plans reflect the skills and competencies that each new employee will require to fulfill his or her job responsibilities. 3. General orientation must be completed prior to the employee's formal contact with facility residents. 4. Departmental orientation will continue until the employee has demonstrated competency in all the skills necessary for performing his/her job and to meet resident needs.10. When an employee changes roles or departments, he/she will go through a departmental orientation specific to that new role or department. 11. All documentation to support completion of the orientation process shall be maintained in the employee's personnel file.Record review of the staff list provided by the facility with no date reflected no staff member titled Staff Development Coordinator.The facility did not provide a policy that specifically required staff to be trained on effective communication.

Based on observation, interviews, and record reviews, the facility failed to develop and implement a comprehensive person-centered care plan with measurable objectives to meet resident's highest practicable physical, mental, and psychosocial well-being for 2 (Resident #10 and Resident #15) of 12 residents reviewed for comprehensive person-centered care plans. 1. The facility failed to develop care plans based on the assessed needs with measurable objectives and timeframes in area of hospice services for Resident #10. 2. The facility failed to develop care plans based on the assessed needs with measurable objectives and timeframes in area of insulin and diabetes for Resident #15. This failure could place the residents at risk for decreased quality of life and not having their needs met.Findings include: Resident #10 Review of Resident #10's electronic face sheet accessed on 12/18/2025, revealed an [AGE] year-old male readmitted to the facility on [DATE] with diagnoses to include: Alzheimer's disease, fracture of vertebra, adjustment disorder. Review of Resident #10's Quarterly MDS assessment dated [DATE], revealed a BIMS score of 06 which indicated severe cognitive impairment. Review of Section O revealed Resident #10 was on hospice care. Review of Resident #10's Comprehensive Care Plan last revised 12/15/2025, revealed no evidence of Resident #10 being on hospice services and no evidence of code status. Review of Resident #10's electronic Physicians Orders revealed: Admit to hospice services, dated 09/11/2025. Resident #15 Review of Resident #15's electronic face sheet accessed on 12/18/2025, revealed an [AGE] year-old male admitted to the facility on [DATE] with diagnoses to include: dementia, anxiety, and depression. Review of Resident #15's Quarterly MDS dated [DATE], revealed a BIMS score of 13 which indicated intact cognition. Review of Section I: revealed Resident #15 had a diagnosis of Diabetes. Review of Section N: revealed Resident #15 received insulin injections. Review of Resident #15's Comprehensive Care Plan last revised 10/23/2025, revealed no evidence of Resident #15 having diabetes or receiving insulin. Review of Resident #15's electronic Physicians Orders revealed: Basaglar Kwik Pen Subcutaneous Solution Pen-injector 100 Unit/ML (Insulin Glargine) inject 30 unit subcutaneously one time a day related to Type 2 Diabetes, dated 03/05/2025. During an interview on 12/18/2025 at 3:00 pm, the RCN stated hospice services, diabetes, and insulin should have been on the care plan. He stated that he was responsible for ensuring that care plans were current and accurate. He stated he did not know why the failure occurred. He stated that he did not see a negative outcome for residents. Review of facility's policy titled Comprehensive Care Plans, revised 01/012024 revealed in part: Policy: it is the policy of this facility to develop and implement a comprehensive person-centered care plan for each resident's, consistent with resident rights, that includes measurable objectives and time frames to meet a residence medical, nursing, and mental and psychosocial needs that are identified in the resident's comprehensive assessment. Policy explanation and compliance guidelines.3. The comprehensive care plan will describe, at a minimum, the following: a. the services that are to be furnished to attain or maintain the resident's highest practical people, and mental, and psychosocial well-being.

Based on interviews and record review, the facility failed to ensure the activities program was directed by a qualified professional who was a therapeutic recreation specialist or an activity professional for 1 of 1 activity director (AD) reviewed for qualifications. The facility failed to ensure the AD, hired on 9/29/2025, was a qualified therapeutic recreation specialist or an activities professional that met state licensing requirements.This failure could place residents at risk for reduced quality of life due to lack of activities that were individualized to match the skills, abilities, and interests/preferences of each resident. Findings includedRecord review of the AD's employee file revealed the AD was hired on 9/29/2025, as the activity director. Further review revealed no evidence of certification or training as a qualified therapeutic recreation specialist or an activities professional that met state licensing requirements.During an interview on 12/15/2025 at 8:14 a.m., the RDO stated he expected all staff to have appropriate education and certification for their roles. He stated he expected for the activities director to have required experience or certification to offer an effective activities program to the residents. He stated he had worked for the company for two months, and knew there was improvement to be made. He stated the failure occurred due to change in management and did not know what had been discussed between the AD and the previous ADMIN.During an interview on 12/18/2025 at 9:55 a.m., the AD stated she was a CNA prior to being an activities director. She stated she was hired as an activities assistant, and the facility did not have an activities director. She stated, the previous ADMIN stated he was going to get her in the appropriate training course but then he no longer at the facility. She stated she had experience owning her own daycare service and did activities with those children. She stated she was willing to get what was needed to keep her position, but she did not know what that was. During an interview on 12/18/2025 at 9:38 a.m., the AIT stated the AD was not certified, but was working on that certification. She stated she would provide a job description of the AD position. She stated the AD was hired before she started working at the facility and she did not know what was done by the previous ADMIN to ensure the AD had appropriate certification. Record review of the facility's unsigned AD Job Description reflected The activities program must be directed by a qualified professional who is a qualified therapeutic recreation specialist or an activities professional who: Is licensed or registered, (preferred) if applicable, by the state in which practicing and Is:o Eligible for certification as a therapeutic recreation specialist or as an activities professional by a recognized accrediting body on or after October 1, 1990; oro Has completed a training course approved by the State.

Based on observation, interview and record review, the facility failed to ensure residents received the necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection and prevent new ulcers from developing for 1 of 4 resident (Resident #1) reviewed for pressure ulcers. The facility failed to develop a plan of care based on comprehensive assessment to prevent a medical device (stabilizing boot) from causing unnecessary pressure to Resident #1's right lower leg and right lower lateral leg, which caused wound #1 and wound #2, which acquired a Stage IV (a deep wound that reaches the muscles, ligaments, or even bone) pressure injury and one newly identified area on the right lower leg to form Stage III (a full thickness of skin is lost, exposing the subcutaneous tissues) pressure injuries from a medical device, (Wound #1 on 2/28/22) and (Wound #2 on 3/14/22). Resident #1 had leg amputated below knee on 3/18/22. An Immediate Jeopardy (IJ) was identified on 3/17/2022 at 1:50 PM. While the IJ was removed on 3/18/2022 at 1:15 PM the facility remained out of compliance, at a scope of isolated and a severity level of no actual harm with the potential for more than minimal harm that is not immediate jeopardy due to the facility's need to continue to monitor the implementation and effectiveness of their Plan of Removal (POR). These failures placed residents with pressure ulcers at risk for improper wound management, the development of new pressure ulcers, deterioration, infection, pain, loss of limb, or death. Findings included: Record review of Resident #1's electronic face sheet dated 3/14/22 revealed she was an [AGE] year-old female, admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of Resident #1's most recent Significant MDS assessment dated [DATE] revealed, a BIMS score was not obtained. Section G revealed Resident #1 required extensive assistance from two persons for bed mobility and toilet use; extensive assistance from two staff for locomotion on and off the unit, dressing, eating, personal hygiene and bathing; Limited assistance of two staff members for transfers. Section H revealed she was always incontinent of both bowel and bladder. Section J revealed she received scheduled pain medication and PRN pain medication. Section M revealed Resident #1 was at risk for pressure ulcers/injuries but did not have any. No documentation on wounds or the boot. Record review of Resident #1's electronic nursing progress note, dated 1/16/22 at 4:35 AM. CNA-F notified RN-A resident had gotten onto floor while she was changing her when she turned her, her legs hit bottom slid off bed onto floor CNA-F states caught resident but had to help her down to floor when this nurse went to see about resident found her in bed check over found to have abrasion to right knee. Record review of Resident #1's electronic nursing progress note, dated 1/16/22 at 1:40 PM, x-ray results show fracture at distal tibia and fibula. Record review of Resident #1's electronic nursing progress note, dated 1/18/22 at 9:58 PM, received lower boot immobilizer for resident was placed on right foot, tolerated well. Placed by DON. Record review of Resident #1's electronic nursing progress note by RN-I, dated 1/18/22 through 2/28/22, daily boot checks for stabilization and in place. Investigator tried to call RN-I by phone on 3/17/22 at 2:00 PM. Left voice message. During an interview on 3/16/22 at 1:15 PM, LVN-A stated she never took the boot off during all of her rounds because she was told by DON to reposition the leg, but do not remove the boot. She stated she never did any skin assessments underneath the boot because she never removed the boot. She stated that when she did assess the resident's leg and boot on rounds, at no point at all did she see any skin breakdown or wounds of the resident's leg outside of the boot. Record review of Resident #1's electronic nursing progress note, dated 2/28/22 at 5:50 AM, while CNA-F's turning repositioning CNA-F's finger got caught on boot noted blood on finger reported to this nurse. Record review of Resident #1's electronic nursing progress note, dated 2/28/22 at 5:50 AM, DON notified boot removed per this nurse noted an open area to outer side of right foot 6 cm x 1 cm et ecchymosis (discoloration of the skin resulting from bleeding underneath, typically caused by bruising) area to heel 2 1/2 x 2 cm. Record review of Resident #1's electronic nursing progress note, dated 2/28/22 at 3:34 PM, DR. D notified of X-ray results. Said I recommend she be seen by ORTHO, or splint for another 6 weeks and re-xray. Record review of Resident #1's Wound Healing Agency report, dated 3/1/22, indicated Wound #1 on right ankle. Pressure ulcer of right ankle, 100% slough (dead tissue separating from living tissue especially : a mass of dead tissue separating from an ulcer, https://www.nursinghomeabusecenter.org), unstageable (1.5 cm X 3.5 cm X 0.3 cm). Stages of Pressure Ulcers: 1. Pressure ulcer means an area where the skin and underlying tissues are eroded as results of a lack of blood flow caused by pressure of friction, commonly described in four stages: a. Stage I: a persistent area of skin redness (without a break in the skin) that does not disappear when pressure is applied. b. Stage II: a partial thickness of skin is lost ([MEDICATION(S)] layer has been lost, but the dermis is at least partially intact); may present as blistering surrounded by an area of redness and/or induration. c. Stage III: a full thickness of skin is lost, exposing the subcutaneous tissues; presents as a shallow crater (unless coved by eschar thick, brown, black, or yellow crust); may be draining. d. Stage IV: a deep wound that reaches the muscles, ligaments, or even bone. (https://www.nursinghomeabusecenter.org/, 3/21/22) Record review of Resident #1's Wound Healing Agency report, dated 3/8/22, Wound #1 on right ankle. Resident #1's pressure injury to her right ankle, just above the malleolus. The wound was previously classified as unstageable due to the amount of slough; however, today it is presenting itself as a stage 3 pressure injury (1.4 X 4.7 X 1.9). Record review of Resident #1's electronic nursing progress note, dated 3/14/22 at 9:00 AM, Daughter here this a.m. visiting Resident #1. During this time, she inspected her Resident #1's leg and requested that Resident #1 be sent to local ER, despite Resident #1 having an appointment to see the orthopedic on 3-23-2022. She stated that going to the ER will get things done now. Tried to educate daughter about the purpose of ER and the services they provide but she still insisted on Resident #1 being transported. So, EMS notified of non-emergency transport. During an interview on 3/16/22 at 1:30 PM, LVN-B stated she never took the boot off because the boot was there for support and she was told to only touch the boot to reposition the leg, never take the boot off, she stated she never assessed the skin underneath the boot. She stated out of all the times she assessed the resident skin for color, dryness, or wounds, she did not see or notice any breakdown of the skin, outside of the boot. During a phone interview on 3/16/22 at 1:45 PM with RN-C (doctors assistance) for Dr. D, she stated Dr. D was on vacation and could not be reached. She stated in her professional opinion and what she has seen from Dr. D, RN-C stated they would like to see the boot taken off every 2-3 days for at least skin assessment. Investigator attempted to call Dr. D on 3/16/22 at 1:55 PM. Left a message. During an interview on 3/16/22 at 2:15 PM, the DON, stated no one took the boot off. She stated the orders were to reposition the boot. She stated they did not learn about the wound until 2/28/22 when a LVN was assessing the boot and got some blood on her finger. She stated that no one took the boot off from 1/18/22 to 2/28/22. She stated she did not think about removing the boot even for a small time to do a skin assessment. DON stated she never reached out to Dr. D and assumed the boot was never to be removed at all. During an interview on 3/16/22 at 4:15 PM, the CNA-F, stated she did give Resident #1 baths. She stated during bath time it was a bath in her bed, with soap and wash cloth. She stated she never removed her boot even during a bed bath. She was told to not touch the boot and to bathe around the boot. She stated the DON told her to never remove any device. Record review of Hospital Narrative Notes Details by PT dated 3/14/22 at 3:36 PM. Notes: Patient was evaluated today for wounds to her R lower leg. Inspection of the area revealed obvious deformity and x-ray confirm a non-healing tib/fib fracture. The patient sustained this fracture in January and was placed in a low boot. She has a larger open ulceration to the Right lateral lower leg which is quite deep and is concerning for [CONDITION(S)] (inflammation or swelling that occurs in the bone). On the opposite side of the leg at the level of the fracture, there is discoloration consistent with a DTI. These are likely a result of sustained pressure from the boot the patient was previously wearing. Record review of Consultation on 3/14/22 at 8:50 PM by Dr. E: Reason for Consultation: Open fracture of the right leg and ulcer. History of Present Illness: This is an [AGE] year-old female, brought to the ER this afternoon, she had evidently sustained a fracture of the distal leg back in January. This was seen in an ER patient was placed in a stabilizing boot and sent back to the nursing home. The patient was seen, had open wounds on her leg and deformity, and was admitted to the Hospitalist Service and Orthopedics consultation requested. Extremities: The right lower extremity at this time has a well-padded splint, but pictures from the emergency room had demonstrated a larger ulcer, skin breakdown over the medical aspect of the distal leg over the medial malleolus (the bony bump on the inner side of the ankle, https://trialsjournal.biomedcentral.com, accessed 3/21/22) and just proximal to that. There is a heel ulcer and then she has a large open would with possible bone measuring about an inch in diameter over the lateral side of the ankle. Imaging Data: Her x-rays show a nonunion with marked displacement of the distal tibia and fibula fracture a couple inches above the ankle. Impression: She has a nonunion distal tibia fracture, now had medial and lateral ulcerations of the skin with probable exposed bone in a patient with probable [CONDITION(S)] (a blood circulation disorder that causes the blood vessels outside of your heart and brain to narrow, block, or spasm, www.healthline.com/health/peripheral-vascular-disease, accessed 3/21/22), who is non-ambulatory and demented. Plan: Basically, this is not anything that we are going to be able to salvage with her overall condition. I think the options are pretty simple, we can either do a primary amputation and remove the leg, probably a below-knee amputation wound suffices on her or she could just manage with open wound care and hospice and figuring that this thing will go on and continue to break down probably get infected and she could eventually get septic and could die from that. Record review of Hospital progress notes by Dr. E on 3/16/22 at 4:13 PM stated, family reports that they want to proceed with an amputation, will put on OR schedule for tomorrow afternoon. During an interview on 3/17/22 at 9:25 AM, the DON, stated all in services that were given to the investigator was everything she had done in the past 3 months. She stated that no in-services were done after 3/1/22 on wound care, she stated she informed the nursing staff via mouth, but no official in-service was done on wound care or assisted devices. During an interview on 3/17/22 at 9:45 AM, the Administrator, stated no in-service had been done that had to do with wounds or devices. She stated, Yes, I would have liked to have seen the boot removed daily if not every other day for skin assessments, but this was not done. She stated that an in-service should have been done but she missed it. During an interview on 3/17/22 at 10:55 AM, LVN-A stated she did not receive any in-service after the Stage 3 wound was discovered. She stated she did all wound care from 3/1/22 to 3/14/22 on Resident #1. She stated that she does feel that if the boot was removed then the wound could have been prevented. Pressure Injury Risk Assessment Policy dated 3/2020 Purpose The purpose of this procedure is to provide guidelines for the structured assessment and identification of residents at risk of developing new pressure injuries or worsening of existing pressure injuries (PIs). General Guidelines l. The purpose of a pressure injury risk assessment is to identify all risk factors and then to determine which can be modified and which cannot, or which can be immediately addressed, and which will take time to modify. 2. Risk factors that increase a resident's susceptibility to develop or to not heal PIs include, but are not limited to: a. Under nutrition, malnutrition, and hydration deficits; b. Impaired/decreased mobility and decreased functional ability; c. The presence of previously healed PI; d. The presence of existing PI; e. Exposure of skin to urinary and fecal incontinence or other source of moisture; f. Elevated body temperature. g. Altered skin status over pressure points. h. Impaired perfusion, oxygenation or circulation deficits, for example, generalized atherosclerosis or lower extrality arterial insufficiency; Conditions, such as end stage renal disease, [CONDITION(S)] disease or diabetes mellitus; j. Drugs such as steroids that may affect healing; k. Advanced age; l. Impaired sensory perception; m. Cognitive impairment; and n. Resident refusal of some aspects of care and treatment. 3. The risk assessment should be conducted as soon as possible after admission, but no later than eight hours after admission is completed. 4. Use only a facility-approved risk assessment tool to obtain risk assessment data. 5. Supplement the risk assessment tool with assessment of additional risk factors. 6. Once the assessment is conducted and risk factors are identified and characterized, a resident-centered care plan can be created to address the modifiable risks for pressure injuries. 7. Repeat the risk assessment weekly for the first four weeks, if there is a significant change in condition, or as often as is required based on the resident's condition. Steps in the Procedure l. Gather assessment tools and documentation and conduct the assessment in the manner most appropriate to the resident's condition and willingness to participate. 2. If necessary, allow the resident to take rest periods during the assessment. 3. Conduct a structured pressure injury risk assessment using a facility-approved tool. 4. Conduct a comprehensive skin assessment with every risk assessment. a. When conducting a skin assessment, provide for the resident's privacy. b. Once inspection of skin is completed document the findings on a facility-approved skin assessment tool. c. If a new skin alteration is noted, initiate a (pressure or non-pressure) form related to the type of alteration in skin. 5. Develop the resident-centered care plan and interventions based on the risk factors identified in the assessments, the condition of the skin, the resident's overall clinical condition, and the resident's stated wishes and goals. a. The interventions must be based on current, recognized standards of care. b. The effects of the interventions must be evaluated. c. The care plan must be modified as the resident's condition changes, or if current interventions are deemed inadequate. Documentation The following information should be recorded in the resident's medical record utilizing facility forms: l . The type of assessment(s) conducted. 2. The date and time and type of skin care provided, if appropriate. 3. The name and title (or initials) of the individual who conducted the assessment. 4. Any change in the resident's condition, if identified. 5. The condition of the resident's skin (i.e., the size and location of any red or tender areas), if identified. 6. How the resident tolerated the procedure or his/her ability to participate in the procedure. 7. Any problems or complaints made by the resident related to the procedure. 8. If the resident refused the treatment, the reason for refusal and the resident's response to the explanation of the risks of refusing the procedure, the benefits of accepting and available alternatives. Document family and physician notification of refusal. 9. Observations of anything unusual exhibited by the resident. 10. The signature and title (or initials) of the person recording the data. l l . Initiation of a (pressure or non-pressure) form related to the type of alteration in skin if new skin alteration noted. 12. Documentation in medical record addressing MD notification if new skin alteration noted with change of plan of care, if indicated. 13. Documentation in medical record addressing family, guardian or resident notification if new skin alteration noted with change of plan of care, if indicated. Reporting l . Notify the supervisor if the resident refuses the procedure, 2. Report other information in accordance with facility policy and professional standards of practice. 3. Notify attending MD if new skin alteration noted. 4. Notify family, guardian or resident update if new skin alteration noted. An Immediate Jeopardy was identified on 3/17/22 at 1:50 PM, due to the above failures. The Administrator was informed of Immediate Jeopardy and the IJ template was provided on 3/17/2022 at 1:50 PM and a Plan of Removal (POR) was requested at that time. The Plan of Removal was accepted on 3/18/2022 at 11:50 PM. Record review of the POR reflected the following: Identified Concern: The facility failed to prevent the development of multiple avoidable pressure sores for one resident. Resident #1 was ordered a stabilizing low boot on 1/18/22 related to a fracture resulting from a fall. From 1/18/22 to 2/18/22 the boot was never removed to assess skin. On 2/28/22 Resident # 1 was identified with an unstageable wound t an area covered by the low boot. On 3/1/22 the wound was identified as a stage 3. On 3/14/22 the family requested the resident be sent to the hospital related to the worsening of the wound and two wounds were assessed as a stage 4 wound and an unstageable wound. This is violation F686 The following plan of action outlines immediate interventions employed by the facility to remove any further concerns surrounding the issues: Immediate Action: The DON provided education to each nurse working on 3/17/22 staff received education on the center's system for skin assessments related to use of low boots and impaired mobility to prevent the acquisition and deterioration of wounds which is likely to result in serious illness, hospitalization , and/or death by. Education covered: 3/17/22 the Regional Nurse Manager provided education to the DON concerning the assessment of skin surrounding/covered by the use of low boots, splints, or other devices related to impaired mobility to prevent the acquisition and deterioration of wounds 3/18/22 the Regional Nurse Manager provided education to the Administrator, DON and CN that in the absence of the DON the CN will educate the nursing staff concerning the assessment of skin surrounding/covered by the use of low boots, splints, or other devices related to impaired mobility to prevent the acquisition and deterioration of wounds. The Wound Nurse and the NP for Wound Healing Agency are also available to provide this education to nursing staff in the absence of the DON. Complete assessment each shift to the skin surrounding/covered by the use of low boots, splints, or other devices related to impaired mobility Completing head to toe skin assessment weekly to include all skin area, even those covered by stabilizing boots, splints, or other devices related to impaired mobility Assessing any area identified by the nursing assistants verbally or by the written CNA observation tool Reporting to the DON and attending MD of any change of skin conditions and implementing new orders Reporting new occurrence to the NP for Wound Healing Agency as appropriate 3/18/22 Regional Nurse provided education to the DON and or CN: Daily clinical meeting is to review all new orders. All orders related to residents with mobility/assistive devices will be clarified to specifically state the monitoring and/or possible removal of assistive devices to assess skin to prevent the risk of removing a device the physician does not want removed. If there is no order to address the device removal, the charge nurse will contact the physician and request the specific orders. Education included that the DON or staff nurses can reach out to the Regional Nurse, Wound Nurse with and the NP for Wound Healing Agency for assistance with questions. Effective 3/18/22 the facility will begin conducting random interviews with nursing staff on the care of residents with mobility/assistive devices and how frequently skin assessment is to be completed and what actions to take if there is redness or injury to skin. Immediate Action: 3.17.22 All residents have been assessed by the DON and CN for skin integrity. Results are documented in the individual resident record. During an interview on 3/18/22 at 9:15 AM, the Administrator stated she reached out to the medical director this morning. He stated he understood what was going on and was in approval of the POR's put in place. He stated he will be in on Monday morning after his vacation was complete. She stated the DON worked last night with her. She stated that in-services started last night with every employee, which covered skin assessments, devices, and reporting to DON or administrator immediately if any skin integrity issues were seen during any skin assessment. During an interview on 3/18/22 at 9:45 AM, the DON stated she started to in-service all Nurses on 3/17/22 at around 7:15 pm. She stated she covered: Preventing Pressure Injuries with all staff. She stated it covered to do skin assessments daily when they are doing all activities. She stated during showers, really take a close look at the skin. She stated the class description was titled skin assessment. She stated that the education to inform all staff if there are any changes in skin anywhere on the body, including under devices, to report to the charge nurse immediately. DON stated she assessed all residents last night 3/17/22. She stated no new skin issues had been seen nor reported to her during all CNA shower checks from 3/17/22 to present time on 3/18/22. During an interview on 3/18/22 at 10:05 AM, TNA-G stated when she got here this morning she was in-serviced on abuse/neglect and skin assessments. She stated with abuse/neglect she was educated on what to look for, how to handle the situation and report any issues she does see to the charge nurse as soon as possible. She stated the in-service on skin assessments was to do in-depth skin assessments of the residents, especially in the shower, since she does do showering for the facility. She stated that if she notices anything at all, bruising, redness, anything that is not normal, she is to inform the charge nurse as soon as possible. She stated that if any device is on the resident she is not allowed to remove the device, but to follow up with the charge nurse that the skin assessment has been done under the device. During an interview on 3/18/22 at 10:40 AM, LVN-B stated she was part of the in-service at 3:45 PM on 3/17/22. She stated there was two in-services, one on abuse/neglect and skin assessments. She stated the in-service on abuse/neglect was on what to look for, how to handle signs of abuse and neglect, and to report to the DON or administrator after witnessing anything. She stated the skin assessment in-service was on head-to-toe skin assessments in relation to residents who wear devices such as, boot, splints and anything that prevents a resident from moving too much. She stated the in-service was education on any device that can be removed, to remove the device and do a skin assessment under the device. Record review of the CNA Observation Tool dated 3/18/22 indicated- During all showers a skin assessment is completed, and body audit form is filled out by the employee conducting the shower. Form contains body outline and is to be marked if any redness, discoloration, open area or anything unusual. Form reviewed is completed with (intact no skin issues) circled, signed by CNA and signed off by charge nurse. During an observation on 3/18/22 at 11:55 AM, the DON was doing a skin assessment of Resident #24. The DON showed how she accessed the skin of the lower left leg of the resident. The DON stated the skin was dry but no redness, no bruising, no changes in color. Record review on 3/18/22, In-services began yesterday 3/17/22 at 3:00 PM. DON leading all in-services on every employee in the facility and anyone that came in afterwards. During a phone interview on 3/18/22 at 12:25 PM, Reg RN-stated she started 3/17/22 at 2:20 PM educating LVN-B, admin, and DON. She stated this morning 3/18/22 at 10:15 AM she did education with the admin, DON, and LVN-B. education to the DON and or CN: Daily clinical meeting is to review all new orders. All orders related to residents with mobility/assistive devices will be clarified to specifically state the monitoring and/or possible removal of assistive devices to assess skin to prevent the risk of removing a device the physician does not want removed. If there is no order to address the device removal, the charge nurse will contact the physician and request the specific orders. During a phone interview on 3/18/22 at 12:35 PM, LVN-H stated when she came in last night 3/17/22 she was in-serviced by the DON on the topics of abuse/neglect and skin assessment. She stated the second in-service was on skin assessment. She stated that the CNA's during showers were to fill out a form on skin assessment and if any changes were noted or seen on the resident, these changes were marked on the form and brought to the charge nurse for a secondary signature of the skin assessment. She stated that once a week all residents were to get a head-to-toe skin assessment and to remove any stabilizing devices such as a lower boot for skin integrity. She stated that if any bruising, redness, tears, or anything new to the resident was seen, to report these findings to the DON immediately. Record review of the Daily Sand Up Meeting on 3/18/22-the DON went over any new orders by the doctor and will contact the physician if any questions arise or something does not seem correct. She stated that when it comes to devices, she will have exact clarity and directions in writing from the doctor on what his expectation is of the device. She stated this information is then shared with all staff during morning meeting that has now been put in place. She stated no new orders had been put in place since yesterday, but open communication has been established with the physician. The administrator was notified the IJ was removed on 3/18/2022 at 1:15 PM. The facility remained out of compliance, at a scope of isolated and a severity level of no actual harm with the potential for more than minimal harm that is not immediate jeopardy due to the facility's need to continue to monitor the implementation and effectiveness of their Plan of Removal (POR).

Based on observation, interview and record review, the facility failed to ensure each resident received adequate supervision and assistance devices to prevent accidents for 1 (Resident #1) of 3 reviewed for accidents and supervision. CNA A and CNA B transferred Resident #1 from her wheelchair to her bed by a two-person underarm lift instead of a Hoyer lift or using a gait belt. She sustained a displaced fracture in the right mid humerus shaft of her arm. This was determined to be past-noncompliance due to the facility having implemented actions that corrected the non-compliance prior to the beginning of the inspection. This failure placed residents at risk of injury. Findings: Record review of Resident #1's most recent admission Minimum Data Set ((MDS) dated [DATE] revealed an [AGE] year-old female admitted from an acute hospital on [DATE] with the following Diagnosis: [REDACTED]. Resident #1 scored a 14 out of 15 on the Brief Interview for Mental Status (BIMS) which indicates an intact cognition. Resident #1 Function Status revealed extensive assistance with two people was needed for bed mobility, dressing, toileting, and personal hygiene. Total dependence with two people needed for transfers. Section G also revealed a functional limitation in range of motion impairment on one side to an upper extremity and that Resident #1 utilizes a wheelchair for mobility. Record review of Resident #1's care plan dated 2/25/20 revealed it did not address her [DIAGNOSES REDACTED]. Record Review of Resident #1 electronic health record accessed on 3/9/20 revealed she arrived at the facility on 2/25/20 at 2:29 pm after a transfer from her wheelchair to the bed by a two person under arm transfer Resident #1 reported to the DON her arm was broken. Resident #1 had limitation in her right upper extremity and was complaining of pain at an 8 out of 10 to her right shoulder upon movement that was aching, and she had not experienced this pain before.The DON notified the Physician at 3:33pm and x-rays were obtained at 6:11 pm confirming an oblique or comminuted, displaced fracture in the right mid humerus shaft. Resident #1 was seen by Physician at 7:52 pm and was sent to area hospital to be evaluated and treated. On 2/26/20 at 3:09 am Resident #1 arrived back to the facility with confirmation of broken arm, her arm in a sling, and recommendation to follow up with an area Orthopedic doctor. In an interview on 3/9/20 at 11:08 am CNA A stated on 2/25/20 she took the facility van to go get Resident #1 from the hospital. Upon arrival to the hospital CNA A observed hospital staff use a Hoyer lift to get Resident #1 out of bed and placed into a wheelchair. CNA A stated the hospital staff said they cannot leave their sling under Resident #1 as they need their sling. CNA A stated the drive to the facility took about 30 minutes. CNA a stated when they arrived at the facility they kept Resident #1 in her wheelchair to obtain a weight and once that was complete at Resident's #1 request they went to lay her down. CNA A and CNA B debated putting a sling under Resident #1, but the slings in their facility are long slings, not cross over slings and it would be very difficult to get it under her. CNA A stated after her and CNA B discussed the options they decided to do a two person under arm lift without the use of a gait belt, CNA a added they did not have a gait belt available in her room. CNA A stated she groaned during the transfer but never yelled in pain. CNA A stated once they had her bottom on the bed the Director of Nursing (DON) entered the room and helped them to get her on the bed. CNA a stated before she left the facility she was informed that Resident #1 may not be able to stand. CNA A stated she did not inform the Administrator or DON they were about to lay Resident #1 down, and even though she observed the hospital use a Hoyer lift to transfer the resident, they still chose to use a two person under arm lift. In an interview on 3/9/20 at 11:44 am CNA B stated when Resident #1 arrived to the facility she assisted CNA A get her off the van and Resident #1 was telling them to hurry she wanted to lay down. CNA B stated she was not aware Resident #1 required a lift and there was no sling under her to indicate the need for one, but since Resident #1 kept pushing them to lay her down they decided to do an under-arm lift. CNA B stated that Resident #1 complained during the transfer and was moaning, but once transfer was complete she was talking with the DON, and they left the room. In an observation and interview on 3/9/20 at 2:00pm Resident #1 stated she arrived at the facility in a wheelchair. Resident #1 states they came to get her to put her to bed, and she told them they needed a Hoyer lift to get her from her chair to her bed. Resident #1 stated the aides talked back and fourth then decided to lift her under her arms. Resident #1 stated she felt her arm break and she told them they broke her arm. Resident #1 was in bed with her right arm in a blue sling. In an interview on 3/9/20 at 3:35 pm the DON revealed she feels the injury occurred because the aides failed to use the Hoyer lift to transfer her. The DON stated CNA A was informed Resident #1 was a Hoyer lift before leaving the facility to pick her up from an area hospital. The DON stated it is not an acceptable practice to lift residents in the manor they lifted Resident #1, and if the aides were uncertain how she needed to be transferred they should ask the charge nurse. The DON stated the two CNAs were suspended; a facility investigation was started; staff were given demonstration training by Habilitation Therapies with check offs for competency in transfers with a using draw sheets, gaitbelt, and Hoyer lift; in servicing on Abuse and Neglect; care plan was updated; and weekly observation of resident transfers will be conducted. In an interview on 3/9/20 at 4:25 pm the Administrator stated she feels the failure occurred because the CNAs knew better, but still used a two person under arm lift with Resident #1. The Administrator stated she suspended both CNAs; insured training on Abuse and Neglect; and transfers. Record review of facility policy dated 2001 with a revision date of July 2017 revealed a policy for Safe Lifting and Movement of Residents . In order to protect the safety and well-being of staff and resident, and to promote quality care, this facility uses appropriate techniques and devices to lift and move resident . 1. Resident safety, dignity, comfort and medical condition will be incorporated into goals and decisions regarding the safe lifting and moving of residents. 2. Manual lifting of residents shall be eliminated when feasible.

Based on observation, interview, and record review the facility failed to have sufficient nursing staff with the appropriate competencies and skills sets to provide nursing and related services to assure resident safety and attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident for one resident (Resident #1) of three reviewed for safe transfers and two of four nurse aides (CNA A and CNA B) observed for transfers. CNA A and CNA B transferred Resident #1 from her wheelchair to her bed by a two-person underarm lift instead of a Hoyer lift or using a gait belt. She sustained a displaced fracture in the right mid humerus shaft of her arm. This was determined to be past-noncompliance due to the facility having implemented actions that corrected the non-compliance prior to the beginning of the inspection. This failure placed residents at risk of injury. Findings: Record review of Resident #1's most recent admission Minimum Data Set ((MDS) dated [DATE] revealed an [AGE] year-old female admitted from an acute hospital on [DATE] with the following Diagnosis: [REDACTED]. Resident #1 scored a 14 out of 15 on the Brief Interview for Mental Status (BIMS) which indicates an intact cognition. Resident #1 Function Status revealed extensive assistance with two people was needed for bed mobility, dressing, toileting, and personal hygiene. Total dependence with two people needed for transfers. Section G also revealed a functional limitation in range of motion impairment on one side to an upper extremity and that Resident #1 utilizes a wheelchair for mobility. Record review of Resident #1's care plan dated 2/25/20 revealed it did not address her [DIAGNOSES REDACTED]. Record Review of Resident #1 electronic health record accessed on 3/9/20 revealed she arrived at the facility on 2/25/20 at 2:29 pm after a transfer from her wheelchair to the bed by a two person under arm transfer Resident #1 reported to the DON her arm was broken. Resident #1 had limitation in her right upper extremity and was complaining of pain at an 8 out of 10 to her right shoulder upon movement that was aching, and she had not experienced this pain before.The DON notified the Physician at 3:33pm and x-rays were obtained at 6:11 pm confirming an oblique or comminuted, displaced fracture in the right mid humerus shaft. Resident #1 was seen by Physician at 7:52 pm and was sent to area hospital to be evaluated and treated. On 2/26/20 at 3:09 am Resident #1 arrived back to the facility with confirmation of broken arm, her arm in a sling, and recommendation to follow up with an area Orthopedic doctor. In an interview on 3/9/20 at 11:08 am CNA A stated on 2/25/20 she took the facility van to go get Resident #1 from the hospital. Upon arrival to the hospital CNA A observed hospital staff use a Hoyer lift to get Resident #1 out of bed and placed into a wheelchair. CNA A stated the hospital staff said they cannot leave their sling under Resident #1 as they need their sling. CNA A stated the drive to the facility took about 30 minutes. CNA a stated when they arrived at the facility they kept Resident #1 in her wheelchair to obtain a weight and once that was complete at Resident's #1 request they went to lay her down. CNA A and CNA B debated putting a sling under Resident #1, but the slings in their facility are long slings, not cross over slings and it would be very difficult to get it under her. CNA A stated after her and CNA B discussed the options they decided to do a two person under arm lift without the use of a gait belt, CNA a added they did not have a gait belt available in her room. CNA A stated she groaned during the transfer but never yelled in pain. CNA A stated once they had her bottom on the bed the Director of Nursing (DON) entered the room and helped them to get her on the bed. CNA a stated before she left the facility she was informed that Resident #1 may not be able to stand. CNA A stated she did not inform the Administrator or DON they were about to lay Resident #1 down, and even though she observed the hospital use a Hoyer lift to transfer the resident, they still chose to use a two person under arm lift. In an interview on 3/9/20 at 11:44 am CNA B stated when Resident #1 arrived to the facility she assisted CNA A get her off the van and Resident #1 was telling them to hurry she wanted to lay down. CNA B stated she was not aware Resident #1 required a lift and there was no sling under her to indicate the need for one, but since Resident #1 kept pushing them to lay her down they decided to do an under-arm lift. CNA B stated that Resident #1 complained during the transfer and was moaning, but once transfer was complete she was talking with the DON, and they left the room. In an observation and interview on 3/9/20 at 2:00pm Resident #1 stated she arrived at the facility in a wheelchair. Resident #1 states they came to get her to put her to bed, and she told them they needed a Hoyer lift to get her from her chair to her bed. Resident #1 stated the aides talked back and fourth then decided to lift her under her arms. Resident #1 stated she felt her arm break and she told them they broke her arm. Resident #1 was in bed with her right arm in a blue sling. In an interview on 3/9/20 at 3:35 pm the DON revealed she feels the injury occurred because the aides failed to use the Hoyer lift to transfer her. The DON stated CNA A was informed Resident #1 was a Hoyer lift before leaving the facility to pick her up from an area hospital. The DON stated it is not an acceptable practice to lift residents in the manor they lifted Resident #1, and if the aides were uncertain how she needed to be transferred they should ask the charge nurse. The DON stated the two CNAs were suspended; a facility investigation was started; staff were given demonstration training by Habilitation Therapies with check offs for competency in transfers with a using draw sheets, gaitbelt, and Hoyer lift; in servicing on Abuse and Neglect; care plan was updated; and weekly observation of resident transfers will be conducted. In an interview on 3/9/20 at 4:25 pm the Administrator stated she feels the failure occurred because the CNAs knew better, but still used a two person under arm lift with Resident #1. The Administrator stated she suspended both CNAs; insured training on Abuse and Neglect; and transfers. Record review of facility policy dated 2001 with a revision date of July 2017 revealed a policy for Safe Lifting and Movement of Residents . In order to protect the safety and well-being of staff and resident, and to promote quality care, this facility uses appropriate techniques and devices to lift and move resident . 1. Resident safety, dignity, comfort and medical condition will be incorporated into goals and decisions regarding the safe lifting and moving of residents. 2. Manual lifting of residents shall be eliminated when feasible.

Based on observation, interviews, and record review, the facility failed, based on the comprehensive assessment, to ensure that residents received treatment and care in accordance with professional standards of practice for 1 of 16 residents (Resident #14) reviewed for quality of care. LVN A alternated applying heat packs and ice packs to Resident #14's left knee without a physician's order or training. As a result, a blister formed, ruptured and became infected. The facility delayed notifying Resident # 14's physician or physician on-call about the blister and subsequent rupture for over 24 hours. As a result, prompt treatment of [REDACTED]. This was determined to be past-noncompliance due to the facility having implemented actions that corrected the non-compliance prior to the beginning of the inspection. This failure could place residents at risk for serious harm, due to receiving non-therapeutic treatments and delayed care. Findings include: Review of Resident #14's Face Sheet, accessed on 12/17/19, revealed she was a 92-yr-old female, admitted to the facility on [DATE] and readmitted on [DATE], with [DIAGNOSES REDACTED]. Review of Resident #14's quarterly Minimum Data Set (MDS), dated [DATE], revealed she required extensive assistance with activities of daily living (ADLs), and she had a Brief Interview for Mental Status (BIMS) score of two, which indicated her cognitive function was severely impaired. Review of Resident #14's care plan, edited 10/10/19 revealed: Category: Pain-I am at risk for pain due to disease process and advanced age- related aches and pains . Goal: my episodes of pain will be resolved or within a tolerable range within 1 hour of intervention over the next 90 days . Approach: Position for comfort. 10/9/19. On 8/17/19 LVN attempted to relieve resident complaint of pain with non-therapeutic intervention of alternating ice pack and hot packs. On 8/28/29 at 12:20 a.m. LVN observed fluid filled blister. No further hot packs applied . Observation on 12/17/19 at 2:20 p.m. revealed Resident #14's knee with scabbing approximately two inches long and ¼ inch wide down the center of her knee. There was no redness or swelling visible. Resident #14 was unable to participate in an interview due to her severely impaired cognitive function. Review of Resident #14's Nurse Progress Notes revealed: 8/17/19 11:05 a.m.-Still complains of left knee pain, unable to rate. Resident moans and hollers out. Ice pack and hot pack alternated. Signed by LVN A 8/18/19 12:20 a.m. Large fluid filled blister on top of resident's left knee .Signed by LVN B. 8/18/19 9:30 a.m.-Fluid seeped out of blister, no redness, no peeling, no complaint of pain and no scarring. Resident not moaning and hollering out in pain like yesterday. Left knee swelling down and able to bend some with tenderness. Will continue to monitor .Signed by LVN [NAME] 8/19/19 11:30 a.m. Called Physician A's office, nurse said that Physician A will not be there until Wednesday. Signed by the Assistant Director of Nursing (ADON). 8/19/19 2:35 p.m. (illegible name) called from the clinic. Stated Nurse Practitioner A (NP A) stated to give resident 200-400 milligrams (mg) [MEDICATION NAME] every 4-6 hours as needed for pain and to use moist heat packs to affected area. Signed by LVN C. 8/20/19 9 a.m.-blood pressure 121/63, pulse 65, respirations 18, temperature 98.2 up in wheelchair for breakfast [MEDICATION NAME] 200 mg. was given at 8:15, showered and warm pack applied to knee by therapy. No distress or pain noted at this time .Signed by ADON. Review of a Physician's telephone order revealed: 8/24/19 Clean site to left knee with wound cleanser or normal saline, pat dry, apply topical antibiotic ointment and cover site every day and as needed. Received and signed by LVN A on 8/24/19 and signed by Physician A on 8/26/19. 8/26/19 Cleanse site to left knee with wound cleanser or normal saline, pat dry, apply [MEDICATION NAME] ointment and cover with dressing every day and as needed. Order received by the ADON, no date of receipt and signed by Physician A on 8/26/19. 8/26/19 Keflex 500 mg 1 by mouth three times a day times 10 days wound to left knee. Order received by the ADON, (no signature date) and signed by Physician A on 8/28/19. 9/10/19 Bactrim DS one by mouth two times/day times 10 days for wound on left knee. Culture site to left knee. Cleanse site with normal saline or wound cleanser. Apply [MEDICATION NAME] ointment and cover with foam dressing twice daily. Order received by the ADON (no signature date). Signed by Physician A on 9/12/19. Review of Resident's lab results dated 9/11/19 for the culture of her left knee collected on 9/10/19 revealed: 9/12/19 many [DIAGNOSES REDACTED] variicola .9/12/19 Many Staphylococus aureus . Review of the facility's Infection Control Data Log, dated (MONTH) 2019, revealed documentation that indicated Resident #14 had a skin infection in (MONTH) 2019. According to the Free Medical Dictionary: [DIAGNOSES REDACTED] is a bacteria that occurs in the respiratory, intestinal and urogenital tracts of humans. (Accessed on 12/20/19 at https://medical-dictionary.thefreedictionary.com/[DIAGNOSES REDACTED]+infections) Staphylolococcus Aureus is a bacterial common species found especially on nasal mucous membranes and skin (hair follicles); it causes furunculosis, [MEDICAL CONDITION], pyemia, pneumonia, osteo[DIAGNOSES REDACTED], endocarditis, suppuration of wounds, other infections, and food poisoning; also a cause of infection in burn patients. Humans are the chief reservoir. (accessed on 12/20/19 at https://medical-dictionary.thefreedictionary.com/staph+aureus) According to the National Institutes of Health U.S. National Library of Medicine at MedlinePlus: [MEDICATION NAME] is used to treat and prevent eye infections caused by certain bacteria and to reduce the irritation, redness, burning, and swelling of eye inflammation caused by infection, chemicals, heat, [MEDICAL CONDITION], foreign bodies in the eye, and other eye conditions. (accessed on 12/20/19 at https://medlineplus.gov/druginfo/meds/a 0.html) [MEDICATION NAME] (Keflex) is and antibiotic used to treat certain infections caused by bacteria such as pneumonia and other respiratory tract infections; and infections of the bone, skin, ears, genital, and urinary tract. [MEDICATION NAME] is in a class of medications called cephalosporin antibiotics. It works by killing bacteria. (Accessed on 12/20/19 at: https://medlineplus.gov/druginfo/meds/a 3.html) Bactrim DS (Co-trimoxazole) is used to treat certain bacterial infections, such as pneumonia (a lung infection), [MEDICAL CONDITION] (infection of the tubes leading to the lungs), and infections of the urinary tract, ears, and intestines. It also is used to treat '[MEDICATION NAME]' diarrhea. Co-trimoxazole is a combination of [MEDICATION NAME] and [MEDICATION NAME] and is in a class of medications called sulfonamides. It works by stopping the growth of bacteria. Antibiotics will not [MEDICAL CONDITION] that can cause colds, flu, or other [MEDICAL CONDITION] infections. (Accessed on 12/20/19 at: https://medlineplus.gov/druginfo/meds/a 6.html) In an interview on 12/17/19 at 9:32 a.m., the Administrator said on 10/9/19 the Regional Nurse Consultant (RNC) came into the facility, checking rounds and found information about the knee injury in Resident #14's clinical records. She said Resident #14 was having knee pain, and the nurse was trying to relieve the pain, so she went to the rehab department, got a heat pack from the [MEDICATION NAME] and placed it on the resident's knee. The Administrator said she did not know how long the heat pack remained on Resident #14's knee, because the nurse had left employment and would not answer the facility's phone calls. The Administrator said a blister formed and popped on its own and became an open sore. She said DON A was suspended for not notifying anyone about the injury. According to Medco-athletics.com, a [MEDICATION NAME] is ideal for athletic trainers and physical therapists. The consistent temperature of 160° to 165°F (71°-74°C) is great for getting heat packs to the perfect temperature. It features a lower-water sensor that shuts the unit off if the water level gets too low. (Accessed on 12/20/19 at: https://www.medco-athletics.com/[MEDICATION NAME]-heating-units) In an interview on 12/17/19 at 11:44 a.m., the Regional Nurse Consultant (RNC) said, on 10/9/19, she came to the facility to do a mock survey and was watching incontinent care on Resident #14 when she noted and inquired about a scabbed area to Resident #14's left knee. The RNC said staff told her that LVN A placed a heat pack on Resident 14's left knee causing a blister that ruptured. She said she started investigating and discovered the facility did not immediately report the incident to the physician. She said the nurse (LVN A) that applied the heat pack on 8/17/19, was no longer employed at the facility at the time of the discovery and would not answer the facility's phone calls. The RNC said Physician A did see Resident #14 after the incident on 8/24/19. Attempts to contact and interview LVN A by telephone were unsuccessful until 12/19/19 at 2:12 p.m. During the interview, LVN A said she did not know what date the incident occurred. She said she did not know how Resident #14's blister happened. LVN A said she did not remember what morning it was, but the oncoming shift reported the blister to her. She said there was no documentation about it. LVN A said she worked the 6 a.m. to 2 p.m. shift and that she assessed Resident #14's knee every day because it was really swollen, and she was having a lot of pain with either arthritis or gout. She said the blister ruptured and she documented on it and let the ADON and DON B know about it. LVN A said she did not know if the DON called the doctor to notify him, she said she followed the chain of command. LVN A said she left for her days off thinking it was taken care of, but when she came back, there was no documentation about it. After being reminded that she documented the treatment on Resident #14's knee on Saturday, 8/17/19 at 11:05 a.m. and the presence of a ruptured blister on Sunday, 8/18/19 at 9:30 a.m., LVN A said, when she noted that the knee looked infected, she could not recall her name, but she notified the weekend RN (Registered Nurse) and the weekend RN notified DON B and the ADON. LVN A said the facility finally got an antibiotic for Resident #14. LVN A said on Saturday, 8/17/19 she alternated heat packs with ice packs on Resident #14's knee per the COTA's (Certified Occupational Therapist Assistant) guidance. LVN A said there was no physician's order for the heat packs. She said the therapy department was already putting heat packs on Resident #14's knee and every nurse continued what therapy was doing. She said she was not the only nurse applying heat-every nurse was applying heat, but she was the only one that documented it. She said she had no training for using heat packs from the [MEDICATION NAME], so she consulted with the COTA and he guided her on applying the heat pack, alternating it with an ice pack. She said the COTA told her to place a towel between Resident #14's skin and the heat pack and to assess her skin every 5 minutes, so she had the CNAs monitor her knee. LVN A said, when she left her shift, there was no blister on Resident #14's knee. LVN A said once Resident #14 got the blister, the treatments were discontinued. LVN A said she was off for a few days and when she returned, the blister had popped and was infected. She said the RN (that she could not identify) called to ER (emergency room ) to notify them, but she did not know if the call was returned. LVN A said Resident #14's level of pain did not change after she sustained the blister. She estimated the size of the blister as 2 cm (centimeters) by less than 1 cm. LVN A said she was not sure if the nurses had a physician's order to apply heat packs to Resident #14's knee, but that therapy had been providing the treatments, so the nurses continued what therapy was doing. In an interview on 12/19/19 at 8:10 a.m., the RNC said the facility did not have a physician's order for the nurses to apply heat packs to Resident #14's knee, prior to the 8/19/19 order. She said the therapy department may have had an order. In an interview on 12/19/19 at 8:20 a.m., the COTA said there was a physician's order for heat packs, but he was not clear as to whether it was for therapy or for the nurses. He said he did not remember LVN A consulting with him about applying the heat packs to Resident #14, and that he had not provided any in-services to the nurses on how to wrap and apply the heat packs from the [MEDICATION NAME]. The COTA said, the temperature of the heat packs in the [MEDICATION NAME] reached 160 degrees. Review of a witness statement written and signed by the ADON on 8/19/19 revealed, On shift change it was reported to this nurse that 10/6 (10p.m-6 a.m.) shift noted a fluid filled blister to this resident's lt (left) knee on 8/18/19 at strt of shift. This nurse reported to DON. DON, OT (occupational therapist) and chg (charge) nurse went to resident's room to assess. Notes blister open no fluid in it. This nurse call (Physician A's) office to report was told he was out of building until Wednesday. In an interview on 12/17/19 at 2:12 p.m., the ADON said Resident #14's blister occurred over the weekend (8/17/19-8/18/19). She said she was notified when she arrived at work on Monday morning 8/19/19, so she notified DON A, and then she, DON A and the COTA went to assess. The ADON said she called Physician A and was informed he was not in the office, so she reported the blister to his nurse who said she would notify the Nurse Practitioner (NP A). The ADON said she thought NP A called the facility that evening (8/19/19) and gave them orders. The ADON said when she saw the blister, it was not covered, and it was an open area approximately three inches long and about one inch wide. She said Resident #14 was placed on antibiotic therapy. The ADON said the facility had an interim Administrator at the time, and she thought DON A had reported Resident #14's condition to her. Review of a witness statement written and signed by DON A on 10/9/19 revealed, On Monday, 8/19/19, upon arriving at work, I was informed that our resident (Resident #14's name) had sustained a blister to her left knee. It apparently resulted from a hot pack placed upon the knee 8/17/19 for the treatment of [REDACTED]. The knee was assessed, and (Physician A' name) was immediately contacted by (ADON's name). (Resident's daughter/POA's name) was contacted by myself. (Resident #14's) knee has been continuously treated from 8/19/19 until the present. Telephone calls were placed to DON A on 12/17/19 at 2:48 p.m. and on 12/19/19 at 12:54 p.m. Messages were left, requesting a call back, but he did not respond. In an interview on 12/17/19 at 4:30 p.m. CNA B said she did not see Resident #14's blister because it was already bandaged. She said she heard Resident #14 got the blister on her left knee from a heating pad. In an interview on 12/17/19 at 2:35 p.m., LVN C, the nurse who documented the physician's telephone order for the [MEDICATION NAME] and moist heat pack, said she did not remember getting an order for [REDACTED].#14 had been having a lot of pain and swelling in her knee, and she felt that was why it was slow to heal. In an interview on 12/17/19 at 10:28 a.m., the COTA said he had been in facilities where nurses use heat packs from the [MEDICATION NAME] and some don't. He said, in this facility, since the incident with Resident #14 nurses were not to use heat packs from the [MEDICATION NAME]. The COTA said injuries can happen when you don't use enough padding. He said he didn't think the blister became infected, it just took a while to heal due to Resident #14's poor circulation. The COTA said the wound was healed now. In an interview on 12/18/19 at 9:02 a.m., the COTA described and demonstrated how to wrap a heat pack from the [MEDICATION NAME] by folding it in a padded terry cloth sleeve. He said he would place a towel between the resident's skin and the wrapped heat pack for additional protection. The COTA said he did not speak to LVN A about applying a heat pack to Resident #14's knee, so he did not know how she prepared the pack or how long it was applied. He said he did not leave it on for more than 15-20 minutes as it would start to lose its heat. The COTA acknowledged that he applied the heat pack after Resident #14's blister formed and ruptured, but he said she did not express any pain, when he applied the treatment. He said he applied the heat pack on the top of the leg from the thigh to below the knee. Review of a witness statement written and signed by LVN B on 10/9/19 revealed, Reporting nurse was notified by CNAs that resident's lt (left) knee had a blister. Reporting nurse assessed resident's knee and noted a lg (large) fluid filled blister on the top of resident's knee. Assess (assessment) charted and passed 'alone' (sp) to charge nurse coming in which happened to be the ADON (ADON's name). In a telephone interview on 12/18/19 at 1:42 p.m. LVN B said Resident #14's blister happened on the weekend (8/17/19-8/18/19). She said the 6 a.m. to 2 p.m. shift nurse was applying warm packs on Resident #14's knee. She said the CNAs told her during her 2 p.m. to 10 p.m. shift, and when she assessed the blister, it was intact. LVN B said she reported the blister to the ADON when she came on shift the next morning (8/19/19). LVN B said she did not know if the wound became infected, but she knew Resident #14 was placed on antibiotics. In a telephone interview on 12/19/19 at 10:38 a.m., LVN C said, when she saw Resident #14's knee, the wound was open. She said it took a while for the injury to heal and the staff put a leg rest on Resident #14's wheelchair to keep her leg straight, because it hurt her knee when she bent it. In an interview on 12/18/19 at 11:50 a.m., the RNC said staff should have notified the physician at the time the issue was identified. The facility completed the following actions to correct the non-compliance on 10/9/19: 1. Initiated a facility investigation on 10/9/19. 2. DON A was suspended and is no longer employed at the facility. 3. The facility contacted Physician A and obtained orders for treatment and care of Resident #14's wound on 8/19/19. 4. LVN A, who applied the heat pack, is no longer employed by the facility. 5. The facility immediately provided the following staff in-services verified by review of the Attendance Forms and curriculum dated 10/9/19: Incidents-Incident Reporting Resident Care-Hot Packs Change in a Resident's Condition Following Physician's Order Abuse and Neglect During interviews on 12/17/19, 12/18/19, and 12/19/19, three nurses and four CNAs confirmed they had received the in-services, and all were able to describe the correct procedure for reporting a resident's change in condition. The nurses were able to describe the procedure for immediately notifying the physician of a resident's change in condition and verbalized their understanding that only therapy personnel were qualified to treat residents with hot packs. Review of the therapy department's policy 8.25-Physical Agent Modalities updated 8/3/18 revealed: Policy: In order to assure the safety of our patients and to provide the highest level of patient care (Therapy Contractor) policy stipulates that all physical agent modalities will be provided only by Therapy contractor employees and/or contractors who have graduated from an accredited professional program and who are licensed-where applicable-to practice as Physical Therapists (PTs), Physical Therapist Assistants (PTAs), Occupational Therapists (OTs), Certified occupational Therapy Assistants (COTAs), Speech Language pathologist, or as Clinical fell ows. This policy covers the use of: Hot packs by PTs, PTAs, OTRs, and COTAs . Procedure to be considered qualified to use hot packs, cold, [MEDICATION NAME], diathermy, ultrasound, or electrical stimulation, all Therapy Contractor clinicians using such modalities must demonstrate theoretical background and clinical practicum applications for the safe and competent integration of the modality into a therapeutic intervention plan. Procedure 8.25-1 Physical Agent Modalities-Hot Fold 4 towels in half, width-wise. Place each towel on top of the other forming 8 layers of toweling. If patient lays on hot packs or is highly sensitive to heat, use additional towels. If using a terry cloth cover, the terry cloth acts a two layers. Always monitor the patient-both verbally and visually -throughout the treatment. You may have to add towels depending on patient assessment. Never leave a patient unattended. Therapist should assess the skin periodically during treatment. Document pre/post skin integrity on daily documentation. [MEDICATION NAME] Maintenance: Maintain temperature logs daily for the [MEDICATION NAME]. [MEDICATION NAME] temperatures should range between 160-175 degrees Fahrenheit Review of the facility's policy Change in a Resident's Condition or Status revised (MONTH) (YEAR) revealed: Policy-Our facility shall promptly notify the resident, his or her attending physician, and representative (sponsor) of changes in the resident's medical/mental condition and/or status . Interpretation and Implementation: 1. The nurse will notify the resident's Attending Physician or physician on call when there has been a (an): a. accident or incident involving the resident . 3. Prior to notifying the Physician or healthcare provider, the nurse will make detailed observations and gather relevant and pertinent information for the provider . 5. Except in medical emergencies, notifications will be made within twenty-four (24) hours of a change occurring in the resident's medical/mental condition or status .

Based on observations, interviews and record review the facility failed to provide pharmaceutical services to ensure the accurate acquiring, receiving, dispensing, and administering of medications to two of twelve residents (Resident #1 and Resident #6) reviewed for Pharmacy Services. The facility failed to: A. Obtain and administer Keppra from 8/23/17 to 8/27/17 to Resident #1 who had a history of [REDACTED].#1 exhibited seizure activity for approximately one hour on 8/27/17, which required being transferred by emergency personnel to the local hospital and then being transferred to a larger hospital in another town for treatment. B. Clarify that Resident #6's Mysoline (Primidone) had been discontinued prior to his admission to the facility. As a result, Resident #6 received one dose of the discontinued medication after his admission. This failure resulted in an Immediate Jeopardy (IJ) identified on 11/2/17. After verification of the facility's Plan of Removal the IJ was lowered on 11/4/17 to a severity level of actual harm that is not Immediate Jeopardy and a scope of isolated due to the facility's need to evaluate the effectiveness of the corrective systems that were put into place. This failure resulted in harm for Resident #1, and placed her and 2 other residents, who received anticonvulsants, at risk for complications due to not receiving medications ordered by the physician or receiving medications that had been discontinued. Findings included: A. Resident #1 Record Review of Resident #1's resident face sheet undated revealed she was a [AGE] year old female admitted to the facility on [DATE] and readmitted to the facility on [DATE]. She was admitted to the facility with [DIAGNOSES REDACTED]. Record Review of Resident #1's Admission evaluation dated 08/23/17 included a current [DIAGNOSES REDACTED]. DON documented Medication orders were verified with Physician A. Neurological section noted pupils equal and reactive on left and right, weakness to left side and facial drooping to left side. Musculoskeletal section of admission evaluation dated 08/23/17 revealed no ambulation and resident does not respond to commands to perform range of motion. Admission evaluation was signed by DON. Record Review of Resident #1's Admission physician orders [REDACTED]. Physician order [REDACTED]. According to the U. S. National Library of Medicine, Levetiracetam (Keppra) is an anticonvulsant used to treat seizures. Levetiracetam is used to help control certain types of seizures in the treatment of [REDACTED]. https://www.ncbi.nlm.nih.gov/pubmedhealth/PMH 56/?report=printable (accessed on 11/08/17) Review of Resident #1's admission MDS (Minimum Data Set) dated 08/27/17 revealed a BIMS (Brief Interview of Mental Status) was not completed due to resident was rarely or never understood. Review of Resident #1's Nursing care plans with admission date of [DATE] did not address seizure disorder. Review of CNA Care Plan with admission date of [DATE] revealed Resident #1 had [DIAGNOSES REDACTED]. Her Activities of Daily Living include she was dependent on staff for bed mobility, transfers, eating, toileting, dressing and bathing. Review of Resident #1's August 2017 Medication Sheets received from Hospital A revealed Levetiracetam (Keppra)1000mg one tablet twice a day at 8am and 8pm and no doses were signed as being administered from admission on 08/23/17 to transfer on 08/27/17. (Medication sheets were sent to Hospital A with Resident #1 on August 27, 2017) Record Review of Resident #1's Daily Skilled Nursing Notes dated 08/24/17 at 9:00 a.m.AM meds given. Physician A here this am orders for lab for next week .Signed ADON. Record Review of Resident #1's Daily Skilled Nursing notes dated 08/27/17 revealed: 0730, alert and responds to verbal stimuli prior to getting out of bed up to chair via lift. VS 98-63-20 139/88 and O2 sat 92% on 2 L N/C Signed RN A 0745 Found unresponsive. Attempted to stimulate by verbal and painful stimuli. Responded some - eyes rolling back in head and starring. VS 137/95-95-O2 sat 97. Became more responsive after placing back to bed. Continued to have starring motion from eyes. Slight tremors noted to extremities. Entry not signed 0750 NP A called regarding seizure activity and patient status. Order received to go ahead and give Clonazepam 0.5mg po (by mouth) if pt (patient) able to take po (by mouth) and may repeat if needed. Signed RN A 0800 Clonazepam 0.5mg po (by mouth) given without difficulty. Cont. to monitor. Signed RN A 0830 Continued to have some seizure activity - repeated Clonazepam 0.5 po (by mouth). Took without difficulty. Not signed 0845 Called NP back regarding seizures activity and patient status. Informed I (RN A) was calling ambulance. Not signed 0905 Pt totally unresponsive. NO breathing noted. CPR started. Signed RN A 0910 EMS here -cont (continued) with bagging and compressions. Monitor applied - Monitor showing sinus tach (tachycardia) 130's IV started per EMS. Resident having jerking motions of bilateral legs and arms. Not signed 0920 Transferred to Hamlin Hospital via EMS (Emergency Medical Services). Signed RN A 0850 Late noted. More pronounced jerking of extremities jaws clenched and salivating (drooling) Signed RN A Review of 24 hour nursing reports from 08/23/17 to 08/27/17 revealed no documentation to indicate Resident #1 did not have all ordered medications for administration. Review of Nursing home to Hospital Transfer Form dated 08/27/17 revealed Resident #1 was transferred to Hospital A with reason to transfer as seizures with risk alert for seizures. Form completed by RN A Review of Hospital A emergency room Record dated 08/27/17 revealed Resident #1 presented to the ER this am via EMS s/p tonic clinic seizure at nursing home. According to Nursing Home RN A, patient was having little seizures where she would flutter her eyes and stare and she would follow commands. EMS administered her an extra clonazepam crushed with water which she took ok .EMS stated when we got there the RN A said she was having a grand mal seizure and they had started CPR, however Resident #1 was in sinus tachycardia (ST) with pulse on arrival. Resident #1 received Valium 10mg IVP by EMS and all seizure activity stopped within minutes. Maintained Airway Dx: Seizures, hypomagnesia, hemorrhagic metastasis. Transfer to Hospital B via ground EMS. Condition stable. Record Review of Resident #1's lab results from Hospital A dated 08/27/17 at 12:51 p.m. revealed Keppra (Levetiracetam) level of 4 (low) with normal range noted to be 12-46. Review of Hospital A EMS Prehospital Care Report dated 08/27/17 revealed Resident #1 has extensive past medical history. Resident #1 had seizure episode this AM and was currently unresponsive. Resident #1 also had period of respiratory arrest earlier this AM and received CPR from care home staff. Resident #1 currently stable. Resident #1 to be taken to Hospital B for increased level of care. Resident #1 was awake and oriented times one, eyes open spontaneously, but did not react to external stimuli. Pupils equal, round and reactive to light, Circulation present all extremities, motor function unobtainable due to patient being unresponsive. Skin warm and dry, Vital signs within normal limits. Heart monitor shows sinus rhythm. 12 lead EKG acquired, software analysis indicated sinus rhythm with PVC's. Resident remains stable until 1218 when seizure activity starts. Patient has seizure that involves only right side of face at 1218 that lasts 20-30 seconds. Resident #1 has additional seizure at 1225 that involves entire body. Resident #1 given Valium 5mg intravenous push with cessation of seizure activity within one minute at 1226 .CPR information revealed time of arrest at 9:04 a.m., time CPR discontinued was 9:16 a.m Upon arrival, EMS walked into Resident #1's room to find CPR in progress by care home staff. Review of Resident #1's Neurology Consultation dated 08/27/17 by Physician C noted the resident was evaluated for altered mental status and seizure. History of present illness: . patient was recently discharged from Hospital B 4 days ago The patient was recently transferred to nursing facility after ischemic stroke with hemorrhagic conversion and also generalized tonic-clonic seizure. According to the son, the patient was talking yesterday; however, on August 27, 2017, the patient was found unresponsive .The patient had 2 episodes of generalized tonic-clonic seizure and became unresponsive. It was unsure how long the seizure was .According to the family, the patient did not receive the Keppra for the last 3 days. The patient was recently admitted and discharged from Hospital B for multiple medical problems. During the last admission, the patient had multi-organ failure with sepsis. Also the patient had multiple ischemic stroke with hemorrhagic conversion and the patient had [DIAGNOSES REDACTED]. The patient also suffered a generalized tonic-clonic seizure. The patient also had a seizure in the past . When I last saw her on August 23, 2017, the patient was confused, did not have conversation for me. The patient had significant left sided weakness . The patient was supposed to be on Keppra however the patient has not been receiving the Keppra .Assessment and Plan: .1. Generalized tonic-clonic seizure. a. This patient had a history of [REDACTED]. Review of Resident #1's Physician note dated 08/27/17 by Physician D revealed Chief Complaint was unresponsiveness. History of present illness: She was actually discharged to nursing facility 4 days ago by myself . She also had history of seizure for prolonged part of her life and has been having tonic-clonic seizure here during last admission for which she was started on Keppra .Patient was returned to Hospital B emergency room early today because she was found apparently unresponsive. Her son and brother by bedside at the time of exam. They said patient may have had 2 episodes of tonic clonic seizure and she became unresponsive. EMS was called. Apparently prior to arrival of EMS patient was started on chest compressions because it was thought she may be in pulseless activity. Weekly EMS arrived patients had good pulses, patient had good blood pressure. CPR was aborted and patient was brought to Hospital B without requiring endotracheal intubation .There is also question if patient really has been taking her Keppra to prevent seizures. Observation and interview at the facility on 11/01/17 at 9:20 a.m. revealed Resident #1 was in bed. She was awake and said she didn't eat breakfast this am because she wasn't hungry. She denied any concerns. In an interview on 11/01/17 at 3:40 p.m., DON said she completed Resident #1's admission on 08/23/17. She sent a list of her medications to the pharmacy. She said the pharmacy did not send Keppra because they had questions regarding the directions. She said she didn't check the meds in to ensure they were all received. She said none of the nurses reported to her they didn't receive the medications from the Pharmacy and that the resident had not received her medications. She said once she faxed the request for medications to the pharmacy, the facility would receive medications within a day. She said she was not aware Resident #1 had not received her Keppra. She said it wasn't until 08/27/17 that she found out the resident had seizures, CPR and required transport to Hospital A and later transported to Hospital B. She said EMS reported Resident #1 had pulse and respirations upon their arrival so she questioned if the CPR was actually needed. She said Resident #1 was admitted to Hospital B on 08/27/17 and discharged back to the facility on [DATE]. She said Hospital B filled the Keppra to ensure Resident #1 received her medication. DON said she now checks physician orders [REDACTED]. In an interview on 11/01/17 at 5:15 p.m., DON said she heard or was told on 08/27/17, Resident #1 had seizure activity for over an hour and nurse told staff to just watch her. She said she found it hard to believe Resident #1 had a seizure lasting for over an hour and questioned if Resident #1 really needed CPR. In an interview on 11/03/17 at 8:25 a.m., RN A said she worked at the facility every other weekend. She said on 08/27/17 there was one CNA, one kitchen staff, one housekeeper and herself on duty. She said on 08/26/17 she was told there was a new resident (Resident #1). She said she was not given a good report but was told the resident was semi-comatose. RN A said on 08/26/17, immediately after report she went to Resident #1's room to meet her. She was awake and alert. RN A said after receiving report on 08/27/17, she said she and CNA A transferred Resident #1 from her bed to her wheelchair using the lift. She said she left Resident #1's room and returned about 10-15 minutes later and found Resident #1 slumped over her chair. RN A said Resident #1's vital signs were okay. She said she and the CNA A put resident back to bed on using a lift. She said Resident #1 was lying on her back and would stare with her eyes open and did not respond. She said Resident #1's arms and legs were shaking and she appeared to be having seizures. RN A said she called NP A and gave report that Resident was unresponsive, Vital signs, and that she was staring. RN A reported to NP A that Resident #1 had nothing to give except Clonazepam if needed. NP A gave RN A an order to crush Clonazepam, try and give it and could repeat the dose of Clonazepam. RN A said she crushed the Clonazepam and administered it to Resident #1. RN A said she was trying to watch dining room and Resident #1 at the same time. She said 30 minutes went by and no changes in Resident #1 so she repeated the dose of Clonazepam. She said Resident #1's seizures got worse so she called the NP A back and called the ambulance. She said about the time the ambulance came, Resident #1 quit breathing so CPR was started. EMS came in and Resident #1 was hooked up to a monitor and had a heart rate so the EMS started bagging her and started an IV. She said Resident #1 was transported via ambulance to Hospital A then on to Hospital B. She said she remembered there were several medications Resident #1 did not have since admission but didn't remember what meds she didn't have to administer. RN A said she did not tell anyone (Physician, DON, Administrator or family) she didn't have medications for Resident #1. In an interview on 11/08/17 at 11:16 a.m., RN A returned phone call and said she recalled on the weekend of 08/26/17 and 08/27/17 a note was taped to the counter at nurses station a list of medications that had not been received for Resident #1 from Pharmacy A. She said she did not recall the specific medications listed on that note. She said on the morning of 08/27/17, numerous call lights were sounding, residents were requesting medications, another resident was attempting to get out of her wheelchair unassisted and the CNA reported another resident had rectal bleeding. She said she went to room across the hall from Resident #1 to assess rectal bleeding. She said she was in that residents room for approximately 10-15 minutes. She said Resident #1 started out with twitching and had a blank stare. She said as time went on it got worse and her arms and legs were jerking. She said this went on for approximately one hour. She said even after administering two doses of Clonazepam, it did not stop the seizures. She said she was unable to stay continuously with Resident #1 morning of 08/27/17. She said there was not enough staff on duty to take care of all the residents. In an interview on 11/02/17 at 4:32 p.m., NP A said facility RN A notified her resident #1 was having seizure activity. She said RN A did not tell her resident had [DIAGNOSES REDACTED].#1 had not received Keppra since admission from 08/23/17 to 08/27/17. RN A said resident had an order for [REDACTED]. NP A said EMS reported to her resident had pulse and respirations upon their arrival to the facility. In an interview on 11/02/17 at 12:35 p.m., CNA A said she worked at the facility from 6am to 6pm on 08/27/17. She said she had not received any inservicing regarding seizures upon admission for Resident #1. She said she was the only CNA on duty at the time of the incident. She said on 08/27/17 around 6:40 a.m., she went to Resident #1's room and noticed she was experiencing seizure like activity so she was placed back to bed. She said Resident #1 was twitching, her eyes were twitching. She said Resident #1 had this on admission but Physician A said it was normal for her, however, on 08/27/17 it was much more pronounced. CNA A said she notified RN A and was told to just watch her. She said she proceeded to take care of other residents but would return to Resident #1's room to check on her. CNA A said Resident #1 had slurred speech, one side of her face was drooping and she was foaming at her mouth and not responding. CNA A was instructed by RN A to keep monitoring Resident #1. CNA A said this seizure activity went on for about two hours. CNA A said Resident #1 started jerking more and had a grand mal seizure. CNA A said Resident #1 became unresponsive and RN A started CPR until EMS arrived. CNA A said she didn't think CPR was done correctly, don't think she needed CPR. CNA A said EMS reported upon their arrival resident was breathing, CNA A said to her knowledge, resident #1 never stopped breathing. CNA A said the only staff on duty at the facility on 08/27/17 at time of incident was RN A, CNA A and Cook A. CNA A said there was not enough staff on duty. In an interview on 11/04/17 at 1:35 p.m., Cook A said she was working when Resident #1 had a seizure on 08/27/17. Cook A said she was in the dining room serving tea and water when RN A took Resident #1 from the dining room to her room. She said Resident was twitching and her arms and legs were moving. Cook A said she walked by Resident #1's room a little later on 08/27/17 (not sure exact time) and saw her arms and legs jerking and Resident #1 was in her room alone in bed lying on her back. Cook A said she went to find staff but RN A was in the restroom and she located CNA A and requested she go to Resident #1's room and check on her. Cook A said CNA A went to Resident #1's room and she returned to the kitchen. In an interview on 11/01/17 at 5 p.m., the ADON said that she had circled on 08/24/17 and 08/25/17 that she did not administer Keppra. She said she did not administer the Keppra and should have called Pharmacy A to inquire about medications. She also said she did not report to DON, physician or anyone else that medications were not available. She said when holding or not giving a medication as ordered, she was to write on back of the MAR why medication was not administered. In an interview on 11/01/17 at 4:50 p.m., DON said if a nurse doesn't administer a medication, they were to write on the back of the MAR the reason the medication was not given. Nurses were to also report to DON if medications are not available. Review of Emergency Kit Inventory at the facility dated 11/03/17 revealed Keppra (Levetiracetam) was not stocked in the Emergency Drug kit. In an interview on 11/01/17 at 2:44 p.m. Pharmacy A LPT (Lead Pharmacy Technician) said the list of medications for Resident #1 received from nursing facility on 08/23/17 was from Discharge Summary of Hospital B. The list of medications did not include Keppra (Levetiracetam). She said Keppra was not filled and sent to facility due to not being on list of medications Pharmacy A received from facility. Record review of the documents faxed to Pharmacy A on 8/23/17 were provided by Pharmacy A on 11/2/17 and revealed the facility had faxed a copy of the Discharge Summary from Hospital B dated 8/23/17. The Discharge Summary contained a list of medications the resident had been receiving outside of the hospital. The list did not include Keppra. In an interview on 11/06/17 at 2:35 p.m., DON said she notified Physician A's office nurse on 08/28/17 that Resident #1 did not receive five medications that included Keppra, Synthroid, Zyprexa, Mag Ox and Temazepam as ordered from 08/23/17 to 08/27/17. Review of office note from Physician A dated 08/28/17 revealed DON called regarding failure to receive two medications that had been ordered. Facility DON wanted us to know that two of the medications the nursing home had ordered from the pharmacy were not delivered, hence not given for 2 days prior to the patient having to go to the hospital. In an interview on 11/02/17 at 1:15 p.m., Physician A said if he was not on call, the facility staff were to call hospital and talk to provider on duty. He said on 08/27/17, the facility staff would have called Hospital A emergency room and spoke to the provider on duty. Physician A reviewed his notes regarding Resident #1 and said he had not received any notes from the facility regarding the incident on 08/27/17. He said the DON did call his office on 08/28/17 and reported Resident #1 did not receive two medications because they had not been delivered by the pharmacy. He said the DON did not specify which two medications Resident #1 did not receive. Physician A said his expectation was for facility to get medications in a timely manner. He said the medications should have been filled at a local pharmacy or facility could call physician to substitute another medication. Physician A said resident #1 should not have gone without her meds, especially Keppra and even the Levothyroxine. Surveyor read list of medications facility identified Resident #1 did not receive Keppra, Synthroid, Zyprexa, Mag Ox and Temazepam as ordered and he said he was not aware Resident #1 went without more than 2 medications. He said he had a note in Resident #1's medical record noting upon her discharge from Hospital B on 08/29/17, Keppra 1000mg 60 tabs were filled by Pharmacy C and sent with Resident #1 back to nursing facility to ensure she had the medication. In an interview on 11/04/17 at 2:40 p.m., LVN C said she worked the day after Resident #1 was admitted . LVN C said the DON had taped a list of medications to the counter at the nurse's station to watch for that the facility had not received from the pharmacy. LVN C said she did not call a physician or pharmacy to check on these medications since the DON knew about them not being available. LVN C said she did not recall which medications were listed on the list of medications. In an interview on 11/04/17 at 3:15 p.m., LVN C said the facility had some of Resident #1's meds but not others. She said she could not remember which ones were available. LVN C was shown copies of Resident #1's medication sheets for August 2017 obtained from Hospital A and copy of Resident #1's August 2017 medication sheets from facility clinical record and she verified they did not match and someone (doesn't remember who) asked her to initial and circle her initial on the August 2017 medication sheet after Resident #1 returned to the facility on [DATE] for medications she should have received from 08/23/17 to time of transfer from the facility on 08/27/17. In an interview on 11/04/17 at 3:30 p.m., the administrator said if a new admission or a re-admit of current resident occurs, the nurses were to send physician's orders [REDACTED]. She said if medications were not delivered, nurses were to call Pharmacy A after-hours phone number. If Pharmacy A cannot fill order for medications, the nurse was to call the physician and notify DON and residents family. She said if this was not done and medications were not available, then the resident was being neglected. She said her expectation was for the nurse to initial on the medication sheet as the medication was administered. She said if the medication was not given, the nurse should circle their initials and document why medication was not administered. In an interview on 11/06/17 at 2:35 p.m., DON said on admissions, she will review orders, list of medications and any medications sent with resident and notify physician for orders and for any clarification needed. Physician orders [REDACTED]. She said if medications were unavailable, she would note this on the 24 hour nurse report for each nurse to follow up on medication. If available from Emergency Drug kit, may use medication from the kit. She said medications can also be filled at Pharmacy B if needed. She said the physician would be notified of any medication that was not available. DON said she considered it neglect when resident goes without medications. She said the Regional Nurse Consultant instructed her to have nursing staff fill in blanks on the August Medication Sheet for Resident #1 on whether or not medication was administered. DON said she felt this situation was a total lack of communication. Nurses not letting anyone know or didn't call the physician when medications were unavailable. DON said she and the corporate nurse decided Resident #1 didn't have a seizure because she took medications during the time she was supposed to be having a seizure and she wasn't incontinent. In an interview on 11/06/17 at 3:35 p.m., ADM said she did not feel procedures were followed and medications were not ordered correctly. She said nurses should have called the physician when medications were unavailable. They should let the physician make the decision. She said the nurses could have followed the after-hours policy and get medications from the hospital or another pharmacy. Her expectation for nurses are to initial as a medication was administered. If the medication is not given for some reason, the nurse should circle their initials and document on back of medication sheet the reason it was not given. She said she would ensure this does not happen again. ADM said she was unaware that Resident #1 had not received her seizure meds from admission on 08/23/17 until she was transferred to Hospital A on 08/27/17. She said she considered this incident as neglect and should have reported to the state. Review of Medication Error Report dated 08/28/17 revealed Resident #1's faxed ordered medication list received from Hospital B discharge with above list of medications not received from Pharmacy A. Medications listed include: Levothyroxine, Mag Ox, Temazepam, Zyprexa, Cholestyramine, Keppra and Megestrol. Outcome to resident lists no adverse reactions identified. Physician A was notified on 08/28/17 at 3:25 p.m. Assessment and Summary of error lists no medications received from pharmacy and nursing miscommunication and pharmacy miscommunication. B. Resident #6 Review of Resident #6's undated Resident Face Sheet revealed he was a [AGE] year old male admitted to the facility on [DATE] with the following Diagnoses: [REDACTED]. Review of Resident #6's Admission MDS (Minimum Data Set) dated 9/13/17 revealed he required extensive assistance with his ADLs (Activities of Daily Living) and his BIMS (Brief Interview for Mental Status) score was 14, which indicated his cognitive function was intact. Review of Resident #6's Care Plan dated 9/12/17 revealed: Problem: I am at risk for injury from tremors and involuntary muscle movements as I have Parkinson's Disease. Goal: I will have no injuries due to my Parkinson's Disease over the next 90 days. Long Term Goal Target Date: 12/29/2017. Approach: .Provide me with the medications and labs ordered by my MD (medical doctor). Review of Resident #6's admission orders [REDACTED].o. (by mouth) at HS (bedtime); Diagnosis: [REDACTED]. Review of Resident #6's recapitulated physician's orders [REDACTED]. The order date was 9/6/17 and the end date was open-ended. According to webmd.com accessed on 11/7/17 at: https://www.webmd.com/epilepsy/guide/essential-tremor-drug#2-5 Primidone (Mysoline) is an anti-seizure drug that is also effective for treating [DIAGNOSES REDACTED] .A small number of people who take anticonvulsants for any condition (such as seizure, bipolar disorder, pain) may experience depression, suicidal thoughts/attempts, or other mental/mood problems. Review of a Release of Responsibility for Medications form dated 9/6/17, sent to the facility with medications for Resident #6 when he transferred there from Facility B, revealed a list of medications, the amount of each medication to be taken, the times the medications were to be taken, the amount of medication on leaving the facility and the amount returned. Included in the list of medications was Primidone; amount to be taken was 2; times to be taken was each evening/bedtime; amount of medication on leaving was 30 and amount returned was blank. Review of a Shipping Manifest from Pharmacy A dated 9/7/17 revealed medications that had been dispensed to the facility for Resident #6. Included on the inventory was Primidone 50 mg tablet, quantity 60 with prescription number 70.00 Review of Resident #6's MAR (Medications Flowsheet/Medication Administration Record) dated 9/1/17-9/30/17 revealed a nurse had initialed the box for 9/6/17 beside the Mysoline which indicated Resident #6 received a dose of the medication at bedtime on 9/6/17. A bracket was drawn after the initials and Not reordered Dc'd (discontinued) was documented. Review of Resident #6's MAR dated 10/1/17-10/31/17 revealed all of the boxes for each date in October were initialed which indicated he received the Mysoline every evening at bedtime in October 2017; a total of 31 doses. Review of Resident #6's Nurse Progress Notes from 9/6/17-10/30/17 revealed no documentation addressing the clarification of the Mysoline order. Observation on 10/31/17 at 10:35 a.m. revealed Resident #6 sitting in his wheelchair in his room. He was alert, dressed and groomed. He said he had no complaints and the food was good. In an interview on 11/1/17 at 4:45 p.m. The ADON identified the Responsibility for Medications form as the inventory of the medications that Facility B sent with Resident #6 when he was transferred from that facility to the current facility on 9/6/17. She said she used the inventory to transcribe the medication orders to the facility's admission orders [REDACTED]

Based on observations, interviews, and record review the facility failed to ensure residents were free from neglect for 1 of 12 residents (Resident #1) reviewed for neglect. The facility failed to obtain and administer [MEDICATION NAME] from [DATE] to [DATE] to Resident #1 who had a history of [REDACTED].#1 exhibited [MEDICAL CONDITION] activity for approximately one hour on [DATE] and then was transferred to hospital A for treatment. This failure resulted in an Immediate Jeopardy (IJ) identified on [DATE]. The IJ was lowered on [DATE] to a severity level of actual harm that is not Immediate Jeopardy and a scope of isolated due to the facility's need to evaluate the effectiveness of the corrective systems that were put into place. This failure resulted in harm for Resident #1, and placed her and 2 other residents who received anticonvulsant medications at risk for life-threatening complications due to the potential for not receiving medications ordered by the physician. Findings included: Record Review of Resident #1's resident face sheet undated revealed she was a [AGE] year old female admitted to the facility on [DATE] and readmitted to the facility on [DATE]. She was admitted to the facility with [DIAGNOSES REDACTED]. Record Review of Resident #1's Admission evaluation dated [DATE] included a current [DIAGNOSES REDACTED]. DON documented Medication orders were verified with Physician A. Neurological section noted pupils equal and reactive on left and right, weakness to left side and facial drooping to left side. Musculoskeletal section of admission evaluation dated [DATE] revealed no ambulation and resident does not respond to commands to perform range of motion. Admission evaluation was signed by DON. Record Review of Resident #1's Admission physician orders [REDACTED]. Physician order [REDACTED]. According to the U. S. National Library of Medicine, Levetiracetam ([MEDICATION NAME]) is an anticonvulsant used to treat [MEDICAL CONDITION]. Levetiracetam is used to help control certain types of [MEDICAL CONDITION] in the treatment of [REDACTED]. https://www.ncbi.nlm.nih.gov/pubmedhealth/PMH 56/?report=printable (accessed on [DATE]) Review of Resident #1's admission MDS (Minimum Data Set) dated [DATE] revealed a BIMS (Brief Interview of Mental Status) was not completed due to resident was rarely or never understood. Review of Resident #1's Nursing care plans with admission date of [DATE] did not address [MEDICAL CONDITION] disorder. Review of CNA Care Plan with admission date of [DATE] revealed Resident #1 had [DIAGNOSES REDACTED]. Her Activities of Daily Living include she was dependent on staff for bed mobility, transfers, eating, toileting, dressing and bathing. Review of Resident #1's [DATE] Medication Sheets received from Hospital A revealed Levetiracetam ([MEDICATION NAME]) 1000mg one tablet twice a day at 8am and 8pm and no doses were signed as being administered from admission on [DATE] to transfer on [DATE]. (Medication sheets were sent to Hospital A with Resident #1 on [DATE]) Record Review of Resident #1's Daily Skilled Nursing Notes dated [DATE] at 9:00 a.m.AM meds given. Physician A here this am orders for lab for next week .Signed ADON. Record Review of Resident #1's Daily Skilled Nursing notes dated [DATE] revealed: 0730, alert and responds to verbal stimuli prior to getting out of bed up to chair via lift. VS [DATE] ,[DATE] and O2 sat 92% on 2 L N/C Signed RN A 0745 Found unresponsive. Attempted to stimulate by verbal and painful stimuli. Responded some - eyes rolling back in head and starring. VS ,[DATE]-95-O2 sat 97. Became more responsive after placing back to bed. Continued to have starring motion from eyes. Slight tremors noted to extremities. Entry not signed 0750 NP A called regarding [MEDICAL CONDITION] activity and patient status. Order received to go ahead and give [MEDICATION NAME] 0.5mg po (by mouth) if pt (patient) able to take po (by mouth) and may repeat if needed. Signed RN A 0800 [MEDICATION NAME] 0.5mg po (by mouth) given without difficulty. Cont. to monitor. Signed RN A 0830 Continued to have some [MEDICAL CONDITION] activity - repeated [MEDICATION NAME] 0.5 po (by mouth). Took without difficulty. Not signed 0845 Called NP (NP A) back regarding [MEDICAL CONDITION] activity and patient status. Informed RN A was calling ambulance. Not signed 0905 Pt totally unresponsive. NO breathing noted. CPR started. Signed RN A 0910 EMS here -cont (continued) with bagging and compressions. Monitor applied - Monitor showing sinus tach ([MEDICAL CONDITION] 130's IV started per EMS. Resident having jerking motions of bilateral legs and arms. Not signed 0920 Transferred to Hamlin Hospital via EMS (Emergency Medical Services). Signed RN A 0850 Late noted. More pronounced jerking of extremities jaws clenched and salivating (drooling) Signed RN A Review of 24 hour nursing reports from [DATE] to [DATE] revealed no documentation to indicate Resident #1 did not have all ordered medications for administration. Review of Nursing home to Hospital Transfer Form dated [DATE] revealed Resident #1 was transferred to Hospital A with reason to transfer as [MEDICAL CONDITION] with risk alert for [MEDICAL CONDITION]. Form completed by RN A Review of Hospital A emergency room Record dated [DATE] revealed Resident #1 presented to the ER this am via EMS s/p tonic clinic [MEDICAL CONDITION] at nursing home. According to Nursing Home RN A, patient was having little [MEDICAL CONDITION] where she would flutter her eyes and stare and she would follow commands. EMS administered her an extra [MEDICATION NAME] crushed with water which she took ok .EMS stated when we got there the RN A said she was having a grand mal [MEDICAL CONDITION] and they had started CPR, however Resident #1 was in sinus [MEDICAL CONDITION](ST) with pulse on arrival. Resident #1 received [MEDICATION NAME] 10mg IVP by EMS and all [MEDICAL CONDITION] activity stopped within minutes. Maintained Airway Dx: [MEDICAL CONDITION], hypomagnesia, hemorrhagic metastasis. Transfer to Hospital B via ground EMS. Condition stable. Record Review of Resident #1's lab results from Hospital A dated [DATE] at 12:51 p.m. revealed [MEDICATION NAME] (Levetiracetam) level of 4 (low) with normal range noted to be ,[DATE]. Review of Hospital A EMS Prehospital Care Report dated [DATE] revealed Resident #1 has extensive past medical history. Resident #1 had [MEDICAL CONDITION] episode this AM and was currently unresponsive. Resident #1 also had period of respiratory arrest earlier this AM and received CPR from care home staff. Resident #1 currently stable. Resident #1 to be taken to Hospital B for increased level of care. Resident #1 was awake and oriented times one, eyes open spontaneously, but did not react to external stimuli. Pupils equal, round and reactive to light, Circulation present all extremities, motor function unobtainable due to patient being unresponsive. Skin warm and dry, Vital signs within normal limits. Heart monitor shows sinus rhythm. 12 lead EKG acquired, software analysis indicated sinus rhythm with PVC's. Resident remains stable until 1218 when [MEDICAL CONDITION] activity starts. Patient has [MEDICAL CONDITION] that involves only right side of face at 1218 that lasts ,[DATE] seconds. Resident #1 has additional [MEDICAL CONDITION] at 1225 that involves entire body. Resident #1 given [MEDICATION NAME] 5mg intravenous push with cessation of [MEDICAL CONDITION] activity within one minute at 1226 .CPR information revealed time of arrest at 9:04 a.m., time CPR discontinued was 9:16 a.m Upon arrival, EMS walked into Resident #1's room to find CPR in progress by care home staff. Review of Resident #1's Neurology Consultation dated [DATE] by Physician C noted the resident was evaluated for altered mental status and [MEDICAL CONDITION]. History of present illness: . patient was recently discharged from Hospital B 4 days ago The patient was recently transferred to nursing facility after ischemic stroke with hemorrhagic conversion and also generalized tonic-clonic [MEDICAL CONDITION]. According to the son, the patient was talking yesterday; however, on [DATE], the patient was found unresponsive .The patient had 2 episodes of generalized tonic-clonic [MEDICAL CONDITION] and became unresponsive. It was unsure how long the [MEDICAL CONDITION] was .According to the family, the patient did not receive the [MEDICATION NAME] for the last 3 days. The patient was recently admitted and discharged from Hospital B for multiple medical problems. During the last admission, the patient had multi-organ failure [MEDICAL CONDITION]. Also the patient had multiple ischemic stroke with hemorrhagic conversion and the patient had [MEDICAL CONDITION]. The patient also suffered a generalized tonic-clonic [MEDICAL CONDITION]. The patient also had a [MEDICAL CONDITION] in the past . When I last saw her on [DATE], the patient was confused, did not have conversation for me. The patient had significant left sided weakness . The patient was supposed to be on [MEDICATION NAME] however the patient has not been receiving the [MEDICATION NAME] .Assessment and Plan: .1. Generalized tonic-clonic [MEDICAL CONDITION]. a. This patient had a history of [REDACTED]. Review of Resident #1's Physician note dated [DATE] by Physician D revealed Chief Complaint was unresponsiveness. History of present illness: She was actually discharged to nursing facility 4 days ago by myself . She also had history of [MEDICAL CONDITION] for prolonged part of her life and has been having tonic-clonic [MEDICAL CONDITION] here during last admission for which she was started on [MEDICATION NAME] .Patient was returned to Hospital B emergency room early today because she was found apparently unresponsive. Her son and brother by bedside at the time of exam. They said patient may have had 2 episodes of tonic clonic [MEDICAL CONDITION] and she became unresponsive. EMS was called. Apparently prior to arrival of EMS patient was started on chest compressions because it was thought she may be in pulseless activity. Weekly EMS arrived patients had good pulses, patient had good blood pressure. CPR was aborted and patient was brought to Hospital B without requiring endotracheal intubation .There is also question if patient really has been taking her [MEDICATION NAME] to prevent [MEDICAL CONDITION]. Observation and Interview at the facility on [DATE] at 9:20 a.m. revealed Resident #1 was in bed. She was awake and said she didn't eat breakfast this am because she wasn't hungry. She denied any concerns. In an interview on [DATE] at 3:40 p.m., DON said she completed Resident #1's admission on [DATE]. She sent a list of her medications to the pharmacy. She said the pharmacy did not send [MEDICATION NAME] because they had questions regarding the directions. She said she didn't check the meds in to ensure they were all received. She said none of the nurses reported to her they didn't receive the medications from the Pharmacy and that the resident had not received her medications. She said once she faxed the request for medications to the pharmacy, the facility would receive medications within a day. She said she was not aware Resident #1 had not received her [MEDICATION NAME]. She said it wasn't until [DATE] that she found out the resident had [MEDICAL CONDITION], CPR and required transport to Hospital A and later transported to Hospital B. She said EMS reported Resident #1 had pulse and respirations upon their arrival so she questioned if the CPR was actually needed. She said Resident #1 was admitted to Hospital B on [DATE] and discharged back to the facility on [DATE]. She said Hospital B filled the [MEDICATION NAME] to ensure Resident #1 received her medication. DON said she now checks physician orders [REDACTED]. In an interview on [DATE] at 5:15 p.m., DON said she heard or was told on [DATE], Resident #1 had [MEDICAL CONDITION] activity for over an hour and nurse told staff to just watch her. She said she found it hard to believe Resident #1 had a [MEDICAL CONDITION] for over an hour and questioned if Resident #1 really needed CPR. In an interview on [DATE] at 8:25 a.m., RN A said she worked at the facility every other weekend. She said on [DATE] there was one CNA, one kitchen staff, one housekeeper and herself on duty. She said on [DATE] she was told there was a new resident (Resident #1). She said she was not given a good report but was told the resident was semi-comatose. RN A said on [DATE], immediately after report she went to Resident #1's room to meet her. She was awake and alert. RN A said after receiving report on [DATE], she said she and CNA A transferred Resident #1 from her bed to her wheelchair using the lift. She said she left Resident #1's room and returned about ,[DATE] minutes later and found Resident #1 slumped over her chair. RN A said Resident #1's vital signs were okay. She said she and the CNA A put resident back to bed on using a lift. She said Resident #1 was lying on her back and would stare with her eyes open and did not respond. She said Resident #1's arms and legs were shaking and she appeared to be having [MEDICAL CONDITION]. RN A said she called NP A and gave report that Resident was unresponsive, Vital signs, and that she was staring. RN A reported to NP A that Resident #1 had nothing to give except [MEDICATION NAME] if needed. NP A gave RN A an order to crush [MEDICATION NAME], try and give it and could repeat the dose of [MEDICATION NAME]. RN A said she crushed the [MEDICATION NAME] and administered it to Resident #1. RN A said she was trying to watch dining room and Resident #1 at the same time. She said 30 minutes went by and no changes in Resident #1 so she repeated the dose of [MEDICATION NAME]. She said Resident #1's [MEDICAL CONDITION] got worse so she called the NP A back and called the ambulance. She said about the time the ambulance came, Resident #1 quit breathing so CPR was started. EMS came in and Resident #1 was hooked up to a monitor and had a heart rate so the EMS started bagging her and started an IV. She said Resident #1 was transported via ambulance to Hospital A then on to Hospital B. She said she remembered there were several medications Resident #1 did not have since admission but didn't remember what meds she didn't have to administer. RN A said she did not tell anyone (Physician, DON, Administrator or family) she didn't have medications for Resident #1. In an interview on [DATE] at 11:16 a.m., RN A returned phone call and said she recalled on the weekend of [DATE] and [DATE] a note was taped to the counter at nurses station a list of medications that had not been received for Resident #1 from Pharmacy A. She said she did not recall the specific medications listed on that note. She said on the morning of [DATE], numerous call lights were sounding, residents were requesting medications, another resident was attempting to get out of her wheelchair unassisted and the CNA reported another resident had rectal bleeding. She said she went to room across the hall from Resident #1 to assess rectal bleeding. She said she was in that residents room for approximately ,[DATE] minutes. She said Resident #1 started out with twitching and had a blank stare. She said as time went on it got worse and her arms and legs were jerking. She said this went on for approximately one hour. She said even after administering two doses of [MEDICATION NAME], it did not stop the [MEDICAL CONDITION]. She said she was unable to stay continuously with Resident #1 morning of [DATE]. She said there was not enough staff on duty to take care of all the residents. In an interview on [DATE] at 4:32 p.m., NP A said facility RN A notified her resident #1 was having [MEDICAL CONDITION] activity. She said RN A did not tell her resident had [DIAGNOSES REDACTED].#1 had not received [MEDICATION NAME] since admission from [DATE] to [DATE]. RN A said resident had an order for [REDACTED]. NP A said EMS reported to her resident had pulse and respirations upon their arrival to the facility. In an interview on [DATE] at 12:35 p.m., CNA A said she worked at the facility from 6am to 6pm on [DATE]. She said she had not received any inservicing regarding [MEDICAL CONDITION] upon admission for Resident #1. She said she was the only CNA on duty at the time of the incident. She said on [DATE] around 6:40 a.m., she went to Resident #1's room and noticed she was experiencing [MEDICAL CONDITION] activity so she was placed back to bed. She said Resident #1 was twitching, her eyes were twitching. She said Resident #1 had this on admission but Physician A said it was normal for her, however, on [DATE] it was much more pronounced. CNA A said she notified RN A and was told to just watch her. She said she proceeded to take care of other residents but would return to Resident #1's room to check on her. CNA A said Resident #1 had slurred speech, one side of her face was drooping and she was foaming at her mouth and not responding. CNA A was instructed by RN A to keep monitoring Resident #1. CNA A said this [MEDICAL CONDITION] activity went on for about two hours. CNA A said Resident #1 started jerking more and had a grand mal [MEDICAL CONDITION]. CNA A said Resident #1 became unresponsive and RN A started CPR until EMS arrived. CNA A said she didn't think CPR was done correctly, don't think she needed CPR. CNA A said EMS reported upon their arrival resident was breathing, CNA A said to her knowledge, resident #1 never stopped breathing. CNA A said the only staff on duty at the facility on [DATE] at time of incident was RN A, CNA A and Cook A. CNA A said there was not enough staff on duty. In an interview on [DATE] at 1:35 p.m., Cook A said she was working when Resident #1 had a [MEDICAL CONDITION] on [DATE]. Cook A said she was in the dining room serving tea and water when RN A took Resident #1 from the dining room to her room. She said Resident was twitching and her arms and legs were moving. Cook A said she walked by Resident #1's room a little later on [DATE] (not sure exact time) and saw her arms and legs jerking and Resident #1 was in her room alone in bed lying on her back. Cook A said she went to find staff but RN A was in the restroom and she located CNA A and requested she go to Resident #1's room and check on her. Cook A said CNA A went to Resident #1's room and she returned to the kitchen. In an interview on [DATE] at 5 p.m., the ADON said that she had circled on [DATE] and [DATE] that she did not administer [MEDICATION NAME]. She said she did not administer the [MEDICATION NAME] and should have called Pharmacy A to inquire about medications. She also said she did not report to DON, physician or anyone else that medications were not available. She said when holding or not giving a medication as ordered, she was to write on back of the MAR why medication was not administered. In an interview on [DATE] at 4:50 p.m., DON said if a nurse doesn't administer a medication, they were to write on the back of the MAR the reason the medication was not given. Nurses were to also report to DON if medications are not available. Review of Emergency Kit Inventory at the facility dated [DATE] revealed [MEDICATION NAME] (Levetiracetam) was not stocked in the Emergency Drug kit. In an interview on [DATE] at 2:44 p.m. Pharmacy A LPT (Lead Pharmacy Technician) said the list of medications for Resident #1 received from nursing facility on [DATE] was from Discharge Summary of Hospital B. The list of medications did not include [MEDICATION NAME] (Levetiracetam). She said [MEDICATION NAME] was not filled and sent to facility due to not being on list of medications Pharmacy A received from facility. Record review of the documents faxed to Pharmacy A on [DATE] were provided by Pharmacy A on [DATE] and revealed the facility had faxed a copy of the Discharge Summary from Hospital B dated [DATE]. The Discharge Summary contained a list of medications the resident had been receiving outside of the hospital. The list did not include [MEDICATION NAME]. In an interview on [DATE] at 2:35 p.m., DON said she notified Physician A's office nurse on [DATE] that Resident #1 did not receive five medications that included [MEDICATION NAME], Mag Ox and [MEDICATION NAME] as ordered from [DATE] to [DATE]. Review of office note from Physician A dated [DATE] revealed DON called regarding failure to receive two medications that had been ordered. Facility DON wanted us to know that two of the medications the nursing home had ordered from the pharmacy were not delivered, hence not given for 2 days prior to the patient having to go to the hospital. In an interview on [DATE] at 1:15 p.m., Physician A said if he was not on call, the facility staff were to call hospital and talk to provider on duty. He said on [DATE], the facility staff would have called Hospital A emergency room and spoke to the provider on duty. Physician A reviewed his notes regarding Resident #1 and said he had not received any notes from the facility regarding the incident on [DATE]. He said the DON did call his office on [DATE] and reported Resident #1 did not receive two medications because they had not been delivered by the pharmacy. He said the DON did not specify which two medications Resident #1 did not receive. Physician A said his expectation was for facility to get medications in a timely manner. He said the medications should have been filled at a local pharmacy or facility could call physician to substitute another medication. Physician A said resident #1 should not have gone without her meds, especially [MEDICATION NAME] and even the [MEDICATION NAME]. Surveyor read list of medications facility identified Resident #1 did not receive [MEDICATION NAME], Mag Ox and [MEDICATION NAME] as ordered and he said he was not aware Resident #1 went without more than 2 medications. He said he had a note in Resident #1's medical record noting upon her discharge from Hospital B on [DATE], [MEDICATION NAME] 1000mg 60 tabs were filled by Pharmacy C and sent with Resident #1 back to nursing facility to ensure she had the medication. In an interview on [DATE] at 2:40 p.m., LVN C said she worked the day after Resident #1 was admitted . LVN C said the DON had taped a list of medications to the counter at the nurse's station to watch for that the facility had not received from the pharmacy. LVN C said she did not call a physician or pharmacy to check on these medications since the DON knew about them not being available. LVN C said she did not recall which medications were listed on the list of medications. In an interview on [DATE] at 3:15 p.m., LVN C said the facility had some of Resident #1's meds but not others. She said she could not remember which ones were available. LVN C was shown copies of Resident #1's medication sheets for [DATE] obtained from Hospital A and copy of Resident #1's [DATE] medication sheets from facility clinical record and she verified they did not match and someone (doesn't remember who) asked her to initial and circle her initial on the [DATE] medication sheet after Resident #1 returned to the facility on [DATE] for medications she should have received from [DATE] to time of transfer from the facility on [DATE]. In an interview on [DATE] at 3:30 p.m., the administrator said if a new admission or a re-admit of current resident occurs, the nurses were to send physician's orders [REDACTED]. She said if medications were not delivered, nurses were to call Pharmacy A after-hours phone number. If Pharmacy A cannot fill order for medications, the nurse was to call the physician and notify DON and residents family. She said if this was not done and medications were not available, then the resident was being neglected. She said her expectation was for the nurse to initial on the medication sheet as the medication was administered. She said if the medication was not given, the nurse should circle their initials and document why medication was not administered. In an interview on [DATE] at 2:35 p.m., DON said on admissions, she will review orders, list of medications and any medications sent with resident and notify physician for orders and for any clarification needed. Physician orders [REDACTED]. She said if medications were unavailable, she would note this on the 24 hour nurse report for each nurse to follow up on medication. If available from Emergency Drug kit, may use medication from the kit. She said medications can also be filled at Pharmacy B if needed. She said the physician would be notified of any medication that was not available. DON said she considered it neglect when resident goes without medications. She said the Regional Nurse Consultant instructed her to have nursing staff fill in blanks on the August Medication Sheet for Resident #1 on whether or not medication was administered. DON said she felt this situation was a total lack of communication. Nurses not letting anyone know or didn't call the physician when medications were unavailable. DON said she and the corporate nurse decided Resident #1 didn't have a [MEDICAL CONDITION] because she took medications during the time she was supposed to be having a [MEDICAL CONDITION] and she wasn't incontinent. In an interview on [DATE] at 3:35 p.m., ADM said she did not feel procedures were followed and medications were not ordered correctly. She said nurses should have called the physician when medications were unavailable. They should let the physician make the decision. She said the nurses could have followed the after-hours policy and get medications from the hospital or another pharmacy. Her expectation for nurses are to initial as a medication was administered. If the medication is not given for some reason, the nurse should circle their initials and document on back of medication sheet the reason it was not given. She said she would ensure this does not happen again. ADM said she was unaware that Resident #1 had not received her [MEDICAL CONDITION] meds from admission on [DATE] until she was transferred to Hospital A on [DATE]. She said she considered this incident as neglect and should have reported to the state. Review of Medication Error Report dated [DATE] revealed Resident #1's faxed ordered medication list received from Hospital B discharge with above list of medications not received from Pharmacy A. Medications listed include: [MEDICATION NAME], Mag Ox, [MEDICATION NAME] and [MEDICATION NAME]. Outcome to resident lists no adverse reactions identified. Physician A was notified on [DATE] at 3:25 p.m. Assessment and Summary of error lists no medications received from pharmacy and nursing miscommunication and pharmacy miscommunication. Review of the facility's undated Investigating Allegations of Neglect policy revealed: Policy Statement: All reported incidents of neglect are promptly and thoroughly investigated. Policy Interpretation: 1. Neglect is defined as failure to provide goods and services necessary to avoid physical harm, mental anguish, mental illness or the deterioration of resident's physical or mental condition. 2. Neglect also means the failure to protect the resident from abuse, neglect and exploitation. 3. Neglect is repeated conduct or a single incident of carelessness which produces or could reasonably be expected to result in serious physical or psychological injury or a substantial risk of death. When conducting an investigation of neglect, implement the following protocol: a. Determine what goods or services were not provided to the resident; b. Determine if physical harm, mental anguish, mental illness or deterioration in the resident's physical or mental condition resulted from the failure of the facility to provide goods or services; and c. Determine if the intent of the negligence was willful (in this case it would become Abuse). Review of facility's Nursing Guidelines for [MEDICAL CONDITION] (undated) revealed Emergency guidelines: 1. Stay with the resident and call for help. Be sure charge nurse is notified .6. Turn head to side or place in side-lying position to open airway and promote drainage of secretions Observe for and report to Charge Nurse: .2. Time [MEDICAL CONDITION] started and stopped and duration of [MEDICAL CONDITION]. 3. Description of body parts involved and severity of convulsive movements. 4. Presence of an aura, incontinence, unconsciousness, and eyes rolled upward, frothing of the mouth, biting of the tongue or injuries due to [MEDICAL CONDITION]. 5. Condition of resident after [MEDICAL CONDITION] such as disorientation or sleepiness 6. Other significant observations. Review of facility's policy Administering Medications dated [DATE] revealed Policy Statement Medications will be administered in a timely manner and as prescribed by the resident's attending physician or the facility's medical director. Policy Interpretation and Implementation .2. The Director of Nursing Services is responsible for the supervision and direction of all personnel with medication administration duties and functions. 3. Medications must be administered in a timely manner and in accordance with the attending physician's written/verbal orders .9. The individual administering the medication must ensure that the right medication, right dosage, right time and right method of administration are verified before the medication is administered. (e.g., review of drug label, physician's orders [REDACTED]. The individual administering the medications must initial the resident's MAR on the appropriate line and date for that specific day before administering the next resident's medication .13. Should a drug be withheld, refused, or given other than at the scheduled time, the individual administering the medication must initial and circle the MAR space provided for that particular drug .15. Any explanatory note on the reverse side of the MAR must be entered when drugs are withheld, refused, or given other than at scheduled times. (Note: The director of nursing services and attending physician must be notified when two (2) consecutive doses of a medication are refused or withheld.) Review of the Facility's Admissions Guideline last revised on [DATE] revealed the following: Procedure: 5. Notify the attending physician of the resident arrival and verify the orders with the physician. Have available for the physician: a. Resident's name b. Resident age c. admitting [DIAGNOSES REDACTED]. Ask for orders for therapy and baseline labs related to medication. 6. Fax your request for medications to the pharmacy. You may use the transfer orders if legible, or fax the white copy of your admission orders [REDACTED] Review of Facility's Nursing Guidelines: Change of Condition Notification (undated) revealed the following: Notification of changes shall include: 1. An accident involving the resident, which results in injury and has the potential for requiring physician intervention; 2. A significant change in the resident's physical, mental or psychosocial status, such as a deterioration in health, mental, or psychosocial status, in life-threatening conditions or clinical complications; 3. A need to alter treatment significantly; 4. A decision to transfer or discharge the resident facility; .or 6. A change in resident rights under Federal or State law or regulations pertaining to care of the resident. Review of the Medical Record (TRUNCATED)

Based on observation, interview and record review, the facility failed to implement their written policies and procedures that prohibited neglect for one of twelve residents (Resident #1) reviewed for neglect. The facility failed to obtain and administer [MEDICATION NAME] from [DATE] to [DATE] to Resident #1 who had a history of [REDACTED].#1 exhibited [MEDICAL CONDITION] activity for approximately one hour on [DATE] and then was transferred to hospital A for treatment. This failure resulted in an Immediate Jeopardy (IJ) identified on [DATE]. After verification of the facility's Plan of Removal the IJ was lowered on [DATE] to a severity level of actual harm that is not Immediate Jeopardy and a scope of isolated due to the facility's need to evaluate the effectiveness of the corrective systems that were put into place. This failure resulted in harm for Resident #1, and placed her and 2 other residents who received anticonvulsant medications at risk for life-threatening complications due to the potential for not receiving medications ordered by the physician. Findings included: Review of the facility's undated Investigating Allegations of Neglect policy revealed: Policy Statement: All reported incidents of neglect are promptly and thoroughly investigated. Policy Interpretation: 1. Neglect is defined as failure to provide goods and services necessary to avoid physical harm, mental anguish, mental illness or the deterioration of resident's physical or mental condition. 2. Neglect also means the failure to protect the resident from abuse, neglect and exploitation. 3. Neglect is repeated conduct or a single incident of carelessness which produces or could reasonably be expected to result in serious physical or psychological injury or a substantial risk of death. When conducting an investigation of neglect, implement the following protocol: a. Determine what goods or services were not provided to the resident; b. Determine if physical harm, mental anguish, mental illness or deterioration in the resident's physical or mental condition resulted from the failure of the facility to provide goods or services; and c. Determine if the intent of the negligence was willful (in this case it would become Abuse). Record Review of Resident #1's resident face sheet undated revealed she was a [AGE] year old female admitted to the facility on [DATE] and readmitted to the facility on [DATE]. She was admitted to the facility with [DIAGNOSES REDACTED]. Record Review of Resident #1's Admission evaluation dated [DATE] included a current [DIAGNOSES REDACTED]. DON documented Medication orders were verified with Physician A. Neurological section noted pupils equal and reactive on left and right, weakness to left side and facial drooping to left side. Musculoskeletal section of admission evaluation dated [DATE] revealed no ambulation and resident does not respond to commands to perform range of motion. Admission evaluation was signed by DON. Record Review of Resident #1's Admission physician orders [REDACTED]. Physician order [REDACTED]. According to the U. S. National Library of Medicine, Levetiracetam ([MEDICATION NAME]) is an anticonvulsant used to treat [MEDICAL CONDITION]. Levetiracetam is used to help control certain types of [MEDICAL CONDITION] in the treatment of [REDACTED]. https://www.ncbi.nlm.nih.gov/pubmedhealth/PMH 56/?report=printable (accessed on [DATE]) Review of Resident #1's admission MDS (Minimum Data Set) dated [DATE] revealed a BIMS (Brief Interview of Mental Status) was not completed due to resident was rarely or never understood. Review of Resident #1's Nursing care plans with admission date of [DATE] did not address [MEDICAL CONDITION] disorder. Review of CNA Care Plan with admission date of [DATE] revealed Resident #1 had [DIAGNOSES REDACTED]. Her Activities of Daily Living include she was dependent on staff for bed mobility, transfers, eating, toileting, dressing and bathing. Review of Resident #1's [DATE] Medication Sheets received from Hospital A revealed Levetiracetam ([MEDICATION NAME]) 1000mg one tablet twice a day at 8am and 8pm and no doses were signed as being administered from admission on [DATE] to transfer on [DATE]. (Medication sheets were sent to Hospital A with Resident #1 on [DATE]) Record Review of Resident #1's Daily Skilled Nursing Notes dated [DATE] at 9:00 a.m.AM meds given. Physician A here this am orders for lab for next week .Signed ADON. Record Review of Resident #1's Daily Skilled Nursing notes dated [DATE] revealed: 0730, alert and responds to verbal stimuli prior to getting out of bed up to chair via lift. VS [DATE] ,[DATE] and O2 sat 92% on 2 L N/C Signed RN A 0745 Found unresponsive. Attempted to stimulate by verbal and painful stimuli. Responded some - eyes rolling back in head and starring. VS ,[DATE]-95-O2 sat 97. Became more responsive after placing back to bed. Continued to have starring motion from eyes. Slight tremors noted to extremities. Entry not signed 0750 NP A called regarding [MEDICAL CONDITION] activity and patient status. Order received to go ahead and give [MEDICATION NAME] 0.5mg po (by mouth) if pt (patient) able to take po (by mouth) and may repeat if needed. Signed RN A 0800 [MEDICATION NAME] 0.5mg po (by mouth) given without difficulty. Cont. to monitor. Signed RN A 0830 Continued to have some [MEDICAL CONDITION] activity - repeated [MEDICATION NAME] 0.5 po (by mouth). Took without difficulty. Not signed 0845 Called NP (NP A) back regarding [MEDICAL CONDITION] activity and patient status. Informed RN A was calling ambulance. Not signed 0905 Pt totally unresponsive. NO breathing noted. CPR started. Signed RN A 0910 EMS here -cont (continued) with bagging and compressions. Monitor applied - Monitor showing sinus tach ([MEDICAL CONDITION] 130's IV started per EMS. Resident having jerking motions of bilateral legs and arms. Not signed 0920 Transferred to Hamlin Hospital via EMS (Emergency Medical Services). Signed RN A 0850 Late noted. More pronounced jerking of extremities jaws clenched and salivating (drooling) Signed RN A Review of 24 hour nursing reports from [DATE] to [DATE] revealed no documentation to indicate Resident #1 did not have all ordered medications for administration. Review of Nursing home to Hospital Transfer Form dated [DATE] revealed Resident #1 was transferred to Hospital A with reason to transfer as [MEDICAL CONDITION] with risk alert for [MEDICAL CONDITION]. Form completed by RN A Review of Hospital A emergency room Record dated [DATE] revealed Resident #1 presented to the ER this am via EMS s/p tonic clinic [MEDICAL CONDITION] at nursing home. According to Nursing Home RN A, patient was having little [MEDICAL CONDITION] where she would flutter her eyes and stare and she would follow commands. EMS administered her an extra [MEDICATION NAME] crushed with water which she took ok .EMS stated when we got there the RN A said she was having a grand mal [MEDICAL CONDITION] and they had started CPR, however Resident #1 was in sinus [MEDICAL CONDITION](ST) with pulse on arrival. Resident #1 received [MEDICATION NAME] 10mg IVP by EMS and all [MEDICAL CONDITION] activity stopped within minutes. Maintained Airway Dx: [MEDICAL CONDITION], hypomagnesia, hemorrhagic metastasis. Transfer to Hospital B via ground EMS. Condition stable. Record Review of Resident #1's lab results from Hospital A dated [DATE] at 12:51 p.m. revealed [MEDICATION NAME] (Levetiracetam) level of 4 (low) with normal range noted to be ,[DATE]. Review of Hospital A EMS Prehospital Care Report dated [DATE] revealed Resident #1 has extensive past medical history. Resident #1 had [MEDICAL CONDITION] episode this AM and was currently unresponsive. Resident #1 also had period of respiratory arrest earlier this AM and received CPR from care home staff. Resident #1 currently stable. Resident #1 to be taken to Hospital B for increased level of care. Resident #1 was awake and oriented times one, eyes open spontaneously, but did not react to external stimuli. Pupils equal, round and reactive to light, Circulation present all extremities, motor function unobtainable due to patient being unresponsive. Skin warm and dry, Vital signs within normal limits. Heart monitor shows sinus rhythm. 12 lead EKG acquired, software analysis indicated sinus rhythm with PVC's. Resident remains stable until 1218 when [MEDICAL CONDITION] activity starts. Patient has [MEDICAL CONDITION] that involves only right side of face at 1218 that lasts ,[DATE] seconds. Resident #1 has additional [MEDICAL CONDITION] at 1225 that involves entire body. Resident #1 given [MEDICATION NAME] 5mg intravenous push with cessation of [MEDICAL CONDITION] activity within one minute at 1226 .CPR information revealed time of arrest at 9:04 a.m., time CPR discontinued was 9:16 a.m Upon arrival, EMS walked into Resident #1's room to find CPR in progress by care home staff. Review of Resident #1's Neurology Consultation dated [DATE] by Physician C noted the resident was evaluated for altered mental status and [MEDICAL CONDITION]. History of present illness: . patient was recently discharged from Hospital B 4 days ago The patient was recently transferred to nursing facility after ischemic stroke with hemorrhagic conversion and also generalized tonic-clonic [MEDICAL CONDITION]. According to the son, the patient was talking yesterday; however, on [DATE], the patient was found unresponsive .The patient had 2 episodes of generalized tonic-clonic [MEDICAL CONDITION] and became unresponsive. It was unsure how long the [MEDICAL CONDITION] was .According to the family, the patient did not receive the [MEDICATION NAME] for the last 3 days. The patient was recently admitted and discharged from Hospital B for multiple medical problems. During the last admission, the patient had multi-organ failure [MEDICAL CONDITION]. Also the patient had multiple ischemic stroke with hemorrhagic conversion and the patient had [MEDICAL CONDITION]. The patient also suffered a generalized tonic-clonic [MEDICAL CONDITION]. The patient also had a [MEDICAL CONDITION] in the past . When I last saw her on [DATE], the patient was confused, did not have conversation for me. The patient had significant left sided weakness . The patient was supposed to be on [MEDICATION NAME] however the patient has not been receiving the [MEDICATION NAME] .Assessment and Plan: .1. Generalized tonic-clonic [MEDICAL CONDITION]. a. This patient had a history of [REDACTED]. Review of Resident #1's Physician note dated [DATE] by Physician D revealed Chief Complaint was unresponsiveness. History of present illness: She was actually discharged to nursing facility 4 days ago by myself . She also had history of [MEDICAL CONDITION] for prolonged part of her life and has been having tonic-clonic [MEDICAL CONDITION] here during last admission for which she was started on [MEDICATION NAME] .Patient was returned to Hospital B emergency room early today because she was found apparently unresponsive. Her son and brother by bedside at the time of exam. They said patient may have had 2 episodes of tonic clonic [MEDICAL CONDITION] and she became unresponsive. EMS was called. Apparently prior to arrival of EMS patient was started on chest compressions because it was thought she may be in pulseless activity. Weekly EMS arrived patients had good pulses, patient had good blood pressure. CPR was aborted and patient was brought to Hospital B without requiring endotracheal intubation .There is also question if patient really has been taking her [MEDICATION NAME] to prevent [MEDICAL CONDITION]. Observation and Interview at the facility on [DATE] at 9:20 a.m. revealed Resident #1 was in bed. She was awake and said she didn't eat breakfast this am because she wasn't hungry. She denied any concerns. In an interview on [DATE] at 3:40 p.m., DON said she completed Resident #1's admission on [DATE]. She sent a list of her medications to the pharmacy. She said the pharmacy did not send [MEDICATION NAME] because they had questions regarding the directions. She said she didn't check the meds in to ensure they were all received. She said none of the nurses reported to her they didn't receive the medications from the Pharmacy and that the resident had not received her medications. She said once she faxed the request for medications to the pharmacy, the facility would receive medications within a day. She said she was not aware Resident #1 had not received her [MEDICATION NAME]. She said it wasn't until [DATE] that she found out the resident had [MEDICAL CONDITION], CPR and required transport to Hospital A and later transported to Hospital B. She said EMS reported Resident #1 had pulse and respirations upon their arrival so she questioned if the CPR was actually needed. She said Resident #1 was admitted to Hospital B on [DATE] and discharged back to the facility on [DATE]. She said Hospital B filled the [MEDICATION NAME] to ensure Resident #1 received her medication. DON said she now checks physician orders [REDACTED]. In an interview on [DATE] at 5:15 p.m., DON said she heard or was told on [DATE], Resident #1 had [MEDICAL CONDITION] activity for over an hour and nurse told staff to just watch her. She said she found it hard to believe Resident #1 had a [MEDICAL CONDITION] for over an hour and questioned if Resident #1 really needed CPR. In an interview on [DATE] at 8:25 a.m., RN A said she worked at the facility every other weekend. She said on [DATE] there was one CNA, one kitchen staff, one housekeeper and herself on duty. She said on [DATE] she was told there was a new resident (Resident #1). She said she was not given a good report but was told the resident was semi-comatose. RN A said on [DATE], immediately after report she went to Resident #1's room to meet her. She was awake and alert. RN A said after receiving report on [DATE], she said she and CNA A transferred Resident #1 from her bed to her wheelchair using the lift. She said she left Resident #1's room and returned about ,[DATE] minutes later and found Resident #1 slumped over her chair. RN A said Resident #1's vital signs were okay. She said she and the CNA A put resident back to bed on using a lift. She said Resident #1 was lying on her back and would stare with her eyes open and did not respond. She said Resident #1's arms and legs were shaking and she appeared to be having [MEDICAL CONDITION]. RN A said she called NP A and gave report that Resident was unresponsive, Vital signs, and that she was staring. RN A reported to NP A that Resident #1 had nothing to give except [MEDICATION NAME] if needed. NP A gave RN A an order to crush [MEDICATION NAME], try and give it and could repeat the dose of [MEDICATION NAME]. RN A said she crushed the [MEDICATION NAME] and administered it to Resident #1. RN A said she was trying to watch dining room and Resident #1 at the same time. She said 30 minutes went by and no changes in Resident #1 so she repeated the dose of [MEDICATION NAME]. She said Resident #1's [MEDICAL CONDITION] got worse so she called the NP A back and called the ambulance. She said about the time the ambulance came, Resident #1 quit breathing so CPR was started. EMS came in and Resident #1 was hooked up to a monitor and had a heart rate so the EMS started bagging her and started an IV. She said Resident #1 was transported via ambulance to Hospital A then on to Hospital B. She said she remembered there were several medications Resident #1 did not have since admission but didn't remember what meds she didn't have to administer. RN A said she did not tell anyone (Physician, DON, Administrator or family) she didn't have medications for Resident #1. In an interview on [DATE] at 11:16 a.m., RN A returned phone call and said she recalled on the weekend of [DATE] and [DATE] a note was taped to the counter at nurses station a list of medications that had not been received for Resident #1 from Pharmacy A. She said she did not recall the specific medications listed on that note. She said on the morning of [DATE], numerous call lights were sounding, residents were requesting medications, another resident was attempting to get out of her wheelchair unassisted and the CNA reported another resident had rectal bleeding. She said she went to room across the hall from Resident #1 to assess rectal bleeding. She said she was in that residents room for approximately ,[DATE] minutes. She said Resident #1 started out with twitching and had a blank stare. She said as time went on it got worse and her arms and legs were jerking. She said this went on for approximately one hour. She said even after administering two doses of [MEDICATION NAME], it did not stop the [MEDICAL CONDITION]. She said she was unable to stay continuously with Resident #1 morning of [DATE]. She said there was not enough staff on duty to take care of all the residents. In an interview on [DATE] at 4:32 p.m., NP A said facility RN A notified her resident #1 was having [MEDICAL CONDITION] activity. She said RN A did not tell her resident had [DIAGNOSES REDACTED].#1 had not received [MEDICATION NAME] since admission from [DATE] to [DATE]. RN A said resident had an order for [REDACTED]. NP A said EMS reported to her resident had pulse and respirations upon their arrival to the facility. In an interview on [DATE] at 12:35 p.m., CNA A said she worked at the facility from 6am to 6pm on [DATE]. She said she had not received any inservicing regarding [MEDICAL CONDITION] upon admission for Resident #1. She said she was the only CNA on duty at the time of the incident. She said on [DATE] around 6:40 a.m., she went to Resident #1's room and noticed she was experiencing [MEDICAL CONDITION] activity so she was placed back to bed. She said Resident #1 was twitching, her eyes were twitching. She said Resident #1 had this on admission but Physician A said it was normal for her, however, on [DATE] it was much more pronounced. CNA A said she notified RN A and was told to just watch her. She said she proceeded to take care of other residents but would return to Resident #1's room to check on her. CNA A said Resident #1 had slurred speech, one side of her face was drooping and she was foaming at her mouth and not responding. CNA A was instructed by RN A to keep monitoring Resident #1. CNA A said this [MEDICAL CONDITION] activity went on for about two hours. CNA A said Resident #1 started jerking more and had a grand mal [MEDICAL CONDITION]. CNA A said Resident #1 became unresponsive and RN A started CPR until EMS arrived. CNA A said she didn't think CPR was done correctly, don't think she needed CPR. CNA A said EMS reported upon their arrival resident was breathing, CNA A said to her knowledge, resident #1 never stopped breathing. CNA A said the only staff on duty at the facility on [DATE] at time of incident was RN A, CNA A and Cook A. CNA A said there was not enough staff on duty. In an interview on [DATE] at 1:35 p.m., Cook A said she was working when Resident #1 had a [MEDICAL CONDITION] on [DATE]. Cook A said she was in the dining room serving tea and water when RN A took Resident #1 from the dining room to her room. She said Resident was twitching and her arms and legs were moving. Cook A said she walked by Resident #1's room a little later on [DATE] (not sure exact time) and saw her arms and legs jerking and Resident #1 was in her room alone in bed lying on her back. Cook A said she went to find staff but RN A was in the restroom and she located CNA A and requested she go to Resident #1's room and check on her. Cook A said CNA A went to Resident #1's room and she returned to the kitchen. In an interview on [DATE] at 5 p.m., the ADON said that she had circled on [DATE] and [DATE] that she did not administer [MEDICATION NAME]. She said she did not administer the [MEDICATION NAME] and should have called Pharmacy A to inquire about medications. She also said she did not report to DON, physician or anyone else that medications were not available. She said when holding or not giving a medication as ordered, she was to write on back of the MAR why medication was not administered. In an interview on [DATE] at 4:50 p.m., DON said if a nurse doesn't administer a medication, they were to write on the back of the MAR the reason the medication was not given. Nurses were to also report to DON if medications are not available. Review of Emergency Kit Inventory at the facility dated [DATE] revealed [MEDICATION NAME] (Levetiracetam) was not stocked in the Emergency Drug kit. In an interview on [DATE] at 2:44 p.m. Pharmacy A LPT (Lead Pharmacy Technician) said the list of medications for Resident #1 received from nursing facility on [DATE] was from Discharge Summary of Hospital B. The list of medications did not include [MEDICATION NAME] (Levetiracetam). She said [MEDICATION NAME] was not filled and sent to facility due to not being on list of medications Pharmacy A received from facility. Record review of the documents faxed to Pharmacy A on [DATE] were provided by Pharmacy A on [DATE] and revealed the facility had faxed a copy of the Discharge Summary from Hospital B dated [DATE]. The Discharge Summary contained a list of medications the resident had been receiving outside of the hospital. The list did not include [MEDICATION NAME]. In an interview on [DATE] at 2:35 p.m., DON said she notified Physician A's office nurse on [DATE] that Resident #1 did not receive five medications that included [MEDICATION NAME], Mag Ox and [MEDICATION NAME] as ordered from [DATE] to [DATE]. Review of office note from Physician A dated [DATE] revealed DON called regarding failure to receive two medications that had been ordered. Facility DON wanted us to know that two of the medications the nursing home had ordered from the pharmacy were not delivered, hence not given for 2 days prior to the patient having to go to the hospital. In an interview on [DATE] at 1:15 p.m., Physician A said if he was not on call, the facility staff were to call hospital and talk to provider on duty. He said on [DATE], the facility staff would have called Hospital A emergency room and spoke to the provider on duty. Physician A reviewed his notes regarding Resident #1 and said he had not received any notes from the facility regarding the incident on [DATE]. He said the DON did call his office on [DATE] and reported Resident #1 did not receive two medications because they had not been delivered by the pharmacy. He said the DON did not specify which two medications Resident #1 did not receive. Physician A said his expectation was for facility to get medications in a timely manner. He said the medications should have been filled at a local pharmacy or facility could call physician to substitute another medication. Physician A said resident #1 should not have gone without her meds, especially [MEDICATION NAME] and even the [MEDICATION NAME]. Surveyor read list of medications facility identified Resident #1 did not receive [MEDICATION NAME], Mag Ox and [MEDICATION NAME] as ordered and he said he was not aware Resident #1 went without more than 2 medications. He said he had a note in Resident #1's medical record noting upon her discharge from Hospital B on [DATE], [MEDICATION NAME] 1000mg 60 tabs were filled by Pharmacy C and sent with Resident #1 back to nursing facility to ensure she had the medication. In an interview on [DATE] at 2:40 p.m., LVN C said she worked the day after Resident #1 was admitted . LVN C said the DON had taped a list of medications to the counter at the nurse's station to watch for that the facility had not received from the pharmacy. LVN C said she did not call a physician or pharmacy to check on these medications since the DON knew about them not being available. LVN C said she did not recall which medications were listed on the list of medications. In an interview on [DATE] at 3:15 p.m., LVN C said the facility had some of Resident #1's meds but not others. She said she could not remember which ones were available. LVN C was shown copies of Resident #1's medication sheets for [DATE] obtained from Hospital A and copy of Resident #1's [DATE] medication sheets from facility clinical record and she verified they did not match and someone (doesn't remember who) asked her to initial and circle her initial on the [DATE] medication sheet after Resident #1 returned to the facility on [DATE] for medications she should have received from [DATE] to time of transfer from the facility on [DATE]. In an interview on [DATE] at 3:30 p.m., the administrator said if a new admission or a re-admit of current resident occurs, the nurses were to send physician's orders [REDACTED]. She said if medications were not delivered, nurses were to call Pharmacy A after-hours phone number. If Pharmacy A cannot fill order for medications, the nurse was to call the physician and notify DON and residents family. She said if this was not done and medications were not available, then the resident was being neglected. She said her expectation was for the nurse to initial on the medication sheet as the medication was administered. She said if the medication was not given, the nurse should circle their initials and document why medication was not administered. In an interview on [DATE] at 2:35 p.m., DON said on admissions, she will review orders, list of medications and any medications sent with resident and notify physician for orders and for any clarification needed. Physician orders [REDACTED]. She said if medications were unavailable, she would note this on the 24 hour nurse report for each nurse to follow up on medication. If available from Emergency Drug kit, may use medication from the kit. She said medications can also be filled at Pharmacy B if needed. She said the physician would be notified of any medication that was not available. DON said she considered it neglect when resident goes without medications. She said the Regional Nurse Consultant instructed her to have nursing staff fill in blanks on the August Medication Sheet for Resident #1 on whether or not medication was administered. DON said she felt this situation was a total lack of communication. Nurses not letting anyone know or didn't call the physician when medications were unavailable. DON said she and the corporate nurse decided Resident #1 didn't have a [MEDICAL CONDITION] because she took medications during the time she was supposed to be having a [MEDICAL CONDITION] and she wasn't incontinent. In an interview on [DATE] at 3:35 p.m., ADM said she did not feel procedures were followed and medications were not ordered correctly. She said nurses should have called the physician when medications were unavailable. They should let the physician make the decision. She said the nurses could have followed the after-hours policy and get medications from the hospital or another pharmacy. Her expectation for nurses are to initial as a medication was administered. If the medication is not given for some reason, the nurse should circle their initials and document on back of medication sheet the reason it was not given. She said she would ensure this does not happen again. ADM said she was unaware that Resident #1 had not received her [MEDICAL CONDITION] meds from admission on [DATE] until she was transferred to Hospital A on [DATE]. She said she considered this incident as neglect and should have reported to the state. Review of Medication Error Report dated [DATE] revealed Resident #1's faxed ordered medication list received from Hospital B discharge with above list of medications not received from Pharmacy A. Medications listed include: [MEDICATION NAME], Mag Ox, [MEDICATION NAME] and [MEDICATION NAME]. Outcome to resident lists no adverse reactions identified. Physician A was notified on [DATE] at 3:25 p.m. Assessment and Summary of error lists no medications received from pharmacy and nursing miscommunication and pharmacy miscommunication. Review of facility's Nursing Guidelines for [MEDICAL CONDITION] (undated) revealed Emergency guidelines: 1. Stay with the resident and call for help. Be sure charge nurse is notified .6. Turn head to side or place in side-lying position to open airway and promote drainage of secretions Observe for and report to Charge Nurse: .2. Time [MEDICAL CONDITION] started and stopped and duration of [MEDICAL CONDITION]. 3. Description of body parts involved and severity of convulsive movements. 4. Presence of an aura, incontinence, unconsciousness, and eyes rolled upward, frothing of the mouth, biting of the tongue or injuries due to [MEDICAL CONDITION]. 5. Condition of resident after [MEDICAL CONDITION] such as disorientation or sleepiness 6. Other significant observations. Review of facility's policy Administering Medications dated [DATE] revealed Policy Statement Medications will be administered in a timely manner and as prescribed by the resident's attending physician or the facility's medical director. Policy Interpretation and Implementation .2. The Director of Nursing Services is responsible for the supervision and direction of all personnel with medication administration duties and functions. 3. Medications must be administered in a timely manner and in accordance with the attending physician's written/verbal orders .9. The individual administering the medication must ensure that the right medication, right dosage, right time and right method of administration are verified before the medication is administered. (e.g., review of drug label, physician's orders [REDACTED]. The individual administering the medications must initial the resident's MAR on the appropriate line and date for that specific day before administering the next resident's medication .13. Should a drug be withheld, refused, or given other than at the scheduled time, the individual administering the medication must initial and circle the MAR space provided for that particular drug .15. Any explanatory note on the reverse side of the MAR must be entered when drugs are withheld, refused, or given other than at scheduled times. (Note: The director of nursing services and attending physician must be notified when two (2) consecutive doses of a medication are refused or withheld.) Review of the Facility's Admissions Guideline last revised on [DATE] revealed the following: Procedure: 5. Notify the attending physician of the resident arrival and verify the orders with the physician. Have available for the physician: a. Resident's name b. Resident age c. admitting [DIAGNOSES REDACTED]. Ask for orders for therapy and baseline labs related to medication. 6. Fax your request for medications to the pharmacy. You may use the transfer orders if legible, or fax the white copy of your admission orders [REDACTED] Review of Facility's Nursing Guidelines: Change of Condition Notification (undated) revealed the following: Notification of changes shall include: 1. An accident involving the resident, which results in injury and has the potential for requiring physician intervention; 2. A significant change in the resident's physical, mental or psychosocial status, such as a deterioration in health, mental, or psychosocial status, in life-threatening conditions or clinical complications; 3. A need to alter treatment significantly; 4. A decision to transfer or discharge the resident facility; .or 6. A change in resident rights under Federal or State law or reg (TRUNCATED)

Based on observations, interviews, and record review the facility failed to ensure residents were free from significant medication errors for 1 of 12 residents (Resident #1) reviewed for significant medication errors. The facility failed to obtain and administer [MEDICATION NAME] from [DATE] to [DATE] to Resident #1 who had a history of [REDACTED].#1 exhibited [MEDICAL CONDITION] activity for approximately one hour on [DATE] and then was transferred to hospital A for treatment. This failure resulted in an Immediate Jeopardy (IJ) identified on [DATE]. The IJ was lowered on [DATE] to a severity level of actual harm that is not Immediate Jeopardy and a scope of isolated due to the facility's need to evaluate the effectiveness of the corrective systems that were put into place. This failure resulted in harm for Resident #1, and placed her and the other 2 residents who resided in the facility at risk for potential life-threatening complications due to the potential for not receiving medications ordered by the physician. Findings included: Record Review of Resident #1's resident face sheet undated revealed she was a [AGE] year old female admitted to the facility on [DATE] and readmitted to the facility on [DATE]. She was admitted to the facility with [DIAGNOSES REDACTED]. Record Review of Resident #1's Admission evaluation dated [DATE] included a current [DIAGNOSES REDACTED]. DON documented Medication orders were verified with Physician A. Neurological section noted pupils equal and reactive on left and right, weakness to left side and facial drooping to left side. Musculoskeletal section of admission evaluation dated [DATE] revealed no ambulation and resident does not respond to commands to perform range of motion. Admission evaluation was signed by DON. Record Review of Resident #1's Admission physician orders [REDACTED]. Physician order [REDACTED]. According to the U. S. National Library of Medicine, Levetiracetam ([MEDICATION NAME]) is an anticonvulsant used to treat [MEDICAL CONDITION]. Levetiracetam is used to help control certain types of [MEDICAL CONDITION] in the treatment of [REDACTED]. https://www.ncbi.nlm.nih.gov/pubmedhealth/PMH 56/?report=printable (accessed on [DATE]) Review of Resident #1's admission MDS (Minimum Data Set) dated [DATE] revealed a BIMS (Brief Interview of Mental Status) was not completed due to resident was rarely or never understood. Review of Resident #1's Nursing care plans with admission date of [DATE] did not address [MEDICAL CONDITION] disorder. Review of CNA Care Plan with admission date of [DATE] revealed Resident #1 had [DIAGNOSES REDACTED]. Her Activities of Daily Living include she was dependent on staff for bed mobility, transfers, eating, toileting, dressing and bathing. Review of Resident #1's [DATE] Medication Sheets received from Hospital A revealed Levetiracetam ([MEDICATION NAME]) 1000mg one tablet twice a day at 8am and 8pm and no doses were signed as being administered from admission on [DATE] to transfer on [DATE]. (Medication sheets were sent to Hospital A with Resident #1 on [DATE]) Record Review of Resident #1's Daily Skilled Nursing Notes dated [DATE] at 9:00 a.m.AM meds given. Physician A here this am orders for lab for next week .Signed ADON. Record Review of Resident #1's Daily Skilled Nursing notes dated [DATE] revealed: 0730, alert and responds to verbal stimuli prior to getting out of bed up to chair via lift. VS [DATE] ,[DATE] and O2 sat 92% on 2 L N/C Signed RN A 0745 Found unresponsive. Attempted to stimulate by verbal and painful stimuli. Responded some - eyes rolling back in head and starring. VS ,[DATE]-95-O2 sat 97. Became more responsive after placing back to bed. Continued to have starring motion from eyes. Slight tremors noted to extremities. Entry not signed 0750 NP A called regarding [MEDICAL CONDITION] activity and patient status. Order received to go ahead and give [MEDICATION NAME] 0.5mg po (by mouth) if pt (patient) able to take po (by mouth) and may repeat if needed. Signed RN A 0800 [MEDICATION NAME] 0.5mg po (by mouth) given without difficulty. Cont. to monitor. Signed RN A 0830 Continued to have some [MEDICAL CONDITION] activity - repeated [MEDICATION NAME] 0.5 po (by mouth). Took without difficulty. Not signed 0845 Called NP (NP A) back regarding [MEDICAL CONDITION] activity and patient status. Informed RN A was calling ambulance. Not signed 0905 Pt totally unresponsive. NO breathing noted. CPR started. Signed RN A 0910 EMS here -cont (continued) with bagging and compressions. Monitor applied - Monitor showing sinus tach ([MEDICAL CONDITION] 130's IV started per EMS. Resident having jerking motions of bilateral legs and arms. Not signed 0920 Transferred to Hamlin Hospital via EMS (Emergency Medical Services). Signed RN A 0850 Late noted. More pronounced jerking of extremities jaws clenched and salivating (drooling) Signed RN A Review of 24 hour nursing reports from [DATE] to [DATE] revealed no documentation to indicate Resident #1 did not have all ordered medications for administration. Review of Nursing home to Hospital Transfer Form dated [DATE] revealed Resident #1 was transferred to Hospital A with reason to transfer as [MEDICAL CONDITION] with risk alert for [MEDICAL CONDITION]. Form completed by RN A Review of Hospital A emergency room Record dated [DATE] revealed Resident #1 presented to the ER this am via EMS s/p tonic clinic [MEDICAL CONDITION] at nursing home. According to Nursing Home RN A, patient was having little [MEDICAL CONDITION] where she would flutter her eyes and stare and she would follow commands. EMS administered her an extra [MEDICATION NAME] crushed with water which she took ok .EMS stated when we got there the RN A said she was having a grand mal [MEDICAL CONDITION] and they had started CPR, however Resident #1 was in sinus [MEDICAL CONDITION](ST) with pulse on arrival. Resident #1 received [MEDICATION NAME] 10mg IVP by EMS and all [MEDICAL CONDITION] activity stopped within minutes. Maintained Airway Dx: [MEDICAL CONDITION], hypomagnesia, hemorrhagic metastasis. Transfer to Hospital B via ground EMS. Condition stable. Record Review of Resident #1's lab results from Hospital A dated [DATE] at 12:51 p.m. revealed [MEDICATION NAME] (Levetiracetam) level of 4 (low) with normal range noted to be ,[DATE]. Review of Hospital A EMS Prehospital Care Report dated [DATE] revealed Resident #1 has extensive past medical history. Resident #1 had [MEDICAL CONDITION] episode this AM and was currently unresponsive. Resident #1 also had period of respiratory arrest earlier this AM and received CPR from care home staff. Resident #1 currently stable. Resident #1 to be taken to Hospital B for increased level of care. Resident #1 was awake and oriented times one, eyes open spontaneously, but did not react to external stimuli. Pupils equal, round and reactive to light, Circulation present all extremities, motor function unobtainable due to patient being unresponsive. Skin warm and dry, Vital signs within normal limits. Heart monitor shows sinus rhythm. 12 lead EKG acquired, software analysis indicated sinus rhythm with PVC's. Resident remains stable until 1218 when [MEDICAL CONDITION] activity starts. Patient has [MEDICAL CONDITION] that involves only right side of face at 1218 that lasts ,[DATE] seconds. Resident #1 has additional [MEDICAL CONDITION] at 1225 that involves entire body. Resident #1 given [MEDICATION NAME] 5mg intravenous push with cessation of [MEDICAL CONDITION] activity within one minute at 1226 .CPR information revealed time of arrest at 9:04 a.m., time CPR discontinued was 9:16 a.m Upon arrival, EMS walked into Resident #1's room to find CPR in progress by care home staff. Review of Resident #1's Neurology Consultation dated [DATE] by Physician C noted the resident was evaluated for altered mental status and [MEDICAL CONDITION]. History of present illness: . patient was recently discharged from Hospital B 4 days ago The patient was recently transferred to nursing facility after ischemic stroke with hemorrhagic conversion and also generalized tonic-clonic [MEDICAL CONDITION]. According to the son, the patient was talking yesterday; however, on [DATE], the patient was found unresponsive .The patient had 2 episodes of generalized tonic-clonic [MEDICAL CONDITION] and became unresponsive. It was unsure how long the [MEDICAL CONDITION] was .According to the family, the patient did not receive the [MEDICATION NAME] for the last 3 days. The patient was recently admitted and discharged from Hospital B for multiple medical problems. During the last admission, the patient had multi-organ failure [MEDICAL CONDITION]. Also the patient had multiple ischemic stroke with hemorrhagic conversion and the patient had [MEDICAL CONDITION]. The patient also suffered a generalized tonic-clonic [MEDICAL CONDITION]. The patient also had a [MEDICAL CONDITION] in the past . When I last saw her on [DATE], the patient was confused, did not have conversation for me. The patient had significant left sided weakness . The patient was supposed to be on [MEDICATION NAME] however the patient has not been receiving the [MEDICATION NAME] .Assessment and Plan: .1. Generalized tonic-clonic [MEDICAL CONDITION]. a. This patient had a history of [REDACTED]. Review of Resident #1's Physician note dated [DATE] by Physician D revealed Chief Complaint was unresponsiveness. History of present illness: She was actually discharged to nursing facility 4 days ago by myself . She also had history of [MEDICAL CONDITION] for prolonged part of her life and has been having tonic-clonic [MEDICAL CONDITION] here during last admission for which she was started on [MEDICATION NAME] .Patient was returned to Hospital B emergency room early today because she was found apparently unresponsive. Her son and brother by bedside at the time of exam. They said patient may have had 2 episodes of tonic clonic [MEDICAL CONDITION] and she became unresponsive. EMS was called. Apparently prior to arrival of EMS patient was started on chest compressions because it was thought she may be in pulseless activity. Weekly EMS arrived patients had good pulses, patient had good blood pressure. CPR was aborted and patient was brought to Hospital B without requiring endotracheal intubation .There is also question if patient really has been taking her [MEDICATION NAME] to prevent [MEDICAL CONDITION]. Observation and Interview, at facility on [DATE] at 9:20 a.m., revealed Resident #1 was in bed. She was awake and said she didn't eat breakfast this am because she wasn't hungry. She denied any concerns. In an interview on [DATE] at 3:40 p.m., DON said she completed Resident #1's admission on [DATE]. She sent a list of her medications to the pharmacy. She said the pharmacy did not send [MEDICATION NAME] because they had questions regarding the directions. She said she didn't check the meds in to ensure they were all received. She said none of the nurses reported to her they didn't receive the medications from the Pharmacy and that the resident had not received her medications. She said once she faxed the request for medications to the pharmacy, the facility would receive medications within a day. She said she was not aware Resident #1 had not received her [MEDICATION NAME]. She said it wasn't until [DATE] that she found out the resident had [MEDICAL CONDITION], CPR and required transport to Hospital A and later transported to Hospital B. She said EMS reported Resident #1 had pulse and respirations upon their arrival so she questioned if the CPR was actually needed. She said Resident #1 was admitted to Hospital B on [DATE] and discharged back to the facility on [DATE]. She said Hospital B filled the [MEDICATION NAME] to ensure Resident #1 received her medication. DON said she now checks physician orders [REDACTED]. In an interview on [DATE] at 5:15 p.m., DON said she heard or was told on [DATE], Resident #1 had [MEDICAL CONDITION] activity for over an hour and nurse told staff to just watch her. She said she found it hard to believe Resident #1 had a [MEDICAL CONDITION] for over an hour and questioned if Resident #1 really needed CPR. In an interview on [DATE] at 8:25 a.m., RN A said she worked at the facility every other weekend. She said on [DATE] there was one CNA, one kitchen staff, one housekeeper and herself on duty. She said on [DATE] she was told there was a new resident (Resident #1). She said she was not given a good report but was told the resident was semi-comatose. RN A said on [DATE], immediately after report she went to Resident #1's room to meet her. She was awake and alert. RN A said after receiving report on [DATE], she said she and CNA A transferred Resident #1 from her bed to her wheelchair using the lift. She said she left Resident #1's room and returned about ,[DATE] minutes later and found Resident #1 slumped over her chair. RN A said Resident #1's vital signs were okay. She said she and the CNA A put resident back to bed on using a lift. She said Resident #1 was lying on her back and would stare with her eyes open and did not respond. She said Resident #1's arms and legs were shaking and she appeared to be having [MEDICAL CONDITION]. RN A said she called NP A and gave report that Resident was unresponsive, Vital signs, and that she was staring. RN A reported to NP A that Resident #1 had nothing to give except [MEDICATION NAME] if needed. NP A gave RN A an order to crush [MEDICATION NAME], try and give it and could repeat the dose of [MEDICATION NAME]. RN A said she crushed the [MEDICATION NAME] and administered it to Resident #1. RN A said she was trying to watch dining room and Resident #1 at the same time. She said 30 minutes went by and no changes in Resident #1 so she repeated the dose of [MEDICATION NAME]. She said Resident #1's [MEDICAL CONDITION] got worse so she called the NP A back and called the ambulance. She said about the time the ambulance came, Resident #1 quit breathing so CPR was started. EMS came in and Resident #1 was hooked up to a monitor and had a heart rate so the EMS started bagging her and started an IV. She said Resident #1 was transported via ambulance to Hospital A then on to Hospital B. She said she remembered there were several medications Resident #1 did not have since admission but didn't remember what meds she didn't have to administer. RN A said she did not tell anyone (Physician, DON, Administrator or family) she didn't have medications for Resident #1. In an interview on [DATE] at 11:16 a.m., RN A returned phone call and said she recalled on the weekend of [DATE] and [DATE] a note was taped to the counter at nurses station a list of medications that had not been received for Resident #1 from Pharmacy A. She said she did not recall the specific medications listed on that note. She said on the morning of [DATE], numerous call lights were sounding, residents were requesting medications, another resident was attempting to get out of her wheelchair unassisted and the CNA reported another resident had rectal bleeding. She said she went to room across the hall from Resident #1 to assess rectal bleeding. She said she was in that residents room for approximately ,[DATE] minutes. She said Resident #1 started out with twitching and had a blank stare. She said as time went on it got worse and her arms and legs were jerking. She said this went on for approximately one hour. She said even after administering two doses of [MEDICATION NAME], it did not stop the [MEDICAL CONDITION]. She said she was unable to stay continuously with Resident #1 morning of [DATE]. She said there was not enough staff on duty to take care of all the residents. In an interview on [DATE] at 4:32 p.m., NP A said facility RN A notified her resident #1 was having [MEDICAL CONDITION] activity. She said RN A did not tell her resident had [DIAGNOSES REDACTED].#1 had not received [MEDICATION NAME] since admission from [DATE] to [DATE]. RN A said resident had an order for [REDACTED]. NP A said EMS reported to her resident had pulse and respirations upon their arrival to the facility. In an interview on [DATE] at 12:35 p.m., CNA A said she worked at the facility from 6am to 6pm on [DATE]. She said she had not received any inservicing regarding [MEDICAL CONDITION] upon admission for Resident #1. She said she was the only CNA on duty at the time of the incident. She said on [DATE] around 6:40 a.m., she went to Resident #1's room and noticed she was experiencing [MEDICAL CONDITION] activity so she was placed back to bed. She said Resident #1 was twitching, her eyes were twitching. She said Resident #1 had this on admission but Physician A said it was normal for her, however, on [DATE] it was much more pronounced. CNA A said she notified RN A and was told to just watch her. She said she proceeded to take care of other residents but would return to Resident #1's room to check on her. CNA A said Resident #1 had slurred speech, one side of her face was drooping and she was foaming at her mouth and not responding. CNA A was instructed by RN A to keep monitoring Resident #1. CNA A said this [MEDICAL CONDITION] activity went on for about two hours. CNA A said Resident #1 started jerking more and had a grand mal [MEDICAL CONDITION]. CNA A said Resident #1 became unresponsive and RN A started CPR until EMS arrived. CNA A said she didn't think CPR was done correctly, don't think she needed CPR. CNA A said EMS reported upon their arrival resident was breathing, CNA A said to her knowledge, resident #1 never stopped breathing. CNA A said the only staff on duty at the facility on [DATE] at time of incident was RN A, CNA A and Cook A. CNA A said there was not enough staff on duty. In an interview on [DATE] at 1:35 p.m., Cook A said she was working when Resident #1 had a [MEDICAL CONDITION] on [DATE]. Cook A said she was in the dining room serving tea and water when RN A took Resident #1 from the dining room to her room. She said Resident was twitching and her arms and legs were moving. Cook A said she walked by Resident #1's room a little later on [DATE] (not sure exact time) and saw her arms and legs jerking and Resident #1 was in her room alone in bed lying on her back. Cook A said she went to find staff but RN A was in the restroom and she located CNA A and requested she go to Resident #1's room and check on her. Cook A said CNA A went to Resident #1's room and she returned to the kitchen. In an interview on [DATE] at 5 p.m., the ADON said that she had circled on [DATE] and [DATE] that she did not administer [MEDICATION NAME]. She said she did not administer the [MEDICATION NAME] and should have called Pharmacy A to inquire about medications. She also said she did not report to DON, physician or anyone else that medications were not available. She said when holding or not giving a medication as ordered, she was to write on back of the MAR why medication was not administered. In an interview on [DATE] at 4:50 p.m., DON said if a nurse doesn't administer a medication, they were to write on the back of the MAR the reason the medication was not given. Nurses were to also report to DON if medications are not available. Review of Emergency Kit Inventory at the facility dated [DATE] revealed [MEDICATION NAME] (Levetiracetam) was not stocked in the Emergency Drug kit. In an interview on [DATE] at 2:44 p.m. Pharmacy A LPT (Lead Pharmacy Technician) said the list of medications for Resident #1 received from nursing facility on [DATE] was from Discharge Summary of Hospital B. The list of medications did not include [MEDICATION NAME] (Levetiracetam). She said [MEDICATION NAME] was not filled and sent to facility due to not being on list of medications Pharmacy A received from facility. Record review of the documents faxed to Pharmacy A on [DATE] were provided by Pharmacy A on [DATE] and revealed the facility had faxed a copy of the Discharge Summary from Hospital B dated [DATE]. The Discharge Summary contained a list of medications the resident had been receiving outside of the hospital. The list did not include [MEDICATION NAME]. In an interview on [DATE] at 2:35 p.m., DON said she notified Physician A's office nurse on [DATE] that Resident #1 did not receive five medications that included [MEDICATION NAME], Mag Ox and [MEDICATION NAME] as ordered from [DATE] to [DATE]. Review of office note from Physician A dated [DATE] revealed DON called regarding failure to receive two medications that had been ordered. Facility DON wanted us to know that two of the medications the nursing home had ordered from the pharmacy were not delivered, hence not given for 2 days prior to the patient having to go to the hospital. In an interview on [DATE] at 1:15 p.m., Physician A said if he was not on call, the facility staff were to call hospital and talk to provider on duty. He said on [DATE], the facility staff would have called Hospital A emergency room and spoke to the provider on duty. Physician A reviewed his notes regarding Resident #1 and said he had not received any notes from the facility regarding the incident on [DATE]. He said the DON did call his office on [DATE] and reported Resident #1 did not receive two medications because they had not been delivered by the pharmacy. He said the DON did not specify which two medications Resident #1 did not receive. Physician A said his expectation was for facility to get medications in a timely manner. He said the medications should have been filled at a local pharmacy or facility could call physician to substitute another medication. Physician A said resident #1 should not have gone without her meds, especially [MEDICATION NAME] and even the [MEDICATION NAME]. Surveyor read list of medications facility identified Resident #1 did not receive [MEDICATION NAME], Mag Ox and [MEDICATION NAME] as ordered and he said he was not aware Resident #1 went without more than 2 medications. He said he had a note in Resident #1's medical record noting upon her discharge from Hospital B on [DATE], [MEDICATION NAME] 1000mg 60 tabs were filled by Pharmacy C and sent with Resident #1 back to nursing facility to ensure she had the medication. In an interview on [DATE] at 2:40 p.m., LVN C said she worked the day after Resident #1 was admitted . LVN C said the DON had taped a list of medications to the counter at the nurse's station to watch for that the facility had not received from the pharmacy. LVN C said she did not call a physician or pharmacy to check on these medications since the DON knew about them not being available. LVN C said she did not recall which medications were listed on the list of medications. In an interview on [DATE] at 3:15 p.m., LVN C said the facility had some of Resident #1's meds but not others. She said she could not remember which ones were available. LVN C was shown copies of Resident #1's medication sheets for [DATE] obtained from Hospital A and copy of Resident #1's [DATE] medication sheets from facility clinical record and she verified they did not match and someone (doesn't remember who) asked her to initial and circle her initial on the [DATE] medication sheet after Resident #1 returned to the facility on [DATE] for medications she should have received from [DATE] to time of transfer from the facility on [DATE]. In an interview on [DATE] at 3:30 p.m., the administrator said if a new admission or a re-admit of current resident occurs, the nurses were to send physician's orders [REDACTED]. She said if medications were not delivered, nurses were to call Pharmacy A after-hours phone number. If Pharmacy A cannot fill order for medications, the nurse was to call the physician and notify DON and residents family. She said if this was not done and medications were not available, then the resident was being neglected. She said her expectation was for the nurse to initial on the medication sheet as the medication was administered. She said if the medication was not given, the nurse should circle their initials and document why medication was not administered. In an interview on [DATE] at 2:35 p.m., DON said on admissions, she will review orders, list of medications and any medications sent with resident and notify physician for orders and for any clarification needed. Physician orders [REDACTED]. She said if medications were unavailable, she would note this on the 24 hour nurse report for each nurse to follow up on medication. If available from Emergency Drug kit, may use medication from the kit. She said medications can also be filled at Pharmacy B if needed. She said the physician would be notified of any medication that was not available. DON said she considered it neglect when resident goes without medications. She said the Regional Nurse Consultant instructed her to have nursing staff fill in blanks on the August Medication Sheet for Resident #1 on whether or not medication was administered. DON said she felt this situation was a total lack of communication. Nurses not letting anyone know or didn't call the physician when medications were unavailable. DON said she and the corporate nurse decided Resident #1 didn't have a [MEDICAL CONDITION] because she took medications during the time she was supposed to be having a [MEDICAL CONDITION] and she wasn't incontinent. In an interview on [DATE] at 3:35 p.m., ADM said she did not feel procedures were followed and medications were not ordered correctly. She said nurses should have called the physician when medications were unavailable. They should let the physician make the decision. She said the nurses could have followed the after-hours policy and get medications from the hospital or another pharmacy. Her expectation for nurses are to initial as a medication was administered. If the medication is not given for some reason, the nurse should circle their initials and document on back of medication sheet the reason it was not given. She said she would ensure this does not happen again. ADM said she was unaware that Resident #1 had not received her [MEDICAL CONDITION] meds from admission on [DATE] until she was transferred to Hospital A on [DATE]. She said she considered this incident as neglect and should have reported to the state. Review of Medication Error Report dated [DATE] revealed Resident #1's faxed ordered medication list received from Hospital B discharge with above list of medications not received from Pharmacy A. Medications listed include: [MEDICATION NAME], Mag Ox, [MEDICATION NAME] and [MEDICATION NAME]. Outcome to resident lists no adverse reactions identified. Physician A was notified on [DATE] at 3:25 p.m. Assessment and Summary of error lists no medications received from pharmacy and nursing miscommunication and pharmacy miscommunication. Review of facility's Nursing Guidelines for [MEDICAL CONDITION] (undated) revealed Emergency guidelines: 1. Stay with the resident and call for help. Be sure charge nurse is notified .6. Turn head to side or place in side-lying position to open airway and promote drainage of secretions Observe for and report to Charge Nurse: .2. Time [MEDICAL CONDITION] started and stopped and duration of [MEDICAL CONDITION]. 3. Description of body parts involved and severity of convulsive movements. 4. Presence of an aura, incontinence, unconsciousness, and eyes rolled upward, frothing of the mouth, biting of the tongue or injuries due to [MEDICAL CONDITION]. 5. Condition of resident after [MEDICAL CONDITION] such as disorientation or sleepiness 6. Other significant observations. Review of facility's policy Administering Medications dated [DATE] revealed Policy Statement Medications will be administered in a timely manner and as prescribed by the resident's attending physician or the facility's medical director. Policy Interpretation and Implementation .2. The Director of Nursing Services is responsible for the supervision and direction of all personnel with medication administration duties and functions. 3. Medications must be administered in a timely manner and in accordance with the attending physician's written/verbal orders .9. The individual administering the medication must ensure that the right medication, right dosage, right time and right method of administration are verified before the medication is administered. (e.g., review of drug label, physician's orders [REDACTED]. The individual administering the medications must initial the resident's MAR on the appropriate line and date for that specific day before administering the next resident's medication .13. Should a drug be withheld, refused, or given other than at the scheduled time, the individual administering the medication must initial and circle the MAR space provided for that particular drug .15. Any explanatory note on the reverse side of the MAR must be entered when drugs are withheld, refused, or given other than at scheduled times. (Note: The director of nursing services and attending physician must be notified when two (2) consecutive doses of a medication are refused or withheld.) Review of the Facility's Admissions Guideline last revised on [DATE] revealed the following: Procedure: 5. Notify the attending physician of the resident arrival and verify the orders with the physician. Have available for the physician: a. Resident's name b. Resident age c. admitting [DIAGNOSES REDACTED]. Ask for orders for therapy and baseline labs related to medication. 6. Fax your request for medications to the pharmacy. You may use the transfer orders if legible, or fax the white copy of your admission orders [REDACTED] Review of Facility's Nursing Guidelines: Change of Condition Notification (undated) revealed the following: Notification of changes shall include: 1. An accident involving the resident, which results in injury and has the potential for requiring physician intervention; 2. A significant change in the resident's physical, mental or psychosocial status, such as a deterioration in health, mental, or psychosocial status, in life-threatening conditions or clinical complications; 3. A need to alter treatment significantly; 4. A decision to transfer or discharge the resident facility; .or 6. A change in resident rights under Federal or State law or regulations pertaining to care of the resident. Review of the Medical Records Manual last reviewed on [DATE] revealed the following: Physician order [REDACTED]. 2. Verbal or telephone orders are considered to be in writing when dictated by the attending physician and later signed or initialed by him/her. Note: Orders must be signed no later than next scheduled visit. 3. Physician orders [REDACTED]. Treatments . e. Special medical procedures required for the safety and well-being of the resident f. Limitation of Activities g. Others as necessary and appropriate. 4. The admission physician order(s) must remain in the resident's chart at all times. 5. physician's orders [REDACTED]. Depending on payer source. 6. Telephone orders are batched and forwarded to the physician's office for signatur (TRUNCATED)

Based on observation, interview and record review the facility failed to establish infection control measures to prevent the transmission of infection and disease by bloodborne pathogens for 3 of 10 sampled diabetic residents (#s 2, 8 and 9), and 3 unsampled diabetic residents(#s 11,12, and 13). The facility failed to ensure that lancing pen devices were not used on multiple residents to obtain blood for blood glucose tests. One of one LVN, LVN A, observed performing a blood glucose test stated that the same lancing pen device was used for all of the diabetic residents that require blood glucose tests. Fingerstick devices (lancing pen devices) touch the skin and come in close proximity to blood with every use. Even if the lancet itself is changed between each use there is potential for blood to contaminate the pen device. Bloodborne pathogens such as Hepatitis B, Hepatitis C and HIV could potentially be transmitted from one person to another. These failures resulted in the identification of an IJ (Immediate Jeopardy) on 08/17/11. While the IJ was removed prior to exit on 08/18/11, the facility remained out of compliance at a severity level of "No actual harm with a potential for more than minimal harm that is not Immediate Jeopardy" and a scope of "Pattern". These failures could affect 6 diabetic residents requiring use of a lancing pen device to obtain blood by fingerstick for blood glucose testing. These 6 residents were placed at risk of bloodborne infections. Findings included: Record review of Resident #13's Record of Admission in the current clinical record revealed she was [AGE] years old and was admitted to the facility on [DATE]. She had a [DIAGNOSES REDACTED]. During medication pass observation on 08/17/11 at 4:00 p.m. LVN A was observed performing a fingerstick for blood glucose testing on Resident #13. LVN A took the case containing the glucometer and lancing pen device into the resident's room. She removed these items and laid them on the resident's bed. LVN A did not clean the glucometer or the lancing pen device prior to use. She inserted a lancet into the lancing pen device, cleaned the resident's left great toe with alcohol, performed the stick, placed the test strip into the glucometer and ran the glucose test. She removed the used lancet from the lancing pen device and laid it on the used alcohol wipes on the bed. She placed the glucometer and lancing pen device back on the resident's bed then administered the dose of insulin. She put the glucometer and lancing pen device back into the case, gathered the used alcohol wipes and lancet and returned to the medication cart. She disposed of the lancet in a sharps containter. She then removed the glucometer and lancing pen device from the case and cleaned the glucometer with an alcohol wipe. She did not clean the lancing pen device. She said she used an alcohol wipe because she could not find any of the "other wipes" that were supposed to be used to clean the glucometer. During an interview immediately following the above observation LVN A was asked if the lancing pen devise belonged to Resident #13. She said the lancing pen device did not belong to any one resident, it was used on all the diabetic residents that required fingerstick glucose testing. The failure to ensure that a lancing pen device was not used on multiple residents to obtain blood for blood glucose tests resulted in the identification of an IJ (Immediate Jeopardy) of which the facility Administrator, DON, and the Regional RN were informed on 08/17/11 at 4:36 p.m. During an interview with the Administrator, DON, and Regional RN on 08/17/11 at 4:36 p.m. they all stated that lancing pen devices are not supposed to be used at all in the facility. The Regional RN said that the company orders disposable, one-time-use lancing devices. She said QUAT wipes (an EPA-registered, hospital-grade quaternary disinfectant cleaner) are supposed to be used to clean the glucometer before and after each use. The DON asked the staff member responsible for ordering supplies why the correct lancets were not being used and was told that they had been ordered but had not come in yet. The Administrator said someone must have brought the lancing pen device into the facility because it was not an item the facility had purchased. During an interview with the DON on 08/18/11 at 8:10 am she said the QUAT wipes were in the medication cart yesterday (during the above observation) but LVN A had overlooked them. Information posted by the Center of Disease Control, updated 08/26/10, at website http://www.cdc.gov/injectionsafety/Fingerstick-DevicesBGM.html contained the following: "The shared use of fingerstick devices is one of the common root causes of exposure and infection in settings such as long-term care (LTC) facilities, where multiple persons require assistance with blood glucose monitoring. Risk for transmission of bloodborne pathogens is not limited to LTC settings but can exist anywhere multiple persons are undergoing fingerstick procedures for blood sampling. For example, at a health fair in New Mexico earlier this year, dozens of attendees were potentially exposed to bloodborne pathogens when fingerstick devices were reused to conduct diabetes screening. Recommendations Anyone performing fingerstick procedures should review the following recommendations to ensure that they are not placing persons in their care at risk for infection. ? Fingerstick devices should never be used for more than one person. ? Auto-disabling single-use fingerstick devices should be used for assisted monitoring of blood glucose. These recommendations apply not only to licensed healthcare facilities but also to any setting where fingerstick procedures are performed, including assisted living or residential care facilities, skilled nursing facilities, clinics, health fairs, shelters, detention facilities, senior centers, schools, and camps. Protection from infections, including bloodborne pathogens, is a basic requirement and expectation anywhere healthcare is provided." The facility submitted an action plan to remove the immediacy dated 08/18/11 to the regional office consisting of the following actions: 1) Removing lancet pen device(s) from the medication cart on 08/17/11. 2) Searching the medication room on 08/17/11 to ensure all lancet pen devices had been removed. 3) Identifying residents at risk of exposure to cross-contamination and performing assessments on those residents to determine if any adverse effects were present. This was performed on 08/17/11 and no adverse effects were identified. 4) Inservicing and testing all licensed nurses on 08/17/11 on lancet pen devices not being allowed to be used at all in the facility, glucometer testing, and cleaning/disinfecting of glucometer machine. This action plan was verified to have been completed on 08/18/11 at 10:14.m. as follows: 1) Until the order of one-time-use disposable lancing devices arrives the facility will use lancets without placing them into a lancing pen device. 2) No lancet pen devices were found in the medication cart or the medication room. 3) Inservices were conducted with the facility nurses at 08/17/11 regarding not using lancing pen devices for fingersticks due the possibility of residents being exposed to blood borne pathogens. 4) Interviews were conducted on 08/18/11 with facility nurses to confirm that inservices were conducted and nurses understood what type of lancing device to use and the rational for not using a lancing pen device on multiple residents. While the IJ was reduced on 08/18/11 at 10:14 a.m., the facility remained out of compliance at a severity level of "No actual harm with a potential for more than minimal harm that is not Immediate Jeopardy" and a scope of "Pattern" as the facility must monitor their action plan over time to ensure that the corrections for this issue are effective. There were 6 diabetic resident requiring use of a lancing device to obtain blood by fingerstick for blood glucose testing according to the list provided by the facility DON on 08/18/11 at approximately 8:30 a.m.