Every finding on record at Julia Manor Nursing and Rehabilitation Center

Based on record reviews, review of facility policy and procedures, and interviews the facility failed to ensure residents were free from avoidable accidents. This was true for 2 of 3 sampled residents (Residents #10 and #14). This failure resulted in harm to Resident #10. The facility implemented a plan of correction with a compliance date of 3/23/2026.The findings include:1.Review done on 4/28/26 at 11:37 PM of the annual Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #10 was cognitively impaired and had severe vision impairment. The MDS assessment also indicated Resident #10 was dependent with eating, oral hygiene, toileting hygiene, showering/bathing, upper and lower body dressing, and personal hygiene. The MDS assessment further indicated Resident #10 was dependent with rolling left and right while in bed.Review done on 4/28/26 at 11:45 PM of the care plan initiated on 4/21/25 indicated Resident #10 had a self-care performance deficit related to mild cognitive impairment, impaired visual acuity/blindness of the right eye, pain/neuropathy, and fractures of the left foot, as evidenced by the need for assistance with self-care Activities of Daily Living (ADL)s and mobility tasks. Interventions included transfers via Hoyer lift with two-person assistance, bed bath only for safety, toileting/incontinent care with one-person assistance, and bed mobility with one-person assistance.Review done on 4/28/26 at 11:50 PM of the progress note dated 3/21/26 at 1:45 PM by Staff Nurse #15 indicated, GNA called this nurse said Resident #10 rolled out of bed, upon entering room found Resident #10 on the floor laying on the left side. Resident #10 had large amount of blood and clots coming from the right side of the scalp. Pressure dressing applied. Resident #10 is complaining of left shoulder pain. Instructed staff to keep Resident #10 on the floor, MD#20 called x2 message left to call facility and 911 called.Review done on 4/28/26 at 11:50 PM of the progress note dated 3/21/26 at 6:40 PM by Staff Nurse #30 indicated Resident #10 returned from the hospital by ambulance on a stretcher and was diagnosed with a closed displaced fracture of the right clavicle due to fall. The note also indicated Resident #10 had a 1 cm x 3 cm laceration with three staples intact.Review done on 4/28/26 at 11:50 PM of the progress note dated 3/21/26 at 8:50 PM by Staff Nurse #9 indicated a skin assessment was completed due to an unwitnessed fall. The note indicated the following was found: 1 x 3 cm laceration with 3 staples intact. No drainage or odor noted. Surrounding skin is intact.Review done on 4/27/26 at 3:05 PM of the facility-reported incident report, including a statement written by the DON on 3/21/26, indicated Staff Nurse #25 notified the DON at 1:30 PM that Resident #10 fell and was going to the ER. Staff Nurse #25 stated GNA #29 was in the room with Resident #10 and went out of the room to get a towel. GNA #29 did not put the bed/floor mat back against Resident #10's bed and did not put the bed in the lowest position. Staff Nurse #15 indicated GNA #29 reported they left the room without the fall intervention in place. The DON's statement further indicated GNA #29 stated, I feel terrible. I went in to change Resident #10 and I moved the floor mat and raised the bed. I realized Resident #10's sheet was wet so I went out of the room because the linen cart was right outside the room and Resident #10 fell that quick. I know I shouldn't have done that and I feel terrible about it. When asked if GNA #29 lowered the bed before stepping away, GNA #29 responded, Yes but not all the way.Review done on 4/27/26 at 3:05 PM of ED provider notes dated 3/21/26 indicated Resident #10 had a fall after rolling out of bed, hit the head, and had a scalp laceration. The ED notes indicated no loss of consciousness, right shoulder pain, a 1 cm crescent-type laceration to the right side of the scalp with large amounts of blood in the hair, a mildly displaced distal clavicle fracture, and probably a minimally displaced right mid-rib fracture. During interview on 4/28/26 at 10:52 AM, Staff Nurse #9 indicated Resident #10 was alert to self only, blind in one eye, hard of hearing, required total assistance with activities of daily living, was not ambulatory, and was incontinent of bowel and bladder. Staff Nurse #9 confirmed Resident #10 required incontinence care to manage toileting. Staff Nurse #9 stated Resident #10 had a history of falls, had a bed alarm, and had fall mats on both sides of the bed. Staff Nurse #9 stated that, to their knowledge, GNA #29 was changing Resident #10 while Resident #10 was in bed, had the bed raised, left the room, and upon return, Resident #10 was on the floor.During interview on 4/28/26 at 10:52 AM, Staff Nurse #9 further indicated that upon entry to the room, Resident #10 was observed on the floor lying on the left side in a lateral position. Staff Nurse #9 indicated the floor mat was moved and Resident #10 was lying on the floor. Staff Nurse #9 stated Resident #10 was bleeding from the head and yelling loudly, saying Resident #10 was in pain. Staff Nurse #9 stated Resident #10 reported left shoulder pain. Staff Nurse #9 stated they held gauze to Resident #10's head and applied pressure until EMS arrived and transferred Resident #10 to the hospital.During interview on 4/28/26 at 12:50 PM, GNA #29 indicated Resident #10 was hard of hearing and blind, required total care, and was incontinent of bowel and bladder. GNA #29 indicated that on the day of the incident, after lunch, around 1:30 PM, they entered Resident #10's room to provide care. GNA #29 stated Resident #10 was in bed with the head of the bed slightly raised, did not have a roommate, and no one else was in the room. GNA #29 stated Resident #10 had fall mats/mattresses on the floor on either side of the bed.During interview on 4/28/26 at 12:50 PM, GNA #29 stated they moved the fall floor mat on Resident #10's left side of the bed, raised the bed to an up position, lowered the head of the bed, and pulled the top sheets to the foot of the bed to check whether Resident #10 required incontinence care. GNA #29 stated Resident #10's brief was wet and the bottom sheet was also wet. GNA #29 indicated that after noticing the entire bed was wet, they left Resident #10 in bed and left the room to get linen/sheets, which were outside the room. GNA #29 indicated they walked out of the room, and upon return, Resident #10 had rolled out of bed and was on the floor.During interview on 4/28/26 at 12:50 PM, GNA #29 confirmed the floor mat to the left side of the bed was not replaced and the bed was not lowered to the lowest position when they stepped out of the room. GNA #29 confirmed Resident #10 was on the floor on the left side of the bed. GNA #29 stated that when they left the room, Resident #10 was positioned supine in the middle of the bed and was not moving. GNA #29 stated that prior to leaving the room, Resident #10 did not show any signs of trying to get out of bed. GNA #29 stated, Resident #10 was perfectly still and I was gone two seconds and come back and Resident #10 was on the floor.During interview on 4/29/26 at 12:19 PM, the Director of Nursing (DON) indicated that GNA #29 was providing incontinence care to Resident #10 and had raised the bed to waist level and moved the mattress and fall mat. The DON indicated that when Resident #10 was turned to the left side, staff realized clean linen was needed and stepped out of the room to retrieve it from the linen cart located immediately outside the room. The DON indicated that during that time, Resident #10 fell from the bed. The DON confirmed that the bed was not lowered completely to the floor and that the fall mat was not properly in place at the time staff left the room. The DON indicated that Resident #10 had a history of falls, was very restless, and required frequent supervision, and could turn from side to side independently in bed. The DON indicated that the aide was not suspended but was educated and allowed to continue working. The DON further indicated that the facility substantiated neglect, stating that fall interventions were not in place prior to leaving the resident unattended, ensuring the bed was in the lowest position, and ensuring the floor mat was in place. The DON indicated that if the bed had been in the lowest position and fall interventions were in place, the incident would likely not have occurred.During interview on 4/29/26 at 1:25 PM, Staff Nurse #26 indicated that Resident #10 was found on the floor wedged between the bed and dresser with active bleeding from the head. Staff Nurse #26 indicated that a large amount of blood was observed and that Resident #10 was lying on the stomach with partial positioning on the left shoulder. Staff Nurse #26 indicated that Resident #10 appeared restless, was attempting to move, and verbalized distress, stating, help, help, I hit my head.Staff Nurse #26 indicated that Resident #10 was a very fast-moving resident, frequently restless, and known to move quickly in bed. Staff Nurse #26 indicated that Resident #10 required close supervision and should not be left unattended, stating, you cannot leave him for a second. Staff Nurse #26 further indicated that lowering the bed completely to the floor and ensuring the floor mat was in place to prevent injury. Staff Nurse #26 confirmed that the bed was not lowered to the floor and that the fall mat was away from the bed at the time of the fall and upon initial observation of Resident #10 on the floor.During interview on 4/29/26 at 2:23 PM, the Administrator indicated that GNA #29 stepped out of the room briefly and that Resident #10 fell from the bed during that time. The Administrator indicated that Resident #10 was known to move quickly and that the incident occurred within a short period of time after staff left the room.During interview on 4/30/26 at 4:51 PM, Medical Doctor #20 indicated that Resident #10 was legally blind, hard of hearing, and had advanced dementia. MD #20 indicated that Resident #10 had a history of decline MD #20 indicated that following the fall, Resident #10 sustained a clavicle fracture and head injury and was transferred to the hospital. MD #20 indicated that Resident #10 was already declining prior to the fall and was receiving hospice-level care upon readmission to the facility, and that the resident's overall condition was poor prior to the incident. 2. Review conducted on 4/28/26 at 12:11 p.m. of the facility's policy and procedure titled Mechanical Lifts: General Guidelines, dated 5/3/23, indicated under bullet number 3.K to perform a safety check prior to lifting, including examining all hooks and fasteners to ensure they are secure and will not unhook during use. The policy further indicated to double-check the position and stability of straps and other equipment prior to lifting and to ensure that clips, latches, and bars are securely fastened and structurally sound. Under bullet number 3.L, the policy indicated to lift the resident and perform a safety check again as described above.Resident #14 was admitted to the facility on [DATE] with diagnoses including hemiplegia affecting the right dominant side. Review conducted on 4/27/26 at 8:07 p.m. of the Annual Minimum Data Set (MDS) assessment dated [DATE] indicated that Resident #14 was cognitively intact. The MDS assessment included a pain interview, which indicated the presence of pain occurring almost constantly, which frequently made it difficult to sleep and occasionally limited daily activities. The pain intensity was documented as 7 out of 10 during the five days prior to the assessment.Review conducted on 4/2/26 at 8:19pm of the care plan initiated on 6/11/21 indicated that Resident #14 had a self-care performance deficit related to history of CVA with hemiplegia, cognitive impairment, arthritis evidenced by need for assistance with dressing, toileting, personal hygiene and bathing with interventions to include but not limited to Transfers via Hoyer lift and 2 assist.Review conducted on 4/27/26 at 8:22 p.m. of progress notes dated 12/23/25 at 5:48 p.m., written by Staff Nurse #9, indicated that the resident experienced a witnessed fall during a transfer from the wheelchair to the bed at approximately 4:35 p.m. Upon entering the room, the nurse observed the resident partially in the wheelchair and lying on the floor with their back on the ground. The resident stated that they had pain but were unable to specify the location. The physician was notified, and the resident was sent to the hospital for further evaluation. The resident remained on the floor until Emergency Medical Services (EMS) arrived.Review conducted on 4/27/26 at 8:24 p.m. of progress notes dated 12/23/25 at 11:55 p.m., written by Staff Nurse #10, indicated that Resident #14 returned to the facility following hospital evaluation. A CT scan of the cervical spine, head, and pelvis was completed, with results negative for fracture or dislocation. There were no reports of pain at that time.Review conducted on 4/27/26 at 1:32 p.m. of the Facility Reported Incident (FRI) indicated that Resident #14 fell from a Hoyer lift while being transferred from the wheelchair to the bed. The FRI indicated that Resident #14 complained of back pain following the fall and was sent to the emergency room for evaluation.Review conducted on 4/27/26 at 1:43 p.m. of the CT scan of the pelvis dated 12/23/25 indicated that staff were attempting to transfer Resident #14 using a Hoyer lift when the resident slipped out of the transfer device and was lowered to the ground. Resident #14 reported tailbone pain. The impression indicated no definite fracture or dislocation.Review conducted on 4/27/26 at 1:48 p.m. of the emergency department (ED) provider notes dated 12/23/25 indicated that Resident #14 reported generalized body pain following a fall, which was not present prior to the incident.Review conducted on 4/27/26 at 2:01 p.m. of a written statement by GNA #7 indicated that the lift was raised while a sling hook was not secured, causing the resident to begin leaning.Review conducted on 4/27/26 at 2:06 p.m. of a written statement by GNA #8 indicated that the lift was initiated under the assumption that all sling hooks were secured.Review conducted on 4/27/26 at 8:31 p.m. of the Medication Administration Record (MAR) for the period of 12/01/25 through 12/31/25 indicated no documented reports of pain prior to the incident. Review conducted on 4/27/26 at 8:32 p.m. of the MAR for January 2026 indicated documented reports of pain following the incident. During an interview on 4/17/26 at 12:47 p.m., Resident #14 indicated that staff transferred them using a mechanical lift. Resident #14 stated that they had fallen one time from the lift. Resident #14 stated that two staff members were transferring them from the wheelchair to the bed when the mechanical lift fell on them. Resident #14 stated that the wheelchair moved back and they fell down. Resident #14 stated that they were sent to the hospital. Resident #14 stated that they still had pain and indicated that, at present, they had pain, pointing to their head. Resident #14 indicated that, on a scale of 0 to 10, their pain level was 7 out of 10 and stated that they had body aches all the time.During an interview on 4/27/26 at 12:53 p.m., GNA #3 indicated that Resident #14 used a mechanical lift for transfers. At the time of observation, Resident #14 was in bed and had not been transferred out of bed that day. GNA #3 indicated that Resident #14 would be transferred if requested. GNA #3 indicated that Resident #14 was able to make their needs known, knew staff names, and was able to communicate their needs. GNA #3 indicated that Resident #14 had a history of stroke with right-sided weakness. GNA #3 indicated that Resident #14 had not complained of pain. When asked if Resident #14 had experienced a fall, GNA #3 indicated awareness of an incident involving a mechanical lift in which Resident #14 fell and indicated that they were not present at the time of the incident.During an interview on 4/28/26 at 10:43 a.m., Staff Nurse #9 indicated that Resident #14 was able to make their needs known and was alert and oriented times four, with possible difficulty related to time. Staff Nurse #9 indicated that Resident #14 was able to report pain to staff. Staff Nurse #9 indicated that on 12/23/25, they were informed that Resident #14 was on the floor. Upon entering the room, Staff Nurse #9 observed Resident #14 lying supine on the floor, with the wheelchair tilted backward. Staff Nurse #9 indicated that, when asked what had occurred, both GNA #6 and GNA #7 stated that they did not know what had happened and reported that the lift had just come down. Staff Nurse #9 indicated that GNA #6 and GNA #7 also stated that they had lowered Resident #14 to the floor. Staff Nurse #9 indicated that, upon assessment, Resident #14 denied hitting their head but reported pain and was unable to identify the location. Staff Nurse #9 indicated that Resident #14 was receiving aspirin. Staff Nurse #9 indicated that a pillow was placed under Resident #14's head and that there were no visible signs of injury. Staff Nurse #9 indicated that, due to Resident #14 being on aspirin and reporting pain, the resident was transferred to the hospital for further evaluation. Staff Nurse #9 indicated that Resident #14 remained on the floor until Emergency Medical Services (EMS) arrived.During an interview on 4/28/26 at 1:37 p.m., GNA #6 indicated that they worked with Resident #14 on the day of the incident. GNA #6 indicated that they entered Resident #14's room with GNA #7 and the mechanical lift to transfer Resident #14 from the wheelchair to the bed. GNA #6 stated that Resident #14 was in the room waiting to be transferred and had the sling underneath them while seated in the wheelchair. GNA #6 indicated that they informed GNA #7 that they were going to the supply closet to obtain gloves. GNA #6 indicated that, at the time they left the room, GNA #7 had not yet begun the transfer process.GNA #6 indicated that, upon returning to the room, GNA #7 had already started attaching the hooks of the sling to the mechanical lift. GNA #6 confirmed that neither they nor GNA #7 double-checked (in accordance with facility policy requiring safety checks prior to and during lift use) to ensure that the straps or hooks were properly secured prior to initiating the lift. GNA #6 indicated that they assumed that the hooks had been secured. GNA #6 stated that the hook under Resident #14's left shoulder had not been attached and that neither staff member had secured it. GNA #6 indicated that they could not recall who used the remote to start lifting the mechanical lift.GNA #6 indicated that, during the transfer, the lift had already been initiated when staff (GNA #6 and GNA #7) realized that Resident #14 was slipping out of the sling. GNA #6 indicated that both GNA #6 and GNA #7 attempted to reach for the wheelchair; however, it had already tilted backward. GNA #6 indicated that Resident #14 was already coming out of the sling and falling, and staff were unable to control the situation. GNA #6 indicated that the only option at that time was to assist in lowering Resident #14 to the floor. GNA #6 indicated that they then left the room to notify Staff Nurse #9 while GNA #7 remained with Resident #14.During interview on 4/29/26 at 11:59 AM, the Director of Nursing (DON) indicated that Resident #14 was being transferred from the wheelchair to the bed using a mechanical lift and that a clip was not secured to the lift. The DON indicated that GNA #6 and GNA #7 did not perform a safety check to ensure that all hooks were secured prior to initiating the lift. The DON indicated that staff are expected to perform a safety check prior to lifting a resident. The DON further indicated that skills competency check-offs for use of the mechanical lift were not completed upon hire or annually as expected for GNA #6 and GNA #7. The DON indicated that competency validation was conducted after the incident to ensure staff were able to safely use the mechanical lift.During interview on 4/29/26 at 2:02 PM, the Administrator indicated that two GNAs were transferring Resident #14 using a Hoyer lift and that staff believed the resident was secured in the sling but did not double-check that all loops were properly attached. The Administrator indicated that when the resident began to lean, staff lowered the resident to the floor. The Administrator indicated that staff did not verify that all loops were secured prior to initiating the transfer. The Administrator further indicated that one GNA #7 was hired on 11/11/25 and oriented from 11/12/25 through 11/19/25, with a mechanical lift competency completed on 11/16/25. The Administrator indicated that the other GNA #7 hired on 3/18/25, did not have a documented skills competency check-off upon hire but received mechanical lift training in July 2025 at the facility. The Administrator indicated that staff were not retrained immediately following the incident and stated that staff should have received one-on-one competency validation. The facility provided the following corrective action plan.The facility provided a mitigation plan dated 3/21/2026 in response to the incident involving Resident #10. The mitigation plan indicated that on 3/21/2026, the identified resident was reviewed for fall risk and that fall interventions were evaluated and validated upon return to the facility.The facility indicated that residents at risk for falls were identified as having the potential to be affected by the deficient practice and that the Director of Nursing reviewed falls from the prior seven days to validate that interventions were appropriate and in place.The facility indicated that reeducation was completed with nursing staff by 3/23/2026 regarding fall management, including ensuring fall interventions are in place at all times, and education was provided on proper use of the Accora bed.The facility indicated that ongoing monitoring would include continued review of care plans and interventions following each fall and that the Director of Nursing has observed fall interventions in place for at-risk residents since 3/21/2026.The facility indicated that an ad hoc QAPI meeting (a meeting called in response to a specific event) was held on 3/21/2026 and that falls are reviewed weekly to ensure appropriate interventions are in place and care plans are updated accordingly.

Based on record review, observation, and staff interview, the facility failed to ensure that care and services were provided in accordance with professional standards of nursing practice for 2 of 5 residents reviewed (Residents #1 and #15). This included failure to follow accepted standards of medication administration, including the five rights of medication administration (right resident, right medication, right dose, right route, and right time) and failure to adhere to manufacturer's guidelines for medication administration.1. Resident #1 was admitted to facility on 9/20/24 with a diagnosis of diabetes.Review done on 4/28/26 at 8:52pm of Quarterly minimum data set (MDS) assessment dated [DATE] indicated that Resident #1 was cognitively intact with a diagnosis of diabetes and received insulin injections daily.Review done on 4/28/26 at 8:56pm of care plan initiated on 10/10/24 indicated that Resident #1 was at risk hypo/hyperglycemia related to DM2 evidenced by history of abnormal blood glucose with interventions to include but not limited to administer hypoglycemic medications per orders.Review done on 4/28/26 at 8:58pm of physician order dated 4/8/26 indicated that Resident #1 to receive Lantus Solostar U-100 insulin (insulin glargine) [antidiabetic medication] 37 units once a day subcutaneous at 8:30 am every day for diabetes.A medication administration observation was conducted on 4/28/26 at 7:45am with Staff Nurse #9. During the medication pass observation, Staff Nurse #9 retrieved an insulin pen from a zip-lock bag labeled for Resident #1, prepared the medication, and administered 37 units of insulin to Resident #1.After administration, the surveyor observed that the insulin pen used was labeled for Resident #14 and not Resident #1. Staff Nurse #9 confirmed the label and stated that they assumed the insulin pen belonged to Resident #1 based on its placement in the bag. Staff Nurse #9 acknowledged that they should have checked the label prior to administration. 2. Resident #15 was admitted on [DATE] with a recent readmission to facility on 4/26/26 with diagnosis of urinary tract infection and dysphagia.Review done on 4/28/26 at 9:32 pm of Annual MDS assessment dated [DATE] indicated that Resident #15 was cognitively impaired and on mechanically altered diet.Review done on 4/28/26 at 10:33am of physician order indicated that Resident #15 had an order for doxycycline hyclate tablet; 100mg; amount to administer: 1 tablet, oral twice a day (take doxycycline 100mg, 1 tablet by mouth twice daily for 3 days for urinary tract infection. (Doxycycline hyclate is an extended-release [enteric-coated] antibiotic)A medication administration observation was conducted on 4/28/26 at 8:24am with Staff Nurse #15. During the medication pass observation, Staff Nurse #15 administered doxycycline hyclate 100 mg by opening a capsule labeled Do Not Crush, mixing the contents with pudding, and administering it to Resident #15.Staff Nurse #15 stated that the resident was on a puree diet and would have difficulty swallowing the capsule whole.During an interview on 04/28/2026 at 8:42 AM, Staff Nurse #15 indicated that Do Not Crush meant the capsule should not be crushed but could be opened.During an interview on 04/28/2026 at 11:04 AM, Staff Nurse #9 indicated that for capsule medications, staff open capsules for administration and, if labeled Do Not Crush, they would not crush but would open them.During an interview on 04/28/2026 at 12:42 PM, Staff Nurse #14 indicated that Do Not Crush means the medication should not be altered, including crushing or opening, particularly for time-release medications, and indicated that doxycycline capsule is a time-release formulation.

Based on record review, observation, and staff interview, the facility failed to ensure proper medication labeling, storage, handling, and administration practices in accordance with pharmacy services policies and procedures and manufacturer's guidelines for 2 of 5 residents reviewed (Residents #1 and #15). This resulted in the administration of medication labeled for another resident and improper alteration of medication despite Do Not Crush instructions.1. Resident #1 was admitted to facility on 9/20/24 with a diagnosis of diabetes.Review done on 4/28/26 at 8:52pm of Quarterly minimum data set (MDS) assessment dated [DATE] indicated that Resident #1 was cognitively intact with a diagnosis of diabetes and received insulin injections daily.Review done on 4/28/26 at 8:56pm of care plan initiated on 10/10/24 indicated that Resident #1 was at risk hypo/hyperglycemia related to DM2 evidenced by history of abnormal blood glucose with interventions to include but not limited to administer hypoglycemic medications per orders.Review done on 4/28/26 at 8:58pm of physician order dated 4/8/26 indicated that Resident #1 to receive Lantus Solostar U-100 insulin, insulin glargine (antidiabetic medicine) 37 units once a day subcutaneous at 8:30 am every day for diabetes.A medication administration observation was conducted on 4/28/26 at 7:45am with Staff Nurse #9. During the medication pass observation, Staff Nurse #9 stated that Resident #1 had a physician's order to receive 37 units of Lantus (insulin glargine). Staff Nurse #9 retrieved a zip-lock bag labeled with the name Resident #1 from the top shelf of the medication cart. From this bag, Staff Nurse #9 removed an insulin pen, applied a needle, and stated the intent to prime the pen prior to administration. Staff Nurse #9 observed priming and dialing the insulin pen. Upon request, Staff Nurse #9 turned the insulin pen in the direction of the surveyor. The surveyor did not handle the insulin pen, as it had been opened with the needle exposed, in accordance with infection control precautions. The surveyor was able to observe that the insulin pen was dialed to 37 units; however, the label on the pen could not be fully visualized at that time because it was partially obscured while being held by Staff Nurse #9.After administration, Staff Nurse #9 returned to the medication cart, removed the needle, disposed of it in the sharps container, and replaced the cap on the insulin pen. The surveyor then requested to inspect the insulin pen. Upon inspection, the surveyor observed that the insulin pen was labeled Resident #14, not Resident #1. The pen was documented as opened on 04/27/2026. The surveyor also noted approximately 260 units of insulin remaining in the pen.Staff Nurse #9 confirmed that the label on the insulin pen indicated Resident #14. Staff Nurse #9 stated that the insulin pen had been stored inside a zip-lock bag labeled for Resident #1 and acknowledged that they assumed the pen belonged to Resident #1 based on its placement in the bag. Staff Nurse #9 further stated that they should have verified the label on the insulin pen prior to administration. Staff Nurse #9 was unable to verify whether the insulin pen labeled for Resident #14 had been previously used.During an interview on 04/28/2026 at 8:10 AM, Staff Nurse #14 stated that on 04/27/2026, Staff Nurse #13 removed a new Lantus (insulin glargine) pen for Resident #14 from the refrigerator in the medication room at the end of the day shift. Staff Nurse #14 indicated that the insulin pen was not administered to Resident #14. Staff Nurse #14 reported that a new insulin pen contains 300 units and that approximately 260 units remained in the pen observed. Staff Nurse #14 further stated that although the insulin pen was labeled for Resident #14, it had not been used on any resident other than Resident #1. Staff Nurse #14 acknowledged that while the medication was correct, it was labeled for the wrong resident.During an interview on 04/28/2026 at 8:21 AM, Staff Nurse #13 confirmed that on 04/27/2026 at approximately 2:30 PM, they removed a new Lantus insulin pen labeled for Resident #14 from the refrigerator in the medication room. Staff Nurse #13 stated that Resident #14 still had insulin remaining in a current pen that was nearing depletion and the new pen was obtained in preparation. Staff Nurse #13 indicated that the new insulin pen was placed in Resident #14's designated medication storage bag and stated that they did not place the insulin pen in Resident #1's bag. 2. Resident #15 was admitted on [DATE] with a recent readmission to facility on 4/26/26 with diagnosis of urinary tract infection and dysphagia.Review done on 4/28/26 at 9:32 pm of Annual MDS assessment dated [DATE] indicated that Resident #15 was cognitively impaired and on mechanically altered diet.Review done on 4/28/26 at 10:33am of physician order indicated that Resident #15 had an order for doxycycline hyclate tablet; 100mg; amount to administer: 1 tablet, oral twice a day (take doxycycline 100mg, 1 tablet by mouth twice daily for 3 days for urinary tract infection. (Doxycycline hyclate is an extended-release [enteric-coated] antibiotic)A medication administration observation was conducted on 4/28/26 at 8:24am with Staff Nurse #15. During the medication pass observation, Staff Nurse #15 administered doxycycline hyclate 100 mg 1 capsule to Resident #15. The physician's order indicated tablet; however, the medication was supplied in a bubble pack labeled Do Not Crush.Review conducted on 4/28/26 at 11.27am of pharmacy services policies and procedures section 4.1 crushing of medication for oral administration dated with complete manual revision 4/17/24 indicated that All orally administered medications which do not lose effectiveness or produce side effects when crushed, may be crushed per prescriber's order for residents who have difficulty swallowing. A physician order is required to crush medications. The facility should have Do Not Crush list accessible to all nurses. Medications which are enteric coated, extended release, sublingual or otherwise noted by manufacturer as inappropriate for crushing, may not be crushed. The authorized staff or licensed nurse should review the Do Not Crush list prior to opening capsules for administration orally or via tube. If the prescriber/physician orders the crushing of a Do Not Crush medication, he/she must document in the medical record that the benefits outweigh the risk of crushing the medication. The Care Plan must reflect the IDT and staff's determination and/or the resident's preference to have orally administered medications crushed and administered together.During the observation on 4/28/26 at 8:24am, Staff Nurse #15 removed the medication from the bubble pack and opened the capsule prior to administration. Staff Nurse #15 stated that the resident was on a puree diet and would have difficulty swallowing the capsule whole, indicating concern for choking. Staff Nurse #15 opened the capsule, poured the contents into a medicine cup, mixed it with pudding and administered via mouth.During an interview on 04/28/2026 at 8:42 AM, Staff Nurse #15 was asked what Do Not Crush means. Staff Nurse #15 indicated that it meant that the capsule should not be crushed, but could be opened.During an interview on 04/28/2026 at 11:04 AM, Staff Nurse #9 indicated that for capsule medications, staff open capsules for administration. Staff Nurse #9 further indicated that if a medication is labeled Do Not Crush, staff would not crush it but would open it.During an interview on 04/28/2026 at 12:42 PM, Staff Nurse #14 indicated that Do Not Crush means you do not want to crush the capsule or its contents. Staff Nurse #14 indicated that crushing could alter the medication, particularly for antibiotics or time-release formulations. Staff Nurse #14 further indicated that time-release medications should not be opened; however, expressed belief that doxycycline could be opened if needed. Staff Nurse #14 indicated that the facility has a Do Not Crush list and showed the surveyor the 2024 reference list, which indicated doxycycline capsule as a time-release formulation.During an interview on 4/29/26 at 12:30 PM, the Director of Nursing (DON) stated that the facility has a back-up system in the medication room and staff would use available back-up medications. The DON stated that if a medication is not available, the physician is contacted. The DON further stated that staff are not allowed to open or crush medications, as it changes the release rate. The DON indicated that the medication was a capsule and staff may have thought it should have been labeled as extended release.

Based on record review, observation, and staff interviews the facility failed to ensure that the medication error rate was less than 5% for 5 residents reviewed during medication pass observations. Administration of insulin to Resident #1 using an insulin pen labeled for another resident (wrong resident medication), and alteration of medication for Resident #15 by opening a medication labeled Do Not Crush (improper administration), were observed. This was evidenced by 2 medication errors out of 29 opportunities observed (6.89%), which exceeds the allowable error rate of 5%.1. Resident #1 was admitted to facility on 9/20/24 with a diagnosis of diabetes.Review done on 4/28/26 at 8:52pm of Quarterly minimum data set (MDS) assessment dated [DATE] indicated that Resident #1 was cognitively intact with a diagnosis of diabetes and received insulin injections daily.Review done on 4/28/26 at 8:56pm of care plan initiated on 10/10/24 indicated that Resident #1 was at risk hypo/hyperglycemia related to DM2 evidenced by history of abnormal blood glucose with interventions to include but not limited to administer hypoglycemic medications per orders.Review done on 4/28/26 at 8:58pm of physician order dated 4/8/26 indicated that Resident #1 to receive Lantus Solostar U-100 insulin (insulin glargine) [antidiabetic medication] 37 units once a day subcutaneous at 8:30 am every day for diabetes.A medication administration observation was conducted on 4/28/26 at 7:45am with Staff Nurse #9. During the medication pass observation, Staff Nurse #9 stated that Resident #1 had a physician's order to receive 37 units of Lantus (insulin glargine). Staff Nurse #9 retrieved a zip-lock bag labeled with the name Resident #1 from the top shelf of the medication cart. From this bag, Staff Nurse #9 removed an insulin pen, applied a needle, and stated the intent to prime the pen prior to administration. Staff Nurse #9 observed priming and dialing the insulin pen.Upon request, Staff Nurse #9 turned the insulin pen in the direction of the surveyor. The surveyor did not handle the insulin pen, as it had been opened with the needle exposed, in accordance with infection control precautions. The surveyor was able to observe that the insulin pen was dialed to 37 units; however, the label on the pen could not be fully visualized at that time because it was partially obscured while being held by Staff Nurse #9.Staff Nurse #9 administered the insulin to Resident #1.After administration, Staff Nurse #9 returned to the medication cart, removed the needle, disposed of it in the sharps container, and replaced the cap on the insulin pen. The surveyor then requested to inspect the insulin pen. Upon inspection, the surveyor observed that the insulin pen was labeled Resident #14, not Resident #1. The pen was documented as opened on 04/27/2026. The surveyor also noted approximately 260 units of insulin remaining in the pen.Staff Nurse #9 confirmed that the label on the insulin pen indicated Resident #14. Staff Nurse #9 stated that they assumed the pen belonged to Resident #1 based on its placement in the zip-lock bag labeled for Resident #1. Staff Nurse #9 acknowledged that they should have verified the label prior to administration. 2. Resident #15 was admitted on [DATE] with a recent readmission to facility on 4/26/26 with diagnosis of urinary tract infection and dysphagia.Review done on 4/28/26 at 9:32 pm of Annual MDS assessment dated [DATE] indicated that Resident #15 was cognitively impaired and on mechanically altered diet.Review done on 4/28/26 at 10:33am of physician order indicated that Resident #15 had an order for doxycycline hyclate tablet; 100mg; amount to administer: 1 tablet, oral twice a day (take doxycycline 100mg, 1 tablet by mouth twice daily for 3 days for urinary tract infection. (Doxycycline hyclate is an extended-release [enteric-coated] antibiotic)A medication administration observation was conducted on 4/28/26 at 8:24am with Staff Nurse #15. During the medication pass observation, Staff Nurse #15 administered doxycycline hyclate 100 mg 1 capsule to Resident #15. The physician's order indicated tablet; however, the medication was supplied in a bubble pack labeled Do Not Crush.During the observation on 4/28/26 at 8:24am, Staff Nurse #15 removed the medication from the bubble pack and opened the capsule prior to administration. Staff Nurse #15 stated that the resident was on a puree diet and would have difficulty swallowing the capsule whole. Staff Nurse #15 opened the capsule, poured the contents into a medicine cup, mixed it with pudding and administered via mouth.

Based on record review, staff and resident interviews, the facility failed to prevent verbal abuse by staff for 2 (R3 and R5) of 2 sampled residents. Findings included: 1.R3 was admitted to the facility on [DATE] with diagnoses including Aftercare following joint replacement surgery and chronic pain. On 4/30/26 at 10:02 a.m., a review of the Quarterly Minimum Data Set (MDS) assessment dated [DATE] noted that R3 is cognitively intact and required extensive assistance with bed mobility, transfers, and incontinent care. On 4/30/26 at 10:02 a.m., a record review of the facility investigation record dated 12/1/25 at 10:00am showed that the allegation was investigated immediately and that Law Enforcement was notified. The facility investigation report revealed R3 reported to nursing on 12/1/25 at 9:00 a.m. about verbal abuse that occurred on 11/28/25 during the 3-11 p.m. shift perpetrated by Geriatric Nurse Aide (GNA46). The facility investigation report showed the incident occurred while R3 was receiving incontinent care by GNA46. The facility investigation report showed that GNA46 was interviewed by phone by the Director of Nursing (DON), who found GNA46 to be uncooperative during the investigation and terminated employment. In an interview with R3 on 4/27/26 at 12:06 p.m. s/he disclosed that s/he had been admitted to the facility after a hip replacement surgery and needed incontinent care. S/he disclosed that GNA46 responded to s/he's call to provide incontinent care. R3 revealed that s/he had asked GNA46 not to be rough, as s/he had come from surgery. R3 disclosed that GNA46 became verbally aggressive and talked back to her/him in a demeaning way and told R3 to hell to whatever R3 was saying regarding s/he's surgery and pain. R3 stated that s/he was hurt and upset because GNA46 was verbally aggressive for no reason. Telephone calls to the prior GNA46 on 4/28/26 at 11:02 a.m. and on 4/29/26 at 8:29 a.m. were not answered, and a voice message was recorded asking GNA46 to return the call. During an interview with the Director of Nursing (DON) on 4/29/26 at 9:31 a.m., she revealed that immediately, R3 reported verbal abuse, GNA46 was suspended and terminated after substantiation of the allegation. DON stated that the investigation showed that GNA46 had been found rude and mean toward other staff and residents in the past. In an interview with the Administrator on 4/29/26 at 11:43 a.m., he revealed that the complaint had been investigated and substantiated. He stated that GNA46 was terminated and that all staff received abuse-prevention education. Mitigation Plan:What corrective action(s) will be accomplished for those residents found to have been affected by the alleged deficient practice:-On 12/1/25, GNA46 was immediately removed from the care of residents and suspended pending investigation.-Continued behavior monitoring to check for tearfulness, nervousness, and increased agitation of the residents. -On 12/3/25, Social services completed a follow-up with all residents for 72 hours s/p incident. -Resident was seen by Nurse Practitioner (NP) 49 with Psychogeriatric services on 12/11/25. -On 12/5/25, the staff involved was terminated for violating the facility abuse policy. How other residents who have the potential to be affected by the alleged deficient practice are identified:-Residents with allegations of abuse have the potential to be affected. -On 12/1/25, all residents residing in the same hallway were interviewed, and no abuse concerns were found. How the corrective action will be monitored to ensure the deficient practice will not recur:-On 12/10/25, staff were educated on reporting, recognizing, and preventing abuse. -The nurse interviewed in the investigation had completed verbal education on reporting GNA behaviors when observed. What quality assurance program will be put into place:-Facility-wide abuse education for all employees was completed on 12/10/25. Corrective action completion date: 12/11/25.On-site validation of the mitigation plan was completed on 4/30/26. Interviews with staff across all departments at the facility confirmed they received in-service training on abuse prevention and reporting by 12/10/25. Compliance date: 12/11/25. 2.R5 was admitted to the facility on [DATE] with a diagnosis including kidney disease. R5 was discharged from the facility on 4/12/26. A review on 4/29/26 at 2:00 p.m. of the admission Minimum Data Set (MDS) assessment dated [DATE] revealed R5 was cognitively intact and needed minimal assistance with activities of daily living. On 4/29/26 at 2:00 p.m., during record review of the facility investigation dated 2/9/26, the allegation was investigated immediately, and Law Enforcement was notified. The record review of the facility investigation showed R5 was visibly upset and crying during an interview with the Director of Nursing (DON) on 2/4/26. The facility investigation report showed that R5 reported asking the Activities Director (AD47) for a word search, and that AD47 began yelling at s/he and being mean. The facility investigation report further revealed that AD47 denied raising his voice when R5 asked for the word search. The investigation report showed that AD47 was suspended pending investigation and consequently terminated from employment.Efforts to contact AD47 through telephone calls on 4/28/2026 at 2:10 p.m. and on 4/29/26 at 11:03 a.m. were not successful. AD47 did not answer or return the calls. A record review on 4/29/26 at 4:00 p.m. of AD47's statement dated 2/4/26 during the facility investigation showed AD47 denied raising his voice but admitted denying R5 a word search because he believed R5 would continue harassing him, asking for more word searches before completing the word searches given to R5 the previous day. AD47 stated in his statement that R5 was faking crying and that R5 was not upset over the incident but was sorry about it. In an interview with Housekeeping Assistant (HKA38) on 4/28/26 at 10:05 a.m., s/he revealed that s/he was standing by the activities room on 2/4/26 at 9:15 a.m. when R5 came out of the elevator and told HKA38 that s/he needed a word search from AD47. HKA38 stated that s/he called the AD47 for R5. HKA38 stated that AD47 came to the door to speak with R5, who requested a word search. HKA38 stated that AD47 yelled out loud at R5, telling s/he was not going to give R5 any more word searches. HKA38 stated that AD47 became loud, saying and screaming that he was not going to give R5 any more word search. HKA38 stated that R5 was in tears. HKA38 stated s/he immediately reported the incident to the Unit Manager (UM12). During an interview with the Unit Manager (UM12) on 4/28/26 at 2:20 p.m., s/he stated that the incident was reported to her by HKA38 on 2/4/26 at about 9:18 a.m. UM12 revealed that s/he interviewed the staff and resident, who both reported that AD47 was rude and yelling at the resident when s/he asked for a word search. In an interview with the Director of Nursing (DON) on 4/29/26 at 9:41 a.m., s/he revealed the resident was upset and crying. The DON stated on 2/4/26 at 9:30 a.m., HKA38 reported a nursing allegation of verbal abuse on R5 when s/he was asking AD47 for a word search activity, and instead AD47 started yelling at the resident, telling s/he was not going to give her a word search. The DON revealed that AD47 was suspended and terminated following substantiation of the investigation. S/he further revealed that all staff received abuse-prevention in-service training.Mitigation Plan: What corrective action(s) will be accomplished for those residents found to have been affected by the alleged deficient practice:-On 2/4/26, R5 was concerned about not having word searches. Word searches were immediately supplied to the resident. -Social Services followed up with all residents for 72 hours after the allegation and completed on 2/7/26 -Family member was made aware on 2/6/26 -No concerns found during follow-up interviews. -Continued behavior monitoring for depression. -Medical Director notified 2/4/26. How other residents who have the potential to be affected by the alleged deficient practice are identified:-Residents with allegations of abuse have the potential to be affected. -On 2/5/26, all residents residing in the same hallway were also interviewed with no concerns found. -Any other identified issues will be investigated as needed, no other identified issues. How the corrective action will be monitored to ensure the deficient practice will not recur: -On 2/6/26, the staff involved was terminated related to a violation of the Abuse policy What quality assurance program will be put into place: -Ongoing education for abuse, including preventing, recognizing, and reporting abuse. -State Facility Reported Incidents were reviewed in Quality Assurance and Performance Improvement (QAPI) meeting on 2/7/26 and again on 3/26/25. Corrective action completion date: 2/8/26.On-site validation of the mitigation plan was completed on 4/30/26. Interviews with staff across all departments at the facility confirmed they received in-service training on abuse prevention and reporting by 2/7/26. Compliance date: 2/8/26

Based on record review and staff and resident interviews, the facility failed to provide dignity and respect for 1(R1) of 3 sampled residents, who preferred to have their bedpan near him/her, but instead moved it away from him/her telling them that they caused a mess while using it.Findings included: R1 was admitted to the facility on [DATE] with diagnoses that included anxiety disorder. On 4/30/26 at 10:02 a.m., a review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] indicated that R1 was cognitively intact for daily decision-making. The MDS indicated that R1 required extensive assistance with bed mobility, transfers, dressing, toileting, and hygiene. During an interview with R1 on 4/28/26 at 1:55 p.m., he/s stated that Geriatric Nurse Aide (GNA48) placed their bedpan out of reach. GNA48 told him he/s makes a mess when he/s uses the bedpan. R1 stated that he/s was upset by GNA48's disrespect. A telephone call to GNA48 on 4/27/26 at 2:09 p.m. and on 4/30/26 at 8:29 a.m. was not answered, and a voice message was left on the voicemail requesting a return call. In an interview with GNA3 on 4/27/26 at 12:44 p.m., she revealed that R1 reported to her that GNA48 took away his/her bedpan and placed it at a nightstand that was far from him/her. GNA3 stated that she reported the incident to her nurse. During an interview on 4/28/26 at 11:59 a.m. with the Housekeeping Assistant (HKA37), she revealed that she was delivering laundry to the resident, and R1 requested his/her bedpan, which was sitting on a nightstand away from the resident. HKA37 stated that R1 thanked her and stated that the night shift GNA48 had placed the bedpan away from him/her because he/she causes a mess. HKA37 stated that she reported the incident to the nurse. In an interview with the Director of Nursing (DON) on 4/29/26 at 9:34 a.m., she revealed that R1 likes its bedpan on the bed rail and can use it independently. The DON stated that the resident reported that the night GNA48 removed the bedpan from R1 and placed it on a nightstand out of R1's reach. The DON stated that GNA48 apologized for the incident and was suspended pending investigation and was terminated from employment. Mitigation PlanWhat corrective action(s) will be accomplished for those residents found to have been affected by the alleged deficient practice: -10/29/25 at 11:00 a.m. R1 told GNA3 that GNA48 took his urinal because s/he makes too much of a mess and placed it on his nightstand at the far corner of his room. -GNA3 reported the incident to LPN52, and the urinal was returned to R1 so s/he could use it. -On 10/29/26 at 1:00 p.m., the representative of R1 was made aware of the incident. -Ongoing Behavior monitoring for any changes. -R1 was seen by the psychiatry services. How other residents who have the potential to be affected by the alleged deficient practice are identified:-On 10/29/25 at 10:29 a.m., all resident interviews were conducted by social services. - Residents felt safe; reported the care was fair/good, and offered no concerns regarding care -The residents also knew who to report grievances to.How the corrective action will be monitored to ensure the deficient practice will not recur: (include re-education)-GNA3 was suspended pending the outcome of the investigation on 10/30/25 and later terminated on 11/3/25. -Maryland Board of Nursing (MBON) was notified of GNA3's deprivation of goods and services on R1.What quality assurance program will be put into place: -Abuse education was completed by RN51 on 12/10/25 for all employees. -MD20 was made aware of the incident and investigation on 10/29/25.Corrective action completion date: 12/11/25. On-site validation of the mitigation plan was completed on 4/30/26. Interviews with staff across all departments at the facility confirmed that they received in-service training in treating residents with dignity and respect.

Based on observations and interviews, it was determined that the facility failed to ensure linens were processed appropriately to prevent cross contamination. This deficient practice had the potential to affect all residents of the facility.The findings include: The facility's laundry room was initially observed on 9/9/25 at 8:55 AM. During the observation, Housekeeping (Staff #12) was on the clean side of the laundry room folding clean linens. The laundry room's clean and soiled side was separated by a door which was observed wide open. Also present in the soiled side were 2 rolling carts full of dirty linens with no covers.On 9/9/25 at 8:58 AM, Staff #12 was interviewed about her process with laundry. During the interview, she confirmed that there were 2 carts full of dirty linens waiting to be put in the washer while she was folding on the clean side of the room. She also confirmed that the door separating the 2 sides of the room was left open.The concern with cross contamination was discussed with Staff #12 and she stated, I totally understand.On 9/9/25 at 11:39 AM, the Housekeeping Director (Staff #13) reported to the surveyor that Staff #12 was getting ready to process a load of dirty linens and invited the surveyor to observe. During the observation, Staff #12 put on disposable gloves and apron prior to sorting the dirty linens and loading them into the washer.Staff #13 was interviewed on 9/9/25 at 11:58 AM. During the interview, she reported and confirmed that the facility staff had been using disposable aprons when processing dirty linens for over 2 years now. She indicated that the facility used to supply them with isolation gowns and then switched over to using disposable equipment.An interview with the Infection Preventionist Nurse (Staff #1) was conducted on 9/10/25 at 9 AM. During the interview, the concerns with leaving the door open between the clean and soiled area of the laundry room, and the use of disposable aprons when processing soiled linens were discussed. Staff #1 reported that she had just done an infection control boot camp and indicated that it included all housekeeping staff and that part of the training was about Personal Protective Equipment (PPE). Staff #1 stated, I don't know why they would use aprons because your arms are still exposed. Staff #1 verbalized understanding and acknowledged the concerns.

Based on observations and interviews, it was determined that the facility failed to ensure that: 1) food was stored in accordance with professional standards, and 2) clean dishes were stored and maintained in a manner to prevent contamination. This practice has the potential to affect all the residents in the facility.The findings include:1) During the initial tour of the kitchen, on 9/9/25 at approximately 8:30 AM, an observation was made of a large white container stored underneath a meal prep area. The container was labeled sugar, and contained a large, open bag of sugar and a serving scoop. The clear lid of the container was noted to be cracked, and the outside of the container was covered with debris. Staff #23, the Dietary Director, was present during the observation and reported that she had another lid, so she would replace it after the surveyor's intervention.2) An observation of the facility's lunch tray line service on 09/11/2025, at 12:16 PM, also showed a dome drying rack filled with covers that were being used to cover the residents' lunch. The rack was noted to have a significant amount of brownish-yellowish debris/substances on it. Staff #25, a Cook, was present and she mentioned that the drying rack was usually cleaned three times a week; however, it had not been cleaned this week. Staff #23 was also present and interviewed. She said, It looks dirty, and added she would take care of it.During a subsequent tray line service observation on 9/11/2025, at 5:34 PM, it was noted that the dome drying rack appeared clean. Staff #23 reported that it was bleached and cleaned after the surveyor's intervention. Staff #23 also added that she would educate her staff to clean the drying rack.

Based on observations, record reviews, and interviews, it was determined that the facility failed to ensure that residents were served meals according to a predetermined menu that incorporated the residents' preferences. This deficient practice has the potential to affect all residents. The findings include:1) A dining observation on the 2S Wing of the 2nd floor Unit on 9/10/2025, at 12:41 PM, revealed Resident #100 eating lunch in his/her room. The Resident's tray consisted of a roast beef sandwich, Ice cream, 1 Jell-O cup, 4oz of cranberry juice, 8 oz of Iced Tea, and 1/2 cup of seasoned peas.However, the Resident's meal ticket listed the following items: 1/2 cup of no-sugar-added ice cream, 1 Jell-O cup, a chicken sandwich, 2 4-oz cranberry Juices, and 1/2 cup of seasoned peas. The Resident said, I don't know what's wrong with the kitchen. I was supposed to get a chicken sandwich, but they sent me a roast beef sandwich instead. And it happens frequently; they don't read what's on the ticket. 2) Observation of lunch on the 2W wing of the 2nd floor Unit on 9/10/2025 at 1:08 PM showed that Residents #53, #54, #92, and #121 were all to get 1/2 cup seasoned peas on their trays per their meal tickets.However, they all received corn on their meal trays instead of peas, and yet there was no indication of corn on their meal tickets.In an interview later that day, Staff #23, the Dietary Director, reported that they had run out of peas and her staff decided to serve the residents corn instead. Staff #23 added that she would ensure that the staff made extra vegetables in the future.3) During an observation of lunch on the 2W wing of the 2nd floor Unit on 09/10/2025 1:11 PM, it was noted that Resident #126 was eating lunch in his/her room. On the Resident's meal tray was a ticket that listed all the food items to be on the tray: 1/2 cup ice cream, 8oz water, 1 Ensure Plus, roast beef with w/gravy, 1/2 cup seasoned peas, and 8 oz Tea.However, the observation failed to show that Resident #126's tray contained Ensure Plus and seasoned peas. The Resident stated s/he did not receive the Ensure Plus and seasoned peas.4) Observation of Lunch on the 2S Wing of the 2nd floor Unit included Resident #85 eating Lunch in his/her room. The observation noted from the Resident's meal ticket was that s/he was to receive one pureed vanilla ice cream, 6 Fl oz of tomato soup, 4oz of apple juice, one fruit yogurt, 6oz of beef broth, and 8oz of water. However, the observation failed to show that Resident #85 received fruit yogurt on his/her tray. The Resident's family was present and stated there was no yogurt on the tray.5) During an observation of the facility's dinner tray line service on 9/11/2025, at 5:35 PM, the surveyor requested a test tray. The tray contained a meal ticket for Resident #35, with a list of food items to be served to the Resident: 1/2 cup of peaches & pears, 3oz pulled pork sandwich, 4 oz baked beans, 6oz coffee, one creamer, and 8 oz Iced tea.However, the observation failed to show that Resident #35's tray contained the portion size listed on the Resident's meal ticket for the baked beans. Staff #23 was present during the observation. She measured the baked beans with a 4-oz spoon and confirmed that it was less than 4 oz. During an interview on 9/15/2025, at 8:54 AM, staff #23 stated that her staff was serving with the right scoop on 9/11/25; however, she was not filling it to the full level. Staff #23 added that training would be provided to her staff to address all the concerns.

Based on interviews and record reviews, it was determined that the facility failed to reassess the effectiveness of resident care plans and revise them to address resident-specific needs. This was evident for 3 (Resident #4, #13, and #60) of 3 residents reviewed for activities. The findings include:In long-term care, a revised care plan is a modified version of a resident's original care plan that reflects a change in their needs, preferences, or medical status. Regulatory requirements mandate revisions after specific assessments, including both comprehensive and quarterly assessments, and whenever a significant change occurs, to ensure the care provided remains appropriate and effective.The resident's care plan must be reviewed after each assessment, as required by S483.20, and revised based on changing goals, preferences, and needs of the resident, and in response to current interventions.1.) On 9/9/25 at 8:44 AM, the Surveyor interviewed Resident #4 who stated that they had lived in the facility for nearly four years. When asked what they do for fun, Resident #4 stated, I sometimes go to Bingo but added that they usually prefer to stay in their room. When asked if the facility provided 1:1 visits or activities of interest in their room, the resident replied, no. The Surveyor did not observe any puzzles, books, or other items that could be considered entertainment, other than the television.On 9/11/25 at 3:10 PM, a review of Resident #4's activities progress notes revealed the following:Quarterly Activities Progress Note dated 1/22/25, documented by the Activities Director (AD): [Resident #4] is alert and able to communicate [their] needs or concerns. [S/he] spends the majority of [their] day watching TV and spending time with [their] family when they are within the facility. [Resident #4] enjoys attending Bingo and monthly Resident Council meeting with peers. [S/he] has recently become more involved in group activities. Enjoys helping with baking activities. [S/he] is meeting [their] goal and will continue with plan of care until next review date.Quarterly Activities Progress Note dated 4/23/25, documented by the Activities Director:An identical note was entered on this date, reflecting the same language as above.On 9/11/25 at 3:30 PM, the Surveyor reviewed Resident #4's current activities care plan, which failed to include resident-specific interests such as those mentioned in the progress notes dated 1/22/25 and 4/23/25 (Bingo, Resident Council, baking, or group activity).The Surveyor noted that the only update to Resident #4's activities care plan since the start date of 10/26/21 occurred on 5/3/22, which addressed behavior issues and directed staff to remind Resident #4 of scheduled group activities using verbal cues. There is no evidence to support that the resident's care plan was updated following the AD assessment notes dated 1/22/25 or 4/23/25, or that the resident's preference for in-room activities was addressed.2.) On 9/9/25 at 11:09 AM, the Surveyor observed Resident #13 in bed and asked about activities. Resident #13 denied participation in activities.On 9/11/25 at 12:41 PM, a review of Resident #13's medical record revealed diagnoses of depression and anxiety. The resident was documented as having lower body impairment, requiring the use of a wheelchair, and needing maximum assistance to get out of bed.On 9/11/25 at 3:05 PM, the Surveyor reviewed Resident #13's activities progress notes, which revealed the following:Quarterly Activities Progress Note dated 1/27/25, documented by the Activities Director (AD): [Resident #13] is able to communicate [their] needs or concerns. [S/he] is very pleasant. [S/he] enjoys eating meals in the dining room and socializing with peers. [S/he] attends group activities of choice such as parties or socials. [S/he] enjoys puzzle books. [S/he] is meeting [their] goal and will continue with plan of care until next review date.Quarterly Activities Progress Note dated 4/29/25, documented by the Activities Director:An identical note was entered on this date, reflecting the same language as above.On 9/11/25 at approximately 3:15 PM, the Surveyor reviewed Resident #13's current activities care plan, which failed to include resident-specific interests mentioned in the AD's notes on 1/27/25 or 4/29/25 (meals in the dining room, parties and socials, and puzzle books). The care plan contained generic interventions with a start date of 7/5/24 and no updates were added after that date.3.) Resident #60 is a paraplegic (the inability to voluntarily move the lower parts of the body), which requires her to be dependent on others for her care, and suffers from anxiety and depression.On 9/9/25 at 9:47 AM, the Surveyor spoke with Resident #60, who stated that she does not attend activities and that they do not provide 1:1 activity in her room.On 9/12/25 at 11:44 AM, the Surveyor reviewed Resident #60's activities progress notes, which revealed the following:Quarterly Activities Progress Note dated 2/5/25, documented by the Activities Director (AD): [Resident #60] is alert and oriented. [S/he] spends the majority of [their] day watching TV and socializing with staff. [S/he] participates in room visits with Activity Staff to discuss what [s/he] is watching on TV or the weather and pet visits. [S/he] also enjoys reading the Daily Chronicle. [S/he] is meeting [their] goal and will continue with plan of care until next review date.Quarterly Activities Progress Note dated 5/7/25, documented by the Activities Director:An identical note was entered on this date, reflecting the same language as above.On 9/11/25 at approximately 3:40 PM, the Surveyor reviewed Resident #60's current activities care plan, which failed to include resident-specific interests mentioned in the AD's notes on 2/5/25 or 5/7/25 (what TV programs s/he enjoys, what in-room activities they enjoy, if they like pets, or enjoyment of the Daily Chronicle).An Evaluation note dated 8/7/25 written by Nurse #8 was included in the evaluation section of the care plan, which stated that the resident prefers to stay in her room due to pain and that she enjoys her soap opera and the Hallmark Channel and that she enjoys snacks and animals, and enjoys reading the Daily Chronicle and devotionals and prefers independent activities. The care plan was not updated to include these activities.The care plan approaches were last updated in May of 2023, and other than mentioning that she prefers to stay in her room and watch TV, it does not provide any details to help a reader understand the resident's preferences for which TV shows she likes or that she enjoys snacks, animals, or devotionals.On 9/12/25 at 9:36 AM, the Surveyor interviewed the Activities Director (AD) regarding the process for determining residents' personal preferences. The AD stated he uses an assessment template that asks questions like preferred name, background, past occupation, music and art interests, enjoyment of cooking or cleaning, and religious preferences. He explained that in the electronic medical record (EMR) system, he must manually enter resident-specific interventions. For example, instead of documenting only that a resident likes music, he could specify the type, such as country.On 9/15/25 at 9:26 AM, the Surveyor conducted a follow-up interview with the Activities Director (AD) and asked whether resident preferences are updated each quarter during care plan meetings. The AD responded, No, I only update that annually. When asked how changes in interests are identified if updates are not made quarterly, the AD stated, Well, I sometimes make changes if it is a major change, but for quarterly assessments, I largely only go by the previous care plan.The Surveyor then asked the AD to review Resident #4's care plan. The AD stated, I can't tell by looking at the care plan what her specifics are. When prompted to examine it, he confirmed that it was just the template and doesn't include resident specifics. The AD then stated, My weakness is in care planning, and stated he had been working with corporate to improve. He also reported, During our mock survey it was brought to my attention that I need to include specifics in the care plans.The Surveyor noted that many components of resident care plans had not been updated since 2021. The AD again stated that he only updates plans with major changes or during the annual review, reiterating, I am still learning.The Surveyor then asked the AD to review Resident #13's care plan, which he confirmed is not resident specific. When asked to review Resident #60's care plan, he agreed that it also lacked resident-specific information. The Surveyor expressed concern that Residents #4, #13, and #60 appeared not to have their care plans updated during their quarterly assessments. The AD responded, I am still learning and can reach out to my corporate contact for more guidance.On 9/15/25 at 10:20 AM, the Surveyor spoke with the Nursing Home Administrator (NHA) and the Director of Nursing (DON) regarding the lack of reassessments for activities care plans for Residents #4, #13, and #60. The NHA stated they were not surprised by this finding because during a recent mock survey it was identified as a concern. The DON added that a plan of correction would be initiated to address the issue.

Based on interviews, record reviews, and observations, it was determined that the facility failed to develop person-centered, resident-specific care plans. This was evident for 1 (Resident #92) of 1 resident reviewed for insulin use and 2 (Residents #4 and #13) of 3 residents reviewed for activities.The findings include: A comprehensive care plan in long-term care is a document that outlines a person-centered roadmap for meeting a resident's unique medical, physical, emotional, and social needs, ensuring high-quality, consistent care across all settings and providers. It facilitates full health management, improves communication and coordination among the care team, prevents medical errors, and supports resident independence and quality of life by addressing their individual preferences and goals. 1.) Resident #92 resides at [NAME] Manor for physical therapy and nursing care following a surgical amputation of one leg. Resident #92 has a long history of Type 2 Diabetes and associated medical conditions including heart disease and chronic kidney disease.Hypoglycemia refers to a condition where blood sugar (glucose) levels drop below normal (below 70 for diabetics). Severe hypoglycemia can occur when blood glucose levels drop below 40 mg/dL. This can lead to serious complications such as seizures, coma, and even death.Glucagon medication is used for emergency treatment of very low blood sugar (severe hypoglycemia).On 9/09/25 at 11:07 AM, the surveyor spoke with Resident #92 and asked questions about the residents' history of diabetes and whether the facility had taught them about the signs and symptoms of low blood sugar (hypoglycemia). Resident #92 stated that s/he had struggled with diabetes for years, and when they were first admitted to [NAME] Manor the facility had some difficulty getting their blood sugar straight. They reported that they were transferred to the hospital following an incident of low blood sugar.On 9/10/25 at 2:08 PM, the surveyor reviewed Resident #92's progress notes which revealed:-Nursing Progress Note dated 7/1/25 at 6:28 AM: .aide alerted nurse to resident [#92] mumbling and not making sense. BS [Blood Sugar] 37, gave glucagon 1mg injection to [Right Arm], call placed to 911. left message for MD, on-call notified.-Nurse Progress Note dated 7/1/25 at 12:46 PM: Resident [#92] returned to the facility at this time from [name of hospital]. The hospital stated that resident diagnosis was hypoglycemia [low blood sugar].-Physician Progress Note dated 7/01/25 10:09 PM: In part stated: Follow-up check on [Resident #93] who had been to the emergency room earlier because of being unresponsive with hypoglycemic [low blood sugar] incident. S/he carries a diagnosis of insulin-dependent diabetes mellitus with a hypoglycemic episode this morning.-Nurse Progress Note dated 7/2/25 at 11:28 AM: Resident #92 approached for blood sugar check at 730AM, awake and groggy. Blood sugar 39. Given chocolates and milk with sugar and cheese crackers with peanut butter. Resident was more responsive and asked what happened. [Nurse] explained to resident that their sugar had dropped again and is doing much better.On 9/10/25 at 2:30 PM, the surveyor reviewed Resident #92's current care plan dated 8/22/25 and apart from a carbohydrate-controlled diet [diabetic diet] was unable to find any interventions for the management of Resident #92's diabetes. On 9/11/25 at 9:50 AM, the surveyor interviewed the facility Director of Nursing (DON) and asked her to explain her understanding of the purpose of a care plan. She replied, It is so that the staff know what interventions are to be taken for the resident. When asked if these are general interventions, she stated, The interventions should be resident specific.The surveyor then asked what diabetic interventions would be expected to be included for a comprehensive care plan. The DON stated, The care plan should include interventions such as lab work, skin checks, blood sugar checks, vitals, medications, and that standing orders for glucagon are also included.The surveyor then asked the DON to review Resident #92's care plan and identify any diabetes related goals, interventions, or treatments. She replied that she did not see any related to Resident #92's diabetes. The surveyor expressed concern and the DON stated, these interventions should have been included in the care plan, and the oversight should have been caught after the transfer to the hospital.On 9/11/25 at 10:27 AM, the DON provided the surveyor with the facility policy and procedure titled Care Plan Processes, Person-Centered Care (revised 5/5/23), which in part states:The facility will develop and implement a baseline and comprehensive care plan for each resident that includes instructions needed to provide effective and person-centered care for the resident and meet professional standards of quality care.Through ongoing assessment, the facility will initiate person-centered care plans when the resident's clinical status or change of condition dictates.2.) On 9/9/25 at 8:44 AM, the Surveyor interviewed Resident #4. Resident #4 stated that they had lived in the facility for nearly four years. When asked what they do for fun, Resident #4 stated, I sometimes go to Bingo but added that they usually prefer to stay in their room. When asked if the facility provided 1:1 visits or activities of interest in their room, the resident replied, no. The surveyor did not observe any puzzles, books, or other items that could be considered entertainment, other than the television.On 9/11/25 at 3:10 PM, the Surveyor performed a review of Resident #4's activities progress notes which revealed the following:Quarterly Activities Progress Note dated 1/22/25, documented by the Activities Director (AD): [Resident #4] is alert and able to communicate [their] needs or concerns. [S/he] spends the majority of [their] day watching TV and spending time with [their] family when they are within the facility. [Resident #4] enjoys attending Bingo and monthly Resident Council meeting with peers. [S/he] has recently become more involved in group activities. Enjoys helping with baking activities. [S/he] is meeting [their] goal and will continue with plan of care until next review date.Quarterly Activities Progress Note dated 4/23/25, documented by the Activities Director:An identical note was entered on this date, reflecting the same language as above.On 9/11/25 at 3:30 PM, the Surveyor reviewed Resident #4's current activities care plan, which failed to include resident-specific interests such as those mentioned in the progress notes on 1/22/25 or 4/23/25 (Bingo, Resident Council, baking, or group activity). The care plan contained generic interventions, each with a start date of 10/26/21, including: Assist as needed in turning television to preferred network for favorite program (favorite network or program not named). Discuss items of interest while in room such as career, family, hobbies, what he/she enjoys doing for fun or pleasure (no note of what the resident enjoys). Provide supplies in room for self-directed activities as needed or requested (no mention of what activities are preferred). Provide with music of preference-invite and encourage attendance at music programs (no mention of music preferences or if the resident likes music). Staff will offer and provide reading materials of interest as needed (no mention of reading preference or if the resident likes to read).The only documented update to Resident #4's activities care plan since the start date of 10/26/21 occurred on 5/3/22, which addressed behavior issues and instructed staff to provide reassurance using calm tone of voice when these behaviors occur and alert nursing staff and to remind Resident #4 of scheduled group activities using verbal cues. There is no evidence to support that the residents care plan was updated following the AD notes dated 1/22/25 or 4/23/25. The resident's current activities care plan did not reflect their stated interests or individualized activity preferences, nor did it address their expressed desire for in-room activities.3.) On 9/9/25 at 11:09 AM, the Surveyor observed Resident #13 in bed and asked about activities. Resident #13 denied participation in activities.On 9/11/25 at 12:41 PM, a review of Resident #13's medical record revealed diagnoses of depression and anxiety. The resident was documented as having lower body impairment, requiring the use of a wheelchair, and needing maximum assistance to get out of bed.On 9/11/25 at 3:05 PM, the Surveyor reviewed Resident #13's activities progress notes, which revealed the following:Quarterly Activities Progress Note dated 1/27/25, documented by the Activities Director (AD): [Resident #13] is able to communicate [their] needs or concerns. [S/he ]is very pleasant. [S/he] enjoys eating [their] meals in the dining room and socializing with peers. [S/he] attends group activities of choice such as parties or socials. [S/he] enjoys puzzle books. [S/he] is meeting [their] goal and will continue with plan of care until next review date.Quarterly Activities Progress Note dated 4/29/25, documented by the Activities Director:An identical note was entered on this date, reflecting the same language as above.On 9/11/25 at approximately 3:15 PM, the Surveyor reviewed Resident #13's current activities care plan, which failed to include resident-specific interests mentioned in the progress notes on 1/27/25 or 4/29/25 (meals in the dining room, parties and socials, and puzzle books). The care plan contained generic interventions with a start date of 7/5/24, including: Provide activity calendar and review some of the programs and available materials and equipment available for use. Staff will assist resident in participating in favorite activities such as watching TV, listening to music, or completing puzzles (no documentation of what specific TV programs or music Resident #13 enjoys).On 9/12/25 at 9:36 AM, the Surveyor interviewed the Activities Director (AD). The Surveyor asked the AD to explain the process for determining residents' personal preferences. The AD stated he uses a template that asks questions like preferred name, background, what they did for a living, music preferences, art interests, if they enjoy cooking or cleaning, and about religious preferences.The Surveyor asked how that assessment is implemented in the care plan. The AD explained that the electronic medical record (EMR) program has a template for activities in which he must manually add resident-specific interventions. He provided an example, stating that for music I could add what type of music versus just saying they like music.On 9/15/25 at 9:26 AM, the Surveyor conducted a follow-up interview with the AD. The Surveyor asked where the Activities Assistant would go to find residents' individual preferences. The AD initially responded, she would ask me. When asked if the assistant could look in the residents' care plan, the AD replied that the assistant does not have access to the EMR, but if she really needed it she could log into my account or myself or the MDS nurse could print it for her. When asked if the care plan would show specifics about residents, the AD responded, the care plan should be able to show the specifics.The Surveyor then asked the AD to look up Resident #4's care plan. The AD immediately said, she likes the newspaper. When asked how he knew that the AD responded, from her initial assessment. The Surveyor asked him to show the assessment. After opening it, the AD stated, oh wait, the assessment is blank, I didn't work here then (October 2021). He then reviewed the annual (dated 8/24/24) and stated, he/she likes her family, dog visits, and beauty shop, has no interest in painting or cooking, and likes games. The assessment did not mention the newspaper. The AD then added, Oh, her most recent annual says she doesn't like reading, but that is wrong because I know she likes the newspaper and daily chronicle.The Surveyor redirected the AD to look at Resident #4's care plan. The AD stated, I can't tell by looking at the care plan what her specifics are. When prompted to review the care plan, he confirmed that it was just the template and doesn't include resident specifics. The AD admitted , My weakness is in care planning, and stated he had been working with corporate to improve. He also reported, During our mock survey it was brought to my attention that I need to include specifics in the care plans.On 9/15/25 at 10:20 AM, the Surveyor spoke with the Nursing Home Administrator (NHA) and the Director of Nursing (DON) regarding the lack of resident-specific care plans and evidence of updates for Residents #4 and #13. The NHA stated they were not surprised by this finding because during a mock survey that we had just completed it was identified as a concern. The DON added that a plan of correction would be initiated to address the issue.On 9/15/25 at 10:52 AM, the NHA returned with his computer and showed the Surveyor a document he described as items identified as issues during a recent mock survey. He pointed to line 20, which addressed care planning and specificity, and acknowledged, the care plan must be specific and regularly updated.

Based on record review, interviews, and observations, it was determined that the facility failed to ensure that residents received their meals at an appropriate and palatable temperature. This deficient practice has the potential to affect all residents who receive meals from the facility's kitchen. The findings include:A review of the facility's grievance summary report revealed that a concern regarding the facility's food was reported to the Social Services Director on 9/4/25, stating that the facility's food was still cold. The report was reviewed by the Nursing Home Administrator and resolved on 9/5/25.Continued review of the facility's Nutrition Policies and Procedures contained a statement that Hot foods are maintained at 135 F or higher and cold foods are maintained at 40 F or below at the point of service.During a tour of the facility on 9/9/2025, Residents #4, #8, and #9 reported that the facility's food was often cold for foods that needed to be warm and warm for foods that required to be cold.During an observation of the facility's dinner tray line service on 9/11/2025, at 5:35 PM, the surveyor requested a test tray. The tray contained a pulled pork sandwich, baked beans, Peaches/Pears, Coffee, Iced Tea, and creamer. Staff #23, the Dietary Director, was present and obtained the food temperatures, which showed 127 degrees for the pulled pork, 129 degrees for the baked beans, and 59 degrees for the peaches/pears. Staff #23 indicated the acceptable temperatures should have been 135 degrees for the pork and beans, and 40 degrees for the peaches/pears.In an interview on 9/15/2025, at 11:09 AM, staff #23 indicated that they had found a 2-lid plate cover to keep the residents' meals warm after the surveyor's intervention. Staff #23 also added that she will train her staff in a new process to address concerns regarding food temperatures.

Based on observation, interview and review of medical records it was determined that the facility failed to ensure medication error rate of less than 5% as evidenced by 3 errors out of 29 opportunities. These errors were identified for 2 (Resident #73 and #10) out of the three residents observed during the medication administration observation task. The findings include: 1)On 9/09/25 at 8:30 AM surveyor observed Nurse #2 prepare and administer medications for Resident #73. One of the medications prepared was Clear Lax which is a laxative that comes in a powder form that needs to be mixed with a liquid. The active ingredient in Clear Lax is polyethylene glycol 3350.Nurse #2 was observed to use the lid of the Clear Lax to measure the powder. The lid was observed to be purple with an inner white section. The nurse filled the powder to approximately 3/4 of the way up the white part of the lid. The nurse then proceeded to mix the powder with water in one of the disposable cups kept on the medication cart. The nurse reported this was a 120 ml cup (120 ml is approximately 4 ounces).On 9/9/25 at approximately 12:00 noon review of the medical record revealed an order for the Miralax (polyethylene glycol 3350) powder 17 grams, mix with 8 ounces of H2O (water) or juice.Review of drugs.com information for Clear Lax revealed the following instructions: fill to top of white section in cap which is marked to indicate the correct dose (17 g).On 9/09/25 at 1:06 PM after viewing the measuring cup portion of the Clear Lax with a flashlight, Nurse #2 acknowledged the powder should be to top of the white portion and confirmed the dose administered was a little under what was ordered for Resident #73.2) On 9/9/25 at 9:42 AM surveyor observed Nurse #3 prepare and administer ten medications for Resident #10. One of the medications prepared was Clear Lax. The nurse was observed pouring the Clear Lax powder into the measuring cup portion of the lid, but the powder did not appear to fully cover the white section of the cup, the nurse then mixed the powder with water. At the end of the observation Nurse #3 confirmed that 10 medications were administered.On 9/9/25 at approximately 12:00 noon review of Resident #10's medical record revealed an order for a multivitamin to be given once a day. Review of the Medication Administration Record (MAR) revealed this medication was scheduled to be given at 9:00 AM. Nurse #3 had documented on 9/9/25 at 9:54 AM that the vitamin was not administered due to being unavailable. The other 10 medications that were observed were documented as administered on the MAR. Further review of the medical record also revealed an order for Miralax 17 grams.On 9/09/25 at 1:11 PM Nurse #3 confirmed the vitamin was not administered, reporting that she only had a vitamin with iron on the medication cart during the med pass observation. Nurse #3 went on to report that she had since obtained the multivitamin and proceeded to show the surveyor a bottle from the medication cart containing a multivitamins. When asked if she had since administered the multivitamin to the resident, Nurse #3 responded: no, because she had already documented it as not given.Also, during the 9/9/25 interview at 1:11 PM surveyor and Nurse #3 observed the lid to the Clear Max. Nurse #3 reported she fills to the line, pointing to the grove in the cup approximately 1/2 to 3/4 the way up the white section. After further observation the nurse confirmed the dose administered to Resident #10 was less than what was ordered. On 9/09/25 at 2:43 PM surveyor informed the Director of Nursing and the Nursing Home Administrator of the medication error rate above 5% based on the three errors: two with wrong dose of the Clear Lax and one of omission related to a vitamin.

Based on records review and interviews, it was determined that the facility failed to ensure residents were free from unnecessary medications. This was evident for 1 (Resident #8) of 5 residents reviewed for unnecessary medications.The findings include: Resident #8 was admitted into the facility in early 2025 with diagnosis that include hypertension. Hypertension, also known as high blood pressure, is a long-term medical condition in which the blood pressure in the arteries is persistently elevated. High blood pressure usually does not cause symptoms itself. It is, however, a major risk factor for stroke, coronary artery disease, heart failure, atrial fibrillation, peripheral arterial disease, vision loss, chronic kidney disease, and dementia.Blood pressure is classified by two measurements, the systolic (first number) and diastolic (second number) pressures.A review of Resident #8's medication orders was conducted on 9/12/25 at 1:09 PM. The review revealed medications that treat hypertension that include:1) Carvedilol, to be taken 2x a day with instructions to hold if systolic blood pressure (SBP) was <120 or heart rate <60.2) Losartan, to be taken at bedtime with instructions to hold if SBP was <120 or heart rate <60.A review of Resident #8's electronic Medication Administration Record (eMAR) for September 2025 was conducted on 9/12/25 at 2:01 PM. The review revealed the following concerns:1) Carvedilol was administered on 9/1at 6 PM with a SBP of 118, 9/4 at 9 AM with a SBP of 107, 9/5 at 6 PM with a SBP of 110, 9/6 at 9 AM with a SBP of 112, and on 9/11 at 6 PM with a SBP of 109.2) Losartan was administered on 9/1 at 9 PM with a SBP of 118 and on 9/11 with a SBP of 109.The Director of Nursing (DON) was interviewed on 9/12/25 at 2:37 PM. Resident #8's eMAR for September was reviewed with the DON and she confirmed that Carvedilol and Losartan were administered on the dates stated above and indicated that they should have been held. The concern was discussed that the medications were administered outside the parameters and the DON agreed and acknowledged the concern.

Based on record review, interview and observation it was determined that the facility failed to ensure adequate supervision and staff assistance during a resident's mechanical lift transfer. This was evident for 1 (Resident #90) of 5 residents reviewed for activities of daily living during the recertification survey. The findings include:A review of Resident #90's clinical record revealed a care plan intervention that stated the resident required assistance of two staff to transfer out of bed with a mechanical lift.A review of the facility's mechanical lift policy revealed that transfers with a mechanical (Hoyer) lift required two staff.On 9/09/2025 at 9:26 AM Resident #90 was interviewed during the initial screening for the recertification survey process. S/he stated that s/he was afraid of Hoyer lift transfers, and that s/he was not sure staff used it right.On 9/11/25 at 4:21 PM Resident #90 was observed in bed as a Geriatric Nursing Assistant (GNA #14) left their room pushing a mechanical lift. Another unidentified person was observed standing in the room.On 9/11/25 at 4:23 PM an interview was conducted with Resident #90 at their bedside. The other person in the room introduced themselves as a family member. When asked, the resident and family member explained that GNA #14 used the mechanical lift alone to transfer the resident from the wheelchair and back to bed. On 9/11/25 at 4:28 PM an interview was conducted with GNA #14 in the hallway outside Resident #90's room. She was asked if she had another staff person to help her transfer Resident #90 with the mechanical lift, and she said no. She further explained that she went to ask another staff person but they were busy, so she did it by herself, and she also said that the resident's family was there in case something happened. GNA #14 acknowledged that the facility policy was to have two staff assist when a mechanical lift was used, but she had wanted to help the resident quickly.On 9/11/24 at 4:33 PM an interview with the unit manager (Staff #10) was conducted. When informed about the finding that the resident stated s/he was transferred by only one staff, and GNA #14 confirmed that she transferred Resident #90 with a mechanical lift by herself, Staff #10 said that was unacceptable. When asked if there were not enough staff to assist, the unit manager said that there were 5 GNAs working on the unit at that time when there were usually only 3 assigned, and that she was also available to help if needed. She confirmed the deficient practice.On 9/12/25 at 9:00 AM the deficiency was reviewed with the Director of Nursing who also confirmed the deficiency.On 9/15/25 at 2:10 PM - the deficiency was also reviewed with the Nursing Home Administrator. No further evidence was provided.

Based on interviews and record review, it was determined that the facility failed to ensure a resident received treatment and care in accordance with professional standards by not including diabetes-related interventions in the care plan. This was evident for 1 (Resident #92) of 1 resident reviewed for insulin use.The findings include:Resident #92 resides at [NAME] Manor for physical therapy and nursing care following a surgical amputation (removal) of one leg. Resident #92 has a long history of Type 2 Diabetes and associated medical conditions including heart disease and chronic kidney disease.Hypoglycemia refers to a condition where blood sugar (glucose) levels drop below normal (below 70 for diabetics). Severe hypoglycemia can occur when blood glucose levels drop below 40 mg/dL. This can lead to serious complications such as seizures, coma, and even death.Glucagon injection (or oral medication) is used for emergency treatment of very low blood sugar (severe hypoglycemia).On 9/09/2025 at 11:07 AM, the surveyor spoke with Resident #92 and asked questions about the resident's history of diabetes and whether the facility had taught them about the signs and symptoms of low blood sugar (hypoglycemia). Resident #92 stated that they had struggled with diabetes for years, and when they were first admitted to [NAME] Manor the facility had some difficulty getting their blood sugar straight. The Resident (#92) reported that they were transferred to the hospital following an incident of low blood sugar.On 9/10/2025 at 2:08 PM, the surveyor reviewed Resident #92's progress notes which revealed:-Nursing Progress Note dated 7/1/25 at 6:28 AM: Resident [#92] lying somewhat sideways in bed during med-pass, helped straighten him out, speaking normally, within 30 minutes aide alerted to resident mumbling and not making sense. BS [Blood Sugar] 37, gave glucagon 1mg injection to RA [Right Arm], call placed to 911. left message for MD, on-call notified.-Nurse Progress Note dated 7/1/25 at 12:46 PM: Resident [#92] returned back to the facility at this time from [name of hospital]. Resident's [spouse] transported resident. [The hospital] stated that resident diagnosis was hypoglycemia [low blood sugar].-Physician Progress Note dated 7/01/2025 10:09 PM: In part stated: Follow-up check on [Resident #93] who had been to the emergency room earlier because of being unresponsive with hypoglycemic [low blood sugar] episode. S/he carries a diagnosis of insulin-dependent diabetes mellitus with a hypoglycemic episode this morning. Monitor patient closely as they had blood glucose level of 37 was given glucagon appropriately and by the time the EMTs came s/he was 47 but would not go above that so was sent to the emergency room where s/he was given 50% dextrose [sugar water] which made them feel better. Their insulin [diabetes medication that helps to control blood sugar levels] is being decreased today.-Nurse Progress Note dated 7/2/25 at 11:28 AM: Resident #92 approached for blood sugar check at 730AM, awake and groggy. Blood sugar 39. Given chocolates and milk with sugar and cheese crackers with peanut butter. Resident was more responsive and asked what happened. [Nurse] explained to resident that their sugar had dropped again and is doing much better. Blood sugar rechecked at 751 AM and was 94. Call placed to physician and received orders to decrease glargine to 20 units at bedtime and give PBJ sandwich at bedtime.A baseline care plan is a detailed, initial plan developed for each resident within 48 hours of admission. It outlines essential care instructions needed to provide effective, person-centered care and serves as the foundation for the residents' overall care.A comprehensive care plan is a detailed, individualized document developed within 7 days after a complete assessment. It outlines a resident's goals, needs, and the services needed to achieve those goals.On 9/10/2025 at 2:30 PM, the surveyor reviewed Resident #92's baseline care plan dated 6/26/25 and current care plan dated 8/22/25 and discovered that aside from a dietary mention of a carbohydrate-controlled diet, no interventions were found for the management of Resident #92's diabetes.On 9/11/2025 at 9:50 AM, the surveyor interviewed the facility Director of Nursing (DON) and asked her to explain her understanding of the purpose of a care plan. She replied, It is so that the staff know what interventions are to be taken for the resident. When asked if these are general interventions, she stated, The interventions should be resident specific.The surveyor then asked about diabetes interventions for a comprehensive care plan. The DON stated, The care plan should include interventions such as lab work like HBgA1c, skin checks, blood sugar checks, vitals, medications, and that standing orders for glucagon are also included with standard parameters for use.The surveyor then asked the DON to review Resident #92's care plan and identify any interventions included in the baseline or comprehensive care plan related to diabetes management other than a carbohydrate-controlled diet. She replied that she did not see any interventions for diabetes management.The surveyor expressed concerns that Resident #92 did not receive appropriate interventions to manage diabetes and the DON stated that she agreed and stated these interventions should have been included in both the initial and comprehensive care plan and caught after the transfer to the hospital (a change in condition).On 9/11/2025 at 10:27 AM, the DON provided the surveyor with the facility policy and procedure titled Care Plan Processes, Person-Centered Care (revised May 5, 2023), which in part states:The facility will develop and implement a baseline and comprehensive care plan for each resident that includes the instructions needed to provide effective and person-centered care for the resident and meet professional standards of quality care.Through ongoing assessment, the facility will initiate person-centered care plans when the resident's clinical status or change of condition dictates.

Based on medical record review, resident and staff interviews and observations, it was determined that the facility failed to ensure that the activities of Daily living needs of a dependent resident were adequately provided and documented. This was evident for 3 of 5 residents (Residents #20, #58, and #60) reviewed for ADL care. The findings include:1) On 9/12/25 at 8:30 AM, review of Intake #303291 revealed that Resident #20, a long-term resident, was interviewed by the Social Services Director (SSD)(Staff #9) on 6/27/25. Documentation showed the resident expressed concerns regarding personal hygiene and shower care. On 9/12/25 at 9:00 AM, the surveyor requested any grievance forms or documentation showing that the residents' concerns had been addressed. On 9/12/25 at 12:48 PM, the Director of Nursing (DON), reported being unable to provide any grievance form or documentation indicating the complaint had been addressed. On 9/12/25 at 1:15 PM, Resident #20 was interviewed and reported being scheduled for a shower on 9/11/25 but instead received a bed bath. The resident stated that no refusal was made and did recall previously voicing her/his concerns with personal hygiene and showers with the SSD, but she/he reported that no one followed up on his/her concerns. On 9/12/25 at 1:19 PM, Geriatric Nursing Assistant (GNA) Staff #7 was interviewed. The staff member explained the second-floor shower schedule, which uses color-coded maps. GNA staff #7 reported that Resident #20 was scheduled for a shower during the evening shift on 9/11/25. On 9/12/25 at 1:21 PM, second-floor Unit Manager (Staff #8) confirmed that Resident #20 was scheduled for a shower on the evening of 9/11/25 but received a bed bath instead. The unit manager also confirmed that Resident #20 was scheduled for two showers per week. On 9/12/25 at 2:12 PM, bathing task documentation was requested for August and September. Additional documentation for June and July was requested on 9/15/25 at 7:20 AM. On 9/16/25 at 8:00 AM, review of GNA task documentation for Resident #20 revealed the following: June 2025: 9 showers scheduled; 6 received July 2025: 9 showers scheduled; 4 received August 2025: 8 showers scheduled; 6 received September 1–11, 2025: 4 showers scheduled; 2 received On 9/12/25 at 2:26 PM, the DON was interviewed regarding staff procedures when a resident refuses a shower. The DON stated that GNAs should re-offer the shower if initially refused. If refused again, the nurse should be notified to encourage the resident and document the refusal in progress notes. The DON confirmed that no documentation of refusal was found for the 9/11/25 shower, and no evidence was provided to indicate the resident had refused showers. On 9/12/25 at 3:20 PM review of progress notes failed to reveal that Resident #20 refused showers. On 9/12/25 at 3:42 PM, review of the MDS (Minimum Data Set) dated 8/7/25 revealed that Resident #20 is dependent on staff for showering and bathing. On 9/15/25 at 2:18 PM, these concerns were discussed with the Administrator. No additional information was provided before the end of the survey. 2) A complaint (Intake #MD303299) submitted by a family member of Resident #58 alleged the resident was not toileted or cleaned for long periods of time, was found in soiled undergarments, not dressed in clean clothing despite clothing being available, had unwashed hair, and grooming needs were neglected. The complainant further reported that staff did not respond to concerns regarding the resident's dignity and care needs. On 09/09/2025 at 8:53 AM, Residents #58 observed; their plan of care was reviewed, as well as the facility's grievance log. The resident required the assistance of staff for ADL care. On 09/15/2025 at 9:10 AM, review of Resident #58's ADL documentation for the period 08/16/2025–09/15/2025 revealed 13 missed entries where the resident's bladder and bowel control, toileting dependence, and hygiene needs were not documented. Review of documentation from 07/01/2025 and 07/31/2025 revealed 9 additional missed entries for the same ADL care areas. On 09/15/2025 at 9:49 AM, Resident #58 was observed in bed with staff assigned to care for the resident. GNA #16 and Nurse #3 reported that both residents were incontinent, wore an incontinence brief, and required at least one-person assistance with bathing and dressing. Both staff further stated that Resident #58 was not known to refuse care. On 09/15/2025 at 10:34 AM, the Nursing Home Administrator and Director of Nursing acknowledged the deficiency related to failing to provide and document consistent ADL care that resulted in residents not receiving the care and assistance they were care planned for. 3) On 09/15/2025 at 9:25 AM, Resident #60 was observed; their plan of care was reviewed, as well as the facility's grievance log. The resident required the assistance of staff for ADL care. The record review revealed 13 missed entries between 08/16/2025 and 09/15/2025, where the resident's bladder and bowel control, toileting dependence, and hygiene needs were not documented. Review of documentation from 07/01/2025 and 07/31/2025 revealed 9 additional missed entries for the same ADL care areas. On 09/15/2025 at 9:49 AM, Resident #60 was observed in bed with staff assigned to care for the resident. GNA #16 and Nurse #3 reported that both residents were incontinent, wore an incontinence brief, and required at least one-person assistance with bathing and dressing. Both staff further stated that Resident #60 was not known to refuse care. On 09/15/2025 at 10:34 AM, the Nursing Home Administrator and Director of Nursing acknowledged the deficiency related to failing to provide and document consistent ADL care that resulted in residents not receiving the care and assistance they were care planned for.

Based on observation and interviews it was determined that the facility failed to ensure a sanitary and homelike environment. This was found during random observations of two residents' rooms (Resident #97 and #67) and 1 out of the 2 nursing units.The findings include:1.On 9/10/25 at 9:45 AM surveyor observed a privacy curtain that was pulled between Bed A and Bed B in Resident #97's room. Surveyor noted several dark red splotches covering an area approximately 2 inches in length on the privacy curtain. This area was noted to be at the far end of the curtain at about five feet above the floor.Review of Resident #97's medical record revealed the resident has resided at the facility for more than one year. Review of the most recent Minimum Data Set assessment, with a reference date of 7/30/25 revealed the resident is cognitively intact as evidenced by a Brief Interview for Mental Status score of 15 out of 15.On 9/12/25 at 11:25 AM surveyor again observed the dark red splotches on the curtain between Bed A and Bed B in Resident #97's room. Resident #97 reported the stain is blood and that it has been there for months.On 9/12/25 at 11:38 AM surveyor requested that the unit nurse manager #10 come to Resident #97's room. The unit nurse manager acknowledged the stains and indicated she would notify housekeeping.On 9/12/25 at 12:45 PM surveyor reviewed the concern with the Director of Nursing (DON) that the stain on the curtain was observed earlier in the survey and that the resident reported it had been there for months. DON reports they have already cleaned it.2. On 9/12/25 at 11:25 AM surveyor observed Resident #97's bathroom. The sink was observed to have at least 7 cracks of various lengths branching out from the drain. Just below the sink counter was a board covered in laminate. The laminate was noted to be loose and a piece of silver duct tape was also noted on this board.On 9/12/25 at approximately 11:30 AM Resident #67 indicated to the surveyor a concern with the state of his/her bathroom. Observation of Resident 67's bathroom revealed the sink had more than 10 cracks branching from the drain with multiple other cracks noted in the sink basin. Observation of the drawers located in the bathroom revealed one of the drawers had two areas of laminate missing exposing the wood underneath. These areas of missing laminate were both approximately 1-inch triangles missing from the corners.On 9/12/25 at 1:12 PM the Maintenance Director #11 reported that staff can report maintenance concerns through TELS (a computer system used to track maintenance needs). When asked if he had any concerns regarding sinks, the Maintenance Director indicated concerns regarding faucets, valves and pipes.On 9/12/25 at 1:18 PM surveyor and Maintenance Director toured the facility. During this tour the bathrooms were observed in Resident #97 and #67's rooms. The Maintenance Director acknowledged the observations of the cracks in the sinks, as well as the issues with the loose/missing laminate. The Maintenance Director indicated he had not previously been made aware of a concern regarding the cracks in the sinks.3. Review of the statement of deficiencies from the previous recertification survey revealed the facility was cited for failure to maintain unit floors in a safe and sanitary condition. The deficiency included observations of cracks in the floor tile at multiple locations on both the second and third floor hallways. Visual observations made on 9/10/25 revealed similar cracks in the floor tiles, however interview with the Maintenance Director on 9/12/25 at 1:12 PM revealed the cracked areas were filled with clear epoxy. A tour conducted with the Maintenance Director on 9/12/25 at 1:18 PM validated the presence of the clear epoxy. However, in the section of tile at the entrance to the 3 East unit there was an area of approximately 1 inch X 1/8th inch where the epoxy was missing. Additionally, upon touching the area of cracks at the entrance to the 3 South unit the middle section was noted to be rough. The Maintenance Director reported he will redo the epoxy to these sections.On 9/15/25 at approximately 1:00 PM the Nursing Home Administrator (NHA) reported they filled in the spots that we deemed needed to be filled. Surveyor reviewed the concern that areas that were previously filled were found to no longer be intact.

Based on record review, observations, and interviews, it was determined that the facility failed to treat residents with respect and dignity during mealtime. This was evident for 3 out of 5 meal observations during the survey.The findings include:1) A record review for Resident #71 showed that s/he required physical assistance from staff with eating.An observation of breakfast on the 3rd floor Unit on 9/10/2025, at 8:35 AM, showed staff #15, an occupational therapy assistant, feeding Resident #71 in his/her room. Resident #71 was lying in bed while staff #15 was standing by the right side of the Resident's bed.Staff #15 was interviewed at that time and stated that she was aware that standing to feed a resident was undignified; however, she stood to feed Resident #71 because it was comfortable for the Resident when she stood up. A review of Resident #71's medical record later that day failed to show documentation that indicated that staff were to stand while feeding the Resident.A subsequent observation of Resident #71 on 9/11/2025, at 8:37 AM, revealed that staff #16, a geriatric nurse aid (GNA), was feeding Resident #71 breakfast. The Resident was in bed while Staff #16 was noted sitting down at the right side of the Resident's bed. Staff #16 was questioned and stated that it was comfortable for residents when staff sat down to be at the residents' level when assisting them with eating.In an interview on 9/11/2025 at 11:17 AM, the Director of Nursing (DON) reported that it was her expectation for her staff to sit down at the residents' level when assisting residents with eating their meals. However, earlier observations showed otherwise.2) An observation of breakfast on 9/11/2025 at 8:26 AM in the 3rd-floor Unit dining room showed a geriatric nurse aid, who was prepping Resident #69 for breakfast. Staff #17 placed a clothing protector on Resident #69's chest without asking.Continued observation showed that Resident #69 was talkative, alert, oriented, and able to verbalize needs. However, staff #17 did not ask the Resident before placing a clothing protector on him/her.During an interview on 9/11/2025, at 9:10 AM, staff #18, a GNA, stated that staff had to ask residents before placing clothing protectors on them to respect their dignity.In an interview on 9/15/2025, at 2:36 PM, the DON stated that staff were expected to ask residents before placing clothing protectors on them for meals. 3) During an observation of breakfast in the 3rd-floor Unit dining room on 9/11/2025 8:26 AM, Residents #69 and #70 were seated at one table while Residents #98 and #31 were also sitting at another table. The observation noted that Residents #69 and #98 had finished eating their breakfast, while Residents #70 and #31 continued to wait for theirs. Resident #30 said, I just gotta wait for my tray while others are eating, there's nothing else I can do about it.Both Residents continued to wait for their breakfast until 9:06 AM, about 30 minutes later, at which time Resident #69 wanted to return to his/her room as s/he began to feel cold in the dining area. In an interview, Staff #5, a licensed practical nurse, indicated that Residents #69, #70, #98, and #31 were typically the four residents in the dining room for breakfast almost every day. However, she could not say why their trays were not sent to the dining room at the same time. During an interview on 9/11/2025, at 11:17 AM, the DON stated that she was made aware of the concern that some residents had waited for their breakfast. The DON indicated that they addressed the situation after the surveyor's intervention.

Based on record review and interviews, it was determined that the facility failed to have an effective process to ensure that medication recommendations made by the pharmacist were delivered to the physician for review. This was evident for 1 (Resident #10) of 5 residents reviewed for unnecessary medications during a survey. The findings include:On 9/10/25 at 1:07 PM, a review of Resident #10's revealed a monthly pharmacy review note dated 12/11/24. The note referenced Omeprazole 20 mg BID for GERD, administered at 0800 and 2000. The pharmacist recommended reviewing and considering a time change to administer the medication either 1 hour before or 2 hours after other medications and food. No other recommendations were noted. On 9/10/25 at 2:02 PM, an interview was conducted with the Director of Nursing (DON) regarding the monthly pharmacy medication review. The DON reported that when the pharmacist made a recommendation, a hard copy was delivered to the facility with the next pharmacy delivery. The document was first received by the DON, who then gave it to the appropriate nurse manager. The nurse manager was responsible for providing the recommendation to the physician. After the physician reviewed and signed it, the hard copy was returned to the DON. On 9/10/25 at approximately 11:30 AM, during another interview, the DON reported not receiving the December pharmacy recommendations mentioned in the progress note dated 12/11/24. As a result, the recommendation was not reviewed by the physician. On 9/11/25 at 11:30 AM, a document titled Consult Pharmacist Summary Report (provided by the DON) was reviewed. Review of the documents listing all recommendations made between 12/01/24 and 12/31/24 did not include the recommendation noted in the progress notes. On 9/11/25 at 9:05 AM, the DON confirmed that Omeprazole was discontinued along with all other medications on 1/11/25 when the resident was hospitalized . The DON also confirmed that the physician did not receive or review the pharmacist's recommendation and acknowledged that the recommendation documented in the progress notes was not followed up on. On 9/15/25 at 2:18 PM, these concerns were discussed with the Administrator. No additional information was provided before the end of the survey.

Based on record review and staff interview, it was determined that the facility failed to ensure that residents received optimal quality of care that aligned with standards of professional practice. This was evident for 4 (Residents #112, #107, #118, and #86) of 84 residents reviewed during the survey. The findings include: The MDS (Minimum Data Set) is a complete assessment of the resident which provides the facility with the information necessary to develop a plan of care, provide the appropriate care and services to the resident, and to modify the care plan based on the resident's status. A care plan is a guide that addresses the unique needs of each resident. It is used to plan, assess, and evaluate the effectiveness of the resident's care. 1) On [DATE] at 5:45 PM, a review of the facility's investigation file for a facility reported incident #MD00181072 was completed which stated that the facility had received an allegation of neglect for Resident #112. The former Director of Nursing Staff #47 conducted an investigation and failed to recognize that staff failed to promptly assess, identify, and notify the attending physician of acute changes in the resident's condition. Furthermore, she failed to note whether she had substantiated the neglect or not. A statement in the facility's investigation report read that measures were taken to prevent further incidents of similar nature, however, she failed to indicate what those measures were, and the investigation file had no evidence of these measures. Subsequently, on [DATE] at 9:00 AM, two allegations of neglect of Resident #112 were reviewed: #MD00180651 and #MD00182736. MD00182736 alleged that the neglect of Resident #112 led to an unexpected death of the resident. The investigation findings were as follows. On ,d+[DATE], according to the attending physician's History and Physical (H&P) note, Resident #112 was admitted to the facility for rehabilitation and continued treatment of cellulitis following a hospitalization for sepsis, cellulitis, and wound care. The resident's other diagnoses were asthma, morbid obesity, hypothyroidism, and high blood pressure. The resident had a foley catheter for urinary retention. This review of the medical record revealed that the resident had the capacity to make his/her own medical decisions. The admission Minimum Data Set, with the assessment reference date of [DATE], revealed in section C that the resident had no cognitive impairment. Further review of the medical record revealed the wound Nurse Practitioner (NP) Staff #67's visit note, dated [DATE], the resident had a Stage 4 pressure ulcer on his/her left heel. A Stage IV pressure ulcer means that there had been skin and tissue loss deep enough to expose the muscle and bone. The resident had a second wound on his/her left posterior (back) thigh that was a Stage 3. A Stage 3 wound means there was skin loss, and the layer of fat has been exposed. According to the resident's lab reports, s/he was diagnosed with C-Diff (Clostridioides difficile - a bacteria that causes diarrhea and inflammation of the colon. Cdc.gov) on [DATE]. Further review of the progress notes revealed on [DATE], it was noted that the C-diff was resolved. This illness was known to cause a decrease in appetite, vomiting, and diarrhea, placing the resident at risk for malnutrition. According to the National Institute of Health https://pubmed.ncbi.nlm.nih.gov) optimal wound healing requires adequate nutrition. Poor nutrition slows down or stops the wound from progressing through the stages of wound healing and malnutrition can increase the risk of infection. A review of the Dietitian's note, dated [DATE], revealed that Resident #112's weight was 218 lbs. which represented a 19 lbs. (8% body weight) loss in 30 days. However, she stated the weight loss was expected due to a gastrointestinal illness (referring to C-diff). The resident's physician's order summary for [DATE], revealed that the resident had a protein supplement daily to aid in wound healing and a protein shake daily for unspecified protein calorie malnutrition. The Wound NP Staff #67 wrote in her progress notes on the following dates that the resident had complained of abdominal pain and/or discomfort: [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], and [DATE]. Staff #67 failed to document that the attending physician had been made aware of any of these complaints. According to the progress notes, Registered Nurse (RN) #16, the facility's wound nurse, was present at these visits and wrote a progress note of her own but failed to mention the resident's complaints of abdominal pain, as well as reporting it to the attending physician. Licensed Practical Nurse (LPN) #76 wrote a progress note on [DATE], that documented the attending Physician #61 had seen the resident for complaints of abdominal pain. Furthermore, the note stated that he ordered the following medications: Mirlax and Colace for stool softener and Bentyl (a medication used to treat irritable bowel syndrome) for abdominal pain. Upon review of the physician's progress note uploaded in the electronic record, it was revealed that there was no progress note uploaded for this date. However, on [DATE] when the surveyor requested the physician progress notes for the resident's entire stay, facility staff provided a physician's progress note, dated [DATE]. In addition, according to the electronic medical record time stamp, attending Physician #61 had not signed the note until [DATE]. A review of the progress note dated [DATE], revealed that attending Physician #61 failed to document the plan of treatment for the abdominal pain and mention the medications he had ordered. Under the section plan, he wrote the resident was medically stable, continuing with present medications and care. A progress note written on [DATE] by LPN Staff #75 documented that the resident complained of side pain and was administered acetaminophen (Tylenol) and then had a small emesis. An hour later when Staff #75 followed up on the effectiveness of the acetaminophen, it had not been effective so she administered the Bentyl which had been ordered on [DATE] as-needed for abdominal pain. According to the medication administration record (MAR) this had been effective. LPN Staff #20 wrote in a progress note on [DATE] that the resident was eating poorly, refused his/her bowel medications, and had a complaint of stomach gasses and bloating. Furthermore, she documented the resident had recently spoken to his/her doctor and Colace (stool softener) and MiraLAX (stool softener) had been ordered. The physician visit had been [DATE], 5 days prior to this note, and there was no evidence that the nurse conducted an assessment of this medical concern and/or notified the attending physician. The Dietitian noted in a progress note on [DATE], that the Resident's weight continued to drop. The admission weight was 262 lbs. At the time of the note, the resident weighed 190 lbs. The resident informed the Dietitian that s/he had not eaten because it made his/her stomach swell up. However, there was no documentation that the physician had been notified. On [DATE], the Dietitian forwarded the surveyor email correspondence, dated [DATE], that she sent to LPN #68, who was the unit manager at the time. The email read that the resident had weight loss, however, there was no mention of abdominal distress. Furthermore, there was no evidence in the medical record that attending Physician #61 was made aware of the weight loss or the abdominal distress. According to a progress note written by LPN Staff #20 on [DATE], she told the Dietitian the resident had not been taking his/her supplements, was eating poorly, and complaining of nausea when out of bed. However, there was no evidence in the medical record that LPN #20 or the Dietitian notified the attending physician. Review of attending Physician #61's progress note, dated [DATE], revealed documentation that the resident had no concerns, with no mention of the resident's complaints of abdominal pain and emesis. Again, facility staff provided this note to the surveyor on [DATE], as this note was not found in the medical record and was not signed until [DATE]. On [DATE], LPN #20 wrote a note that the resident continued to report the medications made him/her feel ill and reported that his/her stomach was upset. There was no evidence that the nurse further assessed the stomach concern and there was no documentation that the attending physician was made aware that, 3 weeks after the visit on [DATE], the resident was not feeling better and the treatment he prescribed was not effective. On [DATE], a late note for [DATE], was entered by LPN Staff #76. Review of the note revealed that Resident #112 complained of pain in the right lower quadrant. Staff #76 failed to document an assessment of the abdomen and gave Tylenol despite having a PRN (as needed) order for Bentyl for abdominal pain. Further review revealed that LPN #76 contacted the on-call Nurse Practitioner (NP) #79 to report a new area on the resident's head, but failed to report the resident's complaint of abdominal distress. A review of the Resident's vital sign report revealed that, on [DATE] at 1:28 AM, the resident's blood pressure (B/P) was ,d+[DATE]. Further review of the medical record revealed this was a decrease in the blood pressure from the resident's norm. On [DATE] at 9:00 AM, a review of the facility's standards of professional practice revealed that hypotension (low blood pressure) is present when the systolic (top number) of the blood pressure falls to 90 mm Hg or below. Furthermore, it stated that while some adults have low b/p normally, for most people a low b/p is an abnormal finding associated with illness. ([NAME] and [NAME], 9th Version, 2017). However, further review of the medical record revealed that the nurse failed to notify the attending physician of this change in condition. On [DATE] at 11:33 AM, an interview with LPN Unit Manager Staff #8 revealed that she would call the doctor when a systolic (top number) was less than 110 mm HG (millimeters of mercury). When asked why she used this as a standard, she stated that nurses learn that information when they are in nursing school. On [DATE] at 9:48 PM, the resident's recorded vital signs were as follows: B/P ,d+[DATE], temperature (T) 97.7 F, pulse (P) 115, respirations (R) 16, and oxygen saturation (SP02) 99%. Further review of the medical record revealed this was a decrease in the blood pressure from the resident's norm and there was no evidence in the medical record that LPN Staff #78 reported this change to the attending physician. A weekly skin assessment conducted on [DATE] revealed the resident had been pale which was a change from the previous skin checks. However, there was no evidence that the nursing staff notified the physician of this change. The Dietitian entered a note on [DATE], that read, nutrition note for supplement review with nursing; ensure, prostat, and B complex with C discontinued. There was no indication that this was discussed with the physician or that he had been aware of the change. A review of the attending Physician #61's progress note, dated [DATE],with a note added under HPI section, that the resident reported continued weakness. There was no indication in this note that attending Physician #61 had been aware of the resident's continued weight loss of 31 % of his/her body weight, the continued abdominal pain, the decrease in blood pressure and increased pulse. Furthermore, facility staff provided this note to the surveyor on [DATE], as this note was not found in the medical record, and was not signed until [DATE]. A review of the Medication Administration Record (MAR) revealed the resident's urinary output for 24 hours on [DATE] was 300 milliliters (mL). (Urine output in 24 hours less than 400 mL can be one of the first signs of kidney failure) The resident had a urinary catheter due to urinary retention and nursing staff failed to recognize this change significant enough to contact the attending physician. A review of the MAR revealed on [DATE] at 12:20 AM that the resident complained of shortness of breath and was given an Albuterol as-needed dose. According to the record, this was a new symptom. In addition, a review of the Resident's vital signs revealed that, on [DATE] at 12:31 AM, the resident's recorded vital signs were as follows: B/P ,d+[DATE], T 97.97 F, P 95, R 18, and SP02 96%. This was a decrease in the blood pressure from the resident's norm and from the previous readings on [DATE] at 9:48 PM. LPN #75 failed to recognize that the shortness of breath was new and the decrease in blood pressure may indicate a significant change in the resident's medical condition and failed to report the changes to the attending physician. A review of the MAR for [DATE] revealed that the LPN #20 documented at 9:05 AM that she attempted to administer Cardizem ER 24 hr. 180 mg, but the resident refused it and stated it upset their stomach. Lasix 20 mg was given. (Lasix is a medication that helps the body get rid of excess water and salt. In the process of doing this Lasix may lower the blood pressure and is at times given to lower blood pressure) This was prior to obtaining a set of vital signs at 9:57 AM, so the last set of VS indicated a B/P of ,d+[DATE]. Further review revealed the resident's urinary output for the last 24 hours was again very low at 375 cc and staff failed to inform the physician. On [DATE], LPN Staff #77 wrote that the resident had complaints of generalized pain, however she failed to conduct an assessment of the pain. The resident continued to have weight loss as the recorded weight for [DATE] was 179.4 lbs. However, the staff failed to notify the physician. The Dietitian failed to assess the resident who, despite her attempts, had continued to lose weight and she failed to discuss this with the attending physician. A review of the MAR for [DATE] revealed that RN #70 attempted at 9:05 AM to administer the resident ' s blood pressure medication but the resident refused. Lasix 20 mg was administered. A review of the resident's vital signs taken on [DATE] at 9:41 AM revealed a B/P of ,d+[DATE], T 98 F, P 109, R 16, and SP02 of 94%. The RN failed to recognize the resident's continued decrease in blood pressure and increase in pulse rate were indications of a change in his/her medical status and failed to notify the physician. RN Staff #70 failed to reassess the blood pressure and notify the physician. On [DATE], Registered Nurse (RN) #70 wrote a note that the resident continued to complain of abdominal pain and that the resident's doctor was aware because it was not a new symptom. There was no evidence that RN #70 assessed the pain or evaluated the plan of care. RN #70 failed to notify the physician of the continued abdominal pain and that the resident continued to refuse medications. A progress note written by the RN Staff #70 on [DATE] at 5:17 PM read, Resident did state that he/she felt his/her Symbicort inhaler wasn't working today. Educated the resident that he/she needed to take a deep breath in at the same time she pushes down on the inhaler. Otherwise she is not getting the full dose of her medication. Offered him/her the Albuterol inhaler and he/she used it. It seemed to help his/her symptoms. SpO2 this AM was 94%. SpO2 this PM was 93%. Assessed his/her lungs and they were clear but diminished. Resident diminished sounds are not uncommon due to her history. She/he has a history of SOB, Anxiety, Moderate persistent Asthma and environmental Allergic Rhinitis. VSS. Will continue to monitor. A review of the medical record failed to reveal that the resident had diminished lungs sounds previously, nor was there frequent use of the as-needed inhaler until [DATE] and [DATE], indicating there was a change. RN Staff #70 failed to recognize these signs that the resident's health condition had changed and notify the physician. A review of the MAR revealed that, on [DATE], the resident's total urinary output was 350 cc and the nursing staff failed to recognize that this decrease in urinary output had continued for 2 days and nursing staff failed to notify the physician. A review of the MAR for [DATE] revealed that RN #70 wrote a note at 8:03 AM that she attempted 2 times to give the resident his/her blood pressure medication, but the resident had refused that and his/her Lasix. RN Staff #70 had knowledge of the resident's low blood pressure the day before and failed to obtain a blood pressure prior to offering the resident their blood pressure medication. When the nurse obtained the vital signs at 10:20 AM that day, they were as follows: B/P ,d+[DATE], T 98 F, P 106, R 16, and SP02 of 93%. However, she failed to notify the physician at this time. In a progress note on [DATE] at 11:52 AM, RN Staff #70 wrote, Encouragement given all shift to the resident to drink more water. Her urine is a dark amber color. NO symptoms of a UTI. Denies any pain in the lower abdominal region where the bladder lies. Went into the resident's room several hours later and he/she still had not drank any fluids. Resident has been non-compliant with any suggestions to help himself/herself feel better or the functionality of his/her body. RN Staff #70 failed to recognize that the resident's urinary output of less than 400 mL for the last 3 days, coupled with the assessment of dark amber urine, the low blood pressure readings, and increased pulse rate were all significant signs that the resident's health condition was declining and failed to call the physician at this time. On [DATE] at 5:55 PM RN #70 wrote, Resident's family into visit resident at this time resident is not talking to them and will not answer them when they talk to her. O2 [oxygen] sat [saturation] 88 % on room air, O2 put on resident, at 3 liters. O2 sat came up to 90% had to turn O2 up 5 liters to get it to come up to 92%. Resident Lung sounds assessed by this writer. He/she has congestion in the right upper lung field. Resident has a dry congested cough. Resident is unresponsive; he/she will open his/her eyes but will not speak to us. Temp. 98.1 pulse 40 Resp 18 B/P ,d+[DATE]. Certified Registered Nurse Practitioner (CRNP) Staff #79 notified N/O to send resident To ER [emergency room ] for evaluation 911 called. However, due to subsequent notes written by RN #70 on [DATE], it was unclear if 911 had been called at this time. In addition, the Situation, Background, Assessment, and Recommendation (SBAR) tool that was completed by RN #70 failed to document all the symptoms the resident had been having and it was unclear if the on call CRNP #80 had been made aware the resident's full decline in condition. On [DATE] at 6:24 PM, Social Service Staff #80 wrote, [Resident #112] being sent to [hospital] at the family's request as [his/her] HCA [Health Care Agent] is argumentative and adamant that there is something medically wrong with [resident]. [Resident's] vital signs are stable and no vital alerts at this time contrary to family's adamancy. [Resident's] symptoms of concern for the family are variable to the attention it receives and is observed by various staff and witnesses . On [DATE] at 6:59 PM, RN Staff #70 wrote a note that the resident had voiced s/he did not want to live any longer. The resident complained of an upset stomach and was given Bentyl which had been effective. The resident had refused all routine medications that day and napped off and on. The nurse failed to recognize these symptoms of the resident's decline in condition and notify the physician earlier that day. On [DATE] at 7:26 PM, RN Staff #70 wrote a note that she informed CRNP #80 of the situation with Resident #112 and it was approved to send the resident to the emergency room per the family request. She wrote she called the hospital and gave a report. It was unclear when the resident left the facility to go to the hospital. A review of the hospital records on [DATE] at 8:30 AM revealed the resident was admitted with septic shock, pneumonia [infection in the lungs] and a urinary tract infection. At times a person with an infection may develop a condition called sepsis. Sepsis is defined as the body's extreme response to an infection. It is a life-threatening medical emergency. Sepsis occurs when a person has an infection and it triggers a chain reaction throughout the body. Most cases of sepsis start before a patient goes to the hospital. Infections that lead to sepsis most often start in the lung, urinary tract, skin, and gastrointestinal tract. Sepsis presents with low blood pressure, high pulse rate, and trouble breathing. Sepsis-induced hypotension (low blood pressure) is defined as the top number of the blood pressure is less than 65 mmHg. Septic Shock is a life threatening condition characterized by sepsis-induced hypotension that does not respond to treatment. Without timely treatment, sepsis/septic shock can rapidly lead to tissue damage, organ failure, and death. (www.cdc.gov) Furthermore, the hospital records showed the resident was treated with intravenous fluids (fluids administered into the veins) with vasopressin (medications to increase the blood pressure) added. Subsequently, the resident expired on [DATE] at 11:27 AM. An interview with Geriatric Nursing Assistant (GNA) Staff #81 on [DATE] at 9:24 AM revealed that she had been unaware that she was assigned Resident #112 on [DATE]. A subsequent review of the GNA documentation on [DATE] at 9:45 AM revealed that Resident #112 had not been provided care by a GNA that day. During an interview with LPN Staff #46 on [DATE] at 12:02 PM, he reported that he was working on [DATE] and went to Resident #112's room to get a set of vital signs for RN Staff #70. He reported that the resident was only responding to a sternal rub (a painful technique of rubbing a person's sternum with the knuckles of the hand to check if they respond to the pain.). He stated he took the resident's vital signs and then stayed with the resident until emergency services arrived. He was unable to recall the time. He was unable to recall the vital sign readings that day, but he stated he would call the doctor for a systolic (top number) b/p below 100 mm Hg or a diastolic (bottom number) below 60. An interview with RN #70 on [DATE] at 2:50 PM, revealed that, if a resident was on a blood pressure medication with no parameters, and if she observed a large drop in the blood pressure or if the systolic (top number) was below 100, she would hold a blood pressure medication and call the doctor. However, the documentation in Resident #112's medical record showed RN #70 failed to notify the physician on multiple occasions. When asked about monitoring a resident's urinary output, she reported she would notify the doctor if the resident's urinary output was less than 400 mL for the day. Furthermore, she stated she would check to see if the urine was amber, a decrease in appetite, their fluid intake, and behavior changes. However, documentation in Resident #112 medical record showed RN #70 failed to report these changes to the doctor. RN #70 reported that she had been assigned to Resident #112 for 16 hours on Saturday [DATE] and Sunday [DATE]. She reported on Saturday ([DATE]) there was not too much going on with the resident, no complaints. It was Sunday ([DATE]) morning that the resident was upset and stated s/he did not want to be here anymore. The resident stated s/he did not want me to call his/her family because they may interrogate him/her. RN #70 stated she remembered the resident talking back and forth with his/her roommate. She stated that closer to lunch time, she was checking the resident every 30 to 45 minutes due to the concern with him/her feeling sad. RN #70 reported that she tried to conduct a physical assessment, but the resident would not turn for her. She reported she obtained a full set of vital signs and had no concerns with the readings, but more concerned about the resident's psychological state. She reported she remembered the family coming and they were concerned because the resident would open his/her eyes but not talk to them. She stated she thought it was the family dynamics. When the family wanted the resident to be sent out, she called the on-call and explained to her that I thought it was behavioral and she said we could send her out per family request. Then RN #70 went down and took the vital signs and the SPO2 was 88% and that was when the resident went downhill fast. During a review of the times the resident had a low blood pressure, high pulse, and a decreased urinary output, RN #70 reported that if the blood pressure had been that low, she would have retaken it but may not have documented it in the record. She offered no explanation for the failure to notify the physician earlier. An interview with the Director of Nursing on [DATE] at 3:55 PM revealed that if a resident has a normal blood pressure and then drops, she expects staff to report that to the physician. If a resident has a catheter and the urinary output drops, then she expects staff to check the catheter for kinks/blockages and notify the physician if there were no issues and urinary output was low. Surveyor reviewed the concerns and she stated she had no rationale for why the nurses would not have reported changes to the physician. When asked if a resident had a history of sepsis, still had wounds, and a urinary catheter what changes would she monitor, she stated the low blood pressure, high pulse rate, and decreased urinary output. An interview with LPN #20 on [DATE] at 11:51 AM revealed she remembered reporting Resident #112's stomach concerns to attending Physician #61. When asked where she had documented these interactions, she stated that at least once it was a verbal interaction and then another time, she wrote it on a list of concerns that was given to him when he came to the unit. She stated she should have written a progress note, but at that time they were using agency staff and she was busy helping them take care of their residents. As result of these findings an Immediate Jeopardy (IJ) was called on [DATE] at 3:00 PM. The facility provided a plan of correction to lift the immediacy and it was accepted by the State Agency on [DATE] at 6:34 PM. The plan of correction was as follows: Resident #112 no longer resides in the facility. Completed on [DATE]. Residents who reside in the facility with a Change of Condition have the potential to be affected by this alleged deficient practice. Completed on [DATE]. The facility activity report and the 24-hour report for the past 72 hours will be audited by the Director of Nursing/ designee to identify any documentation that indicates a change of condition and validate that the physician has been contacted for further direction. This will be completed by [DATE]. An alternate physician has been assigned to residents and will be acting as Medical Director. Completed on [DATE]. Licensed nurses to be re-educated by Director of Nursing and Assistant Director of Nursing on the following: Identifying, assessing and reporting acute change in condition, including abnormal vital signs and notifying physician for further direction Abuse, Neglect and Misappropriation of Funds. Director of Nursing/ Assistant Director of Nursing will educate the Dietitian on the importance of identifying changes of condition/weight changes and notifying the DON immediately. This reeducation will be completed by [DATE]. Any licensed nurse not receiving this training by this date for exceptions such as LOA will receive it prior to the next scheduled shift. Vital alerts were added to the Matrix system ensuring abnormal vital signs are alerted. Completed on [DATE]. The Medical Director was notified on [DATE] of Immediate Jeopardy. An Ad Hoc Quality Assurance Performance Improvement (QAPI) meeting will be held on [DATE] to discuss the contents of this plan. Ongoing QAPI monitoring will include: Director of Nursing/Assistant Director of Nursing will review the Vitals out of Range report daily Monday through Friday in a clinical morning meeting. The Weekend Supervisor will review on the weekend. The Director of Nursing or Designee will review the Facility Activity report and 24-hour report to identify any documentation regarding a change of condition and validate that the resident has been assessed appropriately and physician notified. This will be completed Monday through Friday in the Clinical Morning meeting and by the weekend supervisor on the weekends. Results of the monitoring will be presented to the Quality Assurance and Performance Improvement Committee for review and recommendation for 3 months. Any concern identified will be addressed at time of discovery. Final date of Compliance will be [DATE]. The facility's plan of correction to lift the immediacy was accepted on [DATE] at 6:34 PM. The immediate jeopardy was cleared through record review and interview on [DATE] at 12:30 PM. 16218 2) On [DATE], review of Resident #107's medical record revealed the resident was admitted to the facility in [DATE] with diagnoses that included, but were not limited to, diabetes, high blood pressure and obesity (overweight). Further review of the medical record revealed a physician order for monthly weights, in effect from [DATE] until the resident's discharge in [DATE]. Review of the vital signs section of the medical record revealed the resident's weight on [DATE] was 228.4 lbs and on [DATE] was 227.9 lbs. No weight was found for the month of October. During an interview with the unit nurse manager (Staff #8) on [DATE] at 9:35 AM revealed that, if a resident refused a weight, she would go and talk to the resident and that the expectation is that the nurses would document the refusal in the medical record and that staff would attempt to obtain the weight the next day or later. Further review of the medical record failed to reveal documentation to indicate the resident refused to be weighed during his/her admission. Surveyor reviewed the concern with the Clinical Service Director (Staff #41) on [DATE] at 9:33 AM regarding the failure to obtain the monthly weight as per the physician order. As of time of exit on [DATE], no documentation was provided to indicate a weight was obtained or attempted for [DATE]. Further review of the medical record revealed a weight of 200.8 lbs was obtained on [DATE]. This 27.1 lbs weight loss represents a loss of more than 10% in two months. A weight loss is considered to be severe if it is greater than 7.5% in 3 months, or greater than 10% in 6 months. Further review of the medical record failed to reveal documentation to indicate the primary care provider was made aware of this significant weight loss. The resident was seen by the primary care provider nurse practitioner (NP Staff #59) on [DATE]. Review of this note failed to reveal documentation acknowledging the recently identified weight loss and included the following notation: .no significant weight gain or loss . The RD (Staff #66) wrote a note about the 27 lb weight loss on [DATE] indicating it was expected and beneficial. No documentation was found in this note to indicate the RD informed the physician of the weight loss. On [DATE], further review of Resident #107's medical record revealed an order for metoprolol 25 mg to be given twice a day and to hold if the systolic blood pressure (SBP top number of a blood pressure reading) was less than 100 or if the heart rate was less than 60. This order was in effect from [DATE] until the resident was discharged in [DATE]. Review of the MAR for [DATE] revealed on [DATE] at 5:00 PM, the resident's blood pressure was ,d+[DATE] and [TRUNCATED]

Based on record review and staff interview, it was determined that the facility failed to ensure that their residents were free from abuse and neglect. This was evident for 2 (#112 and #107) out of 26 residents reviewed for abuse and neglect. The findings include: The MDS (Minimum Data Set) is a complete assessment of the resident which provides the facility with the information necessary to develop a plan of care, provide the appropriate care and services to the resident, and to modify the care plan based on the resident's status. A care plan is a guide that addresses the unique needs of each resident. It is used to plan, assess, and evaluate the effectiveness of the resident's care. 1) On [DATE] at 5:45 PM, a review of the facility's investigation file for a facility reported incident #MD00181072 was completed which stated that the facility had received an allegation of neglect for Resident #112. The former Director of Nursing Staff #47 conducted an investigation and failed to recognize that staff failed to promptly assess, identify, and notify the attending physician of acute changes in the resident's condition. Furthermore, she failed to note whether she had substantiated the neglect or not. A statement in the facility's investigation report read that measures were taken to prevent further incidents of similar nature, however, she failed to indicate what these measures were, and the investigation file had no evidence of these measures. Subsequently, on [DATE] at 9:00 AM 2 allegations of neglect of Resident #112 were reviewed: #MD00180651 and #MD00182736. MD00182736 alleged that the neglect of Resident #112 led to an unexpected death of the resident. The investigation findings were as follows. On ,d+[DATE], according to the attending physician's History and Physical (H&P) note, Resident #112 was admitted to the facility for rehabilitation and continued treatment of cellulitis following a hospitalization for sepsis, cellulitis, and wound care. The resident had a foley catheter for urinary retention. Further review of the medical record revealed that the resident had the capacity to make his/her own medical decisions. Furthermore, review of the admission Minimum Data Set, with the assessment reference date of [DATE], revealed in section C that the resident had no cognitive impairment. A review of the wound Nurse Practitioner (NP) Staff #67's visit note, dated [DATE], indicated the resident had a Stage 4 pressure ulcer on his/her left heel. A Stage IV pressure ulcer means that there had been skin and tissue loss deep enough to expose the muscle and bone. The resident had a second wound on his/her left posterior (back) thigh that was classified as a Stage 3 wound. A Stage 3 wound means there was skin loss, and the layer of fat has been exposed. A review of the resident lab reports revealed that Resident #112 was diagnosed with C-Diff (Clostridioides difficile - a bacteria that causes diarrhea and inflammation of the colon. Cdc.gov) on [DATE]. A review of the physician's order summary revealed the resident was treated with Vancomycin until [DATE]. This illness was known to cause a decrease in appetite, vomiting, and diarrhea, placing the resident at risk for malnutrition. According to the National Institute of Health (https://pubmed.ncbi.nlm.nih.gov) optimal wound healing requires adequate nutrition. Poor nutrition slows down or stops the wound from progressing through the stages of wound healing and malnutrition can increase the risk of infection. A review of the Dietitian's note dated [DATE], revealed Resident #112's weight was 218 lbs. which represented a 19 lbs. (8% body weight) loss in 30 days. However, she stated the weight loss was expected due to a gastrointestinal illness.Review of the resident's physicians order summary for [DATE], revealed the resident had an order in place for a protein supplement daily to aid in wound healing and a protein shake daily for unspecified protein calorie malnutrition. The Wound NP Staff #76 wrote in her progress notes on the following dates that the resident had complained of abdominal pain and/or discomfort: [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], and [DATE]. Staff #76 failed to document that the attending physician had been made aware of any of these complaints. Registered Nurse (RN) #16, the facility's wound nurse, was present at these visits and wrote a progress note of her own and failed to mention the resident's complaints of abdominal pain, as well as reporting it to the attending physician. A review of the progress note written by Licensed Practical Nurse (LPN) #76 on [DATE], revealed the resident's attending Physician #61 had seen the resident for complaints of abdominal pain. The note stated that he ordered the following medications: Mirlax and Colace for stool softener and Bentyl (a medication used to treat irritable bowel syndrome) for abdominal pain. However, further review revealed no physician's progress note. Furthermore,when questioned, facility staff provided this note to the surveyor on [DATE], as this note was not found in the medical record and was not signed until [DATE]. A review of the attending Physician #61's progress note, dated [DATE], revealed that he failed to document the plan of treatment for the abdominal pain and mention the medications he had ordered. Under the section plan, he wrote the resident was medically stable, continuing with present medications and care. On [DATE], LPN Staff #75 documented that the resident complained of side pain and was administered acetaminophen (Tylenol) and then had a small emesis. An hour later when Staff #75 followed up on the effectiveness of the acetaminophen, she administered the Bentyl that had been ordered on [DATE] as-needed for abdominal pain. According to the MAR this had been effective. LPN Staff #20 wrote on [DATE] that the resident was eating poorly, refused his/her bowel medications, and had a complaint of stomach gasses and bloating. Staff #20 then wrote that the resident had recently spoken to his/her doctor and Colace (stool softener) and MiraLAX (stool softener) had been ordered. The physician visit had been [DATE], 5 days prior to this note, and there was no evidence that the nurse conducted an assessment of this medical concern and or notified the attending physician. On [DATE], the Dietitian noted in the progress notes that the Resident's weight continued to drop. The admission weight was 262 lbs. At the time of the note, the resident weighed 190 lbs. The resident informed the Dietitian that s/he had not eaten because it made his/her stomach swell up. However, there was no documentation that the physician had been notified. On [DATE], the Dietitian sent the surveyor email correspondence,dated [DATE], that she sent to LPN #68, who was the unit manager at the time, which made the unit manager aware of the weight loss. There was no mention of abdominal distress. Furthermore, there was no evidence in the medical record that attending Physician #61 was made aware of the weight loss or the abdominal distress. That same day, on [DATE], LPN Staff #20 told the Dietitian the resident had not been taking her supplements, was eating poorly, and complaining of nausea when out of bed. However, LPN #20 failed to notify the attending physician. Review of attending Physician #61's progress note, dated [DATE], revealed that s/he documented the resident had no concerns, with no mention of the resident's complaints of abdominal pain and emesis. Again, facility staff provided this note to the surveyor on [DATE], as this note was not found in the medical record and was not signed until [DATE]. On [DATE], LPN #20 wrote a note that the resident continued to report the medications made him/her feel ill and reported that his/her stomach was upset. The nurse failed to further assess the stomach concern and there was no documentation that the attending physician was made aware that, 3 weeks after the visit on [DATE], the resident was not feeling better and the treatment he prescribed was not effective. On [DATE], a late note for [DATE], was entered by LPN Staff #76, who wrote that Resident #112 complained of pain in the right lower quadrant. Staff #76 failed to document an assessment of the abdomen and gave Tylenol despite having a PRN (as needed) order for Bentyl for abdominal pain. When LPN #76 contacted the on-call Nurse Practitioner (NP) #79, for a new area on the resident's head, she failed to report the abdominal distress. A review of the Resident's vital sign report revealed that on [DATE] at 1:28 AM, the resident's blood pressure (B/P) was ,d+[DATE]. Further review of the medical record revealed this was a decrease in the blood pressure from the resident's norm. On [DATE] at 9:00 AM, a review of the facility's standards of professional practice revealed that hypotension (low blood pressure) is present when the systolic (top number) of the blood pressure falls to 90 mm Hg or below. Furthermore, it stated that while some adults have low b/p normally, for most people a low b/p is an abnormal finding associated with illness. ([NAME] and [NAME], 9th Version, 2017). However, further review of the medical record revealed the nurse failed to notify the attending physician of this change in condition. An interview with LPN Unit Manager Staff #8 on [DATE] at 11:33 AM revealed that she would call the doctor when a systolic (top number) was less than 110 mm HG (millimeters of mercury). She stated that nurses learn that information when they are in nursing school. A review of the Resident's vital signs revealed that, on [DATE] at 9:48 PM, the resident's vital signs were as follows: B/P ,d+[DATE], temperature (T) 97.7 F, pulse (P) 115, respirations (R) 16, and oxygen saturation (SP02) 99%. Further review of the medical record revealed this was a decrease in the blood pressure from the resident's norm and there was no evidence in the medical record that LPN Staff #78 reported this change to the attending physician. Review of the nurse's skin assessment sheet on [DATE] revealed the resident had been pale, which was a change from the previous skin checks. However, there was no evidence that the physician had been made aware of this change. The Dietitian entered a note on [DATE], that read, nutrition note for supplement review with nursing; ensure, prostat, and B complex with C discontinued. There was no indication that this was discussed with the physician or that he had been aware of the change. A review of the attending Physician #61's progress note dated [DATE],with a note added under HPI section, that the resident reported continued weakness. There was no indication in this note that attending Physician #61 had been aware of the resident's continued weight loss of 31 % of his/her body weight, the continued abdominal pain, the decrease in blood pressure and increased pulse. Furthermore, facility staff provided this note to the surveyor on [DATE], as this note was not found in the medical record and was not signed until [DATE]. A review of the Medication Administration Record (MAR) revealed the resident's urinary output for 24 hours on [DATE] was 300 milliliters (mL). (Urine output in 24 hours less than 400 mL can be one of the first signs of kidney failure) The resident had a urinary catheter due to urinary retention and nursing staff failed to recognize that this change was significant enough to contact the attending physician. A review of the MAR revealed on [DATE] at 12:20 AM that the resident complained of shortness of breath and was given an albuterol as-needed dose. According to the record, this was a new symptom. In addition, a review of the Resident's vital signs revealed that, on [DATE] at 12:31 AM, the resident's vital signs were as follows: B/P ,d+[DATE], T 97.97 F, P 95, R 18, and SP02 96%. This was a decrease in the blood pressure from the resident's norm and from the previous readings on [DATE] at 9:48 PM. LPN #75 failed to recognize that the shortness of breath was new and the decrease in blood pressure may indicate a significant change in the resident ' s medical condition and failed to report the changes to the attending physician. A review of the MAR for [DATE] revealed that the LPN #20 documented at 9:05 AM she attempted to administer Cardizem ER 24 hr. 180 mg, but the resident refused it and stated it upset their stomach. Lasix 20 mg was given. (Lasix is a medication that helps the body get rid of excess water and salt. In the process of doing this Lasix may lower the blood pressure and is at times given to lower blood pressure) This was prior to obtaining a set of vital signs at 9:57 AM, so the last set of VS indicated a B/P of ,d+[DATE]. Further review revealed the resident's urinary output for the last 24 hours was again very low at 375 cc and staff failed to inform the physician. On [DATE], LPN Staff #77 wrote that the resident had complaints of generalized pain, however she failed to conduct an assessment of the pain. The resident continued to have weight loss as the recorded weight for [DATE] was 179.4 lbs. However, the staff failed to notify the physician. The Dietitian failed to assess the resident who, despite her attempts, had continued to lose weight and she failed to discuss this with the attending physician. A review of the MAR for [DATE] revealed that RN #70 attempted at 9:05 AM to administer the resident's blood pressure medication, but the resident refused. Lasix 20 mg was administered. A review of the resident's vital signs taken on [DATE] at 9:41 AM revealed a B/P of ,d+[DATE], T 98 F, P 109, R 16, and SP02 of 94%. The RN failed to recognize the resident's continued decrease in blood pressure and increase in pulse rate were indications of a change in his/her medical status and failed to notify the physician. On [DATE], Registered Nurse (RN) #70 wrote a note that the resident continued to complain of abdominal pain and that the resident's doctor was aware because it was not a new symptom. There was no evidence that RN #70 assessed the pain or evaluated the plan of care. RN #70 failed to notify the physician of the continued abdominal pain and that the resident continued to refuse medications. A review of the resident's vital signs taken on [DATE] at 9:41 AM revealed a B/P of ,d+[DATE], T 98 F, P 109, R 16, and SP02 of 94%. RN Staff #70 failed to reassess the blood pressure and notify the physician. A progress note written by the RN Staff #70 on [DATE] at 5:17 PM read, Resident did state that he/she felt his/her Symbicort inhaler wasn't working today. Educated the resident that he/she needed to take a deep breath in at the same time she pushes down on the inhaler. Otherwise she is not getting the full dose of her medication. Offered her the Albuterol inhaler and he/she used it. It seemed to help her symptoms. SpO2 this AM was 94%. SpO2 this PM was 93%. Assessed her lungs and they were clear but diminished. Resident diminished sounds are not uncommon due to her history. She has a history of SOB, Anxiety, Moderate persistent Asthma and environmental Allergic Rhinitis. VSS. Will continue to monitor. A review of the medical record failed to reveal that the resident had diminished lungs sounds previously, nor was there frequent use of the as-needed inhaler until [DATE] and [DATE], indicating there was a change. RN Staff #70 failed to recognize these signs that the resident's health condition had changed and notify the physician. A review of the MAR revealed that on [DATE] the resident's total urinary output was 350 cc and the nursing staff failed to recognize that this decrease in urinary output had continued for 2 days and nursing staff failed to notify the physician. A review of the MAR for [DATE] revealed that RN #70 wrote a note at 8:03 AM that she attempted 2 times to give the resident his/her blood pressure medication, but the resident had refused that and his/her Lasix. RN Staff #70 had knowledge of the resident's low blood pressure the day before and failed to obtain a blood pressure prior to offering the resident their blood pressure medication. When the nurse obtained the vital signs at 10:20 AM that day, they were as follows: B/P ,d+[DATE], T 98 F, P 106, R 16, and SP02 of 93%. However, she failed to notify the physician at this time. In a progress note on [DATE] at 11:52 AM, RN Staff #70 wrote, Encouragement given all shift to the resident to drink more water. Her urine is a dark amber color. NO symptoms of a UTI. Denies any pain in the lower abdominal region where the bladder lies. Went into the resident's room several hours later and he/she still had not drank any fluids. Resident has been non-compliant with any suggestions to help himself/herself feel better or the functionality of his/her body. RN Staff #70 failed to recognize that the resident's urinary output of less than 400 mL for the last 3 days, coupled with the assessment of dark amber urine, the low blood pressure readings, and increased pulse rate were all significant signs that the resident's health condition was declining and failed to call the physician at this time. On [DATE] at 5:55 PM, RN #70 wrote, Resident's family into visit resident at this time resident is not talking to them and will not answer them when they talk to her. O2 [oxygen] sat [saturation] 88 % on room air, O2 put on resident, at 3 liters. O2 sat came up to 90% had to turn O2 up 5 liters to get it to come up to 92%. Resident Lung sounds assessed by this writer. He/she has congestion in the right upper lung field. Resident has a dry congested cough. Resident is unresponsive; he/she will open his/her eyes but will not speak to us. Temp. 98.1 pulse 40 Resp 18 B/P ,d+[DATE]. Certified Registered Nurse Practitioner (CRNP) Staff #79 notified N/O to send resident To ER [emergency room ] for evaluation 911 called. However, due to subsequent notes written by RN #70 on [DATE] it was unclear if 911 had been called at this time. In addition, the Situation, Background, Assessment, and Recommendation (SBAR) tool that was completed by RN #70 failed to document all the symptoms the resident had been having and it was unclear if the on call CRNP #80 had been made aware the resident's full decline in condition. On [DATE] at 6:24 PM Social Service Staff #80 wrote, [Resident #112] being sent to [hospital] at the family's request as [his/her] HCA [Health Care Agent] is argumentative and adamant that there is something medically wrong with [resident]. [Resident's] vital signs are stable and no vital alerts at this time contrary to family's adamancy. [Resident's] symptoms of concern for the family are variable to the attention it receives and is observed by various staff and witnesses . On [DATE] at 6:59 PM, RN Staff #70 wrote a note that the resident had voiced s/he did not want to live any longer. The resident complained of an upset stomach and was given Bentyl which had been effective. The resident had refused all routine medications that day and napped off and on. The nurse failed to recognize these symptoms of the resident's decline in condition and notify the physician earlier that day. On [DATE] at 7:26 PM, RN Staff #70 wrote a note that she informed CRNP #80 of the situation with Resident #112 and it was approved to send the resident to the emergency room per the family request. She wrote she called the hospital and gave a report. It was unclear when the resident left the facility to go to the hospital. A review of the hospital records on [DATE] at 8:30 AM revealed the resident was admitted with septic shock, pneumonia [infection in the lungs] and a urinary tract infection. At times a person with an infection may develop a condition called sepsis. Sepsis is defined as the body's extreme response to an infection. It is a life-threatening medical emergency. Sepsis occurs when a person has an infection and it triggers a chain reaction throughout the body. Most cases of sepsis start before a patient goes to the hospital. Infections that lead to sepsis most often start in the lung, urinary tract, skin, and gastrointestinal tract. Sepsis presents with low blood pressure, high pulse rate, and trouble breathing. Sepsis-induced hypotension (low blood pressure) is defined as the top number of the blood pressure is less than 65 mmHg. Septic Shock is a life threatening condition characterized by sepsis-induced hypotension that does not respond to treatment. Without timely treatment, sepsis/septic shock can rapidly lead to tissue damage, organ failure, and death. (www.cdc.gov) Furthermore, the hospital records showed the resident was treated with intravenous fluids (fluids administered into the veins) with vasopressin (medications to increase the blood pressure) added. Subsequently, the resident expired on [DATE] at 11:27 AM. An interview with Geriatric Nursing Assistant (GNA) Staff #81 on [DATE] at 9:24 AM revealed that she had been unaware that she was assigned Resident #112 on [DATE]. A subsequent review of the GNA documentation on [DATE] at 9:45 AM revealed that Resident #112 had not been provided care by a GNA that day. During an interview with LPN Staff #46 on [DATE] at 12:02 PM, he reported that he was working on [DATE] and went to Resident #112 ' s room to get a set of vital signs for RN Staff #70. He reported that the resident was only responding to a sternal rub (a painful technique of rubbing a person's sternum with the knuckles of the hand to check if they respond to the pain.) He stated he took the resident's vital signs and then stayed with the resident until emergency services arrived. He was unable to recall the time. He was unable to recall the vital sign readings that day, but he stated he would call the doctor for a systolic (top number) b/p below 100 mm Hg or a diastolic (bottom number) below 60. An interview with RN #70 on [DATE] at 2:50 PM, revealed that if a resident was on a blood pressure medication with no parameters, if she observed a large drop in the blood pressure or if the systolic (top number) was below 100, she would hold a blood pressure medication and call the doctor. However, the documentation in Resident #112's medical record showed RN #70 failed to notify the physician on multiple occasions. When asked about monitoring a resident's urinary output, she reported she would notify the doctor if the resident's urinary output was less than 400 mL for the day. Furthermore, she stated she would check to see if the urine was amber, a decrease in appetite, their fluid intake, and behavior changes. However, documentation in Resident #112 medical record showed RN #70 failed to report these changes to the doctor. RN #70 reported that she had been assigned to Resident #112 for 16 hours on Saturday [DATE] and Sunday [DATE]. She reported on Saturday ([DATE]) there was not too much going on with the resident, no complaints. It was Sunday ([DATE]) morning that the resident was upset and stated s/he did not want to be here anymore. The resident stated s/he did not want me to call his/her family because they may interrogate him/her. RN #70 stated she remembered the resident talking back and forth with his/her roommate. She stated that closer to lunch time, she was checking the resident every 30 to 45 minutes due to the concern with him/her feeling sad. RN #70 reported that she tried to conduct a physical assessment, but the resident would not turn for her. She reported she obtained a full set of vital signs and had no concerns with the readings, but more concerned about the resident's psychological state. She reported that she remembered the family coming and they were concerned because the resident would open his/her eyes but not talk to them. She stated she thought it was the family dynamics. When the family wanted the resident to be sent out, she called the on-call and explained to her that I thought it was behavioral and she said we could send her out per family request. Then RN #70 went down and took the vital signs and the SPO2 was 88% and that was when the resident went downhill fast. Reviewed with RN #70 the times the resident had a low blood pressure, high pulse, and a decreased urinary output. She reported that if the blood pressure had been that low, she would have retaken it but may not have documented it in the record. She offered no explanation for the failure to notify the physician earlier. An interview with the Director of Nursing on [DATE] at 3:55 PM revealed that if a resident has a normal blood pressure and then drops, she expects staff to report that to the physician. If a resident has a catheter and the urinary output drops, then she expected staff to check the catheter for kinks/blockages and notify the physician if there were no issues and urinary output was low. Surveyor reviewed the concerns and she stated she had no rationale for why the nurses would not have reported changes to the physician. When asked if a resident had a history of sepsis, still had wounds, and a urinary catheter what changes would she monitor, she stated the low blood pressure, high pulse rate, and decreased urinary output. An interview with LPN #20 on [DATE] at 11:51 AM revealed she remembered reporting Resident #112's stomach concerns to attending Physician #61. When asked where she had documented these interactions, she stated that at least once it was a verbal interaction and then another time, she wrote it on a list of concerns that was given to him when he came to the unit. She stated she should have written a progress note, but at that time they were using agency staff and she was busy helping them take care of their residents. As result of these findings an Immediate Jeopardy (IJ) was called on [DATE] at 3:00 PM. The facility provided a plan of correction to lift the immediacy and it was accepted by the State Agency on [DATE] at 6:34 PM. The plan of correction was as follows: Resident #112 no longer resides in the facility. Completed on [DATE]. Residents who reside in the facility with a Change of Condition have the potential to be affected by this alleged deficient practice. Completed on [DATE]. The facility activity report and the 24-hour report for the past 72 hours will be audited by the Director of Nursing/ designee to identify any documentation that indicates a change of condition and validate that the physician has been contacted for further direction. This will be completed by [DATE]. An alternate physician has been assigned to residents and will be acting as Medical Director. Completed on [DATE]. Licensed nurses to be re-educated by Director of Nursing and Assistant Director of Nursing on the following: Identifying, assessing and reporting acute change in condition, including abnormal vital signs and notifying physician for further direction; Abuse, Neglect and Misappropriation of Funds. Director of Nursing/ Assistant Director of Nursing will educate the Dietitian on the importance of identifying changes of condition/weight changes and notifying the DON immediately. This reeducation will be completed by [DATE]. Any licensed nurse not receiving this training by this date for exceptions such as LOA will receive it prior to the next scheduled shift. Vital alerts were added to the Matrix system ensuring abnormal vital signs are alerted. Completed on [DATE]. The Medical Director was notified on [DATE] of Immediate Jeopardy. An Ad Hoc Quality Assurance Performance Improvement (QAPI) meeting will be held on [DATE] to discuss the contents of this plan. Ongoing QAPI monitoring will include: Director of Nursing/Assistant Director of Nursing will review the Vitals out of Range report daily Monday through Friday in a clinical morning meeting. The Weekend Supervisor will review on the weekend. The Director of Nursing or Designee will review the Facility Activity report and 24-hour report to identify any documentation regarding a change of condition and validate that the resident has been assessed appropriately and physician notified. This will be completed Monday through Friday in the Clinical Morning meeting and by the weekend supervisor on the weekends. Results of the monitoring will be presented to the Quality Assurance and Performance Improvement Committee for review and recommendation for 3 months. Any concern identified will be addressed at time of discovery. Final date of Compliance will be [DATE]. The facility's plan of correction to lift the immediacy was accepted on [DATE] at 6:34 PM. The immediate jeopardy was cleared through record review and interview on [DATE] at 12:30 PM. Cross Reference: F607, F692, and F711. 16218 2) Review of facility report MD00177205 revealed that on [DATE], the facility received an allegation of abuse of Resident #107 by Geriatric Nursing Assistant (GNA - Staff #56). Review of Resident #107's medical record, on [DATE], revealed the resident was his/her own responsible party, and was certified as able to make his/her own decisions. The resident was cognitively intact as evidenced by a Brief Interview for Mental Status score of ,d+[DATE]. The resident was discharged from the facility in [DATE] and was not available to be interviewed during the survey. On [DATE] review of a Complaint/Grievance Report, completed by then Director of Social Services (Staff #87), revealed Resident #107 made the initial report of abuse to Staff #87 on [DATE]. On [DATE], the statement of an interview with Resident #107 was reviewed. This statement was signed by then Director of Nursing (Staff #62) and Assistant Director of Nursing (Staff #47) on [DATE]. This statement included the following: Resident stated that [name of GNA #56] aggressively turned [him/her] via pushing and pulling [him/her]. Resident stated this caused pain to [his/her] shoulder. Resident then stated [name of GNA #56] made some African American racial comments. I asked the resident twice what these comments were and both times [s/he] stated [s/he] rather not say. Resident also states [GNA] told [him/her], I don't have to do shit for you, I just have to make it look good. Resident was tearful and stated [s/he] had fear of repercussion if [name of GNA] knew [s/he] told. On [DATE], the statement of an interview with GNA #42 was reviewed. This statement was signed by then Director of Nursing (Staff #62) and Assistant Director of Nursing (Staff #47) on [DATE]. This statement included the following: I asked [GNA #42] to please explain to me in detail what occurred in [room #] with [Resident #107]. She then told me [GNA #56] was already in the room when she came in and [GNA #56] did aggressively attempt to roll the resident by pushing and pulling. The resident asked [GNA #56] to stop. [GNA #56] then stated I don't have to do shit for you, I just have to make it look good for everyone else. Further review of the investigation documentation revealed that additional residents were interviewed and and three of them reported concerns regarding GNA #56. Review of the statement signed by Staff #62 and #47 on [DATE] regarding these interviews revealed the following statements: When my shoulder was broken she jerked my arm and made it hurt bad. Her care is rough sometimes. She yells at me sometimes and refuses to answer my call light and says it's because I make her mad. She is always cussing at me and telling me she doesn't like me. Review of GNA #56's employee file, on [DATE], revealed that, on [DATE], a grievance was filed about the GNA and a Performance Feedback form was completed and signed by then Director of Nursing (Staff #62) and Assistant Director of Nursing (Staff #47). There is a notation that Employee acknowledged incident and future process but in the area for Employee Comments: Refused to sign was documented and the area for employee to sign was noted to be blank. Further review of the employee file revealed that, on [DATE], a Corrective Action Form was completed and signed by Staff #62 and #47. There is a notation that the employee Refused to sign. Reason for Action: [GNA #56] has multiple performance feedbacks and corrective actions in the last 12 months. [GNA #56] has several reports recently of insubordinate behavior towa [TRUNCATED]

Based on medical record review and staff interview, it was determined that the facility 1) failed to prevent a cognitively impaired resident from exiting the facility, unsupervised, for an unknown amount of time. This was found to be evident for 1 (#84) of 16 residents reviewed for accidents. The findings include: 1) Elopement occurs when residents who are incapable of protecting themselves from harm are able to successfully leave the facility unsupervised and unnoticed and possibly enter into harm's way. On 7/19/23 at 10:45 AM, a review of Resident #84 ' s medical record was conducted. In a History and Physical note, the physician documented that Resident #84 was admitted from home with progressive dementia, and stated the resident was alert to self only and could only communicate basic needs. A review of a Physician Certification Related to Medical Condition, Substitute Decision Making and Treatment Limitations form, which was signed by two physicians on 8/10/22, Resident #84 was deemed incapable due to dementia. On 8/10/22 at 1:00 PM, in a psychotherapy progress note, the psychiatrist documented that Resident #84 could not understand his/her medical conditions and diagnoses and lacked the ability to make informed medical decisions. Review of Resident #84's quarterly assessment with a reference date of 2/11/23 documented the resident's BIMS (brief interview for mental status) score was 5, indicating Resident #84 had severe cognitive impairment. Review of the resident's progress notes revealed on 2/23/23 at 8:15 AM, the SSA (social services assistant) documented that Resident #84 was observed getting on the elevator independently, and once downstairs, the resident went outside with a staff member. The SSA indicated that once outside, Resident #84 would not come back inside the facility, that several staff attempts were made to get him/her to come inside, the police were called, and after a while, Resident #84 agreed to go back in the building and returned to his/her unit. Following the incident on 2/23/23, staff initiated the following a care plan, [Resident #84] is at risk for elopement related to impaired cognitive function - Dementia evidenced by going outside of the building (staff aware and were with him) and refusing to come back in . The care plan goal was for the resident not to have any unplanned/unsupervised outings during the review period and the interventions listed were to have Activities staff check on the resident periodically to ensure that s/he had activities to do, encourage participation in activities programs of h/her choosing and socialization with his/her peers, and plan supervised outings to places he/she may wish to visit, encourage family support and to monitor the residents whereabouts and redirect when s/he is standing or hovering near the elevators, and to have the family take the resident ' s hat, coat and gloves home. During an interview on 7/20/23 at 1:00 PM, Staff #20, LPN (Licensed Practical Nurse), indicated that in the days following the incident with Resident #84 on 2/23/23, when he/she was assigned to care for the resident, the nurse was not aware that Resident #84 had attempted to elope and h/she was not conducting frequent checks on the resident. Staff #20 reported that Resident #84 did not consider him/herself a resident in the facility and that he/she was staying at the facility until he/she could get another place to live. Staff #20 stated Resident #84 would seek out new staff and visitors to get them to let him/her on the elevator. Also, Staff #20 reported Resident #84 had been overheard telling other residents that knew the elevator code that s/he was able to go down the elevator to the snack machine with them. Staff #20 stated Resident #84 would hang out at the elevator at the change of shift (between 2:30 PM - 3:00 PM) because it is chaotic at that time, and the resident could slip out. A review of the progress notes dated 2/24/23 - 7/9/23 revealed Staff #20 had failed to document the resident's exit seeking behaviors and the fact that the resident thought that they were not a resident in the facility. Further review of the progress notes revealed that, on 2/27/23 at 2:48 PM, the Social Services Director wrote that Resident #84 was witnessed attempting to enter the elevator and when they intervened, Resident #84 became upset for preventing the resident from getting on the elevator. Resident #84's medical record review revealed Elopement Risk Assessments (used to identify a resident's risk for elopement and implement interventions to prevent a resident from leaving the facility unsupervised) which documented responses to observation detail questions, the decision to proceed or not proceed based on the assessment, and interventions to prevent elopement. On 3/27/23, the assessment documented that Resident #84 had a diagnosis of unspecified dementia, the resident was confused, he/she was able to walk or self-propel in a wheelchair, had a history of wandering, expressed a desire to leave the health care center and had a diagnosis that required supervision. Further review revealed Resident #84's elopement risk assessment was inaccurate and incomplete: On 3/27/23 at 12:07 PM, in a quarterly Elopement Risk Assessment, the question has the resident attempted to leave the health care center? was coded no, which was inaccurate. On 2/23/23 at 8:15 AM, in a progress note, the SSA documented Resident #84 was observed accessing the elevator independently, and once outside with a staff member, the resident would not come back in. Following the incident, on 2/23/23, a care plan, [Resident #84] is at risk for elopement ., was implemented. Also, on 2/27/23 at 2:48 PM, in a progress note, the SSA documented Resident #84 was witnessed attempting to enter the elevator and the resident became upset when prevented from getting on the elevator. In addition, the decision to proceed or not proceed was unanswered, with no interventions documented.A review of an initial self-reported incident #MD00192154 revealed a facility self-report form dated 5/6/23 at 6:10 pm, that documented Resident #84 was missing from the facility. It was unclear how long the resident had been missing, however, the Director of Nurses (DON), the writer of the self-report form, was notified at 5:34 PM. The facility reported the resident was not located in the building and did not sign him/herself out for leave of absence, the resident's representative was contacted and had not heard from the resident and 911 was called. The facility's final self-report, dated 5/8/23 at 1:25 PM, documented Resident #84 was located by local law enforcement at 8:11 PM at a Rescue Mission and returned to the facility around 9:30 PM on 5/6/23 with no injuries noted. The self-report documented that following the resident's elopement, an intervention to place a wanderguard on Resident #84 was attempted, but the resident refused, and the facility conducted 15-minute checks on the resident. In a progress note written on 5/6/23 at 11:41 PM, Staff # 31, LPN wrote that when the nurse went to get the Resident #84's blood pressure, the nurse was unable to find the resident. The nurse checked the bathroom and dining room and was unable to locate the resident. The nurse made the supervisor aware, and a code yellow was announced. Staff came to the 3rd floor and helped search for the resident. The DON and NHA (Nursing Home Administrator) were notified, came to the facility and the police were called. While the police were in the facility, a call was received from Resident 84's family, reporting Resident #84 was seen in town around 1:30 pm. The police located Resident #84 at 8:30 PM and returned them to the facility around 9:35 PM. The resident refused a head-to-toe assessment and refused a wanderguard. The nurse indicated that a new order for 15 min checks was obtained, and the resident was in bed resting. Following Resident #84's elopement on 5/6/23, the resident ' s Risk for Elopement care plan was updated with the interventions, elevator access code changed, 15 minute checks in place for this resident for safety, and apply wanderguard to resident for safety one he/she will allow staff to place it. On 5/7/23 at 12:32 PM, in a progress note Staff #20, LPN indicated Resident #84 would not allow the staff to apply a wanderguard. On 5/7/23 at 2:20 PM, Staff #47, RN (registered nurse) documented that the resident continued to refuse a wanderguard, and on 5/7/23 at 2:40 PM, in a progress note, Staff #20, LPN, wrote that Resident #84 continued to refuse the wanderguard. No other documentation was found in the medical record to indicate that further attempts were made to apply a wanderguard to Resident #84. On 6/21/23 at 3:33 PM, in a social service note, the Social Services Assistant (SSA) Staff #14 wrote that the resident displayed exit seeking behavior, blocking the elevator with staff on it. Staff de-escalated the situation and redirected the resident. Further review of Resident #84's Elopement Risk Assessments revealed that, on 6/21/23, the assessment documented that Resident #84 had a diagnosis of unspecified dementia, the resident was confused, he/she was able to walk or self-propel in a wheelchair, had a history of wandering, expressed a desire to leave the health care center and had a diagnosis that required supervision. Further review revealed Resident #84 ' s elopement risk assessments inaccurate and incomplete. On 6/21/23 at 1:54 PM, in an Elopement Risk Assessment, the question has the resident attempted to leave the health care center? was coded no, which was inaccurate as the Resident #84 attempted to elope on 2/23/23 and eloped from the facility on 5/6/23. Also, on 6/21/23 at 3:33 PM, in a progress note, the nurse documented Resident #84 displayed exit seeking behavior, blocked the elevator with staff on it and was redirected by staff. The question, Decision, was unanswered, and no interventions were documented. On 7/25/23 at 12:56 PM, Unit Manager Staff #33, LPN revealed that they were responsible for completing the elopement assessments and had not been aware that Resident #84 had attempted an elope on 2/23/23 or 5/6/23. An interview on 7/26/23 at 9:25 AM with Staff #21, GNA revealed that the last time s/he saw Resident #84 on 5/6/23 was at 2:30 PM when the resident was standing at the elevators, which was at the time the dayshift GNAs left for the day. Furthermore, Resident #84 had frequently been observed hanging at the elevators. Staff #21 reported that the resident's appearance could be mistaken for a visitor. An interview with Staff #32, GNA on 7/26/23 at 9:35 AM revealed they had cared for Resident #84 on the day the resident eloped. Staff #32 reported s/he had been aware the resident attempted to elope in February 2023 and was supposed to check on the resident more frequently. However, when Resident #84 was out of his/her room during last rounds the GNA was unable to keep an eye on the resident. Staff #32 reported Resident #84 continued to hang around the elevators. When asked what Staff #32 does when they see this behavior, Staff #32 stated he/she would watch the resident or alert someone else. Staff #32 stated it was concerning because the resident could slip on the elevator at any time the elevator opened if no one was watching him/her. Also, Staff #32 could understand how someone could mistake Resident #84 for a visitor due to the resident's appearance. A subsequent interview with LPN #20 on 7/26/23 at 10:33 PM revealed that Resident #84 continued to have exit seeking behaviors. Staff #20 stated that the resident had told him/her that they will get on a bus and will not get caught the next time, however, there was no documentation in the medical record to reflect this information. Based on the investigation, Resident #84's whereabouts were unknown for 5 1/2 hours. The resident was located by local law enforcement officers hours later at a Rescue Mission, which was located 1.3 miles away from the facility. The place where the resident was found required the resident to cross multiple high-trafficked city streets and one busy snow emergency route. This placed the resident at risk for serious injury or death. In addition, in the facility, there were two elevators that are accessible from the nursing units. Although a code is required to access them, once the doors open, there is up to 15 seconds during which the doors remain open. This delay allows time for a resident to go into the elevator and once in the elevator, they can go to the lobby and exit the facility because the front doors are accessible and unlocked during the day. Resident #84 attempted to leave the facility on 2/23/23, by accessing the elevators independently. On 5/6/23, Resident #84 left the facility unsupervised for 5 1/2 hours. Resident #84 refused to wear a wanderguard which would activate an alarm at the front door. As a result of these findings, a state of immediate jeopardy (IJ) was declared on 7/26/23 at 4:34 PM and an IJ summary tool was provided to the facility at that time. The facility submitted the first draft of their plan to remove the immediacy on 7/26/23 at 7:02 PM and it was not accepted. The facility submitted a second draft at 7:44 PM, and it was not accepted. The third draft was submitted on 7/26/23 at 8:04 PM and the facility's written plan to remove the immediacy was accepted on 7/26/23 at 8:28 PM with and alleged date of compliance of 7/27/23. The provisions of the plan to remove the immediacy included the following: 1) Resident #84 currently in the facility. Elopement risk assessment and risk alert added to plan of care. 2) Licensed nursing staff will be educated on appropriate documentation pertaining to elopement, behaviors, wandering behaviors and verbal expressions of wanting to leave the facility. 3) Elevator code changed on 7/26/23. Education to facility staff completed by Administrator that new elevator code is not shared to residents and during the time doors remain open that no resident has unintentionally entered the elevator. 4) Front door access changed on 7/26/23. Education to facility staff completed by the Administrator that employee-fob access will be required to exit the building. 5) Licensed nurses were re-educated by the Director of Nursing/designee on the following: Documentation exit seeking behavior Elopement Policy and Procedure The elopement risk assessment process/accuracy and putting interventions in place based on the risks identified. This included intervening if the resident verbalizes the desire to leave the facility, or threatens to leave the facility, or refuses to wear a wanderguard. Education to be completed by the Assistant Director of Nursing or Director of Nursing by 7/27/23. 6) Facility staff will be educated on documentation of elopement and exit seeking behaviors and identifying exit seeking behaviors. DON and ADON will educate by 7/27/23. 7) The Director of Nursing and Assistant Director of Nursing will randomly interview a minimum of 2 staff weekly times 4 weeks then monthly for 2 additional months to validate understanding and compliance with documentation for residents exhibiting exit seeking behaviors. 8) The facility activity report will be reviewed for documentation that may suggest a resident is expressing desires to leave the facility, if identified, interventions for safety will be implemented and care plan updated. 9) Any concerns will be addressed at time of discovery 10) The medical director was notified on 7/26/23 of the Immediate Jeopardy 11) Ad Hoc Quality Assurance Performance Improvement Meeting will be held on 7/27/23 to discuss the contents of this plan. 12) Administrator will oversee compliance of this plan for three months. 13) Alleged date of compliance: 7/27/23 An observation conducted on 7/28/23 at 8:00 AM found the facility's plan, Employee fob access will be required to exit the building to remove the immediacy of the immediate jeopardy had not been implemented as evidenced by the facility's unlocked front entrance doors, allowing a person to leave the building without an employee fob access. On 7/28/23 at 8:06 AM, the surveyor exited the facility through the front doors, which were unlocked and unattended. On 7/28/23 at 8:10 AM, another surveyor walked into the facility's unlocked front doors. At that time, Staff #38, Admissions Director, asked if the surveyor had a fob. The surveyor replied that they did not have a fob and asked if the doors were not staying locked. Staff #38 indicated that, every once in a while, the doors would not stay locked, and they were trying to figure it out. The front doors continued to be unlocked when the surveyor walked out of the building on 7/28/23 at 8:40 AM. During an observation on 7/28/23 at 8:42 AM, the receptionist was observed in the lobby, sitting outside of the enclosed receptionist area. The receptionist was turned to face the enclosed area, with their back towards the front entrance doors, which did not allow a view of the unlocked front door thus potentially allowing unauthorized persons to leave the facility unattended. On 7/28/23 at 9:00 AM, the NHA, DON, ADON and Staff #41, Clinical Service Director were made informed the immediate jeopardy was not cleared, as their plan to remove the immediacy, Employee- fob access will be required to exit the building had not been implemented, that the front doors were found unlocked, and unattended, allowing a person to leave the facility without employee fob access. In response, the NHA stated that they were unable to get the doors to lock and indicated they were working with an outside company to get the doors to lock. At that time, the NHA was made aware that if the facility could not lock the doors, then a plan/provision needed to be in place until they could implement their plan. On 7/28/23 at 10:40 AM, the NHA stated that the front door was now locked and presented an updated Plan of Removal, to remove the immediacy, which was not accepted. The facility submitted an updated written plan to remove the immediacy which was accepted on 7/28/55 at 12:55 PM with an alleged date of compliance of 7/28/23. The updated written plan to remove the immediacy included the following changes: 1) Vendor door company technician validated on 7/28/23 that the facility door was now locked and only able to be accessed by a key fob. The front door was to be accessed with a key fob. The front door entrance and exit to the facility would be monitored by a facility staff member 24 hours a day through Monday 7/31/23 at 7 PM. Documentation of front door monitoring would be completed in 15-minute increments. NHA attached a schedule of designated door monitors through 7/31/23 at 7 PM. 2) Education was provided to the staff who were assigned to monitor the front door on 7/28/23 by the Administrator. Education included: Required 15-minute documentation. Door monitoring is the staff's only assigned duty If break is required, the door monitor must secure someone else to cover prior to taking break If the door is able to be opened without a key fob, NHA must be notified immediately. 3) Licensed nurses were re-educated by the Director of Nursing/designee on the following: Documentation exit seeking behavior Elopement Policy and Procedure The elopement risk assessment process/accuracy and putting interventions in place based on the risks identified. This included intervening if the resident verbalized the desire to leave the facility, or threatened to leave the facility, or refused to wear a wander guard. Education to be completed by the Assistant Director of Nursing or Director of Nursing by 7/27/23. 4) Targeted audience not receiving the above education would receive it prior to their next scheduled shift. 5) The Medical Director was notified of changes on 7/28/23. 6) Changes were discussed in the Ad Hoc Quality Assurance Performance Improvement Meeting on 7/28/23. On 8/2/23 at 8:00 AM, an onsite visit was conducted. After validation of the implementation of the facility's plan of removal, which included staff interviews, record reviews and direct observation, it was determined the facility met the minimum standards of compliance to remove the findings of an Immediate Jeopardy on 7/28/23 at 12:55 PM

Based on record review, interview, and observation, it was determined that the facility failed to have a system in place to ensure that therapist recommendations were conveyed to nursing when a resident was discharged from therapy resulting in a failure to provide treatment to prevent a decrease in range of motion. This deficient practice resulted in harm to Resident #41 due to the development of a contracture. This was found to be evident for 2 (Resident #41 and Resident #8) out of 3 residents reviewed for position, mobility, and rehabilitation. The findings include: 1. Resident # 41 was a long-term resident of the facility with mild cognitive impairment. On 7/18/23 at 09:48 AM, a review of the physical therapy (PT) evaluation for Resident #41, dated 3/24/23 and signed by PT # 17, revealed that the resident's physician approved therapy to treat a reported decline in Residents #41 functional mobility. However, further review of the PT evaluation documented that the resident's right knee extension was within normal limits and failed to reveal a contracture of the right leg. On 7/18/23 at 10:00 AM, a review of a PT encounter noted, dated 4/3/23, revealed that the resident was educated on the importance of daily exercise to maintain strength and mobility. Further review of a therapy treatment encounter notes, dated 4/12/23, revealed that the resident and resident's spouse were educated about a seated home exercise program to promote knee extension. The MDS is a federally mandated assessment tool used by nursing home staff to gather information on each resident's strengths and needs. Information collected drives resident care planning decisions. On 7/17/23, at 1:48 PM, a record review was performed, including a review of the MDS (minimum data set) assessment with an ARD (assessment reference date) of 4/14/23. The review revealed that the resident required extensive physical assistance for bed mobility and transfers. In addition, the MDS did not document any limited range of motion in the resident's lower extremities. Further review of a PT progress note, dated 4/18/23, revealed that Resident #41 required voice cues for proper form and technique to complete his/her exercises. On 7/18/23 at 10:05am, review of the physical therapy discharge summary, dated 4/20/23 and signed by PT #17, revealed that the resident was discharged from therapy with a home exercise program and functional maintenance program. Further review of the discharge summary from 4/20/23 documented that resident # 41's Prognosis to Maintain CLOF [ current level of function] = Good with consistent staff follow- through. Review of therapy notes during the month of March and April failed to reveal that the resident was ever able to perform exercise independently. On 7/18/23 at 1:34 PM, Physical Therapist #17 was interviewed by phone. During the interview, PT #17 reported that, when a resident is discharged , the nursing staff would be educated on interventions to help assist the resident maintain their current functional level. In addition, he stated that he provided resident #41 with a paper copy of the exercise. PT #17 reported that he did not fill out a therapy communication form regarding Resident #41's seated home exercise discharge instructions, but recalled verbally telling a nurse or nurse's aide which exercises the resident would need assistance with. PT #17 reported he did not document nor recall which nursing staff he educated. During a subsequent interview with PT #17 on 7/20/23 at 9:25 AM, he reported that Resident # 41 would need prompting and reminding to do his/her exercise. On 7/10/23 at 1:13 PM, Resident #41 was observed sitting in the wheelchair trying to fully extend his/her right knee. The resident's spouse reported that the resident could not straighten his/her right leg. On 7/18/23 at 10:16 AM, a review of a social services progress note, dated 7/14/23, revealed that the resident's daughter, who was their power of attorney, had requested that the resident be re-evaluated by therapy to maintain strength. On 7/18/23 at 1:05 PM, during an interview with the Rehabilitation Services Director, he reported that the reason for a reevaluation was to determine if there was decline in a resident's functional mobility. On 7/19/23 at 11:32 AM, review of the PT evaluation & treatment plan, dated 7/14/23, revealed that the resident had a contracture of the right knee. Further review of PT treatment encounter notes revealed that the resident required maximum verbal and tactile cues to properly perform exercises. On 7/25/23, a review of Resident #41's MDS assessment, with an ARD of 7/24/23, revealed that the resident had a limitation in range of motion in the lower extremities. During an Interview on 07/19/23 at 1:43 PM, unit manager Nurse # 8 reported that therapy communicates information regarding a resident discharge through a paper therapy communication form. Instructions on the form would be placed in the medical record as an order and signed by the physician. Nurse #8 reported that therapy did not provide a therapy communication form for resident #41's with seated home exercise instructions. Nurse #8 continued that range of motion exercises would only be placed in the resident's medical record as an order through the therapy communication form. On 07/18/23 02:28 PM, during an interview with GNA # 43, she reported that she had worked with the resident approximately 2 months and was unaware that the resident had been given an exercise program by therapy. On 7/24/23 at 8:28 AM, during an Interview with the Director of Nursing and with the Assistant Director of Nursing, they reported that if therapy decides that a resident can do a home Exercise or functional maintenance program, there was no expectation that anything is given to the nursing department via writing. 48470 2. Resident #8 is a long-term care resident of the facility. The Minimum Data Set (MDS) with Assessment Reference Date (ARD) of 5/23/21 revealed the resident required extensive physical assistance of one person for bed mobility and transfers. [NAME] was marked as a mobility device normally used. The MDS is a federally mandated assessment tool used by nursing home staff to gather information on each resident's strengths and needs. Information collected drives resident care planning decisions. On 7/10/23 at 12:23 PM, the resident reported a decline in range of motion since being admitted in the facility. The MDS with ARD of 7/6/23 revealed the resident required extensive physical assistance of two people for bed mobility and transfers. Wheelchair is marked as a mobility device normally used. The resident had been on and off physical therapy since admission. On 7/18/23 at 11:20 AM review of the Physical Therapy discharge summary dated 4/05/23 for Resident #8 revealed recommendations for functional maintenance program/ restorative nursing program and home exercise program, ROM (range of motion) program, lower extremity ROM exercises in supine and/or sitting. Further review of the care plan and orders failed to reveal documentation to indicate that these recommendations were implemented. On 07/18/23 at 1:17 PM, The Rehab Director (Staff #18) explained that when a resident is done with therapy, a discharge summary is generated with recommendations. These recommendations are then conveyed to the Nursing department by filling out a written form [Therapy and Nursing Communication] and hand delivered to the Unit Manager. On 07/18/23 at 11:28 AM, the unit nurse manager (UM Staff #8) verified that once the written form is received, she then puts all orders in the computer so the Nursing staff can implement the new orders. The UM said she performs this task right away and the form is kept in a binder. The UM was asked to show the Therapy and Nursing Communication form that would have been filled out from the 4/5/23 PT discharge summary but could not find it. On 07/18/23 at 12:02 PM, the UM (Staff #8) confirmed with surveyors that no documentation was found and reports no Restorative or functional program was in place for Resident #8. On 07/18/23 at 1:34 PM, interview with the physical therapist (PT Staff #17) revealed that when he discharges a resident from therapy, he looks for any nursing staff on the floor, and verbally gives them instructions regarding the residents' functional maintenance and/or restorative program, he confirmed that these conversations are not documented in the computer. The PT (Staff #17) further stated that he does not know if the staff he gave the instructions to had documented his instructions.

Based on record review and interview, it was determined that facility staff failed to provide nutritional services for their residents that aligned with professional standards of practice. This deficient practice resulted in harm to Resident #112 due to a weight loss of 31% of their body weight in 3 months. This was evident for 1 (#112) of 5 residents reviewed for nutrition. The findings include: 1) A medical record review for Resident #112, on 8/7/23 at 2:31 PM, revealed that attending Physician #61 documented during a History and Physical (H&P) on 4/9/23 that the resident was admitted to the facility to continue treatment of their wounds and receive rehabilitation services. Review of the wound Certified Nurse Practitioner (CRNP) Staff #67's documentation, dated 4/21/22, revealed the resident had a wound on his/her left heel and wound on his/her left posterior thigh. Optimal wound healing requires adequate nutrition. Nutrition deficiencies impede the normal processes that allow progression through stages of wound healing. Malnutrition has also been related to decreased wound tensile strength (refers to the amount of tension it will take to break the wound open again) and increased infection rates. (https://pubmed.ncbi.nlm.nih.gov) Review of the resident' s weights revealed that, on admission, the resident weighed 262 lbs. On 5/3/22, the Dietitian Staff #66 wrote a progress note that the resident's weight was 218 lbs. which was an 8% loss of body weight in 1 month. The Dietitian stated that this was due to a gastrointestinal illness that the resident had as a side effect of his/her antibiotic treatment. A progress note written by the Licensed Practical Nurse (LPN) Unit Manager (UM) staff #8 stated that she had made the attending physician aware of the weight loss and obtained an order for Ensure 237 mL (milliliters) to be given daily. However, review of the physician progress notes failed to reveal that the physician performed a medical evaluation of the resident to determine the cause of the weight loss. According to the nursing progress notes, the resident started to refuse his/her protein supplement and the Ensure. The resident had intermittent complaints of abdominal pain for which s/he requested pain medication. On 5/27/22, Licensed Practical Nurse (LPN) Staff #20 wrote a note that she made wound CRNP Staff #67 aware of the resident's abdominal pain and that the resident was not eating; however, no medical evaluation was performed to determine the cause. A review of the Medication Administration Record for 5/22 revealed the resident started refusing the protein supplement on 5/9/22 and the Ensure on 5/17/23. No documentation was found that the attending physician had been made aware the resident had not been taking the supplements. On 6/13/22, the resident was weighed and was 190.4 lbs. Further review revealed that the Dietitian wrote a note on 6/14/22 that stated she performed a weight review. Resident #112 weighed 190.4 lbs. , which represented a 29.6 lbs. (13.5% body weight) loss in approximately 30 days. She noted that the resident was seen and the resident's chart reviewed. The Dietitian documented that she observed that the resident had decreased body habitus (meaning a decrease in the shape of the body). The resident had indicated that s/he was proud to lose 50 lbs. in 1 month, however s/he complained that s/he felt full quickly when s/he ate because his/her stomach would swell up. The Dietitian discussed food preferences with the resident. However, there was no documentation that she reported to the attending physician that the resident looked thinner and had voiced concerns regarding feeling full quickly and that her stomach felt swollen after eating. The Dietitian made a recommendation to monitor the resident's weight weekly; however, there was no documented evidence that this was done. During an interview on 8/11/23 at approximately 8:30 AM, the Dietitian reported that she sent an email to LPN Staff #68, who had been the Unit Manager at that time. However, a review of the email revealed it had alerted Staff #66 that a weight loss had occurred but there was no discussion regarding the symptoms the resident had reported. Furthermore, there was no documentation that Staff #68 had reported the weight loss to the attending physician or the complaint of his/her stomach swelling. Further record review revealed that Resident #112 was seen by the attending physician on 6/15/22, and his note did not indicate he had evaluated the resident for the weight loss or the continued abdominal pain. In the Assessment/Plan, he wrote that the resident had been stable and to continue current medications and treatment plan. Further review of the recorded weights revealed the resident was weighed 10 days later on 6/23/22 and was 182.7lbs. There was no documentation that the attending physician had been notified. On 7/7/23, 14 days later the resident was weighed and was 179.2 lbs., again there was no documentation that staff notified the attending physician. A progress note, written on 7/7/22 by, Staff #68 revealed that the resident's representative had requested a Gastroenterology Consult due to the resident's continued complaints of abdominal pain. In addition, the progress notes revealed that the family made a request to send the resident to the hospital on 7/10/22 and the resident passed away at the hospital on 7/11/22. An interview was conducted with the Dietitian on 8/11/23 at approximately 8:30 AM via a phone call with the Nursing Home Administrator (NHA) present. The Dietitian reported that Resident #112 had been a tough case because the resident seemed to want to eat what she wanted and when she wanted. When asked if she had reported to the attending physician the concerns that the resident had told her about feeling full quickly because when s/he ate his/her stomach swelled up, the Dietitian reported that she doesn't talk to the doctors because they were not present when she visits the residents. The Dietitian stated she notified the Unit Managers via email, and they were supposed to report weight loss and concerns to the attending physician. On 8/11/23 at 11:51 AM, an interview with LPN Staff #20 revealed that she remembered Resident #112 having a lot of stomach issues and vomiting. She stated the resident ordered junk food from an online vendor and had it delivered to the nursing home. Staff #20 stated she remembered talking to the resident about the stomach issues to determine if the resident had seen a Gastroenterologist in the past. She reported she had talked to the attending physician verbally and wrote it on his list of people to see one time. During an interview with LPN UM Staff #8 on 8/11/23 at 9:31 AM, she confirmed she had received an email from the Dietitian regarding Resident #112's weight loss on 5/5/22. When asked what her normal process was in response to the email correspondence, she reported at times she would obtain a weight to confirm the weight loss and notify the attending physician. In addition, as a UM her role was to pull a weight report to review the weights of the residents on her assigned unit. She reported that this was a difficult task to keep up with due to being pulled to work as a staff nurse and there was no back up for her when this occurred a few times a week. On 8/14/23 at 8:38 AM, the surveyor made an attempt to contact LPN UM Staff #68 and was unable to reach her. She had been sent an email on 6/14/22, making her aware of the resident's weight loss, however, there was no evidence that the attending physician had been made aware. The NHA and Director of Nursing was made aware of these concerns on 8/11/23 at 3:25 PM. Cross Reference: F600 and F684

Based on observations, review of the maintenance water log, facility incident report, medical records, and staff , resident interviews, it was determined that the facility staff failed to 1.) properly test the temperature of the water prior to immersing a resident's (#1) foot in a basin of water, 2.) adequately supervise a resident while administering a foot soak, resulting in resident #1sustaining 2nd [MEDICAL CONDITION] the left foot. The finding includes: By way of history, the resident has the [DIAGNOSES REDACTED]. The resident is cognitively intact and receives minimal assistance from staff. During the investigation of facility reported incident MD 555, resident #1 was interviewed on 10/31/18 at 3:30pm and 11/1/18 at 10am. The interview revealed that, on 9/16/18, (Nurse #11) soaked (resident #1's ) foot in a basin of water to remove some of the dead skin from (resident #1's) left foot. The resident stated that s/he felt the water was the appropriate temperature the first time, however, it felt a little hot once (nurse#11) changed it. The resident stated that he/she 'does not have the best feelings in his/her feet due to [MEDICAL CONDITIONS] and diabetes. The resident stated that, after his/her left foot had soaked for one hour it appeared red and had small blisters in a few areas. The resident stated the nurse dried his/her foot and did his/her normal treatment. The resident also stated that (Nurse #11) told him/her there were blisters on his/her left foot. However, review of the medical record on 11/1/18 at 2pm failed to reveal any documentation of a foot soak and/or blisters on 9/17/18. The resident went on to state s/he slept during the night but was concerned about his/her foot. S/he stated the incident was reported to the 7am-3pm (Nurse#12) on 9/17/18. During an interview that took place on10/31/18 at 4pm with (Nurse#11), s/he stated that s/he went into the resident's room to do his/her treatment and his/her foot had a terrible odor to it and dead skin sloughing off it. S/he stated s/he decided to soak his/her left foot, because during showers, the GNA's (Geriatric Nursing Assistant) were wrapping his/her left foot with a plastic bag to keep the dressing dry. Nurse#11 (3-11pm shift) stated s/he filled a basin with water and some soap and soaked the resident's left foot, changing the water once during soaking. The nurse stated s/he tested the temperature of the water by touching it to his/her wrist and it was the appropriate temperature. (Nurse#11) stated the resident did not complaint about the water temperature. S/he stated s/he reapplied the dressing to the left foot after soaking the resident's foot for about an hour. S/he did not notice any redness or blisters after soaking the resident foot. S/he states the resident had no complaints the rest of the shift. During interview with Nurse #12, 7-3pm shift nurse on 11/1/18 at 7:30am, s/he stated that s/he was passing out morning medications, on 9/17/18 at around 9:30am, when resident #1 called her/him to his/her room to look at his/her left foot. S/he stated that the resident reported that the nurse on evening shift (3-11pm) soaked his/her foot in hot water causing it to blister and turn red. S/he also stated that the resident reported that Nurse #11 made him/her aware of the blisters and redness. Nurse#12 stated that, during assessment of (resident #1's) left foot, s/he noted that the resident had fluid filled blisters and redness which were not present when s/he changed the last dressing on 9/16/18 (7-3 shift). Nurse#12, stated s/he notified the Unit Manager Nurse#13, and the wound nurse Nurse #9. Upon assessment of the l eft foot by (Nurse#13, LPN) and the wound nurse (Nurse #9, RN) (Registered Nurse) a reddened area was found approx. 2 back from the toes on top of the foot and around the sides to the ankle, slightly [MEDICAL CONDITION], with multiple blisters of varying sizes present. During an interview with Unit Manager (Nurse#13, LPN) and the wound nurse (Nurse#9, RN) on 11/1/18 at 8am, it was verified that the resident had several blisters and redness on his/her left foot. The Unit Manager stated s/he contacted the evening nurse who verified s/he soaked the resident's foot for 1 hour but denied there was any blistering or redness. During an interview with the wound nurse on 11/1/18 at 9am, s/he stated the area to the left foot could have been part of an infectious process; the resident has a [DIAGNOSES REDACTED]. S/he stated the charge nurse called the wound care center to see if the resident could be seen sooner than his/her scheduled appointment for 9/21/18. The wound Center was not willing to move the resident's appointment sooner. A new order for wet-to-dry dressing to open blisters was obtained from the wound center. The CRNP-Certified Registered Nurse Practitioner (staff #16) was made aware of the new area to the resident's left foot by the wound nurse and was asked to give for a second opinion. The CRNP agreed with the treatment plan. According to the medical record the resident was receiving PRN pain medications, which was noted to be effective. According to the facility investigation, the water temperatures in resident #1's room was checked by maintenance at 11:20am on 9/17/18 and the water temperature was (114.8) and again on 9/17/18 at 4:30pm-water temperature reading was (112). During water temperature checks accompanied by the Maintenance Supervisor in resident #1 room on 10/30/18, 10/31/18, 11/1/18 and 11/2/18, the water temperature ranges from 110-114. Continued review of the medical record revealed the following: On 9/18/18 at 2:50 pm, the resident complained of pain in the foot. On 9/19/18 at 11am, the resident was assessed by the wound nurse (staff #9) and the CRNP (staff #17). It was found that the resident's left medial ankle had an intact serous fluid filled blister, measuring 2.2x3.0, heel had a ruptured blister measuring 1.5x3.0, dorsal left blister measures 2.0x1.5, dorsal 2nd toe ruptured blister measures 3.0x2.5, dorsal 3rd toe ruptured blister measures 2.5x 2.0. New order given to send the resident to the hospital by (staff #17) for evaluation and treatment of [REDACTED]. According to the medical record, the resident returned on 9/19/18 at 8:21pm. Review of the hospital discharge summary revealed that the resident had second degrees burn on the left foot, with intact and open blisters of left heel and great, 2nd, and 3rd toes with loss of overlying tissue. New treatment was ordered to cleanse [MEDICAL CONDITION] Prontosan wound spray cleanser. Apply Prontosan wound gel to open blisters of left heel and dorsal great, 2nd, and 3rd toe. Cover the open areas and the intact blisters with [MEDICATION NAME] gauze and kerlix daily. [MEDICATION NAME] are transparent dressings used to protect the skin. During interview with the Director of Nursing on 11/1/18 at 2pm, s/he verified the CRNP (staff#16) and the emergency room Physician diagnosed the resident skin area as a burn.