Every finding on record at Ignite Medical Resort El Paso, LLC

Based on interview and record review the facility failed ensure alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, were reported immediately, but not later than 2 hours after the allegation was made, if the events that caused the allegation involved abuse or resulted in serious bodily injury, to the administrator of the facility and to other officials (including to the State Survey Agency and adult protective services where state law provides for jurisdiction in long-term care facilities) in accordance with State law through established procedures for 1 of 3 residents (Resident #1) reviewed for reporting. The facility failed to report abuse of Resident #1 to State Office Agency, Law Enforcement. This failure could place residents at risk for abuse.Record review of Resident #1's face sheet dated 07/08/2026, revealed a [AGE] year-old male who was admitted to the facility on [DATE] and readmitted on [DATE]. Resident #1's diagnoses included Depressive Disorders (feelings of sadness, tearfulness, emptiness or hopelessness), Post Traumatic Stress Disorder (Mental Health Condition that triggered by experiencing or witnessing a terrifying event), Vascular Dementia (decline in thinking and memory), Hypertension (High blood pressure), Chronic Kidney Disease (kidney damage slowly lose their ability to properly filter waste and extra fluid), Delusional Disorders (mental health issues where a person holds strong, false beliefs that are completely unsupported by reality), Anxiety Disorder (feeling unease or worry). Record review of Resident #1's Quarterly MDS dated [DATE], reflected a BIMS score of 12, which indicated Moderately impaired. Resident #1 had no impairment to of upper extremity (shoulder, elbow, wrist, hand), and no impairment on both sides to lower extremities (hip, knee, ankle, foot). Resident #1 had not exhibit behavior for physical, verbal to others. Resident #1 did not present any reject care for the Quarterly MDS. Record review of Resident #1's Order Summary Report dated 07/08/2026, revealed Behavior Monitoring. Itching, 2.Picking at skin,3. Restlessness (Agitation),4. Hitting, 5. Increase in complaints,6. Biting, 7. Kicking, 8. Spitting, 9. Cussing,10. Racial slurs, 11. Elopement,12. Stealing,13. Delusions,14. Hallucinations, 15. Psycosis,16. Agression,17. Refusing care. Observe closely for significant side effects of Anti-Anxiety medication including drowsiness, slurred speech, dizziness, nausea, aggressive or impulsive behavior every shift every shift Document. Order start date 08/31/2024. Hydroxyzine HCL oral tablet for Anxiety, order start date 01/11/2025. Record review of Resident #1's Progress notes dated 06/09/2026 at 23:41:00, created on 06/12/2026 at 13:41:37 by DON, revealed Resident was observed to be verbally aggressive toward assigned male CNA during routine care. Resident repeatedly made inappropriate comments, including calling the CNA gay in a derogatory manner, and refused to allow the CNA to provide care. CNA remained calm and professional throughout the interaction and attempted to redirect the residents and explain the importance of care. Resident continued to refuse assistance from the male CNA. Charge nurse was notified and assessed the situation. Resident was educated on respectful communication and the importance of allowing staff to provide necessary care. Due to resident continued refusal, alternative staff were assigned when available to ensure residents needs were met. No Physical aggression was noted. Resident remained alert and in no apparent distress. Plan: Continue to monitor residents behaviors, reinforce respectful interactions with staff, and document any further incidents, and notify physician and responsible party as indicated if behaviors persist or escalate. In an observation and interview on 07/08/2026 at 10:19 AM, Resident #1 stated was unable to identify his current location and reported that he was in a hospital, stating, there are two the same as this hospital. Resident #1 was unable to state how long he had been at the facility. He was able to state his name and identify his Family Member C name, but not the time, place, or date. Resident #1 reported bruising to both thumbs and stated that it was caused by a male staff member who worked at the hospital. When asked to clarify, the resident pointed to the floor in reference to the nursing facility. The resident stated that while he was asleep, a younger male wearing glasses attempted to place a hospital gown on him, and when he refused the individual bit him on the left arm and grabbed his thumbs. The resident stated he did not call for help or use the call light because he was asleep and stated, If I would have been awake, I would have punched him in the face, this happened when I was asleep. Resident #1 was unable to describe the individual's appearance other than being a young male wearing glasses and stated he assumed the individual worked at the facility but did not know his name or knew what he was wearing. Resident #1 stated he was unaware of his roommates name and stated there were no witnesses in the room when the incident happen. The resident verbalized that he knew how to use the call light and denied any other concerns regarding the facility. Throughout the interview, Resident #1 did not appear fearful or exhibit signs of distress and was observed joking with the investigator. In an interview on 07/08/2026 at 1:11 PM, Family Member C, stated the incident allegedly occurred during the early morning hours but couldn't recall the exact date; however, she was not notified until approximately 12 hours later, a voicemail was left and when she was able to get a hold of the voicemail she returned the call back to the facility but the nurse did not answer anymore. Family Member C stated the voicemail she received was vague and did not indicate that an altercation had occurred. She reported being informed only that the resident was complaining of pain in his thumbs and had been sent for x-rays. Family Member C stated she went to the facility that evening after the incident and spoke with the evening nurse, who was unable to provide additional information regarding the incident. Family Member C stated that after obtaining the DON contact information, she immediately contacted the DON, who informed her that a meeting could be held the following Monday to discuss the incident. Family member C described the facility's handling of the allegation as confusing and inadequate. Family member C reported attending the care plan meeting with the Ombudsman, DON, Social Worker, and Administrator, during which multiple and inconsistent explanations were provided regarding the resident's injuries. Facility staff reportedly stated the injuries occurred during a brief change at approximately 5:00 to 6:00 a.m. while attempting to place a hospital gown on the resident. Family member C stated Resident #1 had resided at the facility for approximately two years and routinely slept in only a t-shirt. She stated that if Resident #1 refused to wear a hospital gown, he had the right to refuse. Family Member C stated Resident #1 reportedly informed her that a male individual pulled on his thumbs while attempting to place the gown on him. Family Member C expressed concern regarding a skin tear sustained by the resident and stated facility staff were unable to adequately explain how the injury occurred. In an interview on 07/08/2026 at 1:54 PM LVN C, stated she had been employed at the facility for approximately two years and had not experienced difficulties providing care or assisting Resident #1 with transfers. LVN C stated she typically administered medications and assisted with transfers when necessary. LVN C reported that on 06/10/2026, she assumed care of the resident at approximately at 12:00 p.m. and was informed the resident had sustained a skin tear to his left arm and had refused wound care treatment, NP was called and ordered x-rays. LVN C could not recall what nurse handed off report. LVN C observed bruising to the resident's hand and assessed him for pain. The resident acknowledged pain but did not display facial grimacing or other signs of distress. LVN C stated she contacted the resident's family and left a voicemail providing a general summary of the resident's condition, including notification that x-rays were being obtained. She stated it was common practice to leave a voicemail and pass along brief information in report if family members could not be reached immediately. LVN C stated Resident #1 did not voice any concerns regarding an altercation with a staff member when asked what happened. In an interview on 07/08/2026 at 2:47 PM, DON stated that LVN C reported to her that the resident had sustained a skin tear that same day on 06/10/2026. The DON reported she attempted to interview the resident regarding the injury right away; however, the resident was unable or unwilling to provide details and asked her to leave the room. The resident reportedly informed the wound care nurse that he had beat someone up. The DON stated she spoke with the night shift CNA, who reported that the resident attempted to hit staff during a brief change and required assistance from an additional CNA while providing care due to the resident swinging his arms and became combative. The DON stated a care plan meeting was conducted with the resident's POA and the Ombudsman on Monday the 15th. During the meeting, the Ombudsman expressed concerns that the injury appeared more consistent with a bite mark rather than a skin tear. The DON reported that the POA became upset and ended the meeting before the investigation could be explained. Facility staff later obtained statements indicating the resident had exhibited aggressive behaviors toward staff in the past. The DON stated the POA did not attend a subsequent care plan meeting and had canceled it. The DON stated it was the facility's policy to report allegations of abuse and injuries of unknown origin to the State Agency. She reported uncertainty as to whether the allegation had been reported by another staff member. The DON stated she was informed by wound care nurse R that the resident stated he had struck another individual; however, she was unaware of any witness statements indicating that a staff member had bitten the resident. The DON stated facility staff assumed the resident's injuries may have occurred during the altercation when staff attempted to place a hospital gown on him after he refused care. The DON identified CNA A as the staff member who assisted the other CNA during the overnight shift when the alleged incident occurred. DON stated staff had been trained on ANE and in serviced but not for this specific incident because they assumed that was how the resident sustained his injuries. In an interview on 07/08/2026 at 03:05 PM, Administrator stated she had returned to the facility in April 2026 and attended the resident's care plan meeting with the resident's POA, Ombudsman, and facility staff. The Administrator reported the resident's POA expressed concerns regarding the resident's skin tear and bruising. The Administrator stated facility staff initially believed the resident's injuries were related to combative behaviors exhibited during care. She reported that the resident was prescribed anticoagulant medication and stated that bruising could have resulted from incidental trauma, including contact with the bed rail. The Administrator stated these conclusions were assumptions based on the information available at the time. The Administrator stated the facility reports suspected abuse, neglect, and injuries of unknown origin in accordance with policy. She reported she did not believe another individual intentionally harmed the resident and stated the resident had provided varying statements regarding how the injuries occurred. The Administrator stated the only allegation she had heard regarding a bite injury originated from the Ombudsman's review of photographs of the resident's injury. The Administrator further stated that no other staff members reported witnessing or alleging that the resident had been bitten. She reported a second care plan meeting was scheduled; however, the resident's POA did not attend and canceled that same day. The Administrator stated communication with the family remained ongoing. The Risk of the allegation not being reported to the State Agency could be potentially constituted of another injury of unknown origin or possible abuse allegation. In an interview on 07/08/2026 at 03:15 PM, Ombudsman stated she was present at the resident initial care plan meeting following the discovery of the incident. She stated photographs of the injury were obtained and discussed during the meeting and stated the facility staff reported that the resident was found spoiled at the end of the shift and was provided with incontinent care. Staff attempted to place a hospital gown on the resident, at which time the resident became physically aggressive. Ombudsmen stated that CNA N, a newly hired CNA and stated that CNA N was new to the facility and had not yet become familiar with the residents care preferences. CAN N attempted to place the gown on the resident and was unaware of the residents preference not to wear hospital gowns. She stated the bruising and skin tear were believed to have occurred during the resident's aggressive behavior and resistance to care. Ombudsman stated that prior to the care plan meeting, she meet with Resident #1 who informed her that someone had bitten him and that the injury appeared consistent with a bite mark, which she brought up at the meeting. Ombudsmand stated during that meeting staff become upset that she would ask in regard to a bite mark, but she just wanted to get a better understanding on what happened. She stated she was not notified of the incident from the facility until later that afternoon on June 10th when Family Member C notified her. Ombudsman stated that she believed the incident may have been preventable with additional staff training and improved communication regarding residents care needs. In an interview on 07/08/2026 at 03:22 PM, NP, stated LVN C notified her on 06/10/2026 at approximately 11:42 a.m. that Resident #1 had sustained bruising and a skin tear and requested orders for wound care and x-rays. The NP stated she observed the bruising and the skin tear during her assessment the same day on 6/10/ 2026 and did not identify any apparent teeth marks or findings consistent with a human bite injury. NP reported the resident was on anticoagulant medication and explained that residents receiving anticoagulants are more susceptible to bruising and bleeding following minor trauma or incidental injury. NP stated she has evaluated bite injuries previously and, based upon her assessment, did not believe the resident's injury appeared consistent with a bite mark. She further stated the resident was able to communicate verbally during her assessment and had not informed her how the injury occurred. Based upon her clinical assessment, the NP concluded that the injury did not appear to be consistent with a bite injury but was unaware of how the injuries occurred. NP stated that even with the minor rubs against the bed rails or anything Resident #1 could have sustained the skin tear, but it was anonymous. In an interview on 07/08/2026 at 04:13 PM, CNA A stated she had been with the facility since December 2025, and was familiar with Resident #1s care needs, behaviors, and history of refusing care. CNA A stated she was not present at the beginning of the care provided by CNA N. CNA N asked for her help and upon entering the room, Resident #1 had a clean brief and only needed assistance with dressing. CNA A stated that CNA N was holding a hospital gown and informed Resident #1 did not like wearing hospital gown; therefore, CNA A assisted by obtaining a t-shirt and placing it on Resident #1. CNA A stated that while assisting Resident #1 with putting his arms through the sleeves of the t-shirt, she did not observe any bruising, or injuries, or bleeding to his skin. The CNA stated, if he had been bleeding, I would have seen it. CNA A stated that Resident #1 was cursing and using inappropriate language toward CNA N, which she reported was consistent with Resident #1s baseline behavior particularly when he comes upset or refuses care. CNA A stated that CNA N remained calm throughout the interaction and did not force care or physically engage with Resident #1 in an inappropriate manner. CNA A stated that Resident #1 did not report or indicate that CNA N had been physical or abusive toward him any time during care. CNA A stated she had been trained on ANE, and who to report Abuse or neglect too. In an interview attempt on 07/08/2026 at 01:05pm with CNA N, did not answer and could not leave vm, sent via text. In an interview attempt on 07/08/2026 at 03:20 PM with CNA N, did not answer and could not leave vm, sent via text. In an interview third attempt on 07/08/2026 at 04: 20 PM with CNA N, did not answer and could not leave vm, sent via text. Record review of facility policy Abuse & Neglect dated October 2022, revision date April 2025, stated The administrator/designee ensure that all alleged or suspected violations involving mistreatment, neglect, or abuse, including injuries of unknown origin and misappropriation of resident property are investigated and reported immediately to the state agency complaint hotline. Investigations of injuries of unknown origin or suspicious injuries must be immediately investigated to rule out abuse. Injury or unknown origin; The source of the injury was not observed by any person or the source of the injury could not be explained by the resident, The injury suspicious because of the extent of the injury or the location of the injury or the number of injuries observed at one particular point in time or the incidence of injuries over time.

Based on observation, interview and record review, the facility failed to ensure the physician was immediately notified of a need to alter treatment (that is, a need to discontinue an existing form of treatment due to adverse consequences, or to commence a new form of treatment) to meet the needs of each resident for 1 (Resident #2) of 9 residents reviewed for physician notifications. -The facility failed to notify the physician when Resident #2 experienced elevated blood glucose levels exceeding 400 mg/dL from 02/26/2026 through 03/02/2026. An Immediate Jeopardy (IJ) situation was identified on 03/12/2026. While the IJ was removed on 03/13/2026, the facility remained out of compliance at the scope of isolated and a severity level of no actual harm with the potential for minimum harm, due to the facility's need to evaluate the effectiveness of their corrective systems.This failure could have resulted in a decline in health and placing the resident at risk of adverse outcomes like sepsis, DKA, or death.Findings included:Record review of Resident #2's face sheet dated 03/11/2026, revealed an [AGE] year-old female who was admitted to the facility on [DATE]. Resident #2's diagnoses included Vesicointestinal Fistula (abnormal connection between the bladder and the bowel), hypertension (High blood pressure), type 2 diabetes mellitus with hyperglycemia (diabetes with blood sugar elevation), Alzheimer's Diseases with early onset (form of dementia). Record review of Resident #2's MDS dated [DATE], reflected a BIMS score of 14, indicating the resident was cognitively intact. Record review of Resident #2's Order Summary Report dated 03/11/2026 revealed Glucose Monitoring-notify provider if <60 or >400 before meals and at bedtime for diabetes. Record review of Resident #2's admitting physician orders dated 02/25/26 revealed: -Blood glucose monitoring before meals and at bedtime with notification to provider if <60 or >400.Record review of Resident #2's notes revealed on 02/26/2026 at 12:33pm, Resident #2'sblood glucose was documented as 512 mg/dL; at 12:36pm. No evidence of resident's record physician was notified. On 02/27/2026 at 1:04pm, blood glucose was documented as 482 mg/dL. No evidence of resident's record physician was notified. On 03/01/2026 at 11:08 am, blood glucose was documented as 459 mg/dL. No evidence of resident's record physician was notified. On 03/02/2026 at 6:49am, blood glucose was documented at 492 mg/dL. No evidence of resident's record physician was notified.Record review of the Resident #2's medication administration record and blood glucose logs revealed no evidence of documented nighttime blood glucose checks. Record review of Resident #2's Care Plan dated 03/11/2026, for blood glucose monitoring revealed, focus The resident is receiving insulin active med list in EMR with a goal, Blood Glucose levels will be withing normal limits and interventions Blood glucose monitoring as per physician order, hypo/Hyperglycemia (high blood sugar/ low blood sugar) protocol per physician orders, Monitor/Document/report as needed for following adverse effects of insulin therapy: Hypoglycemia, weight gain, hypokalemia (low blood potassium levels), pain at injection site. For antibiotics the focus revealed The resident is receiving antibiotic therapy. (see active med list in EMR) with a goal The resident will be free of any discomfort or adverse side effects of antibiotic therapy through the review date And interventions Monitor/document/report PRN adverse reactions to antibiotic therapy: diarrhea, nausea, vomiting, anorexia, and hypersensitivity/allergic reactions (rashes, welts, hives, swelling face/throat), report labs results to MD. Review of local hospital Emergency Department Note on 03/02/3036, revealed Resident #2's chief complaint was elevated blood glucose levels of approximately 400 mg/dL 400 mg/dL. Resident #2 was administered Lispro 22 units by EMS in route from nursing facility to hospital. After Lispro administration, Resident #2's blood glucose level in route was 23 mg/dL. Resident #2's blood glucose level in the ED on 3/2/2026 at 9:35am revealed 249 mg/dL. Resident's WBC was 14.6. Resident was admitted to hospital for 10 days due to DKA (diabetic ketoacidosis) and septic shock. Resident was admitted to ICU due to critical condition. In an interview on 03/03/2026 at 03:36 PM, the ADON stated he had been employed with the facility since January 1st, 2026. The ADON stated that he and the DON are responsible for overseeing the medication reconciliation processes. He reported that corporate support was available when medications were not accessible, including determining alternative medications or treatment options. The ADON acknowledged that medication pass audits had not been completed by him and stated he could not speak to whether the DON had completed such audits. He indicated that nursing staff received training upon hire and were provided with additional education or corrective action when errors occur. The ADON further acknowledged communication challenges between the facility and external providers, including PACE, that there was a lack of consistent communication and coordination of care. He stated the admitting nurses were responsible for entering physician's orders into the system at the time of admission. He acknowledged that there have been prior difficulties with the process and described the system as not fully aligned with external providers. In an interview on 03/03/2026 at 04:28 pm, the DON stated medication administration was monitored through and electronic reporting systems (PCC), including medication administration reports, order listing reports, and non-administered medication reports. The DON stated that audits of medication administration were conducted periodically, typically every three weeks to monthly, rather than daily. The DON acknowledged that there was no consistent daily process to review medications for accuracy or completeness. The DON reported ongoing communication challenges with external providers, including PACE, that the facility relies on receiving orders but does not consistently have direct communication with providers. She stated that orders were expected to be entered by the admitting nurses and that a communication board within PCC is used to relay updates between shifts. The DON described instances in which residents with fluctuating blood glucose levels required close monitoring; however, inconsistent oversight and communication processes impacted timely intervention. She acknowledged that if a resident's condition worsens, the facility may transfer the resident to the hospital rather than intervening earlier. In an interview on 03/04/2026 at 11:00 am, the NP from PACE stated she was not notified that Resident #2 blood glucose had been over 400. She stated that the lack of notification created potential for harm, hospitalization related to uncontrolled blood glucose levels. The NP reported that upon review following the resident's hospital discharge, orders had been provided for insulin and blood glucose monitoring; however, they were not implemented as ordered by the facility. The NP further stated ongoing concerns with communication, that failure to notify providers of changes in condition had been a recurring issue with this facility. The NP stated that the residents subsequently developed worsening conditions, including infection, skin breakdown, and eventual sepsis ,( life threatening condition that arises when the body's response to an infection injures its own tissues and organs) requiring hospitalization. The NP stated that the resident had not previously experienced that level of decline and attributed the deterioration (DKA and sepsis) , in part, to missed medications and lack of timely intervention.In an interview with 03/04/2026 at 11:18 am the RN from PACE stated that he was notified of elevated blood glucose levels on 02/27/2026. The RN stated that after notification, additional sliding scale insulin coverage was ordered . He further stated that long-acting insulin (Lantus) had been part of the resident's prior medication regimen and should have continued without interruption. The RN stated that communication occurred with facility staff LVN C regarding elevated blood glucose levels and instructions were given to administer sliding scale insulin, including an additional 12 units, and to closely monitor the resident's condition. He stated that LVN C/facility staff were instructed to notify the provider of any changes. The RN stated that on 03/01/2026, the on-call provider from PACE was contacted regarding elevated blood glucose levels; however, there was no documentation available to confirm blood glucose values or provider notification at that time. The facility additionally reported elevated blood glucose readings on 03/02/2026, with continued concerns for lack of documentation and delayed communication . The RN stated that he was notified again early in the morning on 03/02/2026 regarding persistently elevated blood glucose levels, prompting further evaluation by the RN and NP from PACE, who were at the facility to see Resident #2 In an interview on 03/04/2026 at 01:00PM LVN C stated that she had been employed at the facility for approximately one year and received training on medication administration and vital signs monitoring. She stated that PACE physician's orders were typically received via fax and entered into the system; however, she reported that there may be delays in processing orders, particularly during admissions. LVN C stated that during Resident #2's admission, medication orders from PACE required review and verification before implementation. She reported that some medications, including long-acting insulin (Lantus), were not immediately available or did not appear on the medication administration record (MAR), resulting in delays in administration. She further stated that she contacted the external provider (PACE) multiple times regarding elevated blood glucose levels and received instructions to administer sliding scale insulin (there was no documentation found to support this). She stated that she did not complete the admission process and did not verify any medications with providers as that is the admitting nurse's responsibility. LVN C reported that the resident continued to have elevated blood glucose levels despite sliding scale insulin administration . She acknowledged that no new physician's orders were obtained during that time and that communication delays occurred, including lack of response from the on-call provider on the weekend . She further stated that the resident declined transfer to the hospital initially; however, blood glucose levels remained elevated, and monitoring continued for her shifts with Resident #2.In an interview on 03/04/2026 at 01:35 pm, RN M stated that the resident's blood glucose levels remained elevated, including readings in the 400-500 mg/dL range, and at times were unreadable on the glucometer . RN M stated that the resident received sliding scale insulin. She reported that despite elevated blood glucose levels, the resident remained at the facility until the decision was made to transfer the resident to the hospital due to frequent high glucose readings. RN M stated she could not recall who initiated the transfer order but confirmed the transfer was related to critically elevated blood glucose levels. She further reported uncertainty regarding whether antibiotics ordered were administered prior to transfer or during residents stay. In an interview conducted on 03/04/2026 at 4:34 PM, the Medical Director from facility stated that medication reconciliation should be completed promptly upon admission. He reported that in urgent situations residents should be immediately evaluated and appropriate orders implemented without delay with providers from the facility. He further stated that PACE providers should be accessible for communication and that if a resident's condition worsens, the resident should be transferred to a higher level of care. In an interview on 03/05/2026 at 10:07 am the RN from PACE regarding the NP on call the weekend the facility called regarding Resident #2's condition, however, there were communication delays, including missed calls and lack of response from facility staff. He stated that follow-up communication was inconsistent, and documentation did not reflect timely provider notification. He stated that the resident's condition continued, resulting in transfer to the hospital and admission to the ICU . Record review of residents care plan and order summary on 03/05/2026 at 10:25am reveled that MDS revised Resident #2's care plans regarding antibiotic therapy, and blood glucose monitoring. In an interview on 03/05/2026 at 12:20 pm MDS stated that Resident #2 was admitted with a skilled level of care and required ongoing monitoring. She stated that MDS assessments and baseline evaluations were completed after admission; however, she acknowledged that medication-related information was primarily managed by the nursing staff. She stated that she did not recall reviewing documentation indicating the resident was receiving antibiotics therapy or glucose monitoring and acknowledged that follow-up on such treatments was dependent on nursing processes. MDS stated that she does recall revising Resident #2's care plan but did not see anything in regard to her missing medication. In an interview on 03/05/2026 at 03:35 pm the NP from PACE stated that antibiotics had been ordered prophylactically to prevent infection and that failure to administer these medications contributed to the resident developing sepsis. She stated that the resident also required insulin management and should have received appropriate treatment upon admission. The NP stated that the resident's condition declined due to lack of treatment, including failure to administer the insulin sensor and antibiotics , and that earlier intervention could have prevented the progression to sepsis. She further stated that the resident required transfer to the hospital for a higher level care, including management of infection and uncontrolled blood glucose. Interview on 03/05/2026 at 04:45 pm with Resident #2 revealed the resident was alert and oriented. The resident stated that staff checked her blood sugar using facility equipment where they would poke her finger. The resident further reported that she was unaware that prescribed medications were not being administered .In an interview on 03/05/2026 at 05:00 pm the hospital RN stated that upon admission to the hospital, Resident #2 presented with hyperglycemia and urinary tract infection. The resident required initiation of sepsis protocol and was treated with intravenous antibiotics (Zosyn) and insulin therapy. The RN reported that laboratory findings included significantly elevated white blood cell count (28.3) and confirmed infection, including E. coli and yeast identified in cultures. The resident required intensive treatment, including insulin drip and management of diabetic ketoacidosis (DKA). In an interview on 03/06/2026 at 03:53 pm the DON stated that not all admissions were reviewed or receive a pre-admission assessment. She stated that review of hospital records was not consistently required for every admission and may only occur if additional clinical concerns are identified . The DON acknowledged that nursing staff were not consistently instructed to review hospital documentation prior to implementing care. She reported that corporate staff review referrals and approve admissions; however, facility-level review processes are not standardized. The DON further stated that admission documentation, including blood glucose monitoring for diabetic residents, should be completed; however, she could not confirm that this was done for Resident #2. She acknowledged that medication reconciliation is often dependent on timing and communication with on-call providers rather than a consistent internal process. Record review of the facility's policy titled Blood Glucose Monitoring dated November 2020, revised 01/2026 revealed To ensure blood glucose monitoring is completed per provider orders and in accordance with all state and federal regulations. Each physician order for bedside blood glucose testing will include physician notification parameters and hypoglycemic medication holding parameters as applicable. If the resident's glucose result is outside the physician ordered parameters, follow physician orders for notification and/or medication holding. If the resident has a diagnosis of hyperglycemia (diabetes mellitus or insipidus ), insulin will be administered only upon the order of a physician. At no time will nursing staff administer insulin as a nursing judgment. This was determined to be an Immediate Jeopardy (IJ) on 03/12/2026 at 03:28 PM. The Administrator was informed of the IJ. The Administrator was provided with the IJ template on 03/12/2026 at 3:52 PM. The following Plan of Removal submitted by the facility was accepted on 03/13/2026 at 05:00 PM: The facility is committed to ensuring the safety and well-being of all Residents and operates in substantial compliance with Federal and State laws and regulations. This removal plan constitutes Note's written credible allegation of compliance for the immediate jeopardy noted.It is the facility's policy to immediately inform the resident, consult with the resident's physician, and notify the resident representative(s) when there is a need to alter treatment significantly, including the need to discontinue an existing form of treatment due to adverse consequences or commence a new form of treatment, or when there is a significant change in the resident's physical, mental, or psychosocial status, in accordance with 42 CFR S483.10(g)(14). Additionally, it is the facility's policy to ensure that physician orders are documented completely with sufficient content to clearly convey the provider's intent, and that orders that are unclear must be clarified prior to implementation. The facility is further committed to ensuring that blood glucose monitoring is performed as ordered, and that physicians are notified immediately when glucose results are outside ordered parameters.Immediate Action for Affected Residents:On 03/03/26, the facility identified Resident #2 as the affected resident in this citation. The following immediate actions have been taken. The licensed nursing staff and admission staff were notified in a mandatory in-service conducted in person and via phone from 03/05/26-3/12/26. The staff gave verbal and written confirmation they have been educated and understand the new policies and procedures. Ongoing competency checks will be conducted with staff. Staff were informed these policies are readily available to them from the CNO and ACNO . New hires will go through training and written competencies upon hire. On 03/03/26, the facility Administrator and Director of Nursing (DON) reviewed Resident #2's current hospitalization status and confirmed with the hospital that Resident #2 was admitted to the ICU on 03/02/26 for diabetic ketoacidosis (happens when you have a lack of insulin in your body. It's a life-threatening complication of diabetes) and septic shock and is receiving appropriate medical treatment. The resident did not return to the facility. On 03/11/26, the facility conducted nurses meetings with all nursing staff who provided care to Resident #2 between 02/25/26 and 03/02/26 to review the specific failures in this case, including: failure to obtain daily bedtime blood glucose readings as ordered; failure to notify the physician of four blood glucose levels exceeding 400 mg/dl; failure to administer the continuous glucose monitoring device; and failure to communicate with the physician regarding unavailable supplies. From 03/11/26-3/12/2026, the CNO and ACNO conducted mandatory re-education for all licensed nursing staff (RNs and LPNs) this in-service was conducted both in person and via phone/virtually for staff who were unable to be onsite. Staff confirmed verbal understanding of the policy and procedure. The staff were made aware that policies could be given at that time of any time from the Administrator, CNO, or ACNO. The training covered the facility's Blood Glucose Monitoring Policy specifically emphasizing: the requirement to obtain blood glucose readings exactly as ordered by the physician; the requirement to immediately notify the physician when results fall outside ordered parameters; the requirement to notify the physician/CNO/ACNO immediately when ordered supplies or equipment are not available; and the requirement to clarify unclear or unable-to-implement orders prior to implementation. On 03/11/26, the facility established a communication protocol with the local PACE Organization requiring that the facility's nursing staff contact PACE providers immediately for all clinical concerns, significant changes in condition, out-of-parameter laboratory/glucose values, and any inability to implement physician orders due to unavailable supplies or unclear orders. An in-service was conducted with RNs and LVNs both in person and via phone/virtually for staff who were unable to be onsite. Staff confirmed verbal understanding of the policy and procedure. The staff were made aware that policies could be given at that time of any time from the Administrator, CNO, or ACNO. On 03/11/26, the facility implemented a redundant notification system requiring that when any blood glucose result is outside physician-ordered parameters, the nurse must: immediately notify the physician/PACE provider and document the date, time, person contacted, and response received. An in-service was conducted with RNs and LVNs both in person and via phone/virtually f staff who were unable to be onsite. Staff confirmed verbal understanding of the policy and procedure. The staff were made aware that policies could be given at that time or any time from the Administrator, CNO, or ACNO.Identifying Other Residents at Risk:On 03/11/26 through 03/12/26, the facility conducted a comprehensive review to identify all other residents who may be at risk for similar failures in physician notification, blood glucose monitoring, or implementation of physician orders. On 03/12/26, the CNO and ACNO conducted a review of all current residents (census of 49 residents) to identify those with physician orders for blood glucose monitoring. This review identified 15 residents with active blood glucose monitoring orders. On 03/12/26, the DON, ADON, and VP of Operations conducted a comprehensive chart audit of all 15 residents with blood glucose monitoring orders to assess: whether blood glucose monitoring was performed as ordered; whether any blood glucose results fell outside physician-ordered parameters; and whether appropriate and timely physician notification was documented when results were out of parameters. 6 Issues identified and were reported to the physician and clarification of new orders needed were given. Continued monitoring will occur by CNO, ACNO, or nurse manager for daily monitoring. On 03/05/26 through 03/12/26, the facility conducted a comprehensive Root Cause Analysis (RCA) consisting of the Administrator, CNO, ACNO, VP of Clinical, and VP of Operations to determine the underlying factors that led to the immediate jeopardy situation involving Resident #2.On 03/05/26 through 03/12/26, the RCA team conducted individual interviews with the following staff members: Three additional nursing staff who provided care to Resident #2 during the dates in question The CNO and ACNOFishbone Diagram Key Findings: People: Staff lacked clarity on the specific process for notifying PACE providers versus the facility Medical Director; staff did not understand the criticality of obtaining bedtime blood glucose readings for residents with uncontrolled diabetes and DKA; staff did not recognize that failure to administer an ordered continuous glucose monitoring device due to unavailable supplies required immediate physician notification and order clarification.Process: The facility lacked a standardized process for immediate physician notification when blood glucose results exceeded parameters; the facility lacked a redundant safety check system to ensure blood glucose monitoring was completed as ordered; the admission process did not include verification that all ordered supplies and equipment were available prior to accepting the resident; there was no escalation process when nursing staff were unable to implement physician orders due to unavailable supplies.Environment: There was confusion among nursing staff regarding the scope of responsibility for PACE residents versus non-PACE residents; the facility culture did not emphasize the critical importance of immediate escalation when physician orders could not be implemented.Management: The CNO and ACNO did not have a system in place to audit compliance with blood glucose monitoring orders; there was insufficient oversight of the admission process to ensure all necessary supplies and equipment were available; the facility leadership did not provide adequate education and reinforcement regarding the physician notification requirements under 42 CFR S483.10(g)(14).Root Cause Summary:The RCA team identified the following root causes on 03/12/26:1. The facility lacked a comprehensive, redundant system to ensure physician notification occurred immediately when blood glucose results were outside ordered parameters or when significant changes in treatment were needed.2. The facility's staff education and training did not adequately emphasize the critical importance and clinical urgency of immediate physician notification for residents with life-threatening conditions such as DKA with uncontrolled hyperglycemia.3. The facility lacked real-time oversight and quality assurance processes to identify and correct failures in blood glucose monitoring and physician notification before serious harm occurred.Systemic Changes and Preventive Measures:The facility has implemented and will continue to implement the following systemic changes and preventive measures to address the identified root causes and prevent recurrence. The licensed nursing staff and admission staff were notified in a mandatory in-service conducted in person and via phone from 03/05/26-3/12/26. The staff gave verbal and written confirmation they have been educated and understand the new policies and procedures. Ongoing competency checks will be conducted with staff. Staff were informed these policies are readily available to them from the CNO and ACNO.Policy and Procedure Updates: On 03/11/26, the facility revised the Blood Glucose Monitoring Policy to include: explicit requirement that the physician must be notified immediately when blood glucose results are outside ordered parameters; requirement that the nurse document the exact time of the out-of-parameter result, the exact time of physician notification, the name of the person contacted, and the physician's response/orders received. The licensed nursing staff and admission staff were notified in a mandatory in-service conducted in person and via phone from 3/11/26-3/12/26. The staff gave verbal and written confirmation they have been educated and understand the new policies and procedures. Ongoing competency checks will be conducted with staff. Staff were informed these policies are readily available to them from the CNO and ACNO.Staff Education and Training: On 03/11/26 to 03/12/2026, the facility conducted mandatory emergency re-education for all licensed nursing staff (45 RNs and LPNs) covering: the requirements of 42 CFR S483.10(g)(14) regarding immediate physician notification when there is a need to alter treatment significantly; the facility's revised Blood Glucose Monitoring Policy with emphasis on immediate notification requirements and documentation; the clinical consequences of uncontrolled hyperglycemia and DKA, including progression to septic shock. The licensed nursing staff and admission staff were notified in a mandatory in-service conducted in person and via phone from 03/11/26-3/12/26. The staff gave verbal and written confirmation they have been educated and understand the new policies and procedures. Ongoing competency checks will be conducted with staff. Staff were informed these policies are readily available to them from the CNO and ACNO. Effective 03/12/26, the facility implemented mandatory monthly continuing education for all nursing staff on high-risk clinical situations requiring immediate physician notification, with rotating topics including: diabetes management and recognition of hypo/hyperglycemia; recognition and management of sepsis and septic shock; fall prevention and post-fall assessment; and pain management and recognition of acute pain requiring intervention. The CNO, ACNO, or VP of Clinical will conduct post competency trainings. Effective 03/12/26, all newly hired nursing staff will receive intensive orientation training on physician notification requirements during their first week of employment, including: review of all relevant policies; observation of experienced nurses performing blood glucose monitoring and physician notifications; supervised practice with blood glucose monitoring and mock physician notifications; and competency testing prior to being assigned independent patient care responsibilities. This will be conducted by the CNO, ACNO, or other nurse manager. Process Improvements: On 03/11/26, the facility implemented a Daily Blood Glucose Monitoring Audit process requiring: CNO, ACNO, or Nurse manager to review all blood glucose monitoring orders each night and generate a list of residents requiring testing; the charge nurse on each shift to verify that blood glucose testing has been completed for all residents on the list during their shift; documentation of the audit completion in a Blood Glucose Monitoring Log with any missed tests immediately reported to the CNO/ACNO; and follow-up with nursing staff who missed ordered blood glucose testing to determine reason and provide re-education as needed. This will continue daily for one month, weekly for 12 weeks, and monthly thereafter. Leadership Oversight and Accountability: Effective 03/12/26, the CNO and ACNO divide responsibility for conducting daily walking rounds on all units to: They will observe one nursing staff per shift performing blood glucose monitoring and verify proper technique; review blood glucose monitoring logs to ensure all ordered testing has been completed; interview nursing staff about any residents with clinical concerns requiring physician notification; and provide immediate feedback and re-education when deficiencies are identified. Effective 03/10/26, the facility will conduct monthly PACE Coordination Meetings with leadership from the local PACE Organization to: review all PACE residents currently in the facility and discuss any clinical concerns; review communication between facility nursing staff and PACE providers to identify any gaps or delays; review any incidents where PACE residents experienced adverse outcomes and identify opportunities for improved care coordination; and strengthen the partnership to ensure seamless care for PACE residents.Monitoring and Evaluation Plan:The facility has implemented a comprehensive monitoring and evaluation plan to ensure the effectiveness of the systemic changes and preventive measures and to identify any additional areas requiring improvement.Daily Monitoring: Effective 03/12/26, the CNO, ACNO, or nurse manager will conduct a daily audit of all blood glucose monitoring performed in the previous 24-hour period by: reviewing the electronic blood glucose log to verify that all residents with blood glucose monitoring orders had testing completed as ordered; verifying that any out-of-parameter results (outside physician-ordered parameters) had documented physician notification; identifying any instances of non-compliance and immediately reporting to the CNO for follow-up and staff re-education; and documenting the audit completion in the Daily Blood Glucose Monitoring Audit Log.Weekly Monitoring: Effective 03/12/26, the CNO will conduct weekly audits for twelve weeks of 10 randomly selected resident charts (at least 5 residents with diabetes requiring blood glucose monitoring) to assess: compliance with blood glucose monitoring orders; timeliness and completeness of [TRUNCATED]

Based on observation, interview, and record review the facility failed to provided needed care and services that are centered in accordance with residents preferences, goals for care and professional standards of practice that meet each residents physical, mental, and psychosocial needs for 1 (Resident #2) of 10 residents. The facility failed to assess Resident #2 prior to admission and failed to identify and implement physician orders related to antibiotic therapy and blood glucose management for readings outside established parameters which resulted in hospitalization with diagnoses of DKA and sepsis. An Immediate Jeopardy (IJ) situation was identified on 03/12/2026. While the IJ was removed on 03/13/2026, the facility remained out of compliance at the scope of isolation with the potential for more than minimal harm , due to the facility's need to evaluate the effectiveness of their corrective systems. This failure could have resulted in serious deterioration of the residents health, including infection progression, unstable blood glucose levels, and life-threatening complications. Findings included:Record review of Resident #2's face sheet dated 03/11/2026, revealed an [AGE] year-old female who was admitted to the facility on [DATE]. Resident #2's diagnoses included Vesicointestinal Fistula (abnormal connection between the bladder and the bowel), hypertension (High blood pressure), type 2 diabetes mellitus with hyperglycemia (diabetes with blood sugar elevation), Alzheimer's Diseases with early onset (form of dementia). Record review of Resident #2's MDS dated [DATE], reflected a BIMS score of 14, indicating the resident was cognitively intact. Record review of Resident #2's Order Summary Report dated 03/11/2026 revealed Glucose Monitoring-notify provider if <60 or >400 before meals and at bedtime for diabetes. Record review of Resident #2's admitting physician orders dated 02/25/26 revealed: -Semglee (Insulin Glargine) 23 units subcutaneously at bedtime daily -NovoLOG FlexPen (insulin aspart) for blood glucose management [70-160: 0 units;161-200: 4 units; 201-250: 6 units; 251-300: 8 units; 301-349: 10 units; 350-400: 12 units (call MD)]. -FreeStyle Libre 2 CGM (continuous glucose monitoring) sensor apply subcutaneously in the morning every 14 days. -Blood glucose monitoring before meals and at bedtime with notification to provider if <60 or >400.Record review of Resident #2' MAR from 02/25/2026 through 03/02/2026 showed no evidence of transcribed antibiotic orders and no doses were administered during this period.Record review of Resident #2's notes revealed on 02/26/2026 at 12:33pm, Resident #2'sblood glucose was documented as 512 mg/dL; at 12:36pm. No evidence of resident's record physician was notified. On 02/27/2026 at 1:04pm, blood glucose was documented as 482 mg/dL. No evidence of resident's record physician was notified. On 03/01/2026 at 11:08 am, blood glucose was documented as 459 mg/dL. No evidence of resident's record physician was notified. On 03/02/2026 at 6:49am, blood glucose was documented at 492 mg/dL. No evidence of resident's record physician was notified.Record review of the Resident #2's medication administration record and blood glucose logs revealed no evidence of documented nighttime blood glucose checks. Record review of Resident #2's MAR revealed FreeStyle Libre 2 CGM sensor was applied to Resident #2's on 2/26/2026 at 9:00 am.Record review of Resident #2's Care Plan dated 03/11/2026, for blood glucose monitoring revealed, focus The resident is receiving insulin active med list in EMR with a goal, Blood Glucose levels will be withing normal limits and interventions Blood glucose monitoring as per physician order, hypo/Hyperglycemia (high blood sugar/ low blood sugar) protocol per physician orders, Monitor/Document/report as needed for following adverse effects of insulin therapy: Hypoglycemia, weight gain, hypokalemia (low blood potassium levels), pain at injection site. For antibiotics the focus revealed The resident is receiving antibiotic therapy. (see active med list in EMR) with a goal The resident will be free of any discomfort or adverse side effects of antibiotic therapy through the review date And interventions Monitor/document/report PRN adverse reactions to antibiotic therapy: diarrhea, nausea, vomiting, anorexia, and hypersensitivity/allergic reactions (rashes, welts, hives, swelling face/throat), report labs results to MD. Review of local hospital Emergency Department Note on 03/02/3036, revealed Resident #2's chief complaint was elevated blood glucose levels of approximately 400 mg/dL 400 mg/dL. Resident #2 was administered Lispro 22 units by EMS in route from nursing facility to hospital. After Lispro administration, Resident #2's blood glucose level in route was 23 mg/dL. Resident #2's blood glucose level in the ED on 3/2/2026 at 9:35am revealed 249 mg/dL. Resident's WBC was 14.6. Resident was admitted to hospital for 10 days due to DKA (diabetic ketoacidosis) and septic shock. Resident was admitted to ICU due to critical condition.In an interview on 03/03/2026 at 12:39 pm the Admissions Coordinator stated she had been employed at the facility for 6 months. The Admissions Coordinator stated that the facility utilizes an electronic system (Exacare) which pulled all the medication orders from the hospitals and then the admitting nurse enters it into PCC (electronic records) . For residents with PACE services there are certain communication failures regarding medication orders. PACE either emails, fax, or provided orders verbally. She reported that PACE communication may be limited on weekends since they were closed on the weekends, and that emails and order processing may not occur consistently during that time . She stated that medication orders are typically directed to nursing staff, and that the primary orders received were admission orders or discharge-related orders.In an interview on 03/03/2026 at 02:02 pm RN V from PACE stated Resident #2 underwent surgery for colostomy placement and was admitted to the facility on [DATE] following hospitalization. RN V stated that the facility failed to administer two prescribed antibiotics (Ciprofloxacin 500 mg and Metronidazole [Flagyl] 500 mg), which were ordered prophylactically upon admission. RN V reported that these medications were not administered as ordered . RN V further stated that the resident had four blood glucose readings outside of ordered parameters without physician notification . Additionally, the facility failed to obtain blood glucose readings at night as ordered and did not implement the resident's continuous glucose monitoring system. RN V stated that physician's orders from PACE were sent; however, the physician was not notified of missed medications or abnormal blood glucose levels . RN V indicated that nursing staff were responsible for reviewing and implementing hospital orders and medication administration records (MARs) upon admission. In an interview on 03/03/2026 at 03:36 PM, the ADON stated he had been employed with the facility since January 1st, 2026. The ADON stated that he and the DON are responsible for overseeing the medication reconciliation processes. He reported that corporate support was available when medications were not accessible, including determining alternative medications or treatment options. The ADON acknowledged that medication pass audits had not been completed by him and stated he could not speak to whether the DON had completed such audits. He indicated that nursing staff received training upon hire and were provided with additional education or corrective action when errors occur. The ADON further acknowledged communication challenges between the facility and external providers, including PACE, that there was a lack of consistent communication and coordination of care. He stated the admitting nurses were responsible for entering physician's orders into the system at the time of admission. He acknowledged that there have been prior difficulties with the process and described the system as not fully aligned with external providers. In an interview on 03/03/2026 at 04:28 pm, the DON stated medication administration was monitored through and electronic reporting systems (PCC), including medication administration reports, order listing reports, and non-administered medication reports. The DON stated that audits of medication administration were conducted periodically, typically every three weeks to monthly, rather than daily. The DON acknowledged that there was no consistent daily process to review medications for accuracy or completeness. She stated that medication pass audits were completed intermittently and that staff training was provided during meetings or when issues were identified. She further stated that nursing staff were expected to communicate changes in resident conditions to physicians and include leadership in communication; however, the process was still being implemented and was not consistently followed. The DON reported ongoing communication challenges with external providers, including PACE, that the facility relies on receiving orders but does not consistently have direct communication with providers. She stated that orders were expected to be entered by the admitting nurses and that a communication board within PCC is used to relay updates between shifts. The DON further acknowledged that in situations where medications werenot available, staff may not consistently notify the physician and instead rely on external systems or processes to obtain medications. She indicated that the facility does not directly contact certain providers and relies on intermediary processes, which may delay care. The DON described instances in which residents with fluctuating blood glucose levels required close monitoring; however, inconsistent oversight and communication processes impacted timely intervention. She acknowledged that if a resident's condition worsens, the facility may transfer the resident to the hospital rather than intervening earlier. In an interview on 03/04/2026 at 11:00 am, the NP from PACE stated she was not notified that Resident #2 did not receive her antibiotic medication as ordered as well as her blood glucose monitoring sensor. She stated that the lack of notification created potential for harm, including infection and hospitalization related to uncontrolled blood glucose levels. The NP reported that upon review following the resident's hospital discharge, orders had been provided for antibiotics, probiotics, insulin, and other routine medications; however, they were not implemented as ordered by the facility. She stated that there were no recent changes made to these medications that would explain the omissions. The NP further stated ongoing concerns with communication, that failure to notify providers of missed medications and changes in condition has been a recurring issue with this facility. The NP stated that the residents subsequently developed worsening conditions, including infection, skin breakdown, and eventual sepsis ,( life threatening condition that arises when the body's response to an infection injures its own tissues and organs) requiring hospitalization. The NP stated that the resident had not previously experienced that level of decline and attributed the deterioration (DKA and sepsis) , in part, to missed medications and lack of timely intervention.In an interview with 03/04/2026 at 11:18 am the RN from PACE stated that he was notified of elevated blood glucose levels on 02/27/2026. The RN stated that after notification, additional sliding scale insulin coverage was ordered . He further stated that long-acting insulin (Lantus) had been part of the resident's prior medication regimen and should have continued without interruption. The RN stated that communication occurred with facility staff LVN C regarding elevated blood glucose levels and instructions were given to administer sliding scale insulin, including an additional 12 units, and to closely monitor the resident's condition. He stated that LVN C/facility staff were instructed to notify the provider of any changes. The RN stated that on 03/01/2026, the on-call provider from PACE was contacted regarding elevated blood glucose levels; however, there was no documentation available to confirm blood glucose values or provider notification at that time. The facility additionally reported elevated blood glucose readings on 03/02/2026, with continued concerns for lack of documentation and delayed communication . The RN stated that he was notified again early in the morning on 03/02/2026 regarding persistently elevated blood glucose levels, prompting further evaluation by the RN and NP from PACE, who were at the facility to see Resident #2 In an interview on 03/04/2026 at 01:00PM LVN C stated that she had been employed at the facility for approximately one year and received training on medication administration and vital signs monitoring. She stated that PACE physician's orders were typically received via fax and entered into the system; however, she reported that there may be delays in processing orders, particularly during admissions. LVN C stated that during Resident #2's admission, medication orders from PACE required review and verification before implementation. She reported that some medications, including long-acting insulin (Lantus), were not immediately available or did not appear on the medication administration record (MAR), resulting in delays in administration. She further stated that she contacted the external provider (PACE) multiple times regarding elevated blood glucose levels and received instructions to administer sliding scale insulin (there was no documentation found to support this). She stated that she did not complete the admission process and did not verify any medications with providers as that is the admitting nurse's responsibility. LVN C reported that the resident continued to have elevated blood glucose levels despite sliding scale insulin administration . She acknowledged that no new physician's orders were obtained during that time and that communication delays occurred, including lack of response from the on-call provider on the weekend . She further stated that the resident declined transfer to the hospital initially; however, blood glucose levels remained elevated, and monitoring continued for her shifts with Resident #2.In an interview on 03/04/2026 at 01:35 pm RN M stated Resident #2 did not receive her FreeStyle lantus sensor during the initial period following admission . RN M stated that the resident's blood glucose levels remained elevated, including readings in the 400-500 mg/dL range, and at times were unreadable on the glucometer . RN M stated that the resident received sliding scale insulin. She reported that despite elevated blood glucose levels, the resident remained at the facility until the decision was made to transfer the resident to the hospital due to frequent high glucose readings. RN M stated she could not recall who initiated the transfer order but confirmed the transfer was related to critically elevated blood glucose levels. She further reported uncertainty regarding whether antibiotics ordered were administered prior to transfer or during residents stay. In an interview on 03/04/2026 at 02:53pm, LVN K stated she had been employed at the facility since October 2025. LVN K stated that during the admission process, medication reconciliation was completed using hospital records and external provider (PACE) documentation. She stated that orders were expected to be uploaded into the system (PCC) and reviewed; however, she acknowledged that discrepancies may occur. LVN K stated that during Resident #2's admission, she did not recall seeing orders for antibiotics such as Ciprofloxacin or Metronidazole (Flagyl) and could not confirm whether these medications were reviewed or implemented. She also does not recall receiving any supplies from PACE for Resident #2's glucose monitor. She further stated that communication with external providers is inconsistent, and that follow-ups on orders was not always completed. She acknowledged that she could not confirm whether medications were received from the pharmacy or administered as ordered.In an interview conducted on 03/04/2026 at 4:34 PM, the Medical Director from facility stated that medication reconciliation should be completed promptly upon admission. He reported that in urgent situations residents should be immediately evaluated and appropriate orders implemented without delay with providers from the facility. He further stated that PACE providers should be accessible for communication and that if a resident's condition worsens, the resident should be transferred to a higher level of care. In an interview on 03/04/2026 at 04:42 pm LVN P stated she had been at the facility for 2 months now. LVN P stated that she assisted with entering medications during the admission process ; however, she did not recall specific medications ordered for Resident #2. She stated that medication reconciliation responsibilities were shared among staff and that communication with external providers were always required to complete the admissions process. In an interview on 03/05/2026 at 10:07 am the RN from PACE regarding the NP on call the weekend the facility called regarding Resident #2's condition, however, there were communication delays, including missed calls and lack of response from facility staff. He stated that follow-up communication was inconsistent, and documentation did not reflect timely provider notification. He stated that the resident's condition continued, resulting in transfer to the hospital and admission to the ICU . Record review of residents care plan and order summary on 03/05/2026 at 10:25am reveled that MDS revised Resident #2's care plans regarding antibiotic therapy, and blood glucose monitoring. In an interview on 03/05/2026 at 12:20 pm MDS stated that Resident #2 was admitted with a skilled level of care and required ongoing monitoring. She stated that MDS assessments and baseline evaluations were completed after admission; however, she acknowledged that medication-related information wasprimarily managed by the nursing staff. She stated that she did not recall reviewing documentation indicating the resident was receiving antibiotics therapy or glucose monitoring and acknowledged that follow-up on such treatments was dependent on nursing processes. MDS stated that she does recall revising Resident #2's care plan but did not see anything in regard to her missing medication. In an interview on 03/05/2026 at 02:14pm RN M stated that staff did not routinely utilize continuous glucose monitoring devices (Libre) and instead rely on glucometer readings. She stated that she was unfamiliar with consistent use of the Libre system and had never administered one before nor was she ever trained on administering it. In an interview on 03/05/2026 at 03:24 pm the DON stated that while the facility had the capability to utilize Libre devices, implementation depends on availability of supplies and physician's orders . The DON acknowledged that there was not consistent system to ensure the device was in place or functioning upon admission. She further stated the monitoring processes were not consistently verified daily and rely on periodic oversight. The DON acknowledged that medication reconciliation was not completed for Resident #2 upon admission and could not confirm whether all physician's orders, including antibiotics and glucose monitoring, were implemented. She reported that communication gaps exist between the facility and external providers and that corrective actions were typically taken after issues are identified rather than proactively.In an interview on 03/05/2026 at 03:35 pm the NP from PACE stated that antibiotics had been ordered prophylactically to prevent infection and that failure to administer these medications contributed to the resident developing sepsis. She stated that the resident also required insulin management and should have received appropriate treatment upon admission. The NP stated that the resident's condition declined due to lack of treatment, including failure to administer the insulin sensor and antibiotics , and that earlier intervention could have prevented the progression to sepsis. She further stated that the resident required transfer to the hospital for a higher level care, including management of infection and uncontrolled blood glucose. In an interview on 03/05/2026 at 04:02 pm the Medical Director from PACE stated that Resident #2was discharged from the hospital with orders for FreeStyle monitoring device and antibiotics ; however, the medications were not administered at the facility. She stated that the resident required readmission due to failure to implement the orders. The Medical Director stated that the facility failed to notify providers of missed medications, and that appropriate communication could have prevented the resident's deterioration. She stated that the resident's hospitalization for sepsis could have been prevented if ordered antibiotics had been administered as prescribed. Interview on 03/05/2026 at 04:45 pm with Resident #2 revealed the resident was alert and oriented. The resident stated that staff checked her blood sugar using facility equipment where they would poke her finger. The resident further reported that she was unaware that prescribed medications were not being administered .In an interview on 03/05/2026 at 05:00 pm the hospital RN stated that upon admission to the hospital, Resident #2 presented with hyperglycemia and urinary tract infection. The resident required initiation of sepsis protocol and was treated with intravenous antibiotics (Zosyn) and insulin therapy. The RN reported that laboratory findings included significantly elevated white blood cell count (28.3) and confirmed infection, including E. coli and yeast identified in cultures. The resident required intensive treatment, including insulin drip and management of diabetic ketoacidosis (DKA). In an interview on 03/06/2026 at 03:06 pm the ADON stated that he was responsible for tracking new admissions and following up with nursing staff regarding admission processes. He acknowledged that current issues were related to prior system failures and that processes were not fully implemented at the time of Resident #2's admission. The ADON stated that staff training regarding the use of continuous glucose monitoring devices (Libre Freestyle) was not consistently completed. He stated that only limited staff had received training and could not confirm which staff were competent in use of the device. He acknowledged that the nurse assigned to Resident #2 had not been trained to use the Libre device and that it was not implemented. The ADON further stated that admission assessments were not consistently completed prior to residents arriving at the facility. He stated that in some cases, the facility received notification that a resident arrived without prior to review of medical records. He acknowledged that no baseline blood glucose assessment was completed upon admission for Resident #2. The ADON stated that the facility does not have a standardized process to ensure monitoring or use of continuous glucose monitoring systems and confirmed that there was none established policy guiding the use of such devices and also confirmed that they do not carry any supplies of the Libre at the facility. In an interview on 03/06/2026 at 03:53 pm the DON stated that not all admissions were reviewed or receive a pre-admission assessment. She stated that review of hospital records was not consistently required for every admission and may only occur if additional clinical concerns are identified . The DON acknowledged that nursing staff were not consistently instructed to review hospital documentation prior to implementing care. She reported that corporate staff review referrals and approve admissions; however, facility-level review processes are not standardized. The DON further stated that admission documentation, including blood glucose monitoring for diabetic residents, should be completed; however, she could not confirm that this was done for Resident #2. She acknowledged that medication reconciliation is often dependent on timing and communication with on-call providers rather than a consistent internal process. Record review of the facility's policy titled Physician Orders dated November 2018, revised 01/2026 revealed To clarify requirements and ensure that all physician orders are valid and safe for patient care. Documentation of the physician order in the progress notes is sufficient.Record review of the facility's policy titled Blood Glucose Monitoring dated November 2020, revised 01/2026 revealed To ensure blood glucose monitoring is completed per provider orders and in accordance with all state and federal regulations. Each physician order for bedside blood glucose testing will include physician notification parameters and hypoglycemic medication holding parameters as applicable. If the resident's glucose result is outside the physician ordered parameters, follow physician orders for notification and/or medication holding. If the resident has a diagnosis of hyperglycemia (diabetes mellitus or insipidus ), insulin will be administered only upon the order of a physician. At no time will nursing staff administer insulin as a nursing judgment. This was determined to be an Immediate Jeopardy (IJ) on 03/12/2026 at 03:28 PM. The Administrator was informed of the IJ. The Administrator was provided with the IJ template on 03/12/2026 at 3:52 PM. The following Plan of Removal submitted by the facility was accepted on 03/13/2026 at 05:00 PM: The facility is committed to ensuring the safety and well-being of all Residents and operates in substantial compliance with Federal and State laws and regulations. This removal plan constitutes Note's written credible allegation of compliance for the immediate jeopardy noted.It is the facility's policy to immediately inform the resident, consult with the resident's physician, and notify the resident representative(s) when there is a need to alter treatment significantly, including the need to discontinue an existing form of treatment due to adverse consequences or commence a new form of treatment, or when there is a significant change in the resident's physical, mental, or psychosocial status, in accordance with 42 CFR S483.10(g)(14). Additionally, it is the facility's policy to ensure that physician orders are documented completely with sufficient content to clearly convey the provider's intent, and that orders that are unclear must be clarified prior to implementation. The facility is further committed to ensuring that blood glucose monitoring is performed as ordered, and that physicians are notified immediately when glucose results are outside ordered parameters.Immediate Action for Affected Residents:On 03/03/26, the facility identified Resident #2 as the affected resident in this citation. The following immediate actions have been taken. The licensed nursing staff and admission staff were notified in a mandatory in-service conducted in person and via phone from 03/05/26-3/12/26. The staff gave verbal and written confirmation they have been educated and understand the new policies and procedures. Ongoing competency checks will be conducted with staff. Staff were informed these policies are readily available to them from the CNO and ACNO . New hires will go through training and written competencies upon hire. On 03/03/26, the facility Administrator and Director of Nursing (DON) reviewed Resident #2's current hospitalization status and confirmed with the hospital that Resident #2 was admitted to the ICU on 03/02/26 for diabetic ketoacidosis (happens when you have a lack of insulin in your body. It's a life-threatening complication of diabetes) and septic shock and is receiving appropriate medical treatment. The resident did not return to the facility. On 03/11/26, the facility conducted nurses meetings with all nursing staff who provided care to Resident #2 between 02/25/26 and 03/02/26 to review the specific failures in this case, including: failure to obtain daily bedtime blood glucose readings as ordered; failure to notify the physician of four blood glucose levels exceeding 400 mg/dl; failure to administer the continuous glucose monitoring device; and failure to communicate with the physician regarding unavailable supplies. From 03/11/26-3/12/2026, the CNO and ACNO conducted mandatory re-education for all licensed nursing staff (RNs and LPNs) this in-service was conducted both in person and via phone/virtually for staff who were unable to be onsite. Staff confirmed verbal understanding of the policy and procedure. The staff were made aware that policies could be given at that time of any time from the Administrator, CNO, or ACNO. The training covered the facility's Blood Glucose Monitoring Policy and Physician Notification requirements, specifically emphasizing: the requirement to obtain blood glucose readings exactly as ordered by the physician; the requirement to immediately notify the physician when results fall outside ordered parameters; the requirement to notify the physician/CNO/ACNO immediately when ordered supplies or equipment are not available; and the requirement to clarify unclear or unable-to-implement orders prior to implementation. On 03/11/26, the facility established a communication protocol with the local PACE Organization requiring that the facility's nursing staff contact PACE providers immediately for all clinical concerns, significant changes in condition, out-of-parameter laboratory/glucose values, and any inability to implement physician orders due to unavailable supplies or unclear orders. An in-service was conducted with RNs and LVNs both in person and via phone/virtually for staff who were unable to be onsite. Staff confirmed verbal understanding of the policy and procedure. The staff were made aware that policies could be given at that time of any time from the Administrator, CNO, or ACNO. On 03/11/26, the facility implemented a redundant notification system requiring that when any blood glucose result is outside physician-ordered parameters, the nurse must: immediately notify the physician/PACE provider and document the date, time, person contacted, and response received. An in-service was conducted with RNs and LVNs both in person and via phone/virtually f staff who were unable to be onsite. Staff confirmed verbal understanding of the policy and procedure. The staff were made aware that policies could be given at that time or any time from the Administrator, CNO, or ACNO.Identifying Other Residents at Risk:On 03/11/26 through 03/12/26, the facility conducted a comprehensive review to identify all other residents who may be at risk for similar failures in physician notification, blood glucose monitoring, or implementation of physician orders. On 03/12/26, the CNO and ACNO conducted a review of all current residents (census of 49 residents) to identify those with physician orders for blood glucose monitoring. This review identified 15 residents with active blood glucose monitoring orders. On 03/12/26, the DON, ADON, and VP of Operations conducted a comprehensive chart audit of all 15 residents with blood glucose monitoring orders to assess: whether blood glucose monitoring was performed as ordered; whether any blood glucose results fell outside physician-ordered parameters; and whether appropriate and timely physician notification was documented when results were out of parameters. 6 Issues identified and were reported to the physician and clarification of new orders needed were given. Continued monitoring will occur by CNO, ACNO, or nurse manager for daily monitoring. On 03/12/26, the facility conducted a review of all current residents (census of 49 residents) to identify those with physician orders that include continuous monitoring devices or specialized medical equipment. This review identified 15 residents with such orders (including insulin pumps, continuous glucose monitors, cardiac monitors, and oxygen concentrators). No issues identified. On 03/12/26, the CNO and ACNO conducted a physical verification to confirm that all 15 residents had the ordered devices/equipment in place and functioning as ordered. All devices/equipment were confirmed to be present an

Based on observation, interview, and record review the facility failed to ensure that residents are free of any significant mediation errors for 1 (Resident #2) of 3 residents reviewed for medication administration errors.The facility failed to assess Resident #2 prior to admission and failed to identify and implement physician orders related to antibiotic therapy and blood glucose management for readings outside established parameters. An Immediate Jeopardy (IJ) situation was identified on 03/12/2026. While the IJ was removed on 03/13/2026, the facility remained out of compliance at the scope of isolation with the potential for more than minimal harm , due to the facility's need to evaluate the effectiveness of their corrective systems. This failure could have resulted in serious deterioration of the residents health, including infection progression, unstable blood glucose levels, and life-threatening complications. Findings included:Record review of Resident #2's face sheet dated 03/11/2026, revealed an [AGE] year-old female who was admitted to the facility on [DATE]. Resident #2's diagnoses included Vesicointestinal Fistula (abnormal connection between the bladder and the bowel), hypertension (High blood pressure), type 2 diabetes mellitus with hyperglycemia (diabetes with blood sugar elevation), Alzheimer's Diseases with early onset (form of dementia). Record review of Resident #2's MDS dated [DATE], reflected a BIMS score of 14, indicating the resident was cognitively intact. Record review of Resident #2's Order Summary Report dated 03/11/2026 revealed Glucose Monitoring-notify provider if <60 or >400 before meals and at bedtime for diabetes. Record review of Resident #2's admitting physician orders dated 02/25/26 revealed: -Semglee (Insulin Glargine) 23 units subcutaneously at bedtime daily -NovoLOG FlexPen (insulin aspart) for blood glucose management [70-160: 0 units;161-200: 4 units; 201-250: 6 units; 251-300: 8 units; 301-349: 10 units; 350-400: 12 units (call MD)]. -FreeStyle Libre 2 CGM (continuous glucose monitoring) sensor apply subcutaneously in the morning every 14 days. -Blood glucose monitoring before meals and at bedtime with notification to provider if <60 or >400.Record review of Resident #2' MAR from 02/25/2026 through 03/02/2026 showed no evidence of transcribed antibiotic orders and no doses were administered during this period.Record review of Resident #2's notes revealed on 02/26/2026 at 12:33pm, Resident #2'sblood glucose was documented as 512 mg/dL; at 12:36pm. No evidence of resident's record physician was notified. On 02/27/2026 at 1:04pm, blood glucose was documented as 482 mg/dL. No evidence of resident's record physician was notified. On 03/01/2026 at 11:08 am, blood glucose was documented as 459 mg/dL. No evidence of resident's record physician was notified. On 03/02/2026 at 6:49am, blood glucose was documented at 492 mg/dL. No evidence of resident's record physician was notified.Record review of the Resident #2's medication administration record and blood glucose logs revealed no evidence of documented nighttime blood glucose checks. Record review of Resident #2's Care Plan dated 03/11/2026, for blood glucose monitoring revealed, focus The resident is receiving insulin active med list in EMR with a goal, Blood Glucose levels will be withing normal limits and interventions Blood glucose monitoring as per physician order, hypo/Hyperglycemia (high blood sugar/ low blood sugar) protocol per physician orders, Monitor/Document/report as needed for following adverse effects of insulin therapy: Hypoglycemia, weight gain, hypokalemia (low blood potassium levels), pain at injection site. For antibiotics the focus revealed The resident is receiving antibiotic therapy. (see active med list in EMR) with a goal The resident will be free of any discomfort or adverse side effects of antibiotic therapy through the review date And interventions Monitor/document/report PRN adverse reactions to antibiotic therapy: diarrhea, nausea, vomiting, anorexia, and hypersensitivity/allergic reactions (rashes, welts, hives, swelling face/throat), report labs results to MD. Review of local hospital Emergency Department Note on 03/02/3036, revealed Resident #2's chief complaint was elevated blood glucose levels of approximately 400 mg/dL 400 mg/dL. Resident #2 was administered Lispro 22 units by EMS in route from nursing facility to hospital. After Lispro administration, Resident #2's blood glucose level in route was 23 mg/dL. Resident #2's blood glucose level in the ED on 3/2/2026 at 9:35am revealed 249 mg/dL. Resident's WBC was 14.6. Resident was admitted to hospital for 10 days due to DKA (diabetic ketoacidosis) and septic shock. Resident was admitted to ICU due to critical condition.In an interview on 03/03/2026 at 12:39 pm the Admissions Coordinator stated she had been employed at the facility for 6 months. The Admissions Coordinator stated that the facility utilizes an electronic system (Exacare) which pulled all the medication orders from the hospitals and then the admitting nurse enters it into PCC (electronic records) . For residents with PACE services there are certain communication failures regarding medication orders. PACE either emails, fax, or provided orders verbally. She reported that PACE communication may be limited on weekends since they were closed on the weekends, and that emails and order processing may not occur consistently during that time . She stated that medication orders are typically directed to nursing staff, and that the primary orders received were admission orders or discharge-related orders.In an interview on 03/03/2026 at 02:02 pm RN V from PACE stated Resident #2 underwent surgery for colostomy placement and was admitted to the facility on [DATE] following hospitalization. RN V stated that the facility failed to administer two prescribed antibiotics (Ciprofloxacin 500 mg and Metronidazole [Flagyl] 500 mg), which were ordered prophylactically upon admission. RN V reported that these medications were not administered as ordered . RN V further stated that the resident had four blood glucose readings outside of ordered parameters without physician notification . Additionally, the facility failed to obtain blood glucose readings at night as ordered and did not implement the resident's continuous glucose monitoring system. RN V stated that physician's orders from PACE were sent; however, the physician was not notified of missed medications or abnormal blood glucose levels . RN V indicated that nursing staff were responsible for reviewing and implementing hospital orders and medication administration records (MARs) upon admission. In an interview on 03/03/2026 at 03:36 PM, the ADON stated he had been employed with the facility since January 1st, 2026. The ADON stated that he and the DON are responsible for overseeing the medication reconciliation processes. He reported that corporate support was available when medications were not accessible, including determining alternative medications or treatment options. The ADON acknowledged that medication pass audits had not been completed by him and stated he could not speak to whether the DON had completed such audits. He indicated that nursing staff received training upon hire and were provided with additional education or corrective action when errors occur. The ADON further acknowledged communication challenges between the facility and external providers, including PACE, that there was a lack of consistent communication and coordination of care. He stated the admitting nurses were responsible for entering physician's orders into the system at the time of admission. He acknowledged that there have been prior difficulties with the process and described the system as not fully aligned with external providers. In an interview on 03/03/2026 at 04:28 pm, the DON stated medication administration was monitored through and electronic reporting systems (PCC), including medication administration reports, order listing reports, and non-administered medication reports. The DON stated that audits of medication administration were conducted periodically, typically every three weeks to monthly, rather than daily. The DON acknowledged that there was no consistent daily process to review medications for accuracy or completeness. She stated that medication pass audits were completed intermittently and that staff training was provided during meetings or when issues were identified. She further stated that nursing staff were expected to communicate changes in resident conditions to physicians and include leadership in communication; however, the process was still being implemented and was not consistently followed. The DON reported ongoing communication challenges with external providers, including PACE, that the facility relies on receiving orders but does not consistently have direct communication with providers. She stated that orders were expected to be entered by the admitting nurses and that a communication board within PCC is used to relay updates between shifts. The DON further acknowledged that in situations where medications were not available, staff may not consistently notify the physician and instead rely on external systems or processes to obtain medications. She indicated that the facility does not directly contact certain providers and relies on intermediary processes, which may delay care. The DON described instances in which residents with fluctuating blood glucose levels required close monitoring; however, inconsistent oversight and communication processes impacted timely intervention. She acknowledged that if a resident's condition worsens, the facility may transfer the resident to the hospital rather than intervening earlier. In an interview on 03/04/2026 at 11:00 am, the NP from PACE stated she was not notified that Resident #2 did not receive her antibiotic medication as ordered as well as her blood glucose monitoring sensor. She stated that the lack of notification created potential for harm, including infection and hospitalization related to uncontrolled blood glucose levels. The NP reported that upon review following the resident's hospital discharge, orders had been provided for antibiotics, probiotics, insulin, and other routine medications; however, they were not implemented as ordered by the facility. She stated that there were no recent changes made to these medications that would explain the omissions. The NP further stated ongoing concerns with communication, that failure to notify providers of missed medications and changes in condition has been a recurring issue with this facility. The NP stated that the residents subsequently developed worsening conditions, including infection, skin breakdown, and eventual sepsis ,( life threatening condition that arises when the body's response to an infection injures its own tissues and organs) requiring hospitalization. The NP stated that the resident had not previously experienced that level of decline and attributed the deterioration (DKA and sepsis) , in part, to missed medications and lack of timely intervention.In an interview with 03/04/2026 at 11:18 am the RN from PACE stated that he was notified of elevated blood glucose levels on 02/27/2026. The RN stated that after notification, additional sliding scale insulin coverage was ordered . He further stated that long-acting insulin (Lantus) had been part of the resident's prior medication regimen and should have continued without interruption. The RN stated that communication occurred with facility staff LVN C regarding elevated blood glucose levels and instructions were given to administer sliding scale insulin, including an additional 12 units, and to closely monitor the resident's condition. He stated that LVN C/facility staff were instructed to notify the provider of any changes. The RN stated that on 03/01/2026, the on-call provider from PACE was contacted regarding elevated blood glucose levels; however, there was no documentation available to confirm blood glucose values or provider notification at that time. The facility additionally reported elevated blood glucose readings on 03/02/2026, with continued concerns for lack of documentation and delayed communication . The RN stated that he was notified again early in the morning on 03/02/2026 regarding persistently elevated blood glucose levels, prompting further evaluation by the RN and NP from PACE, who were at the facility to see Resident #2 In an interview on 03/04/2026 at 01:00PM LVN C stated that she had been employed at the facility for approximately one year and received training on medication administration and vital signs monitoring. She stated that PACE physician's orders were typically received via fax and entered into the system; however, she reported that there may be delays in processing orders, particularly during admissions. LVN C stated that during Resident #2's admission, medication orders from PACE required review and verification before implementation. She reported that some medications, including long-acting insulin (Lantus), were not immediately available or did not appear on the medication administration record (MAR), resulting in delays in administration. She further stated that she contacted the external provider (PACE) multiple times regarding elevated blood glucose levels and received instructions to administer sliding scale insulin (there was no documentation found to support this). She stated that she did not complete the admission process and did not verify any medications with providers as that is the admitting nurse's responsibility. LVN C reported that the resident continued to have elevated blood glucose levels despite sliding scale insulin administration . She acknowledged that no new physician's orders were obtained during that time and that communication delays occurred, including lack of response from the on-call provider on the weekend . She further stated that the resident declined transfer to the hospital initially; however, blood glucose levels remained elevated, and monitoring continued for her shifts with Resident #2.In an interview on 03/04/2026 at 01:35 pm RN M stated Resident #2 blood glucose levels remained elevated, including readings in the 400-500 mg/dL range, and at times were unreadable on the glucometer . RN M stated that the resident received sliding scale insulin. She reported that despite elevated blood glucose levels, the resident remained at the facility until the decision was made to transfer the resident to the hospital due to frequent high glucose readings. RN M stated she could not recall who initiated the transfer order but confirmed the transfer was related to critically elevated blood glucose levels. She further reported uncertainty regarding whether antibiotics ordered were administered prior to transfer or during residents stay. In an interview on 03/04/2026 at 02:53pm, LVN K stated she had been employed at the facility since October 2025. LVN K stated that during the admission process, medication reconciliation was completed using hospital records and external provider (PACE) documentation. She stated that orders were expected to be uploaded into the system (PCC) and reviewed; however, she acknowledged that discrepancies may occur. LVN K stated that during Resident #2's admission, she did not recall seeing orders for antibiotics such as Ciprofloxacin or Metronidazole (Flagyl) and could not confirm whether these medications were reviewed or implemented. She also does not recall receiving any supplies from PACE for Resident #2's glucose monitor. She further stated that communication with external providers is inconsistent, and that follow-ups on orders was not always completed. She acknowledged that she could not confirm whether medications were received from the pharmacy or administered as ordered.In an interview conducted on 03/04/2026 at 4:34 PM, the Medical Director from facility stated that medication reconciliation should be completed promptly upon admission. He reported that in urgent situations residents should be immediately evaluated and appropriate orders implemented without delay with providers from the facility. He further stated that PACE providers should be accessible for communication and that if a resident's condition worsens, the resident should be transferred to a higher level of care. In an interview on 03/04/2026 at 04:42 pm LVN P stated she had been at the facility for 2 months now. LVN P stated that she assisted with entering medications during the admission process ; however, she did not recall specific medications ordered for Resident #2. She stated that medication reconciliation responsibilities were shared among staff and that communication with external providers were always required to complete the admissions process. In an interview on 03/05/2026 at 10:07 am the RN from PACE regarding the NP on call the weekend the facility called regarding Resident #2's condition, however, there were communication delays, including missed calls and lack of response from facility staff. He stated that follow-up communication was inconsistent, and documentation did not reflect timely provider notification. He stated that the resident's condition continued, resulting in transfer to the hospital and admission to the ICU . Record review of residents care plan and order summary on 03/05/2026 at 10:25am reveled that MDS revised Resident #2's care plans regarding antibiotic therapy, and blood glucose monitoring. In an interview on 03/05/2026 at 12:20 pm MDS stated that Resident #2 was admitted with a skilled level of care and required ongoing monitoring. She stated that MDS assessments and baseline evaluations were completed after admission; however, she acknowledged that medication-related information was primarily managed by the nursing staff. She stated that she did not recall reviewing documentation indicating the resident was receiving antibiotics therapy or glucose monitoring and acknowledged that follow-up on such treatments was dependent on nursing processes. MDS stated that she does recall revising Resident #2's care plan but did not see anything in regard to her missing medication. In an interview on 03/05/2026 at 03:24 pm the DON stated that medication reconciliation was not completed for Resident #2 upon admission and could not confirm whether all physician's orders, including antibiotics and glucose monitoring, were implemented. She reported that communication gaps exist between the facility and external providers and that corrective actions were typically taken after issues are identified rather than proactively.In an interview on 03/05/2026 at 03:35 pm the NP from PACE stated that antibiotics had been ordered prophylactically to prevent infection and that failure to administer these medications contributed to the resident developing sepsis. She stated that the resident also required insulin management and should have received appropriate treatment upon admission. The NP stated that the resident's condition declined due to lack of treatment, including failure to administer the insulin sensor and antibiotics , and that earlier intervention could have prevented the progression to sepsis. She further stated that the resident required transfer to the hospital for a higher level care, including management of infection and uncontrolled blood glucose. In an interview on 03/05/2026 at 04:02 pm the Medical Director from PACE stated that Resident #2 was discharged from the hospital with orders for glucose monitoring device and antibiotics; however, the medications were not administered at the facility. She stated that the resident required readmission due to failure to implement the orders. The Medical Director stated that the facility failed to notify providers of missed medications, and that appropriate communication could have prevented the resident's deterioration. She stated that the resident's hospitalization for sepsis could have been prevented if ordered antibiotics had been administered as prescribed. Interview on 03/05/2026 at 04:45 pm with Resident #2 revealed the resident was alert and oriented. The resident stated that staff checked her blood sugar using facility equipment where they would poke her finger. The resident further reported that she was unaware that prescribed medications were not being administered .In an interview on 03/05/2026 at 05:00 pm the hospital RN stated that upon admission to the hospital, Resident #2 presented with hyperglycemia and urinary tract infection. The resident required initiation of sepsis protocol and was treated with intravenous antibiotics (Zosyn) and insulin therapy. The RN reported that laboratory findings included significantly elevated white blood cell count (28.3) and confirmed infection, including E. coli and yeast identified in cultures. The resident required intensive treatment, including insulin drip and management of diabetic ketoacidosis (DKA). In an interview on 03/06/2026 at 03:06 pm the ADON stated that he was responsible for tracking new admissions and following up with nursing staff regarding admission processes. He acknowledged that no baseline blood glucose assessment was completed upon admission for Resident #2. The ADON stated that the facility does not have a standardized process to ensure monitoring or use of continuous glucose monitoring. In an interview on 03/06/2026 at 03:53 pm the DON stated that not all admissions were reviewed or receive a pre-admission assessment. She stated that review of hospital records was not consistently required for every admission and may only occur if additional clinical concerns are identified . The DON acknowledged that nursing staff were not consistently instructed to review hospital documentation prior to implementing care. She reported that corporate staff review referrals and approve admissions; however, facility-level review processes are not standardized. The DON further stated that admission documentation, including blood glucose monitoring for diabetic residents, should be completed; however, she could not confirm that this was done for Resident #2. She acknowledged that medication reconciliation is often dependent on timing and communication with on-call providers rather than a consistent internal process. Record review of the facility's policy titled Physician Orders dated November 2018, revised 01/2026 revealed To clarify requirements and ensure that all physician orders are valid and safe for patient care. Documentation of the physician order in the progress notes is sufficient.Record review of the facility's policy titled Blood Glucose Monitoring dated November 2020, revised 01/2026 revealed To ensure blood glucose monitoring is completed per provider orders and in accordance with all state and federal regulations. Each physician order for bedside blood glucose testing will include physician notification parameters and hypoglycemic medication holding parameters as applicable. If the resident's glucose result is outside the physician ordered parameters, follow physician orders for notification and/or medication holding. If the resident has a diagnosis of hyperglycemia (diabetes mellitus or insipidus ), insulin will be administered only upon the order of a physician. At no time will nursing staff administer insulin as a nursing judgment. This was determined to be an Immediate Jeopardy (IJ) on 03/12/2026 at 03:28 PM. The Administrator was informed of the IJ. The Administrator was provided with the IJ template on 03/12/2026 at 3:52 PM. The following Plan of Removal submitted by the facility was accepted on 03/13/2026 at 05:00 PM: The facility is committed to ensuring the safety and well-being of all Residents and operates in substantial compliance with Federal and State laws and regulations. This removal plan constitutes Note's written credible allegation of compliance for the immediate jeopardy noted.It is the facility's policy to immediately inform the resident, consult with the resident's physician, and notify the resident representative(s) when there is a need to alter treatment significantly, including the need to discontinue an existing form of treatment due to adverse consequences or commence a new form of treatment, or when there is a significant change in the resident's physical, mental, or psychosocial status, in accordance with 42 CFR S483.10(g)(14). Additionally, it is the facility's policy to ensure that physician orders are documented completely with sufficient content to clearly convey the provider's intent, and that orders that are unclear must be clarified prior to implementation. The facility is further committed to ensuring that blood glucose monitoring is performed as ordered, and that physicians are notified immediately when glucose results are outside ordered parameters.Immediate Action for Affected Residents:On 03/03/26, the facility identified Resident #2 as the affected resident in this citation. The following immediate actions have been taken. The licensed nursing staff and admission staff were notified in a mandatory in-service conducted in person and via phone from 03/05/26-3/12/26. The staff gave verbal and written confirmation they have been educated and understand the new policies and procedures. Ongoing competency checks will be conducted with staff. Staff were informed these policies are readily available to them from the CNO and ACNO . New hires will go through training and written competencies upon hire. On 03/03/26, the facility Administrator and Director of Nursing (DON) reviewed Resident #2's current hospitalization status and confirmed with the hospital that Resident #2 was admitted to the ICU on 03/02/26 for diabetic ketoacidosis (happens when you have a lack of insulin in your body. It's a life-threatening complication of diabetes) and septic shock and is receiving appropriate medical treatment. The resident did not return to the facility. On 03/11/26, the facility conducted nurses meetings with all nursing staff who provided care to Resident #2 between 02/25/26 and 03/02/26 to review the specific failures in this case, including: failure to obtain daily bedtime blood glucose readings as ordered; failure to notify the physician of four blood glucose levels exceeding 400 mg/dl; failure to administer the continuous glucose monitoring device; and failure to communicate with the physician regarding unavailable supplies. From 03/11/26-3/12/2026, the CNO and ACNO conducted mandatory re-education for all licensed nursing staff (RNs and LPNs) this in-service was conducted both in person and via phone/virtually for staff who were unable to be onsite. Staff confirmed verbal understanding of the policy and procedure. The staff were made aware that policies could be given at that time of any time from the Administrator, CNO, or ACNO. The training covered the facility's Blood Glucose Monitoring Policy and Physician Notification requirements, specifically emphasizing: the requirement to obtain blood glucose readings exactly as ordered by the physician; the requirement to immediately notify the physician when results fall outside ordered parameters; the requirement to notify the physician/CNO/ACNO immediately when ordered supplies or equipment are not available; and the requirement to clarify unclear or unable-to-implement orders prior to implementation. On 03/11/26, the facility established a communication protocol with the local PACE Organization requiring that the facility's nursing staff contact PACE providers immediately for all clinical concerns, significant changes in condition, out-of-parameter laboratory/glucose values, and any inability to implement physician orders due to unavailable supplies or unclear orders. An in-service was conducted with RNs and LVNs both in person and via phone/virtually for staff who were unable to be onsite. Staff confirmed verbal understanding of the policy and procedure. The staff were made aware that policies could be given at that time of any time from the Administrator, CNO, or ACNO. On 03/11/26, the facility implemented a redundant notification system requiring that when any blood glucose result is outside physician-ordered parameters, the nurse must: immediately notify the physician/PACE provider and document the date, time, person contacted, and response received. An in-service was conducted with RNs and LVNs both in person and via phone/virtually f staff who were unable to be onsite. Staff confirmed verbal understanding of the policy and procedure. The staff were made aware that policies could be given at that time or any time from the Administrator, CNO, or ACNO.Identifying Other Residents at Risk:On 03/11/26 through 03/12/26, the facility conducted a comprehensive review to identify all other residents who may be at risk for similar failures in physician notification, blood glucose monitoring, or implementation of physician orders. On 03/12/26, the CNO and ACNO conducted a review of all current residents (census of 49 residents) to identify those with physician orders for blood glucose monitoring. This review identified 15 residents with active blood glucose monitoring orders. On 03/12/26, the DON, ADON, and VP of Operations conducted a comprehensive chart audit of all 15 residents with blood glucose monitoring orders to assess: whether blood glucose monitoring was performed as ordered; whether any blood glucose results fell outside physician-ordered parameters; and whether appropriate and timely physician notification was documented when results were out of parameters. 6 Issues identified and were reported to the physician and clarification of new orders needed were given. Continued monitoring will occur by CNO, ACNO, or nurse manager for daily monitoring. On 03/12/26, the facility conducted a review of all current residents (census of 49 residents) to identify those with physician orders that include continuous monitoring devices or specialized medical equipment. This review identified 15 residents with such orders (including insulin pumps, continuous glucose monitors, cardiac monitors, and oxygen concentrators). No issues identified.Root Cause Analysis:On 03/05/26 through 03/12/26, the facility conducted a comprehensive Root Cause Analysis (RCA) consisting of the Administrator, CNO, ACNO, VP of Clinical, and VP of Operations to determine the underlying factors that led to the immediate jeopardy situation involving Resident #2.On 03/05/26 through 03/12/26, the RCA team conducted individual interviews with the following staff members: Three additional nursing staff who provided care to Resident #2 during the dates in question The CNO and ACNOFishbone Diagram Key Findings:People: Staff lacked clarity on the specific process for notifying PACE providers versus the facility Medical Director; staff did not understand the criticality of obtaining bedtime blood glucose readings for residents with uncontrolled diabetes and DKA; staff did not recognize that failure to administer an ordered continuous glucose monitoring device due to unavailable supplies required immediate physician notification and order clarification.Process: The facility lacked a standardized process for immediate physician notification when blood glucose results exceeded parameters; the facility lacked a redundant safety check system to ensure blood glucose monitoring was completed as ordered; the admission process did not include verification that all ordered supplies and equipment were available prior to accepting the resident; there was no escalation process when nursing staff were unable to implement physician orders due to unavailable supplies.Environment: There was confusion among nursing staff regarding the scope of responsibility for PACE residents versus non-PACE residents; the facility culture did not emphasize the critical importance of immediate escalation when physician orders could not be implemented.Management: The CNO and ACNO did not have a system in place to audit compliance with blood glucose monitoring orders; there was insufficient oversight of the admission process to ensure all necessary supplies and equipment were available; the facility leadership did not provide adequate education and reinforcement regarding the physician notification requirements under 42 CFR S483.10(g)(14).Root Cause Summary:The RCA team identified the following root causes on 03/12/26:1. The facility lacked a comprehensive, redundant system to ensure physician notification occurred immediately when blood glucose

Based on interview, and record review, the facility failed to ensure that all alleged violations involving injuries of unknown source are reported immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury to the administrator of the facility and to other officials (including to the State Survey Agency and adult protective services where state law provides for jurisdiction in long-term care facilities) in accordance with State law through established procedures for 1of 8 resident (Resident #9) reviewed for Injury of unknown origin. The facility failed to ensure Resident #9 injury of unknown origin was reported to the state agency. This failure could have resulted in protection of residents from further potential harm. In an interview on 03/10/2026 at 02:20 pm the ADON stated that while conducting rounds, Resident #9 was found in bed in an abnormal position, with the head positioned opposite the foot of the bed. The resident had extremely limited mobility at baseline and required assistance with transfers. The ADON stated that the resident had a history of removing their oxygen and was typically on 2-3 liters. Upon assessment, the resident was noted to have temporal swelling. Emergency Medical Services (EMS) were contacted, and the resident was transferred to the hospital for further evaluation. The ADON stated that initial assessment did not reveal open areas or active bleeding; however, hospital evaluation l [NAME] confirmed that the resident sustained a rib fracture and head injury consistent with a fall. The ADON acknowledged that the fall was unwitnessed. The ADON stated that the incident was communicated to the Director of Nursing (DON), that the resident's family member was also notified. He stated that the resident was confused and unable to clearly describe how the fall occurred.In an interview on 03/10/2026 at 02:45 pm the DON stated that she was aware of the incident and that it was discussed during a morning administrative meeting. She stated that there was uncertainty regarding whether the incident should be reported to the state. The DON reported because the fall was unwitnessed, but staff believed they understood how the fall occurred. It was assumed that it was reported by the Administrator since it was reported to him. The DON stated she was just getting used to the process of reporting which is why she let the Administrator know. In an interview on 03/10/2026 at 02:51pm the Administrator stated that reporting decisions were based on whether the cause of the incident was unknown. He stated that if staff believed they knew how an incident occurred, it may not be considered reportable. The Administrator acknowledged that the resident sustained a fracture following the incident but that reporting was not completed because staff believed the cause of the fall was understood. He further acknowledged that he did not personally interview the resident regarding the incident and relied on information provided to him by staff. The Administrator stated the ADON spoke to the resident when assessing him for the fall and the resident was able to tell him exactly how he fell, which was why he did not report it. Record review of facility policy Abuse & Neglect dated October 2022, revision date April 2025, revealed The administrator/designee ensure that all alleged or suspected violations involving mistreatment, neglect, or abuse, including injuries of unknown origin and misappropriation of resident property are investigated and reported immediately to the state agency complaint hotline. Investigations of injuries of unknown origin or suspicious injuries must be immediately investigated to rule out abuse.

Based on observation, interview, and record review 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 disease and infection for 2 of 7 residents (Resident #10 and Resident #11) reviewed for infection control.The facility failed to ensure RN M performed hand hygiene and/or used PPE while conducting a blood glucose check.The facility failed to ensure LVN R properly discarded of used lancet after use. This failure could place residents at risk for cross contamination and the spread of infection. Findings included: In an Observation on 03/08/2026 at 11:36am revealed LVN R prepared to perform a blood glucose check before lunch for Resident #11. LVN R prepared all his materials for the blood glucose test and entered the resident's room, performed the blood glucose test and read the numbers to the resident. LVN R exited the room and walked to his med cart. He then inputted Observation of the resident's blood glucose level revealed a reading 103 which indicated no insulin to be administered. It was observed that LVN R folded his bilateral (both hands) gloves inwards, removing them from his hands while having the used lancet (finger needle used for blood sugar check on resident) inside the gloves, balled up. When asked what proper disposal method was indicated for that type of sharp, he stated, Since lancets retract, I throw it in the trash. The glucometer was not disinfected; nor did LVN R perform proper hand hygiene after completing the blood sugar check with the resident. In an interview and observation on 03/08/2026 at 11:47am RN M stated this was her first nursing job and had just graduated. She stated it had been about a month that she started at the facility. RN M grabbed her supplies but did not perform sanitation of the supplies prior to entering Resident #10's room. RN M knocked and entered the resident's room. She then asked the resident if she could grab the urinal holder that was located on the floor because he could not reach it. RN M grabbed the urinal holder by the top of the rim and handed it to the resident. Resident #10 stated he would use it once she was done with his blood sugar and handed it back to RN M who placed it on the bedside table. RN M did not perform any hand hygiene or change of gloves and proceeded to use the same gloves to check resident's blood sugar. RN M finished with Resident #10 and then grabbed all her supplies and wrapped the used Lantus in the gloves and tossed them in the trash. RN M stated she did not know where the Lantus went, and she did at times place them in the sharps container but tended to do both but wrapped it around her gloves. RN M then walked to another resident's room without sanitizing/cleaning the glucose monitor or area being used on her med cart and proceeded to gather supplies and conduct another blood glucose test. In an interview with the ADON on 03/09/26 at 11:44 am the ADON stated lancets were to be disposed of in sharps containers and not be disposed of in the trash can as that was considered a sharp. is the ADON said that was standard practice because lancets did not always retract, and that could be harmful to housekeeping and other staff members. In an interview on 03/08/2026 at 12:14pm, the ADON, DON and Administrator, the DON stated a used lancet needed to be disposed of the sharps container; and staff should know they were considered a sharp's and should not throw it in the trash. The DON stated it was considered an infection control issues and the risk was contamination and infection control. The DON stated they had not assessed or trained in blood glucose levels and will be addressed training immediately. In an interview on 03/10/2026 at 11:46 am LVN R stated the facility only provided basic training on the glucometers but that's it. When asked what was the proper way in performing a blood glucose check he stated hand hygiene, outside of the rooms, then gloves, then staff proceeded to get the equipment ready outside the room and then soap in glove up and ask for the residents name verify and then wipe the finger down with the alcohol get the Lantus poke the finger and take the read and dispose of the used items either in the sharps container or trash can, and if needed provide the insulin. LVN R stated, Since the Lantus does retract it should be okay to dispose in the sharps container, but ADON did talk to me about the Lantus not going in the trash, no one told me anything otherwise, and no one has ever observed me at the facility. LVN R stated he had been at the facility for 5 years and had gone through several skills and couldn't recall if he was checked off on blood glucose testing. The could not recall the last time he received in-services for infection control or hand hygiene. In an interview on 03/10/2026 at 12:19pm RN M stated she had not been trained on infection control, and her knowledge of infection control was mainly from schooling since this was her first nursing job. She stated Basically all I've learned was from nursing school, on my clinical experience from school and as to bed side care was the basic, I did not get a lot of training at the facility maybe a couple of days before I started on my own. RN M stated she should have changed her gloves and that was a mistake on her end and was completely her fault. RN M stated the Lantus was supposed to be thrown in the sharp's container always. RN M stated, I always throw them in the sharps at that time I was just overwhelmed. It's a risk for cross contamination. Record review of the facility policy name Infection control policy dated March 2020, revision 01/2026 reveled This facility will facilitate a safe care of all residents and staff with known or suspected communicable disease by establishing and maintaining 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. This facility will follow standard precautions for infection control and prevention including but not limited to: Perform hand hygiene, before and after contact with a resident, immediately after removing gloves, after touching objects and medical equipment in immediate resident care area. Needlestick and sharps injury prevention: use safety devices on needles and other sharps immediately after use, used needles will be discarded immediately after use and no recapped, bent, cut, removed from syringe or tube holder or otherwise manipulated. Any used needleless, lancets, or other contaminated sharps will be placed in a lead proof, puncture-resistant sharps container that Is either red in color or labeled with a biohazard label Record review of the facility policy name Blood Glucose monitoring dated November 2020, revision 01/2026 reveled Instrumentation of glucometer; The glucometer will be cleaned prior to each use and after each use per manufacture recommendation. Sample Procedure; Remove test strip from monitor and discard it and lancet in sharps container, remove gloves and wash hands, clean glucometer per manufacturer recommendations prior to replacing the device in the storage container.

Based on observation, interview, and record review 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 disease and infection for 1 of 3 residents (Resident #2) reviewed for infection control. The facility failed to ensure the urinary catheter bag for Resident #2 was anchored and secured to prevent infection. This failure could place residents at risk of infection due to improper care practices. Record review of Resident #2's face sheet dated 12/15/2025, revealed an [AGE] year-old female who was admitted to the facility on [DATE]. Resident #2's diagnoses included type 2 diabetes with hyperglycemia (high amount of glucose in blood), Hypermagnesemia (too much magnesium), and Acute kidney failure (kidneys stop working). Record review of Resident #2's MDS dated [DATE], reflected a BIMS score of 09, which indicated moderate cognitive impairment. Resident #2 had no impairment to one side of upper extremity, and no impairment to both sides of lower extremities. Resident #2 had an indwelling catheter (including suprapubic catheter and nephrostomy tube). Record review of Resident #2's Order Summary Report dated 12/17/2025, stated to ensure foley catheter care to include anchoring tubing and checking skin integrity every shift and PRN. Record review of Resident #2's hospital history and physical dated 11/23/25 revealed an [AGE] year-old female diagnosed with hypertension (high blood pressure), paroxysmal atrial fibrillation chronically anticoagulated with Eliquis, (the use of medication for an abnormal heart rhythm) hypothyroidism (thyroid gland produces too much hormone), sleep apnea (interruptions in breathing during sleep), morbid obesity (overweight). Record review of Resident #2's Care Plan dated 12/15/2025, stated focus The resident has a urinary catheter for obstructive uropathy and prone to infections. The goal stated, The resident will have minimal complications related to catheter use through the review date. With interventions stating check placement of tubing each shift, monitor/document for pain/discomfort due to catheter, Monitor/record/report to MD for s/sx UTI: pain, burning, blood tinged urine, cloudiness, no output, deepening of urine color, increased pulse, increased temp, Urinary frequency, foul smelling urine, fever, chills, altered mental status, change in behavior, change in eating patterns. In an interview and observation on 12/12/2025 at 4:02 pm Resident #2 was observed asleep in bed. While speaking with Resident #2's roommate, investigator observed Resident #2's catheter drainage bag resting on the floor. Investigator notified CNA A to address the catheter bag. CNA A stated staff receive monthly infection control training and indicated the catheter bag likely fell to the floor. CNA A stated staff are expected to check residents every two hours. CNA A acknowledged the risk associated with catheter bag contacting the floor could lead to an infection. In an interview on 12/15/2025 at 10:00 a.m. the DON stated that a catheter bag on the floor was a risk for infection control. All nursing staff were responsible to assure that catheter bags are not on the floor and positioned correctly so there is no risk of infection. In an interview on 12/16/2025 at 12:03 pm, LVN C stated she has been a LVN at the facility for over a year. If there was a catheter bag on the floor, the risk was infection because bacteria can transfer. Nursing and CNAs are to be rounding on residents every two hours or as needed to ensure catheter bags are being looked after. LVN C stated she was trained on a workshop from the company a couple of months back relating to infection control. In an interview on 12/16/2025 at 12:19 pm CNA D stated she has been a CNA for 30 years but at the facility only a month. She stated that catheter bags are not supposed to be on the floor. That is a risk for infection. CNAs are to round on residents every 2 hours or as needed. In an interview on 12/16/2025 at 12:41 pm CNA E stated she has been a CNA at the facility for over a year. She stated it was everyone's (staff) responsibility and nursing departments to ensure that catheter bags are not on the floor. It could be contaminated, or it can empty out on the floor and that is not proper protocol. Staff are supposed to round every 2 hours. Record review of facility policy titled Infection Control Policy dated March 2020, revised 11/2024, stated This facility will facilitate a safe care of all residents and staff with known or suspected communicable disease by establishing and maintaining 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.

Based on interview and record review, the facility failed to provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of each resident for 1 (Resident #1) of 2 reviewed for medication administration in that: The facility failed to ensure that Resident #1 was provided with wound care treatment according to physician's routine, PRN, and STAT orders, due to the order being placed incorrectly in the MAR. This failure could place residents at risk of a decline in health due to incorrect medication administration and inaccurate orders.Record review of Resident #1's face sheet dated 12/15/2025, revealed admission on [DATE] to the facility. Record review of Resident #1 's H&P dated 11/09/2025, revealed an [AGE] year-old male diagnosed with pulmonary embolism (a blood clot blocking the flow to the lungs), rheumatoid arthritis (arthritis in the joints), chronic congestive heart failure/cardiomyopathy with reduced EF (heart failure where the heart is unable to pump blood to meet the body's needs), osteoporosis (disease that weakens bones), chronic pain syndrome (pain lasting longer than three months) and chronic back pain (pain lasting longer than three months) and chronic left foot ulcer (open sore on the foot). Record review of Resident #1's baseline care plan dated 11/25/2025 revealed, a focus The resident has actual impairment to skin integrity, with a goal the resident will have no complications r/t documented skin impairment through the review date and interventions, apply barrier cream, evaluate and treat per physician orders, follow facility protocols for treatment for injury and keep skin clean and dry , wound consult as needed. Record review of Resident #1's admission MDS dated [DATE], revealed a BIMS score of 15, which indicated the person was intact cognitively. Resident #1 was diagnosed with sepsis for his wound care when he entered the facility and was on antibiotics through a PICC line. Record review of wound assessment dated [DATE] at 7:11 pm completed by DON, revealed Resident #1 had a clinical stage 3 pressure ulcer in sacrum. Record review of Resident #1's physician order dated 11/26/2025 revealed, coccyx wound to be cleaned with wound cleanser, pat dry, apply mupirocin and cover daily and PRN for soilage/dislodgement. Record review of Resident #1's daily skilled note readmission dated 11/28/2025 at 04:01 pm, revealed treatment was provided by admitting nurse J for pressure ulcer on coccyx. Record review of Resident #1's 'Former wound assessment dated 12/03/2025 indicated the pressure ulcer remained a stage 3 with wound exudate levels (fluid that leaks out of the wound) and wound characteristics not showing any signs of infections, which were marked as low. In an interview on 12/15/2025 at 12:11 PM, with the DON, she stated Resident #1 received wound care during his stay; however, she was unable to provide documentation verifying that wound care was consistently completed. The DON stated she did not work on the weekends but indicated a wound care nurse was assigned on weekends to complete wound care. She further stated nursing staff are trained to date and sign wound care bandages and document when the wound care is complete; however, no documentation was available for review. In an interview on 12/15/2025 at 12:50, the RN stated he works weekends providing wound care and did not recall Resident #1. He explained wound care documentation is completed by clicking the physicians order in the electronic record to indicate treatment was completed. He stated if wound care orders are properly entered into the TAR they populate for completion. He did not recall signing documentation for Resident #1. The RN stated the DON are responsible for reviewing wound care documentation upon return on Mondays. RN stated wound deterioration and infection risk could result if wound care was not provided depending on the wound severity and the resident's nutritional status. RN stated he is certified and trained in wound care and has been a wound care nurse for at least 9 years. In an interview on 12/15/2025 at 3:13 PM, the Medical Record Director stated he does not show any documentation regarding wound care treatment for Resident #1. In an interview on 12/15/2025 at 03:15 PM, with DON stated that the order that was placed into the TAR is wrong. The DON is the one responsible for reviewing the orders and that is when the old DON left so the orders were not reviewed. There was no one left to review the orders unfortunately. Administrator was present during this interview and stated there was nothing documented even though he knows that current DON is good and very thorough and knows it was completed but there is no documentation to provide at this time. In an interview on 12/17/2025 at 01:54 pm, the physician stated the risk of not receiving wound care was uncertain. He stated he would need to review the medical record for Resident #1 to determine if the wound stage worsened or remained the same. He stated the resident was already receiving antibiotics via a PICC line. The physician stated that regardless of uncertainty regarding outcome, the resident should have received wound care as ordered. When asked about expectations regarding verbal or incorrect orders, the physician stated nursing staff should be re-educated, and the DON is responsible for following up on orders. He stated if issues continue, additional corrective actions may be necessary; however, for a first occurrence, re-education would be appropriate. The physician stated it was difficult to determine whether this rose to the level of gross neglect and believed the issue may have only been related to misunderstanding rather than intentional failure to provide care. In an interview on 12/17/2025 at 02:06 p.m., Administrator stated they do not have a wound care doctor at the moment it is just the medical director they have at the facility, but the DON is responsible for following up on the orders that are being entered by the nursing staff. Record review of facility policy titled Physician Orders dated November 2018, stated 2.) The physician's order must be documented completely with sufficient content to clearly convey the provider's intent. Indications for PRN orders should be included in the order. 3.) After the authorized provider has completed the orders, the RN or LPN is responsible for transcribe all written orders promptly and accurately, the RRN or LPN must include his/her signature, the date and time of the transcription and credentials. 4.) Orders that are unclear must be clarified prior to implementation.

Based on observations, interviews, and record reviews, the facility failed to ensure that the residents had the right to a dignified existence for 2 (Resident #2 & Resident #3) of 3 residents reviewed for resident rights. The facility failed to ensure the urinary collection bags for Resident #2 and Resident #3's catheters were covered with a privacy bag. This failure could place residents at risk for a loss of dignity, decreased self-worth and decreased self-esteem.Resident #2 Record review of Resident #2's face sheet dated 12/15/2025, revealed an [AGE] year-old female who was admitted to the facility on [DATE]. Resident #2's diagnoses included type 2 diabetes with hyperglycemia (high amount of glucose in blood), Hypermagnesemia (too much magnesium), and Acute kidney failure (kidneys stop working). Record review of Resident #2's MDS dated [DATE], reflected a BIMS score of 09, which indicated moderate cognitive impairment. Resident #2 had no impairment to one side of upper extremity, and no impairment to both sides of lower extremities. Resident #2 had an indwelling catheter (including suprapubic catheter and nephrostomy tube). Record review of Resident #2's Order Summary Report dated 12/17/2025, did not reflect any order to Ensure foley bag is in privacy bag every shift and as needed. Record review of Resident #2's hospital history and physical dated 11/23/25 revealed an [AGE] year-old female diagnosed with hypertension (high blood pressure), paroxysmal atrial fibrillation chronically anticoagulated with Eliquis (the use of medication for an abnormal heart rhythm), hypothyroidism (thyroid gland produces too much hormone), and sleep apnea (interruptions in breathing during sleep), morbid obesity (overweight). Record review of Resident #2's Care Plan dated 12/15/2025, stated focus The resident has a urinary catheter for obstructive uropathy and prone to infections. The goal stated, The resident will have minimal complications related to catheter use through the review date. With interventions stating check placement of tubing each shift, monitor/document for pain/discomfort due to catheter, Monitor/record/report to MD for s/sx UTI: pain, burning, blood tinged urine, cloudiness, no output, deepening of urine color, increased pulse, increased temp, Urinary frequency, foul smelling urine, fever, chills, altered mental status, change in behavior, change in eating patterns. In an interview and observation on 12/12/2025 at 4:02 pm Resident #2 was asleep in bed. Investigator was speaking to Resident #2's roommate when investigator saw Resident #2's catheter bag lying on the floor. Investigator called CNA A to address the catheter bag on the floor she stated staff have training every month on infection control and it probably just fell. CNA A said all catheter bags should be in privacy bags, it's a dignity issue. Resident #3 Record review of Resident #3's face sheet dated 12/17/2025, revealed an [AGE] year-old female who was admitted to the facility on [DATE]. Resident #3's diagnoses included chronic kidney disease (loss of kidney function), type 2 diabetes with hyperglycemia (high amount of glucose in blood), Hypertension (high blood pressure), and Chronic Obstructive Pulmonary Disease with Exacerbation (chronic lung disease that affects the airflow making it hard to breath). Record review of Resident #3's MDS dated [DATE], reflected a BIMS score of 15, which indicated the person had intact cognition. Resident #2 had no impairment to one side of upper extremity, and no impairment to both sides of lower extremities. Resident #2 had an indwelling catheter. Record review of Resident #3's Order Summary Report dated 12/17/2025, did not reflect an order to Ensure foley bag is in privacy bag every shift and as needed. Record review of Resident #3's Care Plan dated 12/17/2025, stated focus The resident has a urinary catheter. The goal The resident will have minimal complications related to catheter use through the review date. With interventions check placement of tubing each shift, monitor/document for pain/discomfort due to catheter, Monitor/record/report to MD for s/sx UTI: pain, burning, blood tinged urine, cloudiness, no output, deepening of urine color, increased pulse, increased temp, Urinary frequency, foul smelling urine, fever, chills, altered mental status, change in behavior, change in eating patterns. In an observation and interview on 12/12/2025 at 4:13 p.m., Resident #3 was sitting in a wheelchair watching television. She was alert and oriented. Her catheter bag was hanging low below the bladder with no privacy bag covering it. Resident #3 stated it did not bother her that the collection bag was left uncovered. In an observation and interview on 12/15/2025 at 9:20 a.m., Resident #3 was sitting in bed eating breakfast, her catheter bag was hung on the right side of her bed, on the side of the door visible to anyone walking the hallways with no privacy bag. Resident #3 wanted to sit up in bed, so investigator called for assistance. CNA F entered room to help with resident's needs and was asked if the catheter bag needed to have a privacy bag. CNA F stated they always have to have privacy bags on and was unsure why it was not on Resident #3's catheter bag. CNA F walked outside to a med cart where a LVN was present and asked for a privacy bag. CNA F stated that some catheter bags do come with privacy bags already on them but Resident #3's catheter bag did not contain a privacy bag, so staff should have placed one on. Privacy bags were always located in the med carts if needed. In an interview on 12/15/2025 at 10:00 a.m., the DON said the purpose of using a privacy bag for the catheter collection bag was to provide privacy. The DON said it was the responsibility of the nurses and CNAs in the hall to ensure that the collection bag was attached to the frame and inside a privacy bag. It is the responsibility of all staff. In an interview on 12/16/2025 at 11:45 am, CNA B stated she has been a CNA for 20 years and 8 years at this facility. CNA B stated privacy bags should always be on the collection bags due to privacy and dignity for residents and others. Nursing staff should always be rounding on residents every two hours to assure that privacy bags are on collection bags. In an interview on 12/16/2025 at 12:03 pm, LVN C stated she has been a LVN at the facility for over a year now. If there is no privacy bag on the catheter bag it could affect the residents' dignity. Nursing and CNAs are to be rounding on residents every two hours or as needed to ensure catheter bags are being looked after. In an interview on 12/16/2025 at 12:19 pm CNA D stated she has been a CNA for 30 years but at the facility only a month. She stated that catheter bags are supposed to have privacy bags always. If there is not a privacy bag the patient does not want anyone to see that, they can end up embarrassed. She said it's about respect for the residents. In an interview on 12/16/2025 at 12:41 pm CNA E stated she has been a CNA at the facility for over a year. She stated that all catheter bags should always be covered with a privacy bag, it is a social risk that residents do not want anyone to really see, it's a privacy thing. It is everyone's (staff) responsibility and nursing department's to assure that catheters have privacy bags as well as therapy when they are providing therapy to residents. Staff are supposed to round every 2 hours. Review of facility policy titled Catheterization of urinary bladder policy dated November 2018, revised 11/2024 does not specify any information regarding privacy bags. Review of facility policy titled Resident Rights policy dated November 2020, stated, It is the responsibility of all who work in this facility, including employees if the facility and any others who provide services to the residents of the facility, to advocate and protect the rights of each resident. Each resident will be treated with dignity will be allowed and encouraged to make choices. On page 2 stated, Resident rights include but are not limited to Privacy and Confidentiality.

Based on observation, interviews and record review the facility failed to have an adequately equipped system that allowed residents to call for staff assistance through a communication system for 2 of 2 call light systems viewed for resident call system. The facility failed to ensure that residents call lights for 3 of 3 Resident Halls were functioning properly. This failure put residents at risk of not being able to call for assistance when needed. Findings included: During an observation 12/01/25 at 12:53 PM in Hall 200 revealed, two residents had turned on the Nurse Call Lights. It was observed that the corridor lights for Nurse Call were on, room [ROOM NUMBER] and 209, and were not ringing in the residents' rooms or at the nurse's station. There were no staff sitting at the nurse's station. During an observation 12/01/25 at 1:33 PM revealed, the resident in room [ROOM NUMBER] had turned on his Nurse Call Light. It was observed that the corridor light for Nurse Call in room [ROOM NUMBER] was on and was not ringing in the residents' room or at the nurse's station. The Nurse was passing medications in the 200 Hall and CNAs were picking up lunch trays throughout the resident halls. There were no staff at the nurse's station. During an observation 12/02/25 at 9:35 AM revealed, the resident in room [ROOM NUMBER] had turned on his Nurse Call Light. It was observed that the corridor light for Nurse Call in room [ROOM NUMBER] was on and was not ringing in the resident's room or at the nurse's station for room [ROOM NUMBER]. There were no staff at the nurse's station or in the 200 Hall. During an observation 12/02/25 at 9:37 AM revealed, the resident in room [ROOM NUMBER] had turned on his Nurse Call Light. It was observed that the corridor Nurse corridor lights for Nurse Call were turned on and were not ringing in the residents' rooms and were not ringing at the nurse's station. It was observed that the call light monitor at the nurse's station directly in front of room [ROOM NUMBER] was not turned on. The Nurse was in the 200 Hall passing medications and the CNAs were picking up lunch trays throughout the resident halls. There were no staff at the nurse's station. During an observation 12/02/25 at 9:51 AM, it was revealed two resident corridor lights for Nurse Call were turned on in the 200 Hall and were not ringing in the residents' room and were not ringing at the nurse's station. The call light monitor at the nurse's station was not on. The Nurse was passing medications and CNAs were in resident rooms assisting residents. There were no staff at the nurse's station. During an observation 12/02/25 at 12:45 PM revealed, the resident in room [ROOM NUMBER] had turned on his Nurse Call Light. It was observed that the corridor Nurse call light was turned on for room [ROOM NUMBER] and was not ringing in the resident's room or at the nurse's station. The CNAs were picking up lunch trays throughout the resident halls and nurses were passing medications in the hallways. During an observation and interview on 12/02/25 at 12:52 PM, with LVN B assigned to the 100 Hall on the 6:00 AM - 6:00 PM, demonstrated to the state surveyor that she had turned on the Nurse Call Light in room [ROOM NUMBER] was not ringing in the resident's room and/or at the nurse's station. She said, I noted yesterday that the Nurse Call Lights only rang once when the call light was turned on by the resident and did not continue to ring and Nurse Call Lights were not ring at the nurse's station. She said she had not reported this to the Maintenance Director. During an observation and interview on 12/02/25 at 1:30 PM, the Maintenance Director revealed he was not aware of any issues with the Nurse call light system. He said he conducted monthly QA checks of the Nurse all light system to ensure the system was working properly. He said he received a reminder via telephone when to complete the scheduled monthly QA checks on the Nurse call light system. He said the next QA check on the call light system was due on 12/31/25. The state surveyor requested copies of the QA checks completed on the Nurse call light system. During an interview on 12/03/25 at 9:15 AM with Chief Nursing Officer revealed that the corridor Nurse call lights were not ringing at the nurse's station or when the residents pushed the red button on the call light for assistance for the last six days. She said, I noticed this week that the corridor light for Nurse Call Lights would turn on and were not ringing resident rooms or at the nurse's station. She said, Prior to that I do not remember if the Nurse call lights rang at the nurse's station. She said the nurses, executive director and some of the department heads today had started to help with answering call lights. She said, The Nurse call lights will light up but do not ring to alert the staff when residents are calling for assistance. During an observation and interview on 12/03/25 at 9:33 AM with RN G revealed, the Nurse call lights should ring at the nurse's station or when the residents called for assistance. She said, I noted this past weekend the Nurse call lights were on and were not ringing, but we can see the corridor Nurse call light, lights up when the residents push the button on the call light for assistance. The surveyor asked the nurse to turn on the emergency light in the resident's bathroom in room [ROOM NUMBER]. It was observed that the corridor Nurse call light turned on and was red but was not ringing in the resident's room or the nurse's station directly across from the resident's room. The nurse said, I had not noted that the emergency lights were not ringing. She said, I am not aware of any concerns voiced by families and/or residents about call lights not being answered. During an observation and interview on 12/03/25 at 9:42 AM with CNA H revealed, she had not noticed that the Nurse call lights were not ringing in the resident rooms or the nurse's station. She said the Nurse corridor light turns on and will only ring once when the residents push the red button for assistance and then stops ringing. She said we look to see if the corridor Nurse call lights are on as we walk down the halls while doing our work and try to assist the residents as soon as possible. During a confidential interview on an undisclosed date at an undisclosed time revealed, the Nurse call lights and the central receiver/panel at the nursing stations had not been working for several months. It was reported that the Maintenance Director was aware that the call light system was not working. It was reported that the nursing staff must be on the lookout to see if the corridor Nurse call lights are on so they can go and assist the residents. During a confidential interview on an undisclosed date at an undisclosed time revealed, the Nurse call lights and the central receiver/panel at the nursing stations had not been working for a long time. It was reported that the Maintenance Director was aware that the call light system was not working. It was reported that the nursing staff must be on the lookout to see if the corridor Nurse call lights are on so they can go and assist the residents. During observation and interview on 12/03/25 at 10:19 AM with Maintenance Director revealed both central receiver/panels at the nurse's stations were fried. He demonstrated to the surveyor that the central receiver/panels did not turn on. He said, I don't know how long the receiver/panels have not been working. He said, Since the Nurse call lights are not ringing, the nursing staff must be on the look out to see if the corridor Nurse Call Lights are on, so they can assist the resident. I already contacted the call light company on 12/02/25 by email to come and check the system to see why it's not working properly. Review of email dated 12/02/25 provided by the Maintenance Director sent to the contractor's Territory Manager revealed, Nurse Call Light issues. Please create a service ticket and copy me please sir. The Maintenance Director documented on the copy of the email sent to vendor 12/02/25 at 7:49 AM, Call Light System not working. Not ringing at nurse's stations. During an interview on 12/03/25 at 11:00 AM, with the Executive Director revealed that he was aware that the Resident Call Light System was not ringing in the resident rooms and not ringing at the nurse's station. He said the contractor was still pending to come to the facility to check the call light system. He said he had started a QA plan to address the call light system not working and had asked some of the department heads, including him to assist the nursing staff in answering call lights. Review of QA Logbook Documentation on call system provided by Maintenance Director on 12/02/25 revealed: -11/07/25 documented All lights in good condition. Resident Halls 100, 200 and 300. -10/10/25 documented All Call Lights and main panel properly functioning. Resident Halls 100, 200 and 300.-09/05/25 documented All lights and panels in good working condition. Resident Halls 100, 200 and 300.-08/11/25 documented All call lights in good condition and Main Panel. Resident Halls 100, 200 and 300. Review of facility's policy & procedure on Call-Light Outage revised 11/2024 provided by Maintenance Director on 12/02/25 revealed: General: Call lights are to be answered in a timely and reasonable manner. This is to provide a guideline for the building should the call light system become inoperable. Responsible Party: Administrator, DON, Supervisor. Guideline: Should a staff member find a call light not to be working, they will immediately notify maintenance to replace the call light. Should it occur after hours, the resident will be given an alternate way to call for help until the light can be repaired (bell etc.) If it is discovered that multiple lights are out, the maintenance director will be notified. If the maintenance director is not in the building, the administrator will be notified. An additional staff member will be utilized on each wing where the outage occurs to walk from room to room to monitor residents. Bells or another alternate way to call for help will be distributed to those residents who are able to use the device. If this occurs during the day, residents will be encouraged to be in public area (dining rooms, etc.) for monitoring.

Based on observations, interview and record review the facility failed to ensure the facility had 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, as determined by the resident assessments and individual plans of care and considering the number, acuity and diagnoses of the facility's resident population in accordance with the facility assessment including other personnel, including but not limited to nurse aides for 5 (Resident #1, Resident #2, Resident #3, Resident #4 and Resident #5) of 5 residents reviewed for sufficient staff. The facility failed to have sufficient staff, which resulted in missed showers, delayed response to call lights, and delayed incontinent care for dependent residents. This failure could place residents at risk of decreased physical, mental, and psychosocial well-being. Findings include: During an observation on 12/01/25 at 12:51 PM, it revealed the facility had two CNAs and three nurses were working on the first shift scheduled from 6:00 AM through 6:00 PM with a resident census of 51. During an observation on 12/02/25 at 9:00 AM, it revealed the facility had two CNAs and three nurses were working on the first shift scheduled from 6:00 AM through 6:00 PM with a resident census of 51.During an interview on 12/02/25 at 9:32 AM with alert and interviewable Resident #6 revealed resident was alert, oriented to person, place, and time revealed, and the resident had been at the facility for 5 months. She said it took a long time for the staff to answer the call light, because there were not enough staff and the CNAs tried their best to answer the call lights as soon as possible. She said the CNAs come and rush to provide the needed care. During an interview on 12/02/25 at 9:36 AM with alert and interviewable Resident #7 revealed he was alert, oriented to person, place and situation. He said he was admitted two weeks ago from the hospital for rehabilitation services. He said he used his call light to call for assistance as needed and said the staff tried to answer his call light as soon as possible because he knew that the staff were very busy. He said the CNAs rushed to provide care as fast as possible. During an interview on 12/02/25 at 9:44 AM with Resident #3 and family member revealed she visited Resident #3 daily. The family member said it took 30 minutes or more for the staff to answer call lights. She said Resident #3 had been waiting over 20 minutes for staff to come and change her wet brief. She said, the nurse has come to tell us two times that the CNAs are busy and will come to change [Resident #3] as soon as possible. She said the day before yesterday Resident #3's call light was on, and she was left wet for over 30 minutes.During an interview on 12/02/25 at 9:48 AM with LVN C revealed CNA E on the unit was aware Resident #3 needed to be changed. She said, Let me go and tell the CNA again that the resident is wet and needs to be changed. The CNA is busy changing another resident. She said there was only one CNA assigned to work on the 300 Hall for twelve residents, and that was why she had to help her at times to provide incontinent care to dependent residents and tried not to fall behind in her work because she also had to assist in answering call lights. During an observation on 12/02/25 at 9:55 AM, revealed CNA E entered Resident #3's room to provide incontinent care. The resident was lying in bed and resident's family member was at her bedside. The resident's family member told the CNA Resident #3 had been waiting a long time to be changed. The CNA said, I know the nurse had told me she was wet, but I was changing other residents. The CNA washed her hands, put on gloves and prepared to change the resident. The divider curtain was pulled for privacy. The sheets were pulled back and it was observed the fitted sheet was wet with urine. The brief was removed, and perineal area was cleaned with cleaning wipes. It was observed the resident did not have any skin irritation in the perineal area or skin breakdown on buttocks. Once the disposable brief was changed, she changed the sheets, gown and changed gloves. During an interview on 12/02/25 at 12:22 PM, with LVN B assigned to the 100 Hall from 6:00 AM - 6:00 PM, revealed they only had two CNAs assigned to the 100 and 200 Resident Halls and each CAN was assigned 18-19 residents and they tried to do rounds every two hours. She said they should have three CNAs on each shift but were short of CNAs off and on for the past three weeks due to high staff turnover. She said she assisted the CNAs at times to change incontinent residents and answer call lights as time permitted because she was busy doing her work. She said sometimes the families and residents complained the residents were left wet for long periods of time. She said she never found residents with dried urine rings or dried feces. During an interview on 12/02/25 at 12:28 PM with LVN C revealed, there were three LVNs and two CNAs working today. She said they had been working with only two CNAs for about a month. She said, today we have two CNAs and one new CNA in training. She said the CNAs did not have time to make rounds every two hours. She said the CNAs usually checked the residents for incontinence at the start of shift, before lunch and in-between as time permitted. She said the CNAs tried to make rounds every 2-3 hours, depending on the needs of the residents. She said she assisted the CNAs at times to answer call lights and change incontinent residents. She said they tried to promptly answer call lights but at times they were in resident rooms caring for other residents. She said families and residents complained about being left wet for long periods of time, especially at the change of shift. During a confidential interview on an undisclosed date at an undisclosed time revealed, today there were only two CNAs and one CNA training. It was reported the regular staff pattern for CNAs was for three CNAs per shift. It was reported that when there were only two CNAs on duty, they had to look for someone to assist with turning & repositioning, transfers, and answering call lights. It was reported rounds were not made every two hours and they tried their best to care for the residents. It was reported it took a long time to change incontinent residents and to assist the residents as needed due to only having two CNAs for more than 50 residents. During a confidential interview on an undisclosed date at an undisclosed time revealed, there were only two CNAs and one CNA training. It was reported the regular staff pattern for CNAs was for three CNAs per shift and the facility was scheduling two CNAs for approximately two and half weeks. It was reported there was not enough time to make rounds every two hours, answer call lights, and change incontinent residents on a timely basis. It was reported residents were left wet for long periods of time. It was reported residents frequently were not showered according to shower schedules due to not having sufficient time and assistance to do the work. During a confidential interview on an undisclosed date at an undisclosed time revealed, it took a long time for staff to answer call lights, due to the facility always being short of staff. It was reported the CNAs were too busy taking care of all the residents and did not have time to check on the residents on a regular basis. It was reported the staff did not make rounds every two hours, and it took 30 minutes or more to answer resident call lights which resulted in residents being left wet for long periods of time. It was reported that concerns had not been reported to the facility's management for fear of retaliation. During an interview on 12/03/25 at 9:42 AM with CNA H revealed, they were short of staff and at times worked with only two CNAs, and on those days, there was not sufficient time to make rounds every two hours. She said they were only able to make 3-4 rounds during the twelve-hour shifts. She said each CNA was assigned 18 residents, and that was why it took a long time to change the incontinent residents and showers were not given according to shower schedules when there were only two CNAs on the floor. She said the staff tried to catch up with showers the next day, depending on how busy they were. During an interview on 12/03/25 at 9:45 AM with Resident #4 revealed the resident was alert, oriented to person, time, and place, and was admitted for rehabilitation services a week ago. She said the facility was short of help at times and it took long for the staff to answer the call lights. She said today she called for assistance to use the toilet, and they took a long time to come and help her, so she had a bowel movement in her brief. She said she felt bad, because the CNAs were very busy and worked very hard and she did not want to give them extra work. During a confidential interview on an undisclosed date at an undisclosed time revealed, the facility had been short of CNAs for the last four months. It was reported that residents and families complained it took a long time for call lights to be answered, and residents were left wet for long periods of time. It was reported the staff were always very busy, and they tried to do as much as possible for the residents. During a confidential interview on an undisclosed date at an undisclosed time revealed, the facility was always short of staff and did not have sufficient CNAs to care properly for the residents. It was reported that because of not having sufficient staff the residents were not showered according to shower schedules and were left wet for long periods of time. During an interview on 12/03/25 at 9:59 AM, the Executive Director revealed he had been employed at the facility for several months and was aware of the CNA shortage due to staff leaving for more pay. He said they did not have a policy and procedure on staffing. He said they determined the number of staff based on PPD information. He said, So the number of staff is determined by resident census. He said all the facility staff, including him, assisted the CNAs with answering call lights. He said he was not aware of any concerns related to call lights not being answered timely or residents were left wet for long periods of time. The state surveyor requested the Grievance Binder. During an interview on 12/03/25 at 10:34 AM with CNA K revealed the usual staffing pattern should be for three CNAs on each shift. However, the facility only had two CNAs for more than 50 residents. She said because of not having sufficient staff, residents were not showered according to shower schedules and were left wet for long periods of time. She said there was not sufficient time to make rounds every two hours because each CNA was assigned 18 residents. During an interview and record review on 12/03/25 at 3:01 PM with Assistant Chief Nurse Officer of the facility's untitled staffing schedules revealed:- Review of the facility's untitled staffing schedule for September 2025 for three resident halls (100/200/300) documented that on weekdays and weekends there were always three CNAs scheduled on the first shift from 6 AM - 6 PM shift and second shift there were always three CNAs from 6 PM - 6 AM shift. The scheduled documented there were only two CNAs scheduled 15 times for the first shift. -Review of the facility's untitled staffing schedule for November 2025 for three resident halls (100/200/300) documented that on weekdays and weekends there were always three CNAs scheduled on the first shift from 6 AM - 6 PM shift and second shift there were always three CNAs from 6 PM - 6 AM shift. The scheduled documented there were only two CNAs scheduled 4 times for the first shift. -Review of the facility's untitled staffing schedule for December 2025 for three resident halls (100/200/300) documented that on weekdays and weekends there were always three CNAs scheduled on the first shift from 6 AM - 6 PM shift and second shift there were always three CNAs from 6 PM - 6 AM shift. The scheduled documented there were only two CNAs scheduled 3 times for the first shift. The Assistant Chief Nurse Officer said they had a high turnover of CNAs and were in the process of hiring staff. Record review of the Grievance Binder revealed:-September 2025: Grievance Form dated 09/15/25 documented, Staff voiced they were understaffed, call lights taking longer than expected to be answered. Date Grievance Occurred: 09/15/25. Date resolved: 09/16/25. Staff re-educated on answering calls in a timely manner. -Grievance Form dated 09/15/25 documented, Staff voiced they were understaffed, call lights taking longer than expected to be answered. Resident's son is upset over staff, telling his father that information. Date Grievance Occurred: 09/13/25. Date resolved: Was left blank. No resolution documented. The form was signed by the previous Executive Director.-Grievance Form dated 09/15/25 documented, Resident's son stated, staff had voiced that they were under staff, taking long to answer call lights. Son upset over staff, telling his father that information. Grievance Follow Up: Spoke to The Sun over the weekend and reassured staff will be re-educated on letting guests know they are understaffed. Son is OK with reeducation. The form was signed by the previous Executive Director.October 2025: -Grievance Form dated 10/15/25 documented, Daughter stated pt. not being changed in timely manner - no water at bedside. Findings of investigation: Pt. brief has been changed as needed. No complaints from pt. Pt. had no skin irritation or rash. Date resolved: 10/17/25, Signed by Executive Director.November 2025:-Grievance Form dated 11/23/25 documented, Resident's family requesting more monitoring during the night shift and more continuous CNAs checks due to them believing resident needing more care and attention during the night. Grievance follow-up: Option to move closer to nurse's station for close monitoring. Family refused, demanding patient be transferred home and discharged from this facility. Date resolved: 11/23/25, Signed by Executive Director.-Grievance Form dated 11/21/25 documented, Resident's Spouse reported we were giving very poor care to his wife and complained that why he should have to pay co-payment. Person completing this form: BOM. No resolution documented related to complaint. Date resolved: 11/21/25, Signed by Executive Director.

Based on observation, interview and record review the facility failed to provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of each resident for 5 (Resident #1, #2, #,3, #4, and #5) of 5 residents reviewed for pharmacy services. 1. The facility failed to administer Dapagliflozin Propanediol, Levothyroxine, Acetylcysteine Solution, Eliquis, Memantine HCI, to Resident #1 according to physician's orders. 2. The facility failed to administer Farxiga and Folic Acid, to Resident #2 according to physician's orders. 3. The facility failed to administer Pravastatin Sodium, Alendronate Sodium, Sodium Chloride, Linagliptin, and Calcium 600 + D to Resident #3 according to physician's orders. 4. The facility failed to administer Levothyroxine, Rifaximin, Symbicort Inhalation Aerosol to Resident #4 according to physician's orders. 5. The facility failed to immediately consult with and/or Nurse Practitioner when the facility did not have Dapagliflozin Propanediol, Levothyroxine, Acetylcysteine Solution, Eliquis, Memantine HCI, for Resident #1 to administer as ordered. 6. The facility failed to immediately consult with and/or Nurse Practitioner when the facility did not have Farxiga and Folic Acid, for Resident #2 to administer as ordered. 7. The facility failed to immediately consult with and/or Nurse Practitioner when the facility did not have Pravastatin Sodium, Alendronate Sodium, Sodium Chloride, Linagliptin, and Calcium 600 + D for Resident #3 to administer as ordered. 8. The facility failed to immediately consult with and/or Nurse Practitioner when the facility did not have Levothyroxine, Rifaximin, Symbicort Inhalation Aerosol for Resident #4 to administer as ordered. 9. The facility failed to immediately consult with and/or Nurse Practitioner when the facility did not have Aspirin, Colace, Farxiga, Latanoprost Ophthalmic Solution, Lidocaine External Patch, Pravastatin Sodium, Prenatal Vitamin, Calcium Antacid Chewable, Vitamin C, Advanced Probiotic, Lisinopril, and Amoxicillin for Resident #5 to administer as ordered. These failures could place residents at risk of inadequate therapeutic outcomes and a decline in health due to not receiving medication as ordered. Findings include: 1. Record review of the admission Record dated 12/01/25 for Resident #1 revealed an admission date of 11/10/25. discharge date [DATE] to an Acute Care Hospital.Record review of the Hospital Physician Progress Note for Resident #1 dated 11/09/25, revealed an [AGE] year-old male with a history of esophageal cancer (abnormal cells grow out of control in the food pipe, making it hard to swallow, causing pain, weight loss, and a persistent cough or hoarseness as the tumor blocks the passage or irritates the area) on enteral feedings (giving liquid nutrition formulas directly into their stomach through a tube), and CAD with history of mitral valve replacement (blocked heart arteries damaged the heart muscle, causing the mitral valve to leak, both problems are fixed bypass surgery for the arteries and replacing the faulty valve with a new mechanical one, to improve blood flow and heart function). Record review of the admission MDS assessment, dated 11/16/25, for Resident #1 revealed, Entry Date: 11/10/25. BIMS Summary Score - 10 (cognition was moderately impaired). Clear speech, makes self-understood, and understands others. Active Diagnoses: Cancer, Heart Failure (the heart cannot pump enough blood and oxygen to meet the body's needs), Hypertension (is when the force of blood against your artery wall is consistently too high), Diabetes Mellitus (a chronic disease where the body had high blood sugar levels, either because the pancreas does not produce enough insulin or the body cannot use insulin effectively), Non-Alzheimer's Dementia (brain disorder causing memory, thinking, and behavior problems), Dysphagia (difficulty swallowing, which can make it hard for food and liquids to move from the mouth down to the stomach), lack of coordination, and Gastrostomy (is a feeding tube that goes directly into the stomach through a small opening in the stomach, by bypassing your mouth and throat, to deliver liquid food, medicine, or to help air and fluids come out). Record review of the Care Plan for Resident #1, initiated 11/10/25 revealed: the Resident has an ADL self-care performance deficit and limitations in physical mobility. Interventions: Partial/moderate assistance with toileting hygiene, dressing and turning and repositioning in bed. Resident is NPO, G-tube on bolus feedings every six hours. The resident was receiving anticoagulant therapy and was prone to bleeding and bruising. Interventions: Labs as ordered. Report abnormal results to the MD. Monitor/document/report PRN (as needed) black tarry stools, sudden changes in mental status, significant or sudden changes in vital signs. Record review of the Order Summary Report, dated 12/03/25, for Resident #1 revealed, Farxiga (Dapagliflozin Propanediol) Oral Tablet 10 mg give one tablet via G-Tube one time a day for DM, Levothyroxine Sodium Oral tablet 50 mg give one tablet via G-Tube one time a day for Hypothyroidism, Eliquis 2.5 mg give one tablet via G-Tube every 12 hours for PPX (Prophylaxis-preventive treatment), Memantine HCI 5 mg give one tablet via G-Tube every 12 hours for Dementia, Acetylcysteine Solution 10% 10 ml inhale orally every 6 hours for mucous secretions. Record review of the Medication Administration Record dated November 2025 for Resident #1 revealed:- 11/11/25 at 9:00 AM, Dapagliflozin Propanediol Oral Tablet 10 mg give one tablet via G-Tube one time a day for DM was not administered, it documented on the MAR code 9 (Other/See Nurses Notes). - 11/11/25 at 6:00 AM, Levothyroxine Sodium Oral tablet 50 mg give one tablet via G-Tube one time a day for Hypothyroidism was not administered it documented on the MAR code 9 (Other/See Nurses Notes).- 11/11/25 at 9:00 AM, Eliquis 2.5 mg give one tablet via G-Tube every 12 hours for PPX was not administered it documented on the MAR code 9 (Other/See Nurses Notes).- 11/10/25 at 9:00 PM and 11/11/25 at 9:00 AM, Memantine HCI 5 mg give one tablet via G-Tube every 12 hours for Dementia was not administered it documented on the MAR code 9 (Other/See Nurses Notes).- 11/09/25 at 9:00 AM, Acetylcysteine Solution 10% 10 ml inhale orally every 6 hours for mucous secretions was not administered it documented on the MAR code 9 (Other/See Nurses Notes).- 11/21/25 12:00 AM, 6:00 AM, 12:00 PM, and 6:00 PM, Acetylcysteine Solution 10% 10 ml inhale orally every 6 hours for mucous secretions was not administered the MAR documented code 9 (Other/See Nurses Notes). - 11/22/2025 at 12:00 AM, 6:00 AM, and 12:00 PM Acetylcysteine Solution 10% 10 ml inhale orally every 6 hours for mucous secretions was not administered, it documented on the MAR code 9 (Other/See Nurses Notes). During an interview and record review on 12/01/25 at 3:39 PM, with LVN A in the presence of the Assistant Chief Nurse Officer revealed Resident #1 had an order for Acetylcysteine Solution to be given every 6 hours for mucous secretions. She said the Acetylcysteine Solution had not been administered as ordered from 11/11/25 through 11/22/25 due to the medication not being available to administer according to physician's orders. She said, sometimes the medications are not dispensed from the pharmacy because they are pending cost approval. She said she had not notified the physicians that the medication was not administered according to physician's order due to not having the prescribed medication. he said they were trained to immediately notify the physicians if the medications were not on hand to administer the scheduled doses according to physician's orders. LVN A could not give a reason why she had not notified the physician. During an interview and record review on 12/01/25 at 3:48 PM, the Medical Director said he was not aware the residents were not administered medications as ordered by the physicians due to medications not being available. He said, We would expect the nurses notify the physicians right away if medications are not administered as ordered for whatever reason. He said the facility should attempt to get the medication from the contracted local pharmacy to start new medications as soon as possible.During an interview and record review on 12/01/25 at 4:40 PM, with the Assistant Chief Nurse Officer revealed, the licensed staff had documented in the Medication Administration Record a code of 9 which meant medications were not administered according to physician's orders due to not being available and/or medication pending delivery. She said the licensed staff were trained to notify the attending physician and Assistant Chief Nurse Officer when medications were not available to administer according to the physician's orders. During an interview on 12/03/25 at 9:33 AM with RN G revealed, she said for the most part they had the medications at the facility to administer as ordered. She said they were trained to notify the Chief Nursing Officer and Assistant Chief Nursing Officer when medications were not available to administer and to document on the Medication Administration Record when the medications were not administered according to physician's orders. She said she was not aware if they needed to notify the physician if medications were not administered due to not having the medication available to administer at facility. During a telephone interview 12/03/25 at 11:49 PM, with physician on coverage on 11/22/25 revealed he was not notified by the licensed staff that Resident #1 was not administered the Acetylcysteine Solution 10% nebulizer treatment as ordered on 11/10/25 according to physician's orders. He said the Acetylcysteine Solution 10% nebulizer treatment opened helped bring up lung secretions. He said he gave an order for a chest x-ray on 11/10/25 and it was clear. He said the failure to administer the Acetylcysteine Solution 10% nebulizer treatment would not have changed his condition. He said he expected the nurses to notify the physicians right away if medications were not available to administer according to physician's orders. 2. Record review of admission Record dated 12/01/25, for Resident #2 revealed an admission date of 09/06/25 and discharge date of 09/10/25 at 11:54 AM to an Acute Care Hospital. Record review of Hospital History & Physical, dated 08/2025for Resident #2 revealed, a [AGE] year-old-female. Resident #2 had diagnoses which included Congestive heart failure (Heart muscle is not pumping as well it should, causing blood and fluid to back up in the lungs and body, leading to symptoms of shortness of breath, swollen legs, fatigue and difficulty exercising as the heart struggles to deliver enough oxygen-rich blood to meet the body's needs), Ischemia of left lower extremity (legs and feet are not getting enough blood flow), Status post above knee amputation of right lower extremity, Diabetes Mellitus (A chronic disease. Where the body has high blood glucose levels. Either because the pancreas doesn't produce enough insulin or the body cannot use insulin effectively), Hypertension (when the force of blood against your artery wall is consistently too high), Status post left foot transmetatarsal amputation (surgical procedure to remove the damaged part of the front of the foot, including some toes and the long bone to stop severe infection or tissue death, saving the rest of the foot and ankle) and Left. foot ulcer. Record review of 5-day PPS MDS, dated [DATE], for Resident #2 revealed, Date of Entry: 09/06/2025. BIMS Summary Score 6 (cognitively severely impaired); GG0115: Functional limitation and range of motion - Impairment on both sides of lower extremities. Section I - Active Diagnoses: Heart failure, Peripheral vascular disease, Diabetes Mellitus, Non-pressure chronic ulcer to left foot, Status post. Below the knee amputation to right leg, Surgical Wound. High-Risk Drug Classes: Antidepressant, Opioid, Antiplatelet, Hypoglycemic and anticonvulsant. Record review of the Care Plan for Resident #2, dated 09/06/25, revealed:-Resident has actual impairment of skin integrity r/t surgical wound. Interventions: Treat per physician's orders.-Resident is receiving anticoagulant therapy. Interventions: Labs as ordered. Monitor for adverse reaction of anticoagulant, blood-tinged urine, black tarry stools, bright red blood in stools, bruising, sudden change in vital signs and/or mental status. Record review of the Order Summary Report, dated 12/03/25, for Resident #2 revealed:Farxiga Oral Tablet give 1 tablet by mouth for diabetes one time a day for Diabetes. Folic Acid Oral Tablet 1 mg give 1 tablet by mouth two times a day for supplement. Record Review of the Medication Administration Record, dated September 2025, for Resident #2 revealed:-09/08/25 at 9:00 AM, Farxiga Oral Tablet give 1 tablet by mouth for diabetes was not administered and it documented on the MAR code 9 (Other/See Nurse's Notes).-09/09/25 at 9:00 AM, Folic Acid Oral Tablet 1 mg give 1 tablet by mouth two times a day for supplement at 9:00 AM was not administered and it documented on the MAR code 9 (Other/See Nurse's Notes). Record review of Nurse's Progress note, dated 09/08/25 at 9:00 AM, for Resident #2 revealed Farxiga Oral Tablet 10 mg pending delivery. Record review of Nurse's Progress note, dated 09/08/25 at 9:00 AM, for Resident #2 revealed, Folic Acid 1 mg medication pending delivery. Record review of Nurse's Progress note, dated 09/08/25 at 9:00 AM, revealed Folic Acid 1 mg medication pending delivery. 3. Record review of the admission Record dated 12/02/25 for Resident #3 revealed, admission date 11/28/25. Record review of the History & Physical for Resident #3, dated 12/01/25, revealed [AGE] year-old male with a history of hypertension (when the force of blood against your artery walls is consistently too high) diabetes mellitus (A chronic disease where the body has high. Blood glucose levels either because the pancreas doesn't produce enough insulin or the body cannot use insulin effectively), osteoporosis (bones become weak, thin and brittle like a sponge with holes, making them super easy to break, often from a minor), and recent L3 vertebral fracture and kyphoplasty (Is a quick, minimally invasive procedure to fix a painful collapse vertebrae by inserting a tiny [NAME] to lift it back into place and then filling the space with special cement to stabilize it, restoring height, reducing pain and preventing further deformity, often for osteoporosis-related fractures) 2 weeks ago, chronic kidney disease Stage 1 (Kidneys are filtering blood well , but there's subtle damage, often just protein in the urine or high blood pressure with no symptoms), muscle weakness, status post Urinary Tract Infection . Alert and oriented X person, place, and time. Record review of the Entry MDS assessment dated [DATE] for Resident #3 revealed, Entry Date: 11/28/25. Entered From - Short-Term acute hospital. Record review of the Baseline Care Plan for Resident #3 dated 11/28/25 revealed:-Resident has ADL self-care performance deficits and limitations in physical mobility.-Resident is incontinent. Interventions: The resident uses disposable briefs. Change as needed. Clean peri-area after each incontinent episode. Check every 2-3 hours and as needed for incontinence. Record review of Order Summary Report, dated 12/03/25, for Resident #3 revealed,- Alendronate Sodium Oral Tablet 70 mg give 1 tablet by mouth one-time a day every 7 day(s) for supplement.- Calcium 600 + D 600-5 MG-MCG Oral Tablet give 1 tablet by mouth one-time day for supplement,- Pravastatin Sodium Oral Tablet 20 mg give 1 tablet by mouth at bedtime for Cholesterol- 11/28/25 Sodium Chloride Oral Tablet 1 GM give 1 tablet by mouth one time a day for supplement for seven days, end date 12/06/25.- 12/01/25 Sodium Chloride Oral Tablet 1 GM give 1 tablet by mouth two times a day for supplement. Record review of Medication Administration Record dated November 2025 for Resident #3 revealed:-11/29/25 Alendronate Sodium Oral Tablet 70 mg give 1 tablet by mouth one-time a day every 7 days for supplement at 9:00 AM was not administered. The MAR documented code 9-refer to nurse's note.-11/29/25 Calcium 600 + D Oral Tablet give 1 tablet by mouth one-time day for supplement at 9:00 AM was not administered. The MAR documented code 9-refer to nurse's note.-11/29/25 Linagliptin Oral Tablet give one tablet by mouth one time a day for Diabetes at 9:00 AM was not administered. The MAR documented code 9-refer to nurse's note.-11/28/25 and 11/29/25 Pravastatin Sodium Oral Tablet 20 mg give 1 tablet by mouth at bedtime for Cholesterol at 9:00 PM was not administered. The MAR documented code 9-refer to nurse's note.-11/28/25 and 11/29/25 Sodium Chloride Oral Tablet 1 GM give 1 tablet by mouth one time a day at 9:00 AM for supplement for 7 days. The MAR documented code 9-refer to nurse's note. Record review of Medication Administration Record dated December 2025, for Resident #3 revealed:-12/01/25 Sodium Chloride Oral Tablet 1 GM give 1 tablet by mouth one time a day at 9:00 AM, for supplement for 7 days. The MAR documented code 9-refer to nurse's note.-12/02/25 Sodium Chloride Oral Tablet 1 GM give 1 tablet by mouth one time a day at 9:00 AM and 9:00 PM, for supplement for 7 days. The MAR documented code 9-refer to nurse's note.-12/03/25 Sodium Chloride Oral Tablet 1 GM give 1 tablet by mouth one time a day at 9:00 AM, for supplement for 7 days. The MAR documented code 9-refer to nurse's note. Record review of Nurse's Progress Notes for Resident #3 revealed:-11/28/25 at 10:22 PM, Pravastatin Sodium Oral Tablet 20 mg give 1 tablet by mouth at bedtime for Cholesterol. On order.-11/28/25 at 9:36 AM, Alendronate Sodium Oral Tablet 70 mg give 1 tablet by mouth one-time a day every 7 day(s) for supplement. Pending pharmacy delivery.-11/29/25 at 9:37 AM, Sodium Chloride Oral Tablet 1 GM give 1 tablet by mouth one time a day for supplement for seven days. Pending pharmacy delivery.-11/29/25 9:38 AM Linagliptin Oral Tablet give one tablet by mouth one time a day for Diabetes. Pending pharmacy delivery.-11/29/25 1:37 PM Calcium 600 + D 600-5 MG-MCG Oral Tablet give 1 tablet by mouth one-time day for supplement. Pending pharmacy delivery.-11/29/25 10:40 PM, Pravastatin Sodium Oral Tablet 20 mg give 1 tablet by mouth at bedtime for Cholesterol. On order.-12/01/25 9:37 AM, Sodium Chloride Oral Tablet 1 GM give 1 tablet by mouth one time a day for supplement for seven days. Not available.-12/01/25 21:59 PM, Sodium Chloride Oral Tablet 1 GM give 1 tablet by mouth two times a day for supplement. The Entry did not document the medication was pending delivery from pharmacy.-12/03/25 10:56 AM Sodium Chloride Oral Tablet 1 GM give 1 tablet by mouth two times a day for supplement. Not available, pending delivery. 4. Record review of admission Record, dated 12/03/25, revealed Resident #4 was admitted to the facility on [DATE]. Record review of History & Physical, dated 12/01/25 for Resident #4 revealed, L2 vertebral compression fracture (a fracture in the second lumbar vertebra, where the bone gets a squished from the sides, often causing the front to collapse into a wedge shape, making it shorter and sometimes causing severe back pain), atrial fibrillation (is an irregular and often rapid heartbeat caused by abnormal electrical signals in the heart's upper chambers, which causes them to quiver instead of contracting properly, right hydronephrosis (A problem with the right kidney causing it to leak protein into the urine, leading to swelling, especially around eyes, legs and belly, foamy urine, low protein and high cholesterol), Hepatic Encephalopathy (temporary loss of brain function that happens when a damaged liver can't remove toxins (like ammonia) from the blood, allowing them to build up and affect the brain, causing confusion, memory problems, personality changes, and event coma in severe cases), Asthma (is a chronic lung disease that makes breathing hard, causing airways to swell, narrow, and produce extra mucus, leading to symptoms like wheezing, coughing, chest tightness, and shortness of breath). Record review of admission MDS, dated [DATE], for Resident #4 revealed, Entry Date: 11/27/25. Review of BIMS Summary Score: 9 Cognitively moderately impaired. Section GG - Functional Abilities - Dependent with toileting, shower and lower body dressing; Substantial assistance with upper body dressing and personal hygiene. Mobility - Dependent roll left and right, sit to lying, lying to sitting, sit to stand and chair/be transfer and toilet transfer. Indwelling catheter. Incontinent of bowel. Section I - Active Diagnoses: Renal Insufficiency, Obstructive Uropathy (Urinary system has a blockage, stopping urine from flowing out, causing it to back up, swelling the kidneys and potentially cause pain, frequent infection or difficulty urinating, which can harm the kidneys if not treated), Diabetes Mellitus, Other fracture, psychotic disorder, compression of lumbar vertebrae, muscle weakness, lack of coordination. High-Risk Drug Classes: Anticoagulant, and Antipsychotic. Record review of the Care Plan, dated 11/28/25 for Resident #4 revealed:-The resident has ADL self-care performance deficits and limitations in physical mobility. Interventions: Requires substantial/maximal assistance with toileting, shower, dressing, turning & reposition in bed, toilet transfer.-The resident is incontinent of bowel and bladder. Interventions: The resident uses disposable briefs. Change as needed. Check every two to three hours and as needed for incontinence.-The resident has a urinary catheter. Interventions: Check placement of tubing each shift.-The resident has actual skin integrity. Interventions. Apply barrier cream after incontinent episodes per facility protocol. Evaluate and treat per physicians' orders. Keep skin clean and dry.- The resident is receiving anticoagulant therapy and prone to bleeding and bruising. Interventions: Labs as ordered. Report abnormal labs to physician. Monitor and document adverse reactions to anticoagulant therapy. Record review of Physician Order Summary, dated 12/03/25, for Resident #4 revealed:- Levothyroxine Sodium Oral Tablet 137 MCG give one tablet by mouth one time a day for hypothyroidism.- Rifaximin Oral Tablet 550 mg give one tablet by mouth two times a day for Hepatic Encephalopathy.- Symbicort Inhalation Aerosol 160-4.5 MCG/ACT 2 puffs inhale orally two times a day for SOB. Record review of the Medication Administration Record, dated November 2025, for Resident #4 revealed:-11/28/25 Levothyroxine Sodium Oral Tablet 137 MCG give one tablet by mouth one time a day for hypothyroidism at 6:00 AM was not administered. The MAR documented a code of 9 (refer to Nurse's Note).-11/28/25 Rifaximin Oral Tablet 550 mg give one tablet by mouth two times a day for Hepatic Encephalopathy at 9:00 AM and 9:00 PM were not administered. The MAR documented a code of 9 (refer to Nurse's Note).-11/28/25 Symbicort Inhalation Aerosol 160-4.5 MCG 2 puffs inhale orally two times a day for SOB at 9:00 AM and 9:00 PM were not administered. The MAR documented a code of 9 (refer to Nurse's Note). Record review of the Medication Administration Record, dated December 2025, for Resident #4 revealed:-12/01/25 Levothyroxine Sodium Oral Tablet 137 MCG give one tablet by mouth one time a day for hypothyroidism at 6:00 AM. The entry on the MAR was left blank. Record review of Nurse's IDT progress Notes, dated November 2025, for Resident #4 revealed: -11/28/25 Levothyroxine Sodium Oral Tablet 137 MCG give one tablet by mouth one time a day for hypothyroidism at 6:00 AM. Medication pending from pharmacy.-11/28/25 Rifaximin Oral Tablet 550 mg give one tablet by mouth two times a day for Hepatic Encephalopathy at 9:00 AM and 9:00 PM. Medication pending from pharmacy.-Symbicort Inhalation Aerosol 160-4.5 MCG 2 puffs inhale orally two times a day for SOB at 9:00 AM and 9:00 PM. Medication pending from pharmacy. Record review of Nurse's IDT Progress Notes, dated December 2025, for Resident #4 revealed:-Review of Nurse's Notes did not document if Levothyroxine Sodium Oral Tablet 137 MCG give one tablet by mouth one time a day for hypothyroidism at 6:00 AM was administered as ordered. During an interview on 12/03/24 at 1:40 PM with Resident #4's attending physician revealed, she was not aware medications were not being administered according to physician's orders due to medications pending delivery from the pharmacy, or due to cost approval, or not available in the automated medication management system's formulary. She said she expected the nurses to immediately notify her if medications were not available to administer, especially if they were significant medications such as Levothyroxine. She said the facility had a contract with a local pharmacy to deliver medications after hours and the nurses should have called the pharmacy to order the medication to have on hand to administer the medication as ordered. During an interview on 12/03/25 at 3:10 PM with RN Assistant CNO revealed the nurses were trained to notify her and the attending physician when medications were not available to administer as ordered. 5. Record Review of admission Record dated 12/03/25, for Resident #5 revealed admission date 05/23/2023. Record review of Resident #5's electronic medical records revealed the resident did not have a History & Physical. Record review of the Nurse Practitioner Progress Note, dated 06/25/2025, for Resident #5 provided by RN Assistant Chief Nurse Officer revealed, [AGE] year-old female resident who was alert, oriented to person only; able to follow simple commands. The MPOA expressed concern regarding whether medications are being administered consistently. There were no diagnoses documented on the progress note. Record review of Quarterly MDS, dated [DATE], for Resident #5 revealed BIMS Summary Score 7 - Cognitively Severely Impaired. Active Diagnoses: Heart Failure (the heart cannot pump enough blood and oxygen to meet the body's needs), Hypertension (when the force of blood against your artery wall is consistently too high), Alzheimer's Disease (is a specific disease that slowly destroys brain cells, leading to confusion, memory gaps, personality changes, and difficulty with everyday tasks), Hypothyroidism (a condition where your thyroid gland does not produce enough essential hormones that control body energy use, leading to slow metabolism and symptoms of fatigue, weight gain, feeling cold, and dry skin), Glaucoma (a group of eye diseases that damage the optic nerve, due to increased pressure inside the eye, leading to gradual peripheral vision loss and potentially blindness if untreated), Osteoporosis (when the bones become weak, thin, and brittle making super easy to break) . History of falls. High-Risk Drug Classes: Diuretic, Antiplatelet. Record review of Care Plan, dated 07/29/25, for Resident #5 revealed:-The resident is receiving antiplatelet medication. Interventions: Monitor and report as needed adverse reactions.-The resident has ADL self-care performance deficits and limitations in physical mobility. Alzheimer's, Hypothyroidism, and Hypertension. Interventions: Uses wheelchair. Partial/moderate assistance with personal hygiene, dressing; Dependent for shower, toileting. -The resident has hypothyroidism. Interventions: Obtain and monitor labs as ordered. Administer medication as ordered. -The resident at risk of skin alteration related to incontinence, and decreased mobility. Interventions: Apply skin barrier to help protect skin from excess moisture. -The resident is at risk for falls r/t lack of safety awareness, decreased mobility. Interventions: Keep call light within reach. Bed in low position when in bed. Anticipate needs. Record review of Physician Order Summary Report, dated 12/04/25, for Resident #5 revealed:-11/18/25 Amoxicillin Oral Tablet 500 mg give 1 tablet by mouth three times a day for mouth sore for 7 days.-Aspirin Oral Capsule 81 mg give 1 tablet by mouth one time a day for pain.- Calcium Antacid Chewable 500 mg give 1 tablet by mouth two times a day for supplement.- Colace Oral Capsule 100 mg give 1 capsule by mouth one time a day for constipation.- Farxiga Oral Tablet 5 mg give 2 tablets by mouth in the morning for hyperglycemia.- Latanoprost Ophthalmic Solution 0.005% instill 1 drop in both eyes in the evening for glaucoma- Levothyroxine Sodium 25 mcg give 1 tablet by mouth in the morning for hypothyroidism.- Lidocaine External Patch 4% apply to left shoulder topically in the morning for pain may wear up to 12 hours per day and remove as scheduled.- Pravastatin Sodium Oral Tablet give 1 tablet by mouth at bedtime for HLD.- Lisinopril Oral Tablet give 1 tablet in the morning for HTN.- Vitamin C Oral Tablet 1000 mg give 1 tablet by mouth two times a day for supplement. Record review of Medication Administration Record, dated October 2025, for Resident #5 revealed:-10/11/25 - 10/13/25 Aspirin 81 mg give 1 tablet by mouth one time a day at 8:00 AM, was not administered as ordered. The MAR documented code 9 (see nurses' notes)-10/17/25 - 10/20/25 Colace Oral Capsule 100 mg give 1 capsule by mouth one time a day at 9:00 AM, for constipation was not administered as ordered. The MAR documented code 9 (see nurses' notes)-10/25/25 - 10/27/25 Farxiga 5 mg give tablets give two tablets by mouth in the morning at 9:00 AM, for hyperglycemia were not administered as ordered. The MAR documented code 9 (see nurses' notes)-10/15/25 - 10/16/25 Latanoprost Ophthalmic Solution 0.005% instill 1 drop in both eyes in the evening at 6:00 PM, for glaucoma at 6:00 PM was not administered as ordered. The MAR documented code 9 (see nurses' notes)-10/03/25 and 10/11/25 Levothyroxine Sodium 25 mcg give 1 tablet by mouth in the morning at 5:00 AM for hypothyroidism was not administered as ordered. The MAR documented code 9 (see nurses' notes)-10/08/25 - 10/09/25 Lidocaine External Patch 4% apply to left shoulder topically in the morning for pain may wear up to 12 hours per day and remove as scheduled. The MAR documented code 9 (see nurses' notes)-10/05/25, 10/07/25, 10/10/25 - 10/12/25, 10/15/25, 10/26/25, 10/20/25, 10/21/25, 10/24/25 - 10/26/25 Pravastatin Sodium Oral Tablet give 1 tablet by mouth at bedtime at 9:00 PM, for HLD (high levels of cholesterol and fats in the blood) was not administered as ordered. The MAR documented code 9 (see nurses' notes)-10/24/25 - 10/27/25 Prenatal Vitamin give 1 tablet by mouth one time a day for supplement at 9:00 AM was not administered as ordered. The MAR documented code 9 (see nurses' notes)-10/13/25 Spironolactone Oral [NAME] 25 mg give 1 tablet by mouth in the morning at 9:00 AM for HTN was not administered as ordered. The MAR documented code 9 (see nurses' notes)-10/13/25 - 10/20/25 Calcium Antacid Chewable 500 mg give 1 tablet by mouth two times a day for supplement at 8:00 AM and 9:00 PM was not administered as ordered. The MAR documented code 9 (see nurses' notes)-10/16/25 - 10/23/25 Vitamin C Oral Tablet 1000 mg give 1 tablet by mouth two times a day at 9:00 AM and 9:00 PM was not administered as ordered for supplement. The MAR documented code 9 (see nurse's notes). Record review of Medication Administration Record dated October 2025 for Resident #5 revealed:-10/11/25 - 10/13/25 Aspirin 81 mg give 1 tablet by mouth one time a day at 8:00 AM. The MAR documented code 9 (see nurses' notes)-10/17/25 - 10/20/25 Colace Oral Capsule 100 mg give 1 capsule by mouth one time a day at 9:00 AM for constipation. The MAR documented code 9 (see nurses' notes)-10/25/25 - 10/27/25 Farxiga 5 mg give tablets give two tablets by mouth in the morning for hyperglycemia. The MAR documented code 9 (see nurses' notes)-10/15/25 - 10/16/25 Latanoprost Ophthalmic Solution 0.005% instill 1 drop in both eyes in the evening for glaucoma at 6:00 PM. The MAR documented code 9 (see nurses' notes)-10/03/25 and 10/11/25 Levothyroxine Sodium 25 mcg give 1 tablet by mouth in the morning at 5:00 AM for hypothyroidism. The MAR documented code 9 (see nurses' notes)-10/08/25 - 10/09/25 Lidocaine External Patch 4% apply to left shoulder topically in the morning for pain may wear up to 12 hours per day and remove as scheduled. The MAR documented code 9 (see nurses' notes)-10/05/25, 10/07/25, 10/10/25 - 10/12/25, 10/15/25, 10/26/25, 10/20/25, 10/21/25, 10/24/25 - 10/26/25 Pravastatin S

Based on observation, interview and record review the facility failed to establish procedures for storing and disposing of drugs and biological in accordance with federal, state, and local laws. -The facility failed to ensure medication deliveries were not left unattended at the nurse's station. -The facility failed to ensure licensed staff did not leave medications unattended at the nurse's station This failure could place residents living at the facility at risk of drug diversion. The findings included:During an observation on 12/03/25 at 9:00 AM, revealed a cardboard box was on top of the nurse's station countertop labeled El Paso with a label on one side that documented Dressing Change Kits. During an observation, interview and record review on 12/03/25 at 9:50 AM revealed, LVN I, was sitting at the nurse's station taking medication blister packets out of the cardboard box that was labeled El Paso, that was on the nurse's station countertop unattended earlier that morning. He said the pharmacy ships medications in cardboard boxes from out of town and the boxes should be received by one of the nurses. He said, These blister packets are controlled substances, and I need to store them in the locked medication room next to the nurse's station. The nurse walked away from the nurse's station for approximately two minutes and left several medication blister packets unattended on top of the counter in front of the computer unattended. It was observed that the housekeeper standing in the hallway directly in front of the nurse's station preparing cleaning equipment to enter a resident's room and the facility driver was standing on the side of the nurse's station talking to a resident. The nurse returned to the nurse's station and continued to pull medication blister packets from the cardboard box. The surveyor requested copies of the packing slips from the cardboard box. Record review of the Packing Slips dated 12/02/2025 revealed the following medications were listed on the packing list. Alprazolam 0.5 mg 42 tablets, Dronabinol 2.5 mg 30 tablets, Tramadol HCL 50 mg 30 tablets, and Tramadol HCL 50 mg 30 tablets. The packing slips documented, By signing below, you acknowledge that the items above have been received. It was observed that the packing slips were not signed by the receiving nurse. During an interview on 12/03/25 at 9:57 AM LVN stated, they had been trained to never leave medications unattended at the nurse's station. During an interview on 12/02/25 at 3:12 PM, with RN Assistant Chief Nursing Officer in the presence of the Executive Director and Chief Nursing Officer revealed, they had contracts with two out-of-town pharmacies that provided pharmaceutical services to the facility and with a local pharmacy for after hour services. It was reported that the delivery people should hand the box of medication to one of the nurses on duty and should never leave the box with medication unattended at the nurse's station. She said the delivery person and receiving nurse had to sign and date the packet delivery slip for the person that delivered the medication to the facility. During an interview 12/03/25 at 3:21 PM, with RN Assistant Chief Nursing Officer in the presence of the Executive Director and Chief Nurse Officer revealed, she had followed up with the nurses and they had reported that the cardboard box that contained medication was just left by the delivery person at the nurse's station and was not left with any of the three nurses that were on duty. Review of facility's policy and procedure on Medication Ordering and Receiving Form from Pharmacy ProviderReturns a signed copy of the delivery receipt/manifest to the pharmacy via driver, fax or other method, as defined by the pharmacy provider. Retains a copy of the delivery for an appropriate time to reconcile any ordering issues.

Based on interview and record review the facility failed to ensure, in accordance with accepted professional standards and practices, medical records were maintained on each resident that were accurately documented for 1 (Resident #22) of 8 residents reviewed for medical records. -The facility failed to ensure LVN A documented in the Nurse's Notes on 11/18/25 when she notified the physician of resident family's non-compliance of NPO status. -The facility failed to ensure that licensed staff promptly wrote physician's telephone orders and entered new orders in the medication administration record. This failure could place residents at risk of residents records not reflecting accurate and complete information. Findings include:Closes Record Review of the admission Record dated 12/01/25 for Resident #1 revealed, admission date 11/10/25. discharge date [DATE] to Acute Care Hospital.Review of the Hospital Physician Progress Note for Resident #1 dated 11/09/25 revealed, [AGE] year-old male with a history of esophageal cancer (abnormal cells grow out of control in the food pipe, making it hard to swallow, causing pain, weight loss, and a persistent cough or hoarseness as the tumor blocks the passage or irritates the area) on enteral feedings (giving liquid nutrition formulas directly into their stomach through a tube), CAD with history of mitral valve replacement (blocked heart arteries damaged the heart muscle, causing the mitral valve to leak, both problems are fixed by bypass surgery for the arteries and replacing the faulty valve with a new mechanical one, to improve blood flow and heart function). Review of the admission MDS assessment dated [DATE] for Resident #1 revealed, Entry Date: 11/10/25. BIMS Summary Score - 10 (cognition was moderately impaired). Clear speech, makes self-understood, and understands others. Active Diagnoses: Cancer, Heart Failure (the heart cannot pump enough blood and oxygen to meet the body's needs), Hypertension, Diabetes Mellitus (a chronic disease where the body had high blood sugar levels, either because the pancreas does not produce enough insulin or the body cannot use insulin effectively), Non-Alzheimer's Dementia (brain disorder causing memory, thinking, and behavior problems), Dysphagia (difficulty swallowing, which can make it hard for food and liquids to move from the mouth down to the stomach), lack of coordination, and Gastrostomy (is a feeding tube that goes directly into the stomach through a small opening in the stomach, by bypassing your mouth and throat, to deliver liquid food, medicine, or to help air and fluids come out). Review of the Care Plan for Resident #1 dated 11/10/25 revealed: Resident has ADL self-care performance deficit and limitations in physical mobility. Interventions: Partial/moderate assistance with toileting hygiene, dressing and turning and repositioning in bed. Resident is NPO (nothing by mouth) on G-tube on bolus feedings (give a single, large amount of liquid food through a feeding tube, instead of a slow, continuous drip) every six hours. The resident was receiving anticoagulant therapy and are prone to bleeding and bruising. Interventions: Labs as ordered. Report abnormal results to the MD. Monitor/document/report PRN (as needed) black tarry stools, sudden changes in mental status, significant or sudden changes in vital signs. Record review of the IDT Notes revealed that LVN A had not documented the physician she had notified the physician on 11/18/25 when she had seen the resident's family member giving Resident #1 water with ice chips and was not following the NPO order. LVN A only documented she had notified the Speech Therapist Record review of the Medication Administration Record dated November 2025 for Resident #1 did not document the orders for the Chest x-ray, Saline Nasal Spray and Oxygen order for 1 Liter. During an interview and record review on 12/01/25 at 3:39 PM with LVN A in the presence of RN Assistant Chief Nurse Officer revealed she was assigned to Resident #1 on 11/22/25 and had worked from 6:00 AM - 6:00 PM on that day. She said on 11/22/25 Resident #1 was having more chest congestion than usual in the morning, and she had notified the physician, and they had given an order for chest x-ray, Saline Nasal Spray, Oxygen at 1 Liter and she did not write the telephone order and had not entered the new orders on the Medication Administration Record. She said, There is no reason why I did not write the Telephone Order and did not enter the order for the Saline Nasal Spray in the Medication Administration Record. She said licensed staff had been trained to immediately write the Telephone Order for new orders and to enter the new order on the Medication Administration Record. LVN A said the resident was NPO and was not aware that he was ever served regular food while at the facility. She said the resident was always requesting ice chips, and the speech therapist had given an order to give ice chips only when directly supervised by the nurses. She said the resident received three bolus enteral feeding via G-Tube during her shift. She said that on 11/18/25 she had seen the resident's family member giving the resident water with ice. She said the Speech Therapist had given orders for only the licensed staff to give ice chips to the resident because he was high risk for aspiration. She said she had immediately reported this to the speech therapist and did not remember if she had notified the physician, because she had not documented the physician notification in her nurse's notes on 11/18/25. During an interview and record review 12/01/25 at 4:40 PM with RN Assistant Chief Nursing Officer revealed LVN A had seen when the resident's family member was giving the resident water mixed with ice chips on 11/18/25 and she had notified the speech therapist. She said that she did not know if the nurse had reported this to the attending physician because the nurse had not documented in the electronic Nursing Progress that the physician had been notified of the non-compliance with the resident's NPO status. She said the nurses had been trained to document in the resident's clinical record physician notifications and to promptly write a Telephone Order and enter the new orders in the Medication Administration Record. She said LVN A had not written the Telephone Order and had not entered the new order for the Nasal Saline spray, and Oxygen order for 1 liter and had not entered in the Resident's Medication Administration Record for the Saline Nasal Spray and Oxygen ordered by the physician on 11/22/25. Review of the facility's policy & procedures on Documentation by Exception revised 11/2024, provided by RN Assistant Chief Officer revealed, Policy: Documentation should include any unusual event or change of condition of the resident. Documentation may be completed under Progress Notes, evaluations, etc. Any communication with a physician, nurse practitioner, consultant physician, or family should also be documented as appropriate.

Based on observations, interviews, and record review the facility failed to ensure nurse staffing data was posted daily and readily accessible to residents and visitors, for 1 of 1 nursing unit reviewed for nurse staffing information. The facility failed to post and maintain the required nursing staffing information since 11/20/25. These failures could place residents, their families, and facility visitors at risk of not having access to information regarding facility regarding staffing schedule and facility census. Findings included: During an observation and record review on 12/01/25 at 12:55 PM revealed, the daily staffing sheet posting information, posted by the main entrance to the facility, was dated 11/20/25. During an interview and record review on 12/01/25 at 4:46 PM with RN D Assistant Chief Nursing Officer revealed, the previous Chief Nurse Officer's last day of work was on 11/20/25 and she posted the nurse staff data daily. She said she had requested access to the electronic PPD reports to complete the nurse staff data daily and as of today she had not been granted access to the needed information. She said, that is why she has not posted an updated nurse staff data sheet since 11/20/25. The Assistant Chief Nurse Officer said that the purpose of the nurse staff data was to communicate with visitors' information on the number of staff available at the facility. The Assistant Chief Nurse Officer said the risk of not having the information posted was that staff members and family members would not know the current staffing situation at the facility. During an interview and record review on 12/02/25 at 12:06 PM with Executive Director revealed the nurse staff data posted by the main entrance to the facility was dated 11/20/25. He said, the previous Chief Nurse Officer's last day of employment was on 11/20/25 and she was responsible for posting the nurse staff data daily. He said he had requested access to the electronic PPD reports for the Assistant Chief Nurse officer on 11/20/25 and as of today, she still had not been granted access to the electronic PPD reports to be able to complete the nurse staff data to post daily. The state surveyor requested the facility's policy on nurse staff data and was not provided prior to exit by the Assistant Chief Nurse Officer.

Based on observation, interview, and record review the facility failed to develop and implement comprehensive person-centered care plan that includes measurable objectives and time frames to meet a resident medical and nursing needs to be furnished to attain or maintain the residents highest practicable physical, mental, and psychosocial well-being for two residents (Residents #1, and #2) of 4 residents reviewed for care plans.The facility failed to have a comprehensive person-centered care plan for Resident # 1 and #2 to address resident's wound vac.These failures could affect residents and put them at risk for not receiving care and services to meet their needs.Findings included: Resident #1Record review of Resident #1's admission record dated 10/27/2025 revealed a [AGE] year old male with an admission date of 09/22/25.Review of Resident #1's history and physical dated 09/23/2025 revealed resident had a left 5th toe amputation and the presence of a wound vac to distal lower leg.Review of Resident #1 's admission MDS (Minimum Data Set) assessment dated [DATE] revealed a BIMS score of 15 indicating intact cognitive function. Section M- skin conditions -revealed surgical wound care and application of dressing to feet.Review of Resident #1's Physician orders dated 09/24/2025 revealed WOUND CARE TO LEFT FOOT: NPWT@125mmHG CONTS. NOT TO BE REMOVED/CHANGED UNTIL SEEN BY SURGEON ON 9/25.Review of Resident #1 's Care Plan initiated on 09/23/2025 revealed the care plan did not address resident's use of wound vac.Resident #2Record review of Resident #2's face sheet revealed a [AGE] year-old male with an admission date of 10/01/25.Record review of Resident #2's history and physical dated 10/01/25 revealed medical history of high blood pressure, chronic kidney disease (condition where the kidneys gradually lose their ability to filter waste products from the blood), coronary artery disease (heart condition where the arteries that supply blood to the heart become narrowed or blocked), and diabetic foot ulcer (open sore or wound that develops on the foot of a person with diabetes). Record review of Resident #2's 5 day MDS dated [DATE] revealed a BIMS score of 15, indicating resident was cognitively intact. Section M- Skin Conditions revealed surgical wound care, and application of dressings to feet.Record review of Resident #2's physician orders dated 10/01/2025 revealed WOUND CARE TO RIGHT FOOT:IRRIGATE WITH NSS, PAT DRY, APPLY SKIN PREP TO PERIWOUND, APPLY TRANSPARENT FILM TO PERIWOUND, FILL SPACE WITH BLACK GRANUFOAM, SECUREWITH TRANSPARENT FILM, ATTACH STINGRAY, RESUME NPWT @125mmHG CONTS. 3XWK every day shift every Mon, Wed, Fri.Record review of Resident #2's care plan with initiation date of 10/01/25 revealed the care plan did not address resident's use of wound vacIn an interview on 10/27/25 at 1:40pm with RN A revealed if a resident was using wound vac, that treatment would have to be included in the care plan, as the care plan was a blueprint of residents care and the wound vac was something that needed to be taken care of. She stated that a risk of not being care planned would be the chance of it being missed by someone new to caring for the resident.In a telephone interview on 10/28/25 at 10:54am with RN B revealed that the admitting nurse was responsible for completing a baseline care plan. She stated that she then was responsible for completing the comprehensive care plan. She stated that wound care or wound vac would be included in the baseline care plan and if it became a new treatment during the residents stay, then it would be the floor nurses responsibility to update the care plan. She stated that it was important for the care plan to be accurate because it was part of their treatment, and reason for stay at the facility. She stated that there was no risk for the residents wound vac not being care planned because treatment was still being done because it showed up on the MAR. She stated that it was the responsibility of nursing staff including herself to ensure that care plans were up to date. She stated that she could not recall last Inservice done regarding care plans.In an interview on 10/28/25 at 11:20am with the DON revealed, that the purpose of a care plan was so staff could know the needs of the resident and was a form of individualized care. She stated that wound vac was supposed to be included in the care plan because it was something pertaining to residents care. She stated that initially the admitting nurse was responsible for completing the baseline care plan and then the MDS nurse would go through each and revise, she would add it because it would not have to be added to baseline care plan but it would have to be added in the comprehensive care plan done by MDS nurse. She stated that it was important for wound vac to be included so that every nurse could know that it was a required care and it was a form of personalized care. She stated that it was the DONs responsibility along with ADON to monitor that care plans were correct . She stated that her and the ADON conduct chart audits upon admission daily to monitor care plans were correct along with IDT meetings weekly to bring up any concerns concerning care plans. In an interview on 10/28/2025 at 12:50pm with Administrator revealed that the purpose of the care plan was for it to be used as a baseline of the resident and their needs. He stated that wound vac needed to be included in the care plan. He stated that the importance of including in the care plan was for insurance purpose and to ensure treatment was being done. The risk of it not being care planned was miscommunication between staff regarding care and it could potentially be a health hazard for the resident. He stated that it was a team effort including MDS nurse, floor nurses, DON, ADONs and Social Worker to ensure that care plans were accurate by communicating with each other and updating one another. He stated that the corporate nurse consultant was responsible for monitoring the care plans were correct and will send emails weekly detailing any missing information/ documentation to DON and ADONS. He stated that he did not recall an Inservice over care plans.Record review of facility's care plan policy, titled Care Plan revised on 11/2024 read in part . A baseline care plan is developed for each resident upon admission, but no later than 48 hours of admission to the facility. This care plan includes minimum healthcare information necessarily to properly care for the resident.The care plan consists of the following: a. Problems as identified by reviewing the medical record and discussion with the resident and/ or significant others.

Based on observation, interview, and record review, the facility failed to ensure that each resident received food that is palatable, attractive, and at a safe and appetizing temperature for 1 of 1 meal (7/30/25) tested for nutritive value, flavor, and appearance:The facility failed on 7/30/25 to serve and address the residents concerns regarding their meals not being at a safe and palatable temperature for residents who were served their meals in their rooms.The facility failed on 7/30/25 to serve a sample food tray for the surveyors at a safe and palatable temperature. The facility failed on 7/30/25 to serve meals at a safe temperature. This failure could affect the residents who ate food from the facility's kitchen by placing them at risk of poor food intake and/or dissatisfaction due to not providing appetizing temperature meals. The findings included:Record review of the facility's lunch menu for Wednesday July 30th, 2025, consisted of Beef Pepper Steak, Garlic Mashed Potatoes and Buttered Carrots. In an observation on 7/30/35 at 12:28 PM, the meal cart left the kitchen followed by the Executive Chef towards hallway 300. The first food tray was delivered to room [ROOM NUMBER] at 12:29 PM. The food cart finished delivering the food trays to the residents' rooms and made its way to the conference room arriving at 12:35 PM for tray testing. The Executive Chef took the food temperatures under the surveyors observations and findings were as follows: Regular diet tray: garlic mashed potatoes, beef peppered steak and buttered carrots, all registered at 120 degrees Fahrenheit at 12:36 PM. Pureed diet tray: garlic mashed potatoes, beef peppered steak and buttered carrots, all registered at 120 degrees Fahrenheit at 12:37 PM.In an interview on 7/31/25 at 10:05 AM with the Executive Chef, he stated that food needed to be at 135 degrees Fahrenheit once residents received their meals in their rooms. He explained the kitchen had made test trays to take the temperature to ensure residents meals were being served at the right temperatures, but there was no documentation of this. The Executive Chef said there was a risk of bacteria growing if the food got cold, and residents could get sick. The Executive Chef also stated that there was a possibility that residents could lose weight or get dehydrated if their meals were not at the correct temperature and they declined to eat the meals that the facility prepared for them.In an interview on 7/31/25 at 10:34 AM with the Cook, she stated that food needed to be at least 140 degrees Fahrenheit once it got to the residents' rooms. The [NAME] said some residents had complained that their meals were cold when they received them. The [NAME] stated that if a resident received food at 120 degrees Fahrenheit, it could create bacteria and make the resident sick or make them feel that the facility did not pay attention to their needs. The [NAME] also said residents could stop eating and lose weight or get dehydrated, stating that it was not acceptable for residents to be receiving their meals at 120 degrees Fahrenheit.In an interview on 7/31/25 at 1:20 PM with CNA B, she stated that it was the kitchen's responsibility to ensure the food was hot once the residents received their meals in their rooms. CNA B said a possible negative outcome of residents receiving cold meals could result in them not eating their food and possibly result in them losing weight. She also stated that if the meal included meat and was left out and got cold, there was a possibility for bacteria to grow. CNA B explained that if a resident ate the meal with bacteria, there was a possibility for them to get sick, which could lead to food poisoning, vomiting, diarrhea, or dehydration.In an interview on 7/31/25 at 1:52 PM with the Administrator, she stated that CNAs were responsible for distributing meal trays to residents who ate in their rooms. The Administrator said the temperature should not be below 130 degrees Fahrenheit, and anything below that temperature was unacceptable. The Administrator said there was a risk for residents receiving cold food, which could potentially result in them refusing their meal, discouraging them from following their diet, which could lead to malnutrition. The Administrator said if the food was cold and bacteria developed, it could potentially make them sick and provoke illnesses such as vomiting, diarrhea, or dehydration.Record review of the facility's policy revised in 2017 and titled Holding and Service, stated in part: Food is held and served using safe food handling methods which protect the food from contamination, prevent food-borne illness and preserve the nutritive value of the food. Holding: Hot foods are held at a minimum temperature of 135 F. The Dining Services Director/Cook(s) will be responsible for food preparation techniques which minimize the amount of time that food items are exposed to temperatures greater than 41 F and/or less than 135 F, or per state regulation.

Based on observation, interviews and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety for 1 of 1 kitchen reviewed in that:The facility's kitchen staff failed to thaw food properly.This failure could place residents who eat foods prepared in the kitchen at risk of cross contamination and food-borne illnesses.The findings include: In an observation on 7/29/25 at 8:13 AM in the kitchen, two packs of beef, approximately four pounds each, were thawing inside a large and clear plastic container. The container was observed next to the kitchen sink. Meat juice was visible outside of the bags containing the meat and a pool of juices was forming inside the container. In an observation on 7/29/25 at 8:25 AM in the kitchen, the same receptacle containing the meat had been moved to a different sink and was completely submerged in water below the faucet and the water was left running. In an interview on 7/31/25 at 9:53 AM with the Executive Chef, he stated that the procedure for thawing meat was to take the meat product out from the walk-in refrigerator, place it on a container and immediately take it to the sink to submerge it in water and leave the faucet running to help the meat thaw evenly. The Executive Chef said this procedure was not followed on 7/29/25, which created a risk for the meat to develop bacteria. The Executive Chef said the person responsible for following these procedures would be the cook or whoever takes the meat out of the refrigerator and that it was his expectation for staff to follow the facility's policies for thawing food. The Executive Chef stated that the risk for not thawing the meat per the policies was that the meat or the meat juices could grow bacteria and if the residents ate contaminated meat, they could potentially get sick which could result in them having diarrhea, vomiting, and dehydration.In an interview on 7/31/25 at 10:22 AM with the Cook, she stated that meat needed to be placed in a container immediately below a faucet with running water to thaw. The [NAME] said she was last trained on this proper thawing technique two months ago, but there was no record of training, and it was done orally. The [NAME] stated that she had made a mistake of taking the beef out of the refrigerator, placing it in a container next to the sink to thaw at air temperature, and not placing it below the faucet with running water. The [NAME] stated the risk for not properly thawing meat, as per policies, was that the meat could create bacteria which could contaminate it, and if residents ate it, it could make them sick with a stomach illness such as vomiting or diarrhea.In an interview on 7/31/25 at 1:52 PM with the Administrator, she stated the procedure for thawing beef was the meat needed to either be defrosted inside the refrigerator making sure the meat juices didn't spill on other food which could potentially contaminate them, or to thaw it by taking it out of the refrigerator, putting the meat in a container and immediately place it under running water so that there was a constant flow of water. The Administrator said that meat, such as beef, should not be left to thaw at room temperature because there was a risk of bacteria growth which could potentially make the residents sick. The Administrator stated that if residents ate meat that was contaminated with bacteria, it could result in them getting gastrointestinal infections which could lead to vomiting or diarrhea and making them sick. The Administrator stated the expectation was for all the kitchen staff to follow the facility's policies and procedures at all times to ensure the residents did not get sick from eating the meals provided by the facility. Record review of the facility's policy titled Dining Services Policy and Procedure Manual, revised February 2025 stated in part: Food: Preparation Policy Statement. All foods are prepared in accordance with the FDA Food Code. Procedures: The Cook(s) thaws frozen items that requires defrosting prior to preparation using one of the following methods: Completely submerging the item under cold water (at a temperature of 70 F or below) that is running fast enough to agitate and float off loose ice particles.

Based on observation, interview, and record review, the facility failed to ensure each resident received services in the facility with reasonable accommodation of resident needs and preferences for 1 of 14 Residents (Resident #62) reviewed for accommodation of needs.The facility failed to ensure Resident #62's call light was in reach.This failure could affect the residents' dependent on staff for transferring in and out of their bed and/or wheelchair by causing feelings of isolation, frustration, hunger, and a diminished quality of life.Findings include:Record review of Resident #62's face sheet dated 07/30/25 revealed a [AGE] year-old female with an initial admission date of 12/18/24 and a re-admission date of 07/25/25. Record review of Resident #62's history and physical dated 07/27/25 revealed medical history of: Senile Degeneration of brain (decline of cognitive function impacting memory and reasoning), Anxiety (a feeling of worry, nervousness, or unease, typically about an imminent event or something with an uncertain outcome), and Debility (physical weakness).Record review of Resident #62's Discharge Minimum Data Set (MDS) assessment dated [DATE] revealed the BIMS was not conducted since Resident #62 was rarely/never understood.Record review of Resident #62's care plan dated 06/20/25 revealed resident was at risk for falls. Interventions included for staff to anticipate and meet resident's needs.During an observation on 07/29/25 at 10:20 AM, it was revealed that a resident's call light was observed on the floor, in between the head of the bed and resident's chair located in the corner of resident's room. Resident #62 was observed laying in her bed and the call light was out of resident's reach. CNA A was notified by this surveyor of the call light on the resident's floor and she placed it on Resident #62's bed next to the resident and within her reach. CNA A stated the call light was to be within Resident #62's reach so she could use it as resident was able to.During an interview on 07/31/25 at 1:15 PM with CNA B, she stated that all staff were responsible for ensuring the call lights were within residents' reach. CNA B stated if residents threw or dropped the call light, then any staff can assist with ensuring residents have their call light within reach. She stated nurses and CNAs rounded residents every hour or as needed, to ensure call lights were within reach. CNA B stated the DON and nurses monitored residents' rooms daily, including the call light being within reach. She stated the risks of call lights not being within reach included injury to the resident, and delay in resident care.During an interview on 07/31/25 at 1:40 PM with LVN D, she stated the purpose of call lights were for residents to request assistance. LVN D stated the call light should be placed next to the resident and within their reach. LVN D stated CNAs rounded on residents every 2 hours, or sooner, as needed. She stated it was all staff's responsibility to monitor call light placement. LVN D stated the risks of call lights being out of residents' reach included not having their needs met and place residents at risk for skin breakdown if the resident was soiled and needed assistance with a brief change. During an interview on 07/31/25 at 2:09 PM with the ADON, she stated the purpose of the call light was for residents to communicate their needs to staff. The ADON stated call lights were to be near the resident. She stated all staff were responsible for ensuring call lights were within reach. The ADON stated CNAs and nurses rounded on residents every 2 hours which included ensuring call light placement was within the residents' reach. She stated the DON and self, as the ADON, monitored residents' call lights within their reach. She stated the risks to the residents not having their call light within their reach included inability to communicate with staff and having their needs met.During an interview on 07/31/25 at 2:25 PM with the DON, she stated call lights were for residents to communicate with staff requesting assistance. The DON stated all staff were responsible for ensuring call lights were within the residents' reach. The DON stated she and the ADON rounded on residents every 1-2 hours to monitor for call light placement. She stated nursing staff also rounded on residents every 2 hours and ensured call lights were within residents' reach. The DON stated risks to the residents of not having their call light within their reach included possible skin breakdown if a resident were soiled and unable to request for assistance with a brief change. She stated another risk for residents included possible falls if residents did not have the call light within their reach and needed assistance, such as a resident attempting to go to the restroom by themselves. During an interview on 07/31/25 at 3:05 PM with the Administrator, she stated call lights were for residents to request help from staff. She stated call lights were to be next to the resident. She stated all staff were responsible for ensuring call lights were within the residents' reach. The Administrator stated managers from different departments did Angel Rounds, which meant the managers round on residents daily in the morning. She stated the purpose of Angel Rounds was for managers to check-in with residents' and their needs, and an environment assessment which included call light placement being within resident reach. She stated the risks for residents not having their call light within reach included not having their needs met such as untreated pain, soiled residents, and being uncomfortable.Record review of facility's policy Call Light-Ability to Use with revised date of 11/2024, read in part:-The call light system is provided as a tool for residents to communicate with staff.-Staff members will ensure that call lights are within reach of a resident who is able to cognitively use a call light each time they leave a room.

Based on observation, interview, and record review, the facility failed to ensure the resident's environment was as free from accident hazards as possible for 2 of 18 residents (Resident #2 and Resident # 49) reviewed for accidents. The facility failed to properly dispose of shaving razors in a sharps container in Residents #2 and 49's shared room. This deficient practice could place residents at risk of harm or injury and contribute to avoidable accidents. The findings included: Resident #2 Record review of Resident #2's face sheet dated 07/31/2025 revealed a [AGE] year-old male that was initially admitted to facility on 10/12/2022 and readmitted on [DATE]. Record review of Resident #2's history and physical dated 01/17/2025 revealed, Resident #2 was diagnosed with dementia (decline in mental ability). Record review of Resident 2's MDS assessment dated [DATE] revealed a BIMS score of 09 indicating moderate cognitive impairment. Record review of Resident #2's care plan reviewed on 04/24/25 revealed the Resident had impaired cognitive function/ dementia or impaired thought processes related to dementia. Resident #46 Record review of Resident #46's face sheet dated 07/31/2025 revealed a [AGE] year-old male that was initially admitted to facility on 09/23/2022 and readmitted on [DATE]. Record review of Resident #46's history and physical dated 07/15/2025 revealed, Resident #46 was diagnosed with diabetes mellitus (a chronic metabolic disorder characterized by high blood sugar levels) and other specified depressive episodes. Record review of Resident #46's quarterly MDS dated [DATE] revealed a BIMS score of 10 indicating moderate cognitive impairment. Record review of Resident #46's care plan reviewed on 04/10/25 revealed the Resident had impaired cognitive function. Observation of Residents # 2 and 46's shared room on 07/29/2025 at 09:38 am revealed five used disposable razors on top of the sharp's container. In an interview on 07/31/2025 at 01:06 pm with CNA B, she stated any contents that were to be disposed of in the sharp's container were to be disposed of all the way inside the container. She stated that all staff were responsible for ensuring that there were no contents left sitting in the drop slot or on top of the sharp's container. She stated that when contents were left in the reach of residents, this could pose a risk for residents getting a hold of items and injuring themselves. She stated that she could not remember the last training, but she stated that there were monthly trainings done online regarding proper disposal of sharps. In an interview on 07/31/2025 at 1:50 pm with LVN D, she stated all contents were to be disposed of completely in the sharp's container. She stated that it was the responsibility of whoever was disposing of the items to make sure that it was placed all the way inside the container. She stated that if items were left in the reach of residents, they could be at risk for injury and infection control if razor was reused. In an interview on 07/31/2025 at 2:23 pm with DON, she revealed that sharps containers were used to dispose of hazardous items. She stated that contents were supposed to be disposed of completely inside the container. She stated that if items were left in the reach of residents, residents could get injured and were at risk of cross contamination. She stated that there was an in-service provided to CNA's and nurses regarding sharps disposal on May 11th 2025. Review of the facility's policy revised January 2025 and titled Injection Safety and Sharps injury Protection Plan read in part The main purpose of engineered sharps safety is to increase protection from sharps injuries, which can transmit HIV, hepatitis B, hepatitis C, and other bloodborne pathogens.Throw the entire needle/syringe assembly into the red plastic sharps container.

Based on interview and record review the facility failed to consult with the resident's physician when a significant change in the resident's physical, mental, or psychosoical status for 1 (Resident #3) of 8 residents reviewed for changes in condition. The facility failed to respond timely to a change in condition on 05/04/2018 when Resident #3 alleged that he fell and complained of pain to the right hip. The Licensed staff failed to accurately assess the resident after a fall and consult with the attending physician when it was going to take more than 5 hours for the stat (immediately) x-ray to be done. The x-ray was done 14 hours after receiving the physician's orders [REDACTED]. The resident was transferred to the hospital 5/05/2018 and was admitted to the hospital with [REDACTED]. An Immediate Jeopardy (IJ) was identified on 07/17/2018. The IJ was removed on 07/23/2018, the facility remained out of compliance at actual harm, pattern due to the facility's need to evaluate and monitor their corrective action system. This failure could affect 16 residents that were currently at the facility by placing them at risk of potential medical complications [REDACTED]. Findings include: Resident #3 Closed record review of the Admission Record dated 07/10/2018 for resident #3 documented resident was admitted on [DATE]. Review of the History & Physical dated 05/01/2018 for resident #3 documented in part: [AGE] year old male was hospitalized for [REDACTED]. Resident has a history of hypertension, [MEDICAL CONDITION] (HLD), [MEDICAL CONDITION] bladder and decreased hearing. Right lateral thigh incision intact. Pain to right hip is controlled. Awake, very hard of hearing, which limits our conversation. Oriented x 3. Calm & cooperative. He states he does his own straight urethral catherization twice a day at home. Debility. Continue physical therapy and occupational therapy. Review of the Minimum Data Set (MDS) 5 day PPS (Prospective Payment System) assessment dated [DATE] for resident #3 documented in part: Hearing moderately difficulty, clear speech, makes self understood, understands others, BIMS (Brief Interview for Mental Status) 11 (moderately impaired), verbal behavioral symptoms occurred 1 to 3 days, extensive assistance of two persons with bed mobility, transfers, dressing, and toilet use; extensive assistance of one person with personal hygiene and bathing. Not steady when moving from seated to standing position, moving on and off toilet, transfer between bed and chair or wheelchair. Mobility device: wheelchair. Section GG: Dependent for toilet hygiene; Supervision or touching assistance with sit to lying and lying to sitting on side to bed; Partial/moderate assistance with sit to stand, chair/bed-to-chair transfer, toilet transfer; Independent wheel 50 feet with two turns. Occasionally incontinent of bowel & bladder. Received scheduled and prn (as needed) pain medication. Occasionally has pain. Verbal Descriptor Scale moderate. History of fall in the last month. History of falls in the last 2-6 months. Resident had fracture related to fall in the last 6 months. Medications received-Diuretic and Opioid. Resident participated in assessment. Expects to be discharged to the community. Review of the Care Plan initiated on 04/30/18 for resident #3 documented in part: The resident has an ADL (activities of daily living) self-care performance deficit related to Activity intolerance, confusion, impaired balance, limited mobility, pain to right hip. Interventions did not specify how much assistance the resident needed from staff with bathing, bed mobility, dressing, personal hygiene, and toilet use. Review of the Care Plan initiated on 05/11/2018 for resident #3 documented in part: Actual fall 5-05-2018 voiced by resident. Not witnessed. I am at risk for falls related to balance problems, gait problems, history of falls. Interventions documented in part: Become familiar with my daily routine and attempt to anticipate and meet my needs. Evaluate, interview and document my physical condition and cognitive status. Observe environment to identify any potential factors that could contribute to a fall, such as lighting, uneven/slippery floor surfaces, improper footwear, failure to use assistive devices, etc. Remove any potential causes or hazards, if possible. Educate me about safety reminders and what to do if a fall occurs. Provide a safe environment: clutter free; support/assistive devices are available and in good repair, personal items and my call light is within reach, non-glare lighting at night. Record review and interview on 07/18/2018 at 1:46 PM, MDS Nurse Licensed Vocational Nurse (LVN) F reported that the care plan dated 5/11/2018 for resident #3 had been written by the previous interim Director of Nursing (DON) G after the resident #3 had been discharged on [DATE] to the hospital. Interview on 07/18/2018 at 3:36 PM, current interim Director of Nursing (DON) H confirmed DON G had written the care plan dated 5/11/2018 for resident #3 after the resident #3 had been discharged on [DATE] to the hospital. Hospital Paperwork 05/05/2018: Review of Hospital emergency room Report dated 5/05/2018 at 4:56 PM for resident #3 documented in part: As per EMS (emergency medical services) patient had a complete right hip replacement in (MONTH) (YEAR). Patient reports falling yesterday, had x-ray done this morning which showed right hip dislocation. History of present illness: The patient presents following a fall. The occurrence was single episode. The fall was described as fall out of chair. The location where the incident occurred was at nursing home. Location: Right Hip. The character of symptoms is pain. Physical Examination: Profuse warmth, to lower extremity: Right hip, range of motion (limited secondary to possible dislocation), externally rotated. Differential Diagnosis: [REDACTED]. Review of Hospital X-ray report dated 5/05/2018 at 5:31 PM, for resident #3 documented in part: Right hip arthroplasty with superior dislocation of the femoral head and acetabular components. No acute displaced fractures. Review of Hospital Physician Note dated 05/05/2018 at 5:20 PM, for resident #3 documented in part: Procedural sedation. Closed reduction for dislocation of right hip. Review of Hospital Physician Note dated 05/05/2018 at 8:08 PM for resident #3 documented in part: Worsening AMS (altered mental status) and respiratory, increasing work of breathing, suspect worsening decline since arrival as patient was not a baseline initially, will intubate for airway protection/respiratory distress. admitted to inpatient Telemetry Unit. Review of Hospital Orthopedic Consultation Report dated 05/07/2018 for resident #3 documented in part: Two weeks status [REDACTED]. Apparently sustained a fall in nursing home with subsequent hip dislocation. Reduced in ED (emergency department), [MEDICAL CONDITION] following now in ICU (intensive care). Wound looks clean although he likely has fluid collection/hematoma. Hospital clinical information scanned for admission referral to nursing facility for review on (MONTH) 27, (YEAR) by facility's Liaison: Review of Hospital Nurses Note dated 04/26/2018 at 7:14 AM for resident #3 documented in part: Resident had surgery, was sedated most of the day and night, until 2:00 AM, patient became very confused, began pulling off his lines and IV (intravenous tubing). Physicians called and got an order for [REDACTED].>Review of Hospital Nurses Note dated 04/27/2018 at 9:31 AM for resident #3 documented in part: Patient pulling on Foley and IV catheter. Patient reoriented and repositioned. Sitter at bedside. Review of e-mail dated 04/27/2018 at 1:55 PM from facility's Liaison D provided by the Administrator on 07/20/18 documented in part: DON (Director of Nurses) E approved resident #3 for admission. Patient needs a room in front of Nurses station please. Provider Investigation Report: Review of the Provider Investigation Report dated 05/05/2018 for resident #3 documented in part: Incident Category: Injuries of unknown origin. Incident Date: 05/04/2018. Functional Ability: Extensive. Level of supervision: Within eyesight. Independent ambulatory: No. Interviewable: Yes. Description of the Allegation: Patient reported to Certified Nurse Aide (CNA) S and evening nurse Licensed Vocational Nurse (LVN) A I fell off the bed against the wall, a lady helped me get up. Patient was not able to identify person that assisted him. Investigation Summary: On Friday (MONTH) 4, (YEAR) patient calling out for help around 10 PM. CNA R entered room, patient was sitting down in the recliner with his legs covered with blankets. He requested for CNA to place water pitcher on his table. Patient called out once more, CNA S entered room, patient sitting in recliner and requested to be transferred to bed. Patient stated that his leg was hurting and that it could be broken. CNA S reminded resident about his fall at home and he was here for recovery. CNA S and LVN A walked into the room together. Resident #3 stated he had fallen off the bed against the wall and believed his leg was broken. Resident reported to LVN A a lady helped him off the floor. LVN A immediately assessed and called attending physician. Attending physician ordered stat x-ray of right hip. X-ray revealed resident had right dislocated hip. Patient was sent to hospital. Incident Report: Review of Incident Description revised on 06/05/2018 by LVN A for resident #3 documented in part. 5/04/2018 at 10:00 PM. Patient calling out at end of shift (2:00 PM - 10:00 PM), CNAs entered room, patient was sitting in the recliner with his legs covered with blanket. CNA stated resident requested water jug on his table. Patient called out a second time still sitting in recliner and requesting to be put in bed. CNA requested help from another CNA to put the resident in bed. Patient called out a third time. CNA and I walked in to assess for pain. Patient in bed stated he fell off bed against wall and believed leg to be broken. I asked him who helped him off the floor, he stated a lady helped him up but did not know who. Leg elevated, pain noted to right hip. Attending physician notified and ordered stat x-ray of right hip. Patient given pain medication. No injuries observed at time of incident. Predisposing Physiological Factors: Confused and impaired memory. Predisposing Situation Factors: Ambulating without assistance. Other information: Not really sure that he had a fall, there were no witnesses. He states a woman helped him up. Interview with all staff reveals no indication of anyone helping him up. Unknown if a fall really happened. Interview on 07/12/2018 at 6:06 AM, CNA R reported that she had worked on the night shift 10:00 PM - 6:00 AM on 05/04/2018 and was assigned to resident #3. CNA R stated, I went to his room, because he was yelling out for help at approximately 10:15 PM - 10:20 PM. He was sitting in the recliner chair in his room at the start of their shift. The evening CNAs told me that he did not want to go back to bed. He kepy yelling out for help so we went to his rooms several times on that night. CNA S and I put him back to bed. After we put him back to bed, he started to complain of pain to his lower extremeties. I remember that he kept asking to talk to his sister. He kept yelling and LVN A and I went to his room and at that time he said he had fallen down and that I had picked him up. He continued to complain of pain throughout the shift. Telephone interview on 7/16/2018 at 10:12 AM CNA S reported that she had worked on the night shift on 05/04/2018. CNA S stated, At the beginning of the shift I saw resident #3 sitting in the recliner chair in his room. CNA J and CNA I worked on the evening shift reported resident #3 did not want to go to bed because he wanted to call his sister and kept yelling out for help. After report, I went to his room and asked resident #3 what he needed. He appeared to be in excruciating pain and was anxious. He complained of pain to the right leg. I asked LVN A why resident #3 was still sitting in the recliner chair and she said the CNAs had reported to her that he did not want to go back to bed. Resident #3 kept yelling out for help and kept saying that he fell and broke his hip, so I went to report to LVN A. LVN A told me that resident #3 had a fall at home prior to admission and maybe he was thinking of that fall. When LVN A, CNA R and I went to the resident's room, resident #3 pointed at CNA R and said, she picked me up from the floor. That night the resident's pain would get worse with any movement. He was anxious and more restless than usual. He screamed all night. Resident #3 was not his usual self and I reported this to LVN A. LVN A told me that she was going to give resident #3 something for pain and his anxiety. He was in pain, restless, and anxious all night. After the medication was administered he would sleep off and on and continued to have pain to the right leg with any movement. I remember that the area to the right hip was hot to touch. We changed him 3-4 times during the night shift and he had excruciating pain with movement. At the end of the shift I reported to the morning CNAs. Resident #3 was non-weight bearing, but he would get up by himself and would stand by the side of his bed. We reported this to the nurses. He required close supervision, frequent re-direction not to get up without assistance, and required assistance of one person to put him back to bed. Telephone interview on 7/16/2018 at 5:04 AM, LVN A stated, On 5/04/2018 at the end of the evening shift she and former interim ADON RN N were next door and heard resident #3 yelling out and asking to talk to his sister. LVN A stated He continued to yell out and the CNAs went to his room several times to see what he needed. He kept yelling out for help, so I went to the room and he was sitting in the recliner at the end of the evening shift. The resident reported fell and did not know who had picked him up and was complaining of pain to the right hip. LVN A reported that CNA S and CNA R on the 10:00 PM to 6:00 AM shift had put the resident back to bed on that day and reported that he was complaining of pain with movement. I assessed his lower extremities, there was no deformity to the leg, no shortening, touched right hip and no pain, no bruising or redness was noted. I offered something for pain. He said, I fell & hit the wall. I want to speak to my sister. I left the room and reported this to former interim ADON RN N. About 30-40 minutes later he continued to yell out for help and kept saying he fell and broke his hip. I asked the former interim ADON RN N to go with me to check the resident. The ADON RN N said she was calling the former interim DON G and I was going to call the physician to report that the resident reported he had an unwitnessed fall and complaining of pain to the right hip. I called the attending physician and left a message with the answering service. The answering service called and gave an order for [REDACTED]. I called the portable x-ray service that night and placed the order for the x-ray and I was informed that the x-ray would be done in 5 hours. I did not document any of this in my Nurses notes and I did not call the physician back to let her know it was going to take several hours for the x-ray to be done. LVN A reported resident #3 did not use the call light, was confused, and required total care. He could ambulate with one person assist and could wheel self in his wheelchair. I don't recall if he used an abduction pillow. LVN A reported that she had not completed a Post Fall Risk Assessment and Pain assessment when resident #3 had reported the unwitnessed fall. The former interim ADON RN N called me at home and said that I needed to come to the facility on the weekend to complete a Post Fall Risk Assessment and Pain Assessment after the resident had been sent out to the hospital. In a second interview on 07/16/2018 at 4:36 PM, LVN A reported that she had been assigned to resident #3 on the 2:00 PM -10:00 PM shift on 5/04/2018. LVN A stated, I was not aware that the portable x-ray service did not do x-rays after 10:00 PM. I found this out, a couple of days later after resident #3 had been sent to the hospital by the Administrator and the former interim ADON RN N. Review of Progress Note documented Late entry dated 5/04/2018 at 10:30 PM for resident #3 written by LVN A: Patient in bed, no fall witness. Review of Progress Note documented Late entry dated 5/04/2018 at 10:40 PM for resident #3 written by LVN A: Pain Evaluation Completed. Refer to evaluation for details. Patient given prn medication and fell asleep. Review of the Medication Administration Record [REDACTED]. Review of Progress Note documented Late entry dated 5/04/2018 at 11:07 PM for resident #3 written by LVN A: Fall Risk Scale Completed. Refer to evaluation for details. Review of the Medication Administration Record [REDACTED]. Review of Progress Note documented Late entry dated 5/04/2018 at 12:02 PM for resident #3 written by LVN A: [MEDICATION NAME] tablet 5-325 mg give 1 tablet by mouth every 4 hours as needed for pain. Patient complaining of pain to right hip. Review of the Medication Administration Record [REDACTED]. Review of Progress Note documented Late entry dated 5/05/2018 at 12:13 PM for resident #3 written by LVN A: Patient calling out at end of shift, CNA entered room, patient was sitting in the recliner with his legs covered with blanket. CNA stated resident requested water jug on his table. Patient called out a second time still sitting in recliner and requesting to be put in bed. CNA requested help from another CNA to put the resident in bed. Patient called out a third time. CNA and I walked in to assess for pain. Patient in bed stated he fell off bed against wall and believed leg to be broken. I asked him who helped him off the floor, he stated a lady helped him up but did not know who. Leg elevated, pain noted to right hip. Attending physician notified, orders for stat x-ray of right hip. Patient given medication. In an interview on 07/16/2018 at 4:29 PM, LVN L reported that she had worked 05/04/2018 on the night shift. LVN L stated, I remember coming in 15 minutes late on that day. LVN A reported at the change of shift that resident #3 was saying that he fell at the beginning of the night shift. I went to check him, pulled the sheets off and checked his lower extremities. After I assessed him, I went to the Nurses station to get the former interim ADON RN N and both of us went to assess the resident. Resident #3 complained of pain to the right hip. I saw no deformities, and the area to the right hip was warm to touch. I was concerned because he kept saying that he fell and was complaining of pain throughout the shift. In a second interview on 07/17/2018 at 6:14 PM, LVN L stated, When I got here at 10:15 PM, on 5/04/2018 resident #3 was yelling out and was saying that he fell . I went to the room to check on him. He was lying in bed and he kept saying, I fell and broke my hip, and no one is listening to me. LVN L stated, I went to ask LVN A if she knew what had happened and she reported that resident #3 kept saying that he fell and broke his hip. LVN A reported that she had already notified the attending physician and got an order to do a stat x-ray of the right hip. She reported that she had medicated resident #3 with [MEDICATION NAME] for pain at 10:00 PM. LVN L stated, I went to assess resident #3, pulled the sheets off and I did not see any redness. I did not check for range of motion, because he was squirming in bed, moving to the left side and he was very anxious. At approximately 2:00 AM-3:00 AM, I assisted one of the CNAs (Certified Nurse Aide) to repositioned resident #3 in bed using a sheet to move him. He fell asleep for a while and would wake up and kept yelling throughout the night saying that he had a fell . I remember that he would sleep for a while and then would yell out help, help and moaned like if he was in pain. I did not document any of this in the Nurses Progress Notes. LVN L reported that resident was incontinent and did not know if the CNAs had changed him or turn & repositioned him throughout the shift. LVN L stated, The CNAs did not report to me on that day if resident #3 was complaining of pain. I do remember that he wanted to be on his left side when he kept moving in bed. He was trying to put his legs down on the side of the bed. So, we monitored him throughout the night because he was a risk for falls. LVN L reported that at 4:30 AM-5:30 AM, she was passing medications and the CNAs were making their last round. We try to keep an eye on him as much as we can when we are busy. His room was just across from the Nurses station. I also remember that at the end of my shift on 5/05/2018, I gave report to LVN M who worked on the day and evening shift on that weekend and reported to her that resident #3 was yelling all night and kept saying that he fell . In an interview on 7/14/2018 at 2:29 PM, LVN M reported she had worked a double shift on 05/05/2018 starting at 6:00 AM - 10:00 PM on that day. LVN M reported resident #3 was alert and oriented x 3, was chair bound, impulsive, constantly moving in bed and when sitting in the recliner. His room was in front of the Nurses station and was kept within visual range because he was frequently found sitting on the edge of the bed trying to stand up without assistance. He required close supervision and re-direction. LVN M reported that she had worked a double shift on the day and evening on 5/05/2018 and was assigned to resident #3. It was reported at the change of shift by LVN K that resident #3 had sustained an unwitnessed fall. I do not remember if it was reported that the resident was having pain. LVN K on the 10:00 PM to 6:00 AM, reported that the stat x-ray still had not being done. At the beginning of the shift he was in bed. I went to assess him and noted that his right leg had an internal rotation. He did not complain of pain and was very confuse. The CNAs did not report to me that resident #3 was having pain with movement. I went to help CNA Q to try and turn & reposition the resident. He refused to be moved. He did not look like he was having pain. At 1:30 PM, he was complaining of pain 8/10 (in a pain scale of 1-10, 10 being the worst pain), and I medicated him with [MEDICATION NAME]. I don't recall how long after I gave the [MEDICATION NAME] the x-ray results were received and reported to the physician. I remember that I reported to the interim ADON RN N when she got here that resident #3's leg had an inward rotation. She said to call the answering service back and said to wait for the x-ray to be done. LVN M reported she called the ambulance. I remember that the ambulance staff cut his clothes off and put on a gown. I helped them move the resident from the bed to the stretcher using a sheet. I do not recall if the resident was having pain. I remember that resident #3 was sent to the hospital on that day at 4:40 PM by ambulance. His sister was here and went with the resident to the hospital. LVN M reported that they had been trained to immediately report any changes of condition to the physician. If the attending physician does not call back then we can call the medical director. Review of SBAR (Situation, Background, Assessment, Recommendation) Communication Form dated 5/05/2018 at 3:08 PM, for resident #3 documented in part: Situation: Pain to right hip 7/10 (severe pain) numeric pain scale. Stat x-ray of right hip, dislocation of right hip. This started on 5/05/2018. Things that make the condition or symptom worse are: Movement to lower extremities. Request: Transfer to hospital. Review of the Physician order [REDACTED].#3 documented in part: Order Start Date: 04/27/2018. Monitor pain once every shift. 0=no pain; 1-2 least pain; 3-4 mild pain; 5-6 moderate pain; 7-8 severe pain; 9-10 worst pain. Order Start Date: 04/28/2018. Order Start Date: 05/01/2018. [MEDICATION NAME] 500 mg (milligrams) give 2 tablets by mouth two times a day for pain. [MEDICATION NAME] 500 mg give 1 tablet by mouth every 4 hours as needed for pain or fever. Order Start Date: 04/28/2018. [MEDICATION NAME] 500 mg give on tablet by mouth two times a day for pain. Order Start Date: 4/27/2018 [MEDICATION NAME] 5-325 mg give one tablet by mouth every 4 hours as needed for pain. [MEDICATION NAME] HCL ([MEDICATION NAME]) 50 mg give 1 tablet by mouth three times a day for pain. In an interview on 7/16/2018 at 12:08 AM, attending physician for resident #3 reported she gave the order for a stat x-ray of the right hip on 05/04/2018. She stated, If the resident's pain worsen with movement and the resident was not his usual self. I would have expected the nurses to report to me right away if the pain worsen with movement and they could not move him to re-position and provide the needed care, or the resident had a gross deformity to the leg. I would have sent the resident out to the emergency room for x-rays and evaluation. If the resident is in no distress, then the x-ray would not have to be done right away. Second telephone interview on 7/18/2018 at 9:19 PM, attending physician for resident #3 reported that she was not aware that resident #3, was impulsive, not using the abduction pillow and walking without assistance in his room. I saw resident #3 on 5/03/2018 and he was alert and oriented x 3 and was not impulsive. I remember giving an order for [REDACTED]. We had another similar incident with one of my other residents & x-rays not being done within a certain time. Had the nurse called me back, I would had sent the resident to the emergency room for x-rays. The physician reported that she expected for the nurses to report to her if the resident's pain had caused a change in his prior level of function or if the pain continued with pain medication. The doctor said, If resident #3 was no longer standing up & walking after he reported that he fell , on that day, the nurses should have reported this to me right away. Review of the Physician order [REDACTED].#3 documented in part: Stat x-ray to right hip, 2 views. In an interview on 07/16/2018 at 9:34 AM, CNA Q reported that he had worked on 5/05/2018 on the morning shift and was assigned to resident #3. The first time I saw resident #3 on that day was at approximately 6:30 AM, he was lying in bed wearing a t-shirt and shorts. I remember that resident #3 said that he fell so I went to tell the LVN M. LVN M said that the night nurse had already reported that to her and instructed me to leave him in bed. I checked his diaper and repositioned him. He was having a lot of pain when I moved him to I went to report to LVN M right away. That was the only time that I moved him on my shift because it appeared that the bone was sticking out of the side of the right hip. I also reported to LVN M that resident did not eat on that day. He usually ate 100 % of his meals. I remember that CNA R from the night shift reported to me that resident #3 had an unwitnessed fall and had complained of pain to the right hip all night. CNA Q reported that resident needed two persons with transfers and could stand and bear weight on his left leg. He was not using the abduction pillow and he constantly attempted to stand up and walk without assistance since he was admitted to the facility. He would want to go to the closet, or to the cabinets by the television because he wanted to get dressed and go to work. I reported this to the nurses. We had to frequently assist him back to bed because we would find him walking in the room without assistance or stand up by the side of the bed. On the day before the incident, I found him walking without assistance in his room. We were all at the Nurses station because it was the change of shift. He was assisted to sit on the recliner by one of the on-coming CNAs. Telephone interview on 7/16/2018 at 9:40 AM, resident #3's sister reported that she was with her brother at the nursing home (5/05/2018) when he was sent to the hospital. He told me that he had fallen again the day before at 11:00 PM, and that he was in a lot of pain. I remember that he was out of his head in pain and kept yelling. They told me that they had just given him some pain medication and were waiting for the ambulance to come to send him to the hospital. The sister reported that the evening before (5/04/2018) he ate his dinner, was alert, and in good spirits. He was moving around in the room, sitting on the side of the bed and would put himself back in bed. He was not complaining of pain on that day. He just said that his right hip was bothering him a little. I was in his room when the ambulance arrived, on 5/05/2018 and they cut off his t-shirt & shorts. They used extreme caution when moving him. Prior to 5/05/2018, he was not complaining of pain and was walking in therapy with stand by assistance. They did report to me that my brother would frequently attempt to get up without assistance in the beginning when he got to the nursing home so that is why he was moved to the room directly across from the Nurses station. Telephone interview on 07/16/2018 at 9:57 AM, interim ADON RN N, reported that on 5/04/2018 during the evening shift the CNAs had reported to LVN A that they had found resident #3 on the floor. I remember resident #3 kept saying he fell and a lady had picked him up. I don't know who got him up. I checked him and he had no visible injuries. One of the nurses, I don't remember who it was called the physician and got an order for [REDACTED].#3 and she told me to call LVN A and ask her to come to the facility to do the needed assessments. I don't remember if these assessments were done. The former interim DON G said that she did not believed that resident #3 had sustained a fall. RN N reported that they had been trained to promptly assess the resident when they report an unwitnessed and immediately report finding to physician and DON and to complete a Post Fall Risk Assessment and Pain Assessment. RN N reported that x-ray had been done by the portable x-ray service. How long it's going to take to get the x-ray done depends on the time of day that the orders are received. The x-ray company will call you back and give you an ETA (estimated time of arrival). The nurses should have known to report to the physician if the pain worsen with movement, or if it was going to take too long for the portable x-ray service to do the x-ray. In an interview on 07/16/2018 at 1:58 PM, with Interim DON H in the presence of the Administrator stated, When a doctor gives a stat order, stat means right away. The nurses should not have to wait more than an hour for the x-ray to be done and if it's going to take longer than one hour they should notify the physician to get orders to send the resident to the emergency room for evaluation. If for some reas

Based on interview and record reviews, the facility failed to ensure that the resident environment remains as free of accident hazards as is possible and each resident receives adequate supervision and assistance devices to prevent accidents for e (Resident #3) of 8 residents reviewed for neglect. The facility failed to respond timely to a change in condition on 05/04/2018 when Resident #3 alleged that he fell and complained of pain to the right hip. The Licensed staff failed to accurately assess the resident after a fall and consult with the attending physician when it was going to take more than 5 hours for the stat (immediately) x-ray to be done. The x-ray was done 14 hours after receiving the physician's orders [REDACTED]. The resident was transferred to the hospital 5/05/2018 and was admitted to the hospital with [REDACTED]. An Immediate Jeopardy (IJ) was identified on 07/17/2018. The IJ was removed on 07/23/2018, the facility remained out of compliance at actual harm, pattern due to the facility's need to evaluate and monitor their corrective action system. This failure could affect 16 residents that were currently at the facility by placing them at risk of not receiving the necessary supervision to prevent accidents and injury. Findings include: Resident #3 Closed record review of the Admission Record dated 07/10/2018 for resident #3 documented resident was admitted on [DATE]. Review of the History & Physical dated 05/01/2018 for resident #3 documented in part: [AGE] year old male was hospitalized for [REDACTED]. Resident has a history of hypertension, [MEDICAL CONDITION] (HLD), [MEDICAL CONDITION] bladder and decreased hearing. Right lateral thigh incision intact. Pain to right hip is controlled. Awake, very hard of hearing, which limits our conversation. Oriented x 3. Calm & cooperative. He states he does his own straight urethral catherization twice a day at home. Debility. Continue physical therapy and occupational therapy. Review of the Minimum Data Set (MDS) 5 day PPS (Prospective Payment System) assessment dated [DATE] for resident #3 documented in part: Hearing moderately difficulty, clear speech, makes self understood, understands others, BIMS (Brief Interview for Mental Status) 11 (moderately impaired), verbal behavioral symptoms occurred 1 to 3 days, extensive assistance of two persons with bed mobility, transfers, dressing, and toilet use; extensive assistance of one person with personal hygiene and bathing. Not steady when moving from seated to standing position, moving on and off toilet, transfer between bed and chair or wheelchair. Mobility device: wheelchair. Section GG: Dependent for toilet hygiene; Supervision or touching assistance with sit to lying and lying to sitting on side to bed; Partial/moderate assistance with sit to stand, chair/bed-to-chair transfer, toilet transfer; Independent wheel 50 feet with two turns. Occasionally incontinent of bowel & bladder. Received scheduled and prn (as needed) pain medication. Occasionally has pain. Verbal Descriptor Scale moderate. History of fall in the last month. History of falls in the last 2-6 months. Resident had fracture related to fall in the last 6 months. Medications received-Diuretic and Opioid. Resident participated in assessment. Expects to be discharged to the community. Review of the Care Plan initiated on 04/30/18 for resident #3 documented in part: The resident has an ADL (activities of daily living) self-care performance deficit related to Activity intolerance, confusion, impaired balance, limited mobility, pain to right hip. Interventions did not specify how much assistance the resident needed from staff with bathing, bed mobility, dressing, personal hygiene, and toilet use. Review of the Care Plan initiated on 05/11/2018 for resident #3 documented in part: Actual fall 5-05-2018 voiced by resident. Not witnessed. I am at risk for falls related to balance problems, gait problems, history of falls. Interventions documented in part: Become familiar with my daily routine and attempt to anticipate and meet my needs. Evaluate, interview and document my physical condition and cognitive status. Observe environment to identify any potential factors that could contribute to a fall, such as lighting, uneven/slippery floor surfaces, improper footwear, failure to use assistive devices, etc. Remove any potential causes or hazards, if possible. Educate me about safety reminders and what to do if a fall occurs. Provide a safe environment: clutter free; support/assistive devices are available and in good repair, personal items and my call light is within reach, non-glare lighting at night. Record review and interview on 07/18/2018 at 1:46 PM, MDS Nurse Licensed Vocational Nurse (LVN) F reported that the care plan dated 5/11/2018 for resident #3 had been written by the previous interim Director of Nursing (DON) G after the resident #3 had been discharged on [DATE] to the hospital. Interview on 07/18/2018 at 3:36 PM, current interim Director of Nursing (DON) H confirmed DON G had written the care plan dated 5/11/2018 for resident #3 after the resident #3 had been discharged on [DATE] to the hospital. Hospital Paperwork 05/05/2018: Review of Hospital emergency room Report dated 5/05/2018 at 4:56 PM for resident #3 documented in part: As per EMS (emergency medical services) patient had a complete right hip replacement in (MONTH) (YEAR). Patient reports falling yesterday, had x-ray done this morning which showed right hip dislocation. History of present illness: The patient presents following a fall. The occurrence was single episode. The fall was described as fall out of chair. The location where the incident occurred was at nursing home. Location: Right Hip. The character of symptoms is pain. Physical Examination: Profuse warmth, to lower extremity: Right hip, range of motion (limited secondary to possible dislocation), externally rotated. Differential Diagnosis: [REDACTED]. Review of Hospital X-ray report dated 5/05/2018 at 5:31 PM, for resident #3 documented in part: Right hip arthroplasty with superior dislocation of the femoral head and acetabular components. No acute displaced fractures. Review of Hospital Physician Note dated 05/05/2018 at 5:20 PM, for resident #3 documented in part: Procedural sedation. Closed reduction for dislocation of right hip. Review of Hospital Physician Note dated 05/05/2018 at 8:08 PM for resident #3 documented in part: Worsening AMS (altered mental status) and respiratory, increasing work of breathing, suspect worsening decline since arrival as patient was not a baseline initially, will intubate for airway protection/respiratory distress. admitted to inpatient Telemetry Unit. Review of Hospital Orthopedic Consultation Report dated 05/07/2018 for resident #3 documented in part: Two weeks status [REDACTED]. Apparently sustained a fall in nursing home with subsequent hip dislocation. Reduced in ED (emergency department), [MEDICAL CONDITION] following now in ICU (intensive care). Wound looks clean although he likely has fluid collection/hematoma. Hospital clinical information scanned for admission referral to nursing facility for review on (MONTH) 27, (YEAR) by facility's Liaison: Review of Hospital Nurses Note dated 04/26/2018 at 7:14 AM for resident #3 documented in part: Resident had surgery, was sedated most of the day and night, until 2:00 AM, patient became very confused, began pulling off his lines and IV (intravenous tubing). Physicians called and got an order for [REDACTED].>Review of Hospital Nurses Note dated 04/27/2018 at 9:31 AM for resident #3 documented in part: Patient pulling on Foley and IV catheter. Patient reoriented and repositioned. Sitter at bedside. Review of e-mail dated 04/27/2018 at 1:55 PM from facility's Liaison D provided by the Administrator on 07/20/18 documented in part: DON (Director of Nurses) E approved resident #3 for admission. Patient needs a room in front of Nurses station please. Provider Investigation Report: Review of the Provider Investigation Report dated 05/05/2018 for resident #3 documented in part: Incident Category: Injuries of unknown origin. Incident Date: 05/04/2018. Functional Ability: Extensive. Level of supervision: Within eyesight. Independent ambulatory: No. Interviewable: Yes. Description of the Allegation: Patient reported to Certified Nurse Aide (CNA) S and evening nurse Licensed Vocational Nurse (LVN) A I fell off the bed against the wall, a lady helped me get up. Patient was not able to identify person that assisted him. Investigation Summary: On Friday (MONTH) 4, (YEAR) patient calling out for help around 10 PM. CNA R entered room, patient was sitting down in the recliner with his legs covered with blankets. He requested for CNA to place water pitcher on his table. Patient called out once more, CNA S entered room, patient sitting in recliner and requested to be transferred to bed. Patient stated that his leg was hurting and that it could be broken. CNA S reminded resident about his fall at home and he was here for recovery. CNA S and LVN A walked into the room together. Resident #3 stated he had fallen off the bed against the wall and believed his leg was broken. Resident reported to LVN A a lady helped him off the floor. LVN A immediately assessed and called attending physician. Attending physician ordered stat x-ray of right hip. X-ray revealed resident had right dislocated hip. Patient was sent to hospital. Incident Report: Review of Incident Description revised on 06/05/2018 by LVN A for resident #3 documented in part. 5/04/2018 at 10:00 PM. Patient calling out at end of shift (2:00 PM - 10:00 PM), CNAs entered room, patient was sitting in the recliner with his legs covered with blanket. CNA stated resident requested water jug on his table. Patient called out a second time still sitting in recliner and requesting to be put in bed. CNA requested help from another CNA to put the resident in bed. Patient called out a third time. CNA and I walked in to assess for pain. Patient in bed stated he fell off bed against wall and believed leg to be broken. I asked him who helped him off the floor, he stated a lady helped him up but did not know who. Leg elevated, pain noted to right hip. Attending physician notified and ordered stat x-ray of right hip. Patient given pain medication. No injuries observed at time of incident. Predisposing Physiological Factors: Confused and impaired memory. Predisposing Situation Factors: Ambulating without assistance. Other information: Not really sure that he had a fall, there were no witnesses. He states a woman helped him up. Interview with all staff reveals no indication of anyone helping him up. Unknown if a fall really happened. Interview on 07/12/2018 at 6:06 AM, CNA R reported that she had worked on the night shift 10:00 PM - 6:00 AM on 05/04/2018 and was assigned to resident #3. CNA R stated, I went to his room, because he was yelling out for help at approximately 10:15 PM - 10:20 PM. He was sitting in the recliner chair in his room at the start of their shift. The evening CNAs told me that he did not want to go back to bed. He kepy yelling out for help so we went to his rooms several times on that night. CNA S and I put him back to bed. After we put him back to bed, he started to complain of pain to his lower extremeties. I remember that he kept asking to talk to his sister. He kept yelling and LVN A and I went to his room and at that time he said he had fallen down and that I had picked him up. He continued to complain of pain throughout the shift. Telephone interview on 7/16/2018 at 10:12 AM CNA S reported that she had worked on the night shift on 05/04/2018. CNA S stated, At the beginning of the shift I saw resident #3 sitting in the recliner chair in his room. CNA J and CNA I worked on the evening shift reported resident #3 did not want to go to bed because he wanted to call his sister and kept yelling out for help. After report, I went to his room and asked resident #3 what he needed. He appeared to be in excruciating pain and was anxious. He complained of pain to the right leg. I asked LVN A why resident #3 was still sitting in the recliner chair and she said the CNAs had reported to her that he did not want to go back to bed. Resident #3 kept yelling out for help and kept saying that he fell and broke his hip, so I went to report to LVN A. LVN A told me that resident #3 had a fall at home prior to admission and maybe he was thinking of that fall. When LVN A, CNA R and I went to the resident's room, resident #3 pointed at CNA R and said, she picked me up from the floor. That night the resident's pain would get worse with any movement. He was anxious and more restless than usual. He screamed all night. Resident #3 was not his usual self and I reported this to LVN A. LVN A told me that she was going to give resident #3 something for pain and his anxiety. He was in pain, restless, and anxious all night. After the medication was administered he would sleep off and on and continued to have pain to the right leg with any movement. I remember that the area to the right hip was hot to touch. We changed him 3-4 times during the night shift and he had excruciating pain with movement. At the end of the shift I reported to the morning CNAs. Resident #3 was non-weight bearing, but he would get up by himself and would stand by the side of his bed. We reported this to the nurses. He required close supervision, frequent re-direction not to get up without assistance, and required assistance of one person to put him back to bed. Telephone interview on 7/16/2018 at 5:04 AM, LVN A stated, On 5/04/2018 at the end of the evening shift she and former interim ADON RN N were next door and heard resident #3 yelling out and asking to talk to his sister. LVN A stated He continued to yell out and the CNAs went to his room several times to see what he needed. He kept yelling out for help, so I went to the room and he was sitting in the recliner at the end of the evening shift. The resident reported fell and did not know who had picked him up and was complaining of pain to the right hip. LVN A reported that CNA S and CNA R on the 10:00 PM to 6:00 AM shift had put the resident back to bed on that day and reported that he was complaining of pain with movement. I assessed his lower extremities, there was no deformity to the leg, no shortening, touched right hip and no pain, no bruising or redness was noted. I offered something for pain. He said, I fell & hit the wall. I want to speak to my sister. I left the room and reported this to former interim ADON RN N. About 30-40 minutes later he continued to yell out for help and kept saying he fell and broke his hip. I asked the former interim ADON RN N to go with me to check the resident. The ADON RN N said she was calling the former interim DON G and I was going to call the physician to report that the resident reported he had an unwitnessed fall and complaining of pain to the right hip. I called the attending physician and left a message with the answering service. The answering service called and gave an order for [REDACTED]. I called the portable x-ray service that night and placed the order for the x-ray and I was informed that the x-ray would be done in 5 hours. I did not document any of this in my Nurses notes and I did not call the physician back to let her know it was going to take several hours for the x-ray to be done. LVN A reported resident #3 did not use the call light, was confused, and required total care. He could ambulate with one person assist and could wheel self in his wheelchair. I don't recall if he used an abduction pillow. LVN A reported that she had not completed a Post Fall Risk Assessment and Pain assessment when resident #3 had reported the unwitnessed fall. The former interim ADON RN N called me at home and said that I needed to come to the facility on the weekend to complete a Post Fall Risk Assessment and Pain Assessment after the resident had been sent out to the hospital. In a second interview on 07/16/2018 at 4:36 PM, LVN A reported that she had been assigned to resident #3 on the 2:00 PM -10:00 PM shift on 5/04/2018. LVN A stated, I was not aware that the portable x-ray service did not do x-rays after 10:00 PM. I found this out, a couple of days later after resident #3 had been sent to the hospital by the Administrator and the former interim ADON RN N. Review of Progress Note documented Late entry dated 5/04/2018 at 10:30 PM for resident #3 written by LVN A: Patient in bed, no fall witness. Review of Progress Note documented Late entry dated 5/04/2018 at 10:40 PM for resident #3 written by LVN A: Pain Evaluation Completed. Refer to evaluation for details. Patient given prn medication and fell asleep. Review of the Medication Administration Record [REDACTED]. Review of Progress Note documented Late entry dated 5/04/2018 at 11:07 PM for resident #3 written by LVN A: Fall Risk Scale Completed. Refer to evaluation for details. Review of the Medication Administration Record [REDACTED]. Review of Progress Note documented Late entry dated 5/04/2018 at 12:02 PM for resident #3 written by LVN A: [MEDICATION NAME] tablet 5-325 mg give 1 tablet by mouth every 4 hours as needed for pain. Patient complaining of pain to right hip. Review of the Medication Administration Record [REDACTED]. Review of Progress Note documented Late entry dated 5/05/2018 at 12:13 PM for resident #3 written by LVN A: Patient calling out at end of shift, CNA entered room, patient was sitting in the recliner with his legs covered with blanket. CNA stated resident requested water jug on his table. Patient called out a second time still sitting in recliner and requesting to be put in bed. CNA requested help from another CNA to put the resident in bed. Patient called out a third time. CNA and I walked in to assess for pain. Patient in bed stated he fell off bed against wall and believed leg to be broken. I asked him who helped him off the floor, he stated a lady helped him up but did not know who. Leg elevated, pain noted to right hip. Attending physician notified, orders for stat x-ray of right hip. Patient given medication. In an interview on 07/16/2018 at 4:29 PM, LVN L reported that she had worked 05/04/2018 on the night shift. LVN L stated, I remember coming in 15 minutes late on that day. LVN A reported at the change of shift that resident #3 was saying that he fell at the beginning of the night shift. I went to check him, pulled the sheets off and checked his lower extremities. After I assessed him, I went to the Nurses station to get the former interim ADON RN N and both of us went to assess the resident. Resident #3 complained of pain to the right hip. I saw no deformities, and the area to the right hip was warm to touch. I was concerned because he kept saying that he fell and was complaining of pain throughout the shift. In a second interview on 07/17/2018 at 6:14 PM, LVN L stated, When I got here at 10:15 PM, on 5/04/2018 resident #3 was yelling out and was saying that he fell . I went to the room to check on him. He was lying in bed and he kept saying, I fell and broke my hip, and no one is listening to me. LVN L stated, I went to ask LVN A if she knew what had happened and she reported that resident #3 kept saying that he fell and broke his hip. LVN A reported that she had already notified the attending physician and got an order to do a stat x-ray of the right hip. She reported that she had medicated resident #3 with [MEDICATION NAME] for pain at 10:00 PM. LVN L stated, I went to assess resident #3, pulled the sheets off and I did not see any redness. I did not check for range of motion, because he was squirming in bed, moving to the left side and he was very anxious. At approximately 2:00 AM-3:00 AM, I assisted one of the CNAs (Certified Nurse Aide) to repositioned resident #3 in bed using a sheet to move him. He fell asleep for a while and would wake up and kept yelling throughout the night saying that he had a fell . I remember that he would sleep for a while and then would yell out help, help and moaned like if he was in pain. I did not document any of this in the Nurses Progress Notes. LVN L reported that resident was incontinent and did not know if the CNAs had changed him or turn & repositioned him throughout the shift. LVN L stated, The CNAs did not report to me on that day if resident #3 was complaining of pain. I do remember that he wanted to be on his left side when he kept moving in bed. He was trying to put his legs down on the side of the bed. So, we monitored him throughout the night because he was a risk for falls. LVN L reported that at 4:30 AM-5:30 AM, she was passing medications and the CNAs were making their last round. We try to keep an eye on him as much as we can when we are busy. His room was just across from the Nurses station. I also remember that at the end of my shift on 5/05/2018, I gave report to LVN M who worked on the day and evening shift on that weekend and reported to her that resident #3 was yelling all night and kept saying that he fell . In an interview on 7/14/2018 at 2:29 PM, LVN M reported she had worked a double shift on 05/05/2018 starting at 6:00 AM - 10:00 PM on that day. LVN M reported resident #3 was alert and oriented x 3, was chair bound, impulsive, constantly moving in bed and when sitting in the recliner. His room was in front of the Nurses station and was kept within visual range because he was frequently found sitting on the edge of the bed trying to stand up without assistance. He required close supervision and re-direction. LVN M reported that she had worked a double shift on the day and evening on 5/05/2018 and was assigned to resident #3. It was reported at the change of shift by LVN K that resident #3 had sustained an unwitnessed fall. I do not remember if it was reported that the resident was having pain. LVN K on the 10:00 PM to 6:00 AM, reported that the stat x-ray still had not being done. At the beginning of the shift he was in bed. I went to assess him and noted that his right leg had an internal rotation. He did not complain of pain and was very confuse. The CNAs did not report to me that resident #3 was having pain with movement. I went to help CNA Q to try and turn & reposition the resident. He refused to be moved. He did not look like he was having pain. At 1:30 PM, he was complaining of pain 8/10 (in a pain scale of 1-10, 10 being the worst pain), and I medicated him with [MEDICATION NAME]. I don't recall how long after I gave the [MEDICATION NAME] the x-ray results were received and reported to the physician. I remember that I reported to the interim ADON RN N when she got here that resident #3's leg had an inward rotation. She said to call the answering service back and said to wait for the x-ray to be done. LVN M reported she called the ambulance. I remember that the ambulance staff cut his clothes off and put on a gown. I helped them move the resident from the bed to the stretcher using a sheet. I do not recall if the resident was having pain. I remember that resident #3 was sent to the hospital on that day at 4:40 PM by ambulance. His sister was here and went with the resident to the hospital. LVN M reported that they had been trained to immediately report any changes of condition to the physician. If the attending physician does not call back then we can call the medical director. Review of SBAR (Situation, Background, Assessment, Recommendation) Communication Form dated 5/05/2018 at 3:08 PM, for resident #3 documented in part: Situation: Pain to right hip 7/10 (severe pain) numeric pain scale. Stat x-ray of right hip, dislocation of right hip. This started on 5/05/2018. Things that make the condition or symptom worse are: Movement to lower extremities. Request: Transfer to hospital. Review of the Physician order [REDACTED].#3 documented in part: Order Start Date: 04/27/2018. Monitor pain once every shift. 0=no pain; 1-2 least pain; 3-4 mild pain; 5-6 moderate pain; 7-8 severe pain; 9-10 worst pain. Order Start Date: 04/28/2018. Order Start Date: 05/01/2018. [MEDICATION NAME] 500 mg (milligrams) give 2 tablets by mouth two times a day for pain. [MEDICATION NAME] 500 mg give 1 tablet by mouth every 4 hours as needed for pain or fever. Order Start Date: 04/28/2018. [MEDICATION NAME] 500 mg give on tablet by mouth two times a day for pain. Order Start Date: 4/27/2018 [MEDICATION NAME] 5-325 mg give one tablet by mouth every 4 hours as needed for pain. [MEDICATION NAME] HCL ([MEDICATION NAME]) 50 mg give 1 tablet by mouth three times a day for pain. In an interview on 7/16/2018 at 12:08 AM, attending physician for resident #3 reported she gave the order for a stat x-ray of the right hip on 05/04/2018. She stated, If the resident's pain worsen with movement and the resident was not his usual self. I would have expected the nurses to report to me right away if the pain worsen with movement and they could not move him to re-position and provide the needed care, or the resident had a gross deformity to the leg. I would have sent the resident out to the emergency room for x-rays and evaluation. If the resident is in no distress, then the x-ray would not have to be done right away. Second telephone interview on 7/18/2018 at 9:19 PM, attending physician for resident #3 reported that she was not aware that resident #3, was impulsive, not using the abduction pillow and walking without assistance in his room. I saw resident #3 on 5/03/2018 and he was alert and oriented x 3 and was not impulsive. I remember giving an order for [REDACTED]. We had another similar incident with one of my other residents & x-rays not being done within a certain time. Had the nurse called me back, I would had sent the resident to the emergency room for x-rays. The physician reported that she expected for the nurses to report to her if the resident's pain had caused a change in his prior level of function or if the pain continued with pain medication. The doctor said, If resident #3 was no longer standing up & walking after he reported that he fell , on that day, the nurses should have reported this to me right away. Review of the Physician order [REDACTED].#3 documented in part: Stat x-ray to right hip, 2 views. In an interview on 07/16/2018 at 9:34 AM, CNA Q reported that he had worked on 5/05/2018 on the morning shift and was assigned to resident #3. The first time I saw resident #3 on that day was at approximately 6:30 AM, he was lying in bed wearing a t-shirt and shorts. I remember that resident #3 said that he fell so I went to tell the LVN M. LVN M said that the night nurse had already reported that to her and instructed me to leave him in bed. I checked his diaper and repositioned him. He was having a lot of pain when I moved him to I went to report to LVN M right away. That was the only time that I moved him on my shift because it appeared that the bone was sticking out of the side of the right hip. I also reported to LVN M that resident did not eat on that day. He usually ate 100 % of his meals. I remember that CNA R from the night shift reported to me that resident #3 had an unwitnessed fall and had complained of pain to the right hip all night. CNA Q reported that resident needed two persons with transfers and could stand and bear weight on his left leg. He was not using the abduction pillow and he constantly attempted to stand up and walk without assistance since he was admitted to the facility. He would want to go to the closet, or to the cabinets by the television because he wanted to get dressed and go to work. I reported this to the nurses. We had to frequently assist him back to bed because we would find him walking in the room without assistance or stand up by the side of the bed. On the day before the incident, I found him walking without assistance in his room. We were all at the Nurses station because it was the change of shift. He was assisted to sit on the recliner by one of the on-coming CNAs. Telephone interview on 7/16/2018 at 9:40 AM, resident #3's sister reported that she was with her brother at the nursing home (5/05/2018) when he was sent to the hospital. He told me that he had fallen again the day before at 11:00 PM, and that he was in a lot of pain. I remember that he was out of his head in pain and kept yelling. They told me that they had just given him some pain medication and were waiting for the ambulance to come to send him to the hospital. The sister reported that the evening before (5/04/2018) he ate his dinner, was alert, and in good spirits. He was moving around in the room, sitting on the side of the bed and would put himself back in bed. He was not complaining of pain on that day. He just said that his right hip was bothering him a little. I was in his room when the ambulance arrived, on 5/05/2018 and they cut off his t-shirt & shorts. They used extreme caution when moving him. Prior to 5/05/2018, he was not complaining of pain and was walking in therapy with stand by assistance. They did report to me that my brother would frequently attempt to get up without assistance in the beginning when he got to the nursing home so that is why he was moved to the room directly across from the Nurses station. Telephone interview on 07/16/2018 at 9:57 AM, interim ADON RN N, reported that on 5/04/2018 during the evening shift the CNAs had reported to LVN A that they had found resident #3 on the floor. I remember resident #3 kept saying he fell and a lady had picked him up. I don't know who got him up. I checked him and he had no visible injuries. One of the nurses, I don't remember who it was called the physician and got an order for [REDACTED].#3 and she told me to call LVN A and ask her to come to the facility to do the needed assessments. I don't remember if these assessments were done. The former interim DON G said that she did not believed that resident #3 had sustained a fall. RN N reported that they had been trained to promptly assess the resident when they report an unwitnessed and immediately report finding to physician and DON and to complete a Post Fall Risk Assessment and Pain Assessment. RN N reported that x-ray had been done by the portable x-ray service. How long it's going to take to get the x-ray done depends on the time of day that the orders are received. The x-ray company will call you back and give you an ETA (estimated time of arrival). The nurses should have known to report to the physician if the pain worsen with movement, or if it was going to take too long for the portable x-ray service to do the x-ray. In an interview on 07/16/2018 at 1:58 PM, with Interim DON H in the presence of the Administrator stated, When a doctor gives a stat order, stat means right away. The nurses should not have to wait more than an hour for the x-ray to be done and if it's going to take longer than one hour they should notify the physician to get orders to send the resident

Based on interview and record reviews, the facility failed to ensure that residents receive treatment and care in accordance with comprehensive assessment of a resident, the facility must ensure that residents receive treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices for 1 (Resident #3) of 8 residents reviewed for neglect. The facility failed to respond timely to a change in condition on 05/04/2018 when Resident #3 alleged that he fell and complained of pain to the right hip. The Licensed staff failed to accurately assess the resident after a fall and consult with the attending physician when it was going to take more than 5 hours for the stat (immediately) x-ray to be done. The x-ray was done 14 hours after receiving the physician's orders [REDACTED]. The resident was transferred to the hospital 5/05/2018 and was admitted to the hospital with [REDACTED]. An Immediate Jeopardy (IJ) was identified on 07/17/2018. The IJ was removed on 07/23/2018, the facility remained out of compliance at actual harm, pattern due to the facility's need to evaluate and monitor their corrective action system. This failure could affect 16 residents that were currently at the facility by placing them at risk of potential medical complications [REDACTED]. Findings include: Resident #3 Closed record review of the Admission Record dated 07/10/2018 for resident #3 documented resident was admitted on [DATE]. Review of the History & Physical dated 05/01/2018 for resident #3 documented in part: [AGE] year old male was hospitalized for [REDACTED]. Resident has a history of hypertension, [MEDICAL CONDITION] (HLD), [MEDICAL CONDITION] bladder and decreased hearing. Right lateral thigh incision intact. Pain to right hip is controlled. Awake, very hard of hearing, which limits our conversation. Oriented x 3. Calm & cooperative. He states he does his own straight urethral catherization twice a day at home. Debility. Continue physical therapy and occupational therapy. Review of the Minimum Data Set (MDS) 5 day PPS (Prospective Payment System) assessment dated [DATE] for resident #3 documented in part: Hearing moderately difficulty, clear speech, makes self understood, understands others, BIMS (Brief Interview for Mental Status) 11 (moderately impaired), verbal behavioral symptoms occurred 1 to 3 days, extensive assistance of two persons with bed mobility, transfers, dressing, and toilet use; extensive assistance of one person with personal hygiene and bathing. Not steady when moving from seated to standing position, moving on and off toilet, transfer between bed and chair or wheelchair. Mobility device: wheelchair. Section GG: Dependent for toilet hygiene; Supervision or touching assistance with sit to lying and lying to sitting on side to bed; Partial/moderate assistance with sit to stand, chair/bed-to-chair transfer, toilet transfer; Independent wheel 50 feet with two turns. Occasionally incontinent of bowel & bladder. Received scheduled and prn (as needed) pain medication. Occasionally has pain. Verbal Descriptor Scale moderate. History of fall in the last month. History of falls in the last 2-6 months. Resident had fracture related to fall in the last 6 months. Medications received-Diuretic and Opioid. Resident participated in assessment. Expects to be discharged to the community. Review of the Care Plan initiated on 04/30/18 for resident #3 documented in part: The resident has an ADL (activities of daily living) self-care performance deficit related to Activity intolerance, confusion, impaired balance, limited mobility, pain to right hip. Interventions did not specify how much assistance the resident needed from staff with bathing, bed mobility, dressing, personal hygiene, and toilet use. Review of the Care Plan initiated on 05/11/2018 for resident #3 documented in part: Actual fall 5-05-2018 voiced by resident. Not witnessed. I am at risk for falls related to balance problems, gait problems, history of falls. Interventions documented in part: Become familiar with my daily routine and attempt to anticipate and meet my needs. Evaluate, interview and document my physical condition and cognitive status. Observe environment to identify any potential factors that could contribute to a fall, such as lighting, uneven/slippery floor surfaces, improper footwear, failure to use assistive devices, etc. Remove any potential causes or hazards, if possible. Educate me about safety reminders and what to do if a fall occurs. Provide a safe environment: clutter free; support/assistive devices are available and in good repair, personal items and my call light is within reach, non-glare lighting at night. Record review and interview on 07/18/2018 at 1:46 PM, MDS Nurse Licensed Vocational Nurse (LVN) F reported that the care plan dated 5/11/2018 for resident #3 had been written by the previous interim Director of Nursing (DON) G after the resident #3 had been discharged on [DATE] to the hospital. Interview on 07/18/2018 at 3:36 PM, current interim Director of Nursing (DON) H confirmed DON G had written the care plan dated 5/11/2018 for resident #3 after the resident #3 had been discharged on [DATE] to the hospital. Hospital Paperwork 05/05/2018: Review of Hospital emergency room Report dated 5/05/2018 at 4:56 PM for resident #3 documented in part: As per EMS (emergency medical services) patient had a complete right hip replacement in (MONTH) (YEAR). Patient reports falling yesterday, had x-ray done this morning which showed right hip dislocation. History of present illness: The patient presents following a fall. The occurrence was single episode. The fall was described as fall out of chair. The location where the incident occurred was at nursing home. Location: Right Hip. The character of symptoms is pain. Physical Examination: Profuse warmth, to lower extremity: Right hip, range of motion (limited secondary to possible dislocation), externally rotated. Differential Diagnosis: [REDACTED]. Review of Hospital X-ray report dated 5/05/2018 at 5:31 PM, for resident #3 documented in part: Right hip arthroplasty with superior dislocation of the femoral head and acetabular components. No acute displaced fractures. Review of Hospital Physician Note dated 05/05/2018 at 5:20 PM, for resident #3 documented in part: Procedural sedation. Closed reduction for dislocation of right hip. Review of Hospital Physician Note dated 05/05/2018 at 8:08 PM for resident #3 documented in part: Worsening AMS (altered mental status) and respiratory, increasing work of breathing, suspect worsening decline since arrival as patient was not a baseline initially, will intubate for airway protection/respiratory distress. admitted to inpatient Telemetry Unit. Review of Hospital Orthopedic Consultation Report dated 05/07/2018 for resident #3 documented in part: Two weeks status [REDACTED]. Apparently sustained a fall in nursing home with subsequent hip dislocation. Reduced in ED (emergency department), [MEDICAL CONDITION] following now in ICU (intensive care). Wound looks clean although he likely has fluid collection/hematoma. Hospital clinical information scanned for admission referral to nursing facility for review on (MONTH) 27, (YEAR) by facility's Liaison: Review of Hospital Nurses Note dated 04/26/2018 at 7:14 AM for resident #3 documented in part: Resident had surgery, was sedated most of the day and night, until 2:00 AM, patient became very confused, began pulling off his lines and IV (intravenous tubing). Physicians called and got an order for [REDACTED].>Review of Hospital Nurses Note dated 04/27/2018 at 9:31 AM for resident #3 documented in part: Patient pulling on Foley and IV catheter. Patient reoriented and repositioned. Sitter at bedside. Review of e-mail dated 04/27/2018 at 1:55 PM from facility's Liaison D provided by the Administrator on 07/20/18 documented in part: DON (Director of Nurses) E approved resident #3 for admission. Patient needs a room in front of Nurses station please. Provider Investigation Report: Review of the Provider Investigation Report dated 05/05/2018 for resident #3 documented in part: Incident Category: Injuries of unknown origin. Incident Date: 05/04/2018. Functional Ability: Extensive. Level of supervision: Within eyesight. Independent ambulatory: No. Interviewable: Yes. Description of the Allegation: Patient reported to Certified Nurse Aide (CNA) S and evening nurse Licensed Vocational Nurse (LVN) A I fell off the bed against the wall, a lady helped me get up. Patient was not able to identify person that assisted him. Investigation Summary: On Friday (MONTH) 4, (YEAR) patient calling out for help around 10 PM. CNA R entered room, patient was sitting down in the recliner with his legs covered with blankets. He requested for CNA to place water pitcher on his table. Patient called out once more, CNA S entered room, patient sitting in recliner and requested to be transferred to bed. Patient stated that his leg was hurting and that it could be broken. CNA S reminded resident about his fall at home and he was here for recovery. CNA S and LVN A walked into the room together. Resident #3 stated he had fallen off the bed against the wall and believed his leg was broken. Resident reported to LVN A a lady helped him off the floor. LVN A immediately assessed and called attending physician. Attending physician ordered stat x-ray of right hip. X-ray revealed resident had right dislocated hip. Patient was sent to hospital. Incident Report: Review of Incident Description revised on 06/05/2018 by LVN A for resident #3 documented in part. 5/04/2018 at 10:00 PM. Patient calling out at end of shift (2:00 PM - 10:00 PM), CNAs entered room, patient was sitting in the recliner with his legs covered with blanket. CNA stated resident requested water jug on his table. Patient called out a second time still sitting in recliner and requesting to be put in bed. CNA requested help from another CNA to put the resident in bed. Patient called out a third time. CNA and I walked in to assess for pain. Patient in bed stated he fell off bed against wall and believed leg to be broken. I asked him who helped him off the floor, he stated a lady helped him up but did not know who. Leg elevated, pain noted to right hip. Attending physician notified and ordered stat x-ray of right hip. Patient given pain medication. No injuries observed at time of incident. Predisposing Physiological Factors: Confused and impaired memory. Predisposing Situation Factors: Ambulating without assistance. Other information: Not really sure that he had a fall, there were no witnesses. He states a woman helped him up. Interview with all staff reveals no indication of anyone helping him up. Unknown if a fall really happened. Interview on 07/12/2018 at 6:06 AM, CNA R reported that she had worked on the night shift 10:00 PM - 6:00 AM on 05/04/2018 and was assigned to resident #3. CNA R stated, I went to his room, because he was yelling out for help at approximately 10:15 PM - 10:20 PM. He was sitting in the recliner chair in his room at the start of their shift. The evening CNAs told me that he did not want to go back to bed. He kepy yelling out for help so we went to his rooms several times on that night. CNA S and I put him back to bed. After we put him back to bed, he started to complain of pain to his lower extremeties. I remember that he kept asking to talk to his sister. He kept yelling and LVN A and I went to his room and at that time he said he had fallen down and that I had picked him up. He continued to complain of pain throughout the shift. Telephone interview on 7/16/2018 at 10:12 AM CNA S reported that she had worked on the night shift on 05/04/2018. CNA S stated, At the beginning of the shift I saw resident #3 sitting in the recliner chair in his room. CNA J and CNA I worked on the evening shift reported resident #3 did not want to go to bed because he wanted to call his sister and kept yelling out for help. After report, I went to his room and asked resident #3 what he needed. He appeared to be in excruciating pain and was anxious. He complained of pain to the right leg. I asked LVN A why resident #3 was still sitting in the recliner chair and she said the CNAs had reported to her that he did not want to go back to bed. Resident #3 kept yelling out for help and kept saying that he fell and broke his hip, so I went to report to LVN A. LVN A told me that resident #3 had a fall at home prior to admission and maybe he was thinking of that fall. When LVN A, CNA R and I went to the resident's room, resident #3 pointed at CNA R and said, she picked me up from the floor. That night the resident's pain would get worse with any movement. He was anxious and more restless than usual. He screamed all night. Resident #3 was not his usual self and I reported this to LVN A. LVN A told me that she was going to give resident #3 something for pain and his anxiety. He was in pain, restless, and anxious all night. After the medication was administered he would sleep off and on and continued to have pain to the right leg with any movement. I remember that the area to the right hip was hot to touch. We changed him 3-4 times during the night shift and he had excruciating pain with movement. At the end of the shift I reported to the morning CNAs. Resident #3 was non-weight bearing, but he would get up by himself and would stand by the side of his bed. We reported this to the nurses. He required close supervision, frequent re-direction not to get up without assistance, and required assistance of one person to put him back to bed. Telephone interview on 7/16/2018 at 5:04 AM, LVN A stated, On 5/04/2018 at the end of the evening shift she and former interim ADON RN N were next door and heard resident #3 yelling out and asking to talk to his sister. LVN A stated He continued to yell out and the CNAs went to his room several times to see what he needed. He kept yelling out for help, so I went to the room and he was sitting in the recliner at the end of the evening shift. The resident reported fell and did not know who had picked him up and was complaining of pain to the right hip. LVN A reported that CNA S and CNA R on the 10:00 PM to 6:00 AM shift had put the resident back to bed on that day and reported that he was complaining of pain with movement. I assessed his lower extremities, there was no deformity to the leg, no shortening, touched right hip and no pain, no bruising or redness was noted. I offered something for pain. He said, I fell & hit the wall. I want to speak to my sister. I left the room and reported this to former interim ADON RN N. About 30-40 minutes later he continued to yell out for help and kept saying he fell and broke his hip. I asked the former interim ADON RN N to go with me to check the resident. The ADON RN N said she was calling the former interim DON G and I was going to call the physician to report that the resident reported he had an unwitnessed fall and complaining of pain to the right hip. I called the attending physician and left a message with the answering service. The answering service called and gave an order for [REDACTED]. I called the portable x-ray service that night and placed the order for the x-ray and I was informed that the x-ray would be done in 5 hours. I did not document any of this in my Nurses notes and I did not call the physician back to let her know it was going to take several hours for the x-ray to be done. LVN A reported resident #3 did not use the call light, was confused, and required total care. He could ambulate with one person assist and could wheel self in his wheelchair. I don't recall if he used an abduction pillow. LVN A reported that she had not completed a Post Fall Risk Assessment and Pain assessment when resident #3 had reported the unwitnessed fall. The former interim ADON RN N called me at home and said that I needed to come to the facility on the weekend to complete a Post Fall Risk Assessment and Pain Assessment after the resident had been sent out to the hospital. In a second interview on 07/16/2018 at 4:36 PM, LVN A reported that she had been assigned to resident #3 on the 2:00 PM -10:00 PM shift on 5/04/2018. LVN A stated, I was not aware that the portable x-ray service did not do x-rays after 10:00 PM. I found this out, a couple of days later after resident #3 had been sent to the hospital by the Administrator and the former interim ADON RN N. Review of Progress Note documented Late entry dated 5/04/2018 at 10:30 PM for resident #3 written by LVN A: Patient in bed, no fall witness. Review of Progress Note documented Late entry dated 5/04/2018 at 10:40 PM for resident #3 written by LVN A: Pain Evaluation Completed. Refer to evaluation for details. Patient given prn medication and fell asleep. Review of the Medication Administration Record [REDACTED]. Review of Progress Note documented Late entry dated 5/04/2018 at 11:07 PM for resident #3 written by LVN A: Fall Risk Scale Completed. Refer to evaluation for details. Review of the Medication Administration Record [REDACTED]. Review of Progress Note documented Late entry dated 5/04/2018 at 12:02 PM for resident #3 written by LVN A: [MEDICATION NAME] tablet 5-325 mg give 1 tablet by mouth every 4 hours as needed for pain. Patient complaining of pain to right hip. Review of the Medication Administration Record [REDACTED]. Review of Progress Note documented Late entry dated 5/05/2018 at 12:13 PM for resident #3 written by LVN A: Patient calling out at end of shift, CNA entered room, patient was sitting in the recliner with his legs covered with blanket. CNA stated resident requested water jug on his table. Patient called out a second time still sitting in recliner and requesting to be put in bed. CNA requested help from another CNA to put the resident in bed. Patient called out a third time. CNA and I walked in to assess for pain. Patient in bed stated he fell off bed against wall and believed leg to be broken. I asked him who helped him off the floor, he stated a lady helped him up but did not know who. Leg elevated, pain noted to right hip. Attending physician notified, orders for stat x-ray of right hip. Patient given medication. In an interview on 07/16/2018 at 4:29 PM, LVN L reported that she had worked 05/04/2018 on the night shift. LVN L stated, I remember coming in 15 minutes late on that day. LVN A reported at the change of shift that resident #3 was saying that he fell at the beginning of the night shift. I went to check him, pulled the sheets off and checked his lower extremities. After I assessed him, I went to the Nurses station to get the former interim ADON RN N and both of us went to assess the resident. Resident #3 complained of pain to the right hip. I saw no deformities, and the area to the right hip was warm to touch. I was concerned because he kept saying that he fell and was complaining of pain throughout the shift. In a second interview on 07/17/2018 at 6:14 PM, LVN L stated, When I got here at 10:15 PM, on 5/04/2018 resident #3 was yelling out and was saying that he fell . I went to the room to check on him. He was lying in bed and he kept saying, I fell and broke my hip, and no one is listening to me. LVN L stated, I went to ask LVN A if she knew what had happened and she reported that resident #3 kept saying that he fell and broke his hip. LVN A reported that she had already notified the attending physician and got an order to do a stat x-ray of the right hip. She reported that she had medicated resident #3 with [MEDICATION NAME] for pain at 10:00 PM. LVN L stated, I went to assess resident #3, pulled the sheets off and I did not see any redness. I did not check for range of motion, because he was squirming in bed, moving to the left side and he was very anxious. At approximately 2:00 AM-3:00 AM, I assisted one of the CNAs (Certified Nurse Aide) to repositioned resident #3 in bed using a sheet to move him. He fell asleep for a while and would wake up and kept yelling throughout the night saying that he had a fell . I remember that he would sleep for a while and then would yell out help, help and moaned like if he was in pain. I did not document any of this in the Nurses Progress Notes. LVN L reported that resident was incontinent and did not know if the CNAs had changed him or turn & repositioned him throughout the shift. LVN L stated, The CNAs did not report to me on that day if resident #3 was complaining of pain. I do remember that he wanted to be on his left side when he kept moving in bed. He was trying to put his legs down on the side of the bed. So, we monitored him throughout the night because he was a risk for falls. LVN L reported that at 4:30 AM-5:30 AM, she was passing medications and the CNAs were making their last round. We try to keep an eye on him as much as we can when we are busy. His room was just across from the Nurses station. I also remember that at the end of my shift on 5/05/2018, I gave report to LVN M who worked on the day and evening shift on that weekend and reported to her that resident #3 was yelling all night and kept saying that he fell . In an interview on 7/14/2018 at 2:29 PM, LVN M reported she had worked a double shift on 05/05/2018 starting at 6:00 AM - 10:00 PM on that day. LVN M reported resident #3 was alert and oriented x 3, was chair bound, impulsive, constantly moving in bed and when sitting in the recliner. His room was in front of the Nurses station and was kept within visual range because he was frequently found sitting on the edge of the bed trying to stand up without assistance. He required close supervision and re-direction. LVN M reported that she had worked a double shift on the day and evening on 5/05/2018 and was assigned to resident #3. It was reported at the change of shift by LVN K that resident #3 had sustained an unwitnessed fall. I do not remember if it was reported that the resident was having pain. LVN K on the 10:00 PM to 6:00 AM, reported that the stat x-ray still had not being done. At the beginning of the shift he was in bed. I went to assess him and noted that his right leg had an internal rotation. He did not complain of pain and was very confuse. The CNAs did not report to me that resident #3 was having pain with movement. I went to help CNA Q to try and turn & reposition the resident. He refused to be moved. He did not look like he was having pain. At 1:30 PM, he was complaining of pain 8/10 (in a pain scale of 1-10, 10 being the worst pain), and I medicated him with [MEDICATION NAME]. I don't recall how long after I gave the [MEDICATION NAME] the x-ray results were received and reported to the physician. I remember that I reported to the interim ADON RN N when she got here that resident #3's leg had an inward rotation. She said to call the answering service back and said to wait for the x-ray to be done. LVN M reported she called the ambulance. I remember that the ambulance staff cut his clothes off and put on a gown. I helped them move the resident from the bed to the stretcher using a sheet. I do not recall if the resident was having pain. I remember that resident #3 was sent to the hospital on that day at 4:40 PM by ambulance. His sister was here and went with the resident to the hospital. LVN M reported that they had been trained to immediately report any changes of condition to the physician. If the attending physician does not call back then we can call the medical director. Review of SBAR (Situation, Background, Assessment, Recommendation) Communication Form dated 5/05/2018 at 3:08 PM, for resident #3 documented in part: Situation: Pain to right hip 7/10 (severe pain) numeric pain scale. Stat x-ray of right hip, dislocation of right hip. This started on 5/05/2018. Things that make the condition or symptom worse are: Movement to lower extremities. Request: Transfer to hospital. Review of the Physician order [REDACTED].#3 documented in part: Order Start Date: 04/27/2018. Monitor pain once every shift. 0=no pain; 1-2 least pain; 3-4 mild pain; 5-6 moderate pain; 7-8 severe pain; 9-10 worst pain. Order Start Date: 04/28/2018. Order Start Date: 05/01/2018. [MEDICATION NAME] 500 mg (milligrams) give 2 tablets by mouth two times a day for pain. [MEDICATION NAME] 500 mg give 1 tablet by mouth every 4 hours as needed for pain or fever. Order Start Date: 04/28/2018. [MEDICATION NAME] 500 mg give on tablet by mouth two times a day for pain. Order Start Date: 4/27/2018 [MEDICATION NAME] 5-325 mg give one tablet by mouth every 4 hours as needed for pain. [MEDICATION NAME] HCL ([MEDICATION NAME]) 50 mg give 1 tablet by mouth three times a day for pain. In an interview on 7/16/2018 at 12:08 AM, attending physician for resident #3 reported she gave the order for a stat x-ray of the right hip on 05/04/2018. She stated, If the resident's pain worsen with movement and the resident was not his usual self. I would have expected the nurses to report to me right away if the pain worsen with movement and they could not move him to re-position and provide the needed care, or the resident had a gross deformity to the leg. I would have sent the resident out to the emergency room for x-rays and evaluation. If the resident is in no distress, then the x-ray would not have to be done right away. Second telephone interview on 7/18/2018 at 9:19 PM, attending physician for resident #3 reported that she was not aware that resident #3, was impulsive, not using the abduction pillow and walking without assistance in his room. I saw resident #3 on 5/03/2018 and he was alert and oriented x 3 and was not impulsive. I remember giving an order for [REDACTED]. We had another similar incident with one of my other residents & x-rays not being done within a certain time. Had the nurse called me back, I would had sent the resident to the emergency room for x-rays. The physician reported that she expected for the nurses to report to her if the resident's pain had caused a change in his prior level of function or if the pain continued with pain medication. The doctor said, If resident #3 was no longer standing up & walking after he reported that he fell , on that day, the nurses should have reported this to me right away. Review of the Physician order [REDACTED].#3 documented in part: Stat x-ray to right hip, 2 views. In an interview on 07/16/2018 at 9:34 AM, CNA Q reported that he had worked on 5/05/2018 on the morning shift and was assigned to resident #3. The first time I saw resident #3 on that day was at approximately 6:30 AM, he was lying in bed wearing a t-shirt and shorts. I remember that resident #3 said that he fell so I went to tell the LVN M. LVN M said that the night nurse had already reported that to her and instructed me to leave him in bed. I checked his diaper and repositioned him. He was having a lot of pain when I moved him to I went to report to LVN M right away. That was the only time that I moved him on my shift because it appeared that the bone was sticking out of the side of the right hip. I also reported to LVN M that resident did not eat on that day. He usually ate 100 % of his meals. I remember that CNA R from the night shift reported to me that resident #3 had an unwitnessed fall and had complained of pain to the right hip all night. CNA Q reported that resident needed two persons with transfers and could stand and bear weight on his left leg. He was not using the abduction pillow and he constantly attempted to stand up and walk without assistance since he was admitted to the facility. He would want to go to the closet, or to the cabinets by the television because he wanted to get dressed and go to work. I reported this to the nurses. We had to frequently assist him back to bed because we would find him walking in the room without assistance or stand up by the side of the bed. On the day before the incident, I found him walking without assistance in his room. We were all at the Nurses station because it was the change of shift. He was assisted to sit on the recliner by one of the on-coming CNAs. Telephone interview on 7/16/2018 at 9:40 AM, resident #3's sister reported that she was with her brother at the nursing home (5/05/2018) when he was sent to the hospital. He told me that he had fallen again the day before at 11:00 PM, and that he was in a lot of pain. I remember that he was out of his head in pain and kept yelling. They told me that they had just given him some pain medication and were waiting for the ambulance to come to send him to the hospital. The sister reported that the evening before (5/04/2018) he ate his dinner, was alert, and in good spirits. He was moving around in the room, sitting on the side of the bed and would put himself back in bed. He was not complaining of pain on that day. He just said that his right hip was bothering him a little. I was in his room when the ambulance arrived, on 5/05/2018 and they cut off his t-shirt & shorts. They used extreme caution when moving him. Prior to 5/05/2018, he was not complaining of pain and was walking in therapy with stand by assistance. They did report to me that my brother would frequently attempt to get up without assistance in the beginning when he got to the nursing home so that is why he was moved to the room directly across from the Nurses station. Telephone interview on 07/16/2018 at 9:57 AM, interim ADON RN N, reported that on 5/04/2018 during the evening shift the CNAs had reported to LVN A that they had found resident #3 on the floor. I remember resident #3 kept saying he fell and a lady had picked him up. I don't know who got him up. I checked him and he had no visible injuries. One of the nurses, I don't remember who it was called the physician and got an order for [REDACTED].#3 and she told me to call LVN A and ask her to come to the facility to do the needed assessments. I don't remember if these assessments were done. The former interim DON G said that she did not believed that resident #3 had sustained a fall. RN N reported that they had been trained to promptly assess the resident when they report an unwitnessed and immediately report finding to physician and DON and to complete a Post Fall Risk Assessment and Pain Assessment. RN N reported that x-ray had been done by the portable x-ray service. How long it's going to take to get the x-ray done depends on the time of day that the orders are received. The x-ray company will call you back and give you an ETA (estimated time of arrival). The nurses should have known to report to the physician if the pain worsen with movement, or if it was going to take too long for the portable x-ray service to do the x-ray. In an interview on 07/16/2018 at 1:58 PM, with Interim DON H in the presence of the Administrator stated, When a doctor gives a stat order, stat means right away. The nurses should not have to wait more than an hour for the x-ray to be done an