Every finding on record at King David Nursing and Rehabilitation Center

Based on review of Geriatric Nursing Assistant (GNA) personnel records and staff interviews, it was determined that the facility failed to provide documentation the yearly clinical performance evaluations/reviews occurred at least every 12 months for 3 (GNAs #8, #21, and #22) out of 6 GNA personnel records reviewed. Additionally, the facility failed to provide documentation of the annual mandatory 12-hour clinical education training for 3 (GNA #8, #21, #22) out of 6 GNA personnel files reviewed during an annual survey. The findings include:On 06/17/2026 between 12:42 PM and 1:34 PM the surveyor reviewed the employee HR files and found at least three GNA employees who did not have copies of their annual performance evaluations and or 12- hour annual clinical competency training in their HR folders.-The surveyor reviewed the human resources file for GNA #8 with a hire date of 10/04/2021, no documentation of annual performance evaluations was found since date of hire. Additionally, the last 12-hour annual clinical competency training was as of 04/09/2025.-The surveyor reviewed the human resources file for GNA # 21, with a hire date of 01/27/1981, no annual performance evaluation found since date of hire and the last 12- hour training was not present in the employee's personnel file for the years of 2025 and 2026.-The reviewed the human resources file for GNA #22, with a hire date of 04/18/2025, no annual performance evaluation or a 12-hour annual clinical competency nursing aide training for 2026.On 06/17/2026 at 2:08 PM the administrator was advised of which employee HR records did not have annual performance evaluations present in their HR files. Additionally, the surveyor informed the administrator which employees did not have copies of annual clinical education training. The administrator stated the current staff educator who is also the ADON has only been in the position for two months. The HR director continued to be out of the office per the administrator.

Based on complaint, reviews of a closed clinical record and administrative records, and staff interviews, it was determined that the facility nursing staff failed to follow the physician's order for specific pulse and blood pressure parameters before administering cardiac medications. This was evident for 1 (Resident #7) of 7 residents reviewed during a complaint survey. The findings include: Review of Resident #7's closed clinical record on 04/22/26 revealed that Resident #7 was admitted to the facility on [DATE] with diagnoses that include a stroke, left eye blindness, and Alzheimer's type dementia. Resident #7 and had been deemed incapable of making all medical decisions by 2 attending physician on 12/11/25 and 12/12/25. Further review of Resident #7's closed clinical record on 04/2/26 revealed a physician's order dated 12/17/2025 at 5 pm instructing the nursing staff to administer the medication, Nifedipine, 60 milligrams (mg), extended release, orally, every 24 hours, at bedtime (9 pm) for hypertension. Hold the medication if the systolic blood pressure (SBP) is less than 110 or the heart rate is lower than 60 beats per minute. A review of Resident #7's December 2025 medication administration records (MAR) on 04/2/26 revealed the nursing staff failed to withhold the dose of Nifedipine on the following date and time: 12/20/25, 9 pm dose, with a documented pulse of 59 beats per minute. These findings were shared with the facility director of nurses (DON) and the facility Administrator at the exit conference on 04/27/26 at 5 pm.

Based on observation, medical record review and staff interview, it was determined that the facility failed to provide supervision during a medication pass to ensure the medication was taken by the resident and remove the medication when it was refused. This was observed for 1 (Resident #6) of 7 residents reviewed during a complaint survey. The findings include: During a tour of the facility on 04/23/26 at 5:15 pm, observation revealed 3 small round orange pills located in a medication administration cup on Resident #6's bedside table. Resident #6 was seated in the wheelchair which was next to Resident #6's bed and behind the bedside table. A staff member was observed assisting Resident #6 with the meal tray. After greeting, Resident #6 was asked if the medication sitting on the bedside table was their medication. Resident #6 stated that the medication was their blood pressure pills from this morning and that he/she refused to take the medication. Resident #6 stated that he/she documents every blood pressure the nursing staff obtain before the nurse would administer the medication. Resident #6 stated that his/her blood pressure this morning was 110/66 with a pulse of 68 beats per minute. Resident #6 stated that they interpreted the blood pressure reading as being to low and that he/she was instructed not to take her blood pressure medication if the blood pressure reading was low. RN #1 was made aware and observed the 3 pills sitting in front of Resident #6. The 3 pills were removed at that time. A review of Resident #6's medical record on 04/23/26 revealed a physician's order, dated 01/27/26, instructing the nursing staff to administer the blood pressure medication, Hydralazine, 25 milligram (mg) tablet, give three (3) tablets every 8 hours by mouth for Hypertension. Withhold the medication for a systolic blood pressure reading of less than 110 Hg/mm or a pulse rate less than 60. A review of Resident #6's April 2026 medication administration record (MAR) revealed that LPN #2 administered a dose of Hydralazine to Resident #6 at 6 am and documented a blood pressure of 110/66 and a heart rate of 68 beats per minute. Resident #6 was assessed on 4/15/26 with a BIMS score of 15/15. The BIMS (Brief Interview for Mental Status) score is a 0-15 point tool used in healthcare, particularly long-term care, to assess cognitive function, with higher scores indicating better cognition. It evaluates immediate recall, temporal orientation, and short-term memory. A score of 13-15 indicates intact cognition, 8-12 moderate impairment, and 0-7 severe impairment. A review of the facility policy for Medication Administration on 04/23/26 revealed a compliance guideline, #19, that instructs the nursing staff to report and document any adverse side effects or medication refusals.

Based on observations and interview, it was determined that staff failed to provide dietary services in a safe and sanitary environment. This deficient practice was evident during observations in the kitchen and the Nourishment Room on Sudbrook unit during the complaint survey. The findings include: 1. On 02/18/26 at 8:32 am during observation rounds on the unit Sudbrook, while in the Nourishment Room the surveyor observed an opened container of Amish Style Potato Salad and [NAME] Honey Uncured Ham. Both were dated 01/26/26. Vanilla ice cream was observed spilled in the freezer, and there were multiple spills in the refrigerator, and two unlabeled and undated small containers of applesauce. On 02/20/26 at 10:06 am during an interview with LPN Unit Manager #5 the surveyor asked what department was responsible for monitoring the refrigerator temperatures, keeping the refrigerator clean, and ensuring the food was dated and labeled. LPN Unit Manager #5 verbalized the environmental services department was responsible for keeping the refrigerator clean but they all should monitor what's in the refrigerator; the refrigerator is for the residents. The temperature log was kept in the white binder on the crash cart. On 02/20/26 at 10:35 am the surveyor asked to review the refrigerator temperature log on Sudbrook. A review of the Fridge Temperature Log for the month of February 2026 revealed that the temperature was not recorded on 02/14, 02/15, and 02/20/26. A review of the Fridge Temperature Log for December 2025 revealed there was not a temperature recorded on 12/12, 12/17, 12/24, 12/25, 12/26, 12/27, 12/28, and 12/31/25. The surveyor showed LPN Unit Manager #5 the dates where the refrigerator temperatures were not recorded. On 02/26/26 at 11:50 am during EVS Director #9 he/she verbalized they check the refrigerator on a weekly basis; he/she usually checks it on Monday or Tuesday the latest. EVS is responsible for cleaning the refrigerator. They discard items that are outdated or without a date. The temp is checked once a week and a report is given to Administrator #1 on the Quality Assurance report. 2. A tour of the kitchen on 2/18/2026 at 12:32 PM revealed the following: a. Plastic container sitting under the sink drain with water in it, b. Floor tiles were broken, c. A fan that vented to the outside was covered in dust, d. A window air conditioning unit that was dusty and leaning to the right side, e. There was a stack of bread crates sitting on the floor with loaves of bread on them, f. The dishwashing area had standing water on the floor, In the refrigerator there were several containers of applesauce, fruit and Jello that were not dated sitting on trays. There were containers of egg salad, potato salad, and chicken salad with no dates on them. There were undated, opened juice containers. There were boxes of food stored on the floor. In the freezer there were boxes stored on the floor. The fans had condensation and ice buildup on the ceiling. An observation of the dry storage area on 2/18/26 at 12:47 PM revealed: a. There was a bag of sugar sitting on the floor. c. There were lids and debris on the floor. d. An air conditioning unit that was vented through the wall had 3 boxes piled on tubing. e. There were bags of portion cups stored on the floor. On 2/18/26 at 1:00 PM an interview with [NAME] #23 revealed they had received a shipment of boxes that day. When shown the other supplies on the floor he acknowledged that they were not from the recent delivery. On 2/18/26 at 1:02 PM dietary Staff #24 was observed to be preparing lunch and failed to have a hair and beard restraint on. On 2/19/26 at 1:30 PM an observation of dietary Staff #25 was observed preparing food portion cups for storage and failed to have on a hair and beard restraint. An interview with the Dietary Manager on 2/26/26 at 12:03 PM revealed he was responsible for ensuring the kitchen was cleaned and maintained, and that staff were wearing the appropriate hairnets and beard nets. He stated that he was addressing maintenance issues with the Maintenance Director, such as the leaking sinks, standing water on the floor, and the broken tiles due to environmental rounds that were completed on 2/3/26. He later provided an email outlining these concerns. When asked about the cleanliness of the kitchen he stated that he was aware, however, had not addressed the issue. He stated that he was having issues with staff wearing the hair and beard restraints but had not addressed it with them. The concerns were reviewed with the Nursing Home Administrator on 2/26/26 at 12:30 PM.

Based on observations and interviews it was determined that the facility staff failed to ensure the waste refuse containers were closed and not overflowing with waste. This deficient practice was evidenced in 4 of 4 waste containers observed on the facility's property during the complaint survey.The findings include:On 02/24/26 at 1:28 pm while in the dining room located on Mount [NAME], the surveyor lifted the shade on the second window and observed 4 large waste containers. The top lid of waste container #8320 was opened and large bags of rubbish were exposed at the top. Also, a clear white bag was hanging off the left side of the waste container. The left sliding door of the waste container #8319 was opened and a clear waste bag was hanging out the side. The top lid of waste container #8213 was opened with brown boxes and waste bags exposed. The lid to waste container #8148 was opened with clear waste bags exposed and hanging over the front of the large waste container. There was waste on the ground on both sides of the container. On 02/24/26 at 1:24 pm during an interview with Maintenance Director #8, the surveyor asked what department is assigned to management the waste containers outside Maintenance Director #8 verbalized the Environmental Services Department oversees the dumpsters; the dumpsters are emptied Monday, Wednesday, and Friday. EVS oversees making sure the areas around the dumpsters are clean. On 02/25/26 at 1:24 pm during an interview with EVS Director #9 he/she verbalized the porters were supposed to know when the dumpsters are full to close them after they put the trash in. All departments use the dumpsters, but the porters are responsible for ensuring they are closed.

Based on observations and interview it was determined that the facility staff failed to maintain the building in a safe, comfortable, homelike environment. This deficient practice was discovered during the complaint survey. The findings include: 1. On 02/18/26 at 8:30 am during observation rounds, the surveyor entered the Nourishment Room and observed damaged drywall on two walls. The surveyor opened the cabinet and the door flung open as the bottom hinge was broken. The cabinet under the sink was had water damage and there was a hole in the bottom of the cabinet. On 02/18/26 at 8:35 am the surveyor observed an electric outlet with two red wires and two black uncapped wires hanging out of an electrical box in the shower room on Sudbrook. On 02/18/26 at 8:36 am while in the supply room located on Sudbrook, the surveyor observed a package of clear cups, a blue basket, and plumbing tools and parts on a blanket under the sink. On 02/18/26 at 8:46 am the surveyor observed a broken soap dispenser in the shower room on [NAME]. The front of the soap dispenser cover was on a shower bed inside the stall. On 02/20/26 at 9:55 am the surveyor showed LPN Unit Manager #5 the maintenance concerns on the unit Sudbrook. The surveyor asked how maintenance concerns are communicated to the maintenance department. LPN Unit Manager #5 verbalized there is a maintenance binder on each unit or the staff could communicate the issues to maintenance directly. The maintenance and Environmental Services departments check the binders daily. The surveyor asked who ensures the maintenance issues are addressed. LPN Unit Manager #5 verbalized the clinical team would follow up the next morning during their morning meeting. The surveyor asked if the maintenance concerns were put in the binder. LPN Unit Manager #5 verbalized the maintenance concerns were not documented in the binder. Nobody looked into the cabinet besides the surveyor. On 02/20/26 at 11:10 am Director f Nursing # 2 verbalized there was a maintenance book on each unit and manager's report maintenance issues when they meet. They report issues during the morning meeting. Administrator #1 will follow up to ensure the issues were addressed. On 02/24/26 at 1:12 pm during an interview with Maintenance Director # 8 the surveyor asked is there a preventative maintenance schedule. Maintenance Director #8 verbalized they have a set of rooms to check every quarter; they check call bells to see if they are working properly outside of the door and the nurse's station. There is only one person in the maintenance department. The nourishment and supply rooms are not rooms that are regularly checked; the only way he/she would know if someone reports the issue. There is a yellow maintenance book on each nurse's station that gets check every day or every other day depending on how his/her day is going. The book is checked in the morning. There is not a checklist to verify repairs were made. On 02/24/26 at 1:30 pm while in the dining room on Mount [NAME] the surveyor lifted the shade of the middle window and cold air was coming from the window. After further inspection the surveyor noticed the upper and lower parts of the window had a large gap which allowed the cold air from outside to enter the room. There were two other windows in the room which had large gaps in the window which allowed the cold air to enter the room. On 02/24/26 at 2:05 pm the surveyor demonstrated to Maintenance Director #8 the three set of windows with a large gap which allowed cold air into the dining room on Mount [NAME]. Administrator #1 was present at that time. After surveyor intervention Maintenance Director #8 used a screwdriver to align the three set of windows; afterwards the gap in the windows were resolved. 2. On 2/18/26 at 8:00 AM an observation of the facility parking lot revealed that there were discarded face mask, gloves, water bottles, plastic cups, and other debris in the parking lot. A second observation on 2/19/26 at 8:36 AM revealed that there were mask, gloves, plastic bottles, plastic straws, and other debris laying all over the parking lot and along the curb. Along the right side of the parking lot was a tree line that had plastic bags stuck in the trees and bushes, plastic cups, paper, and other debris scatter. The area in front of the building near the front door had mask, water bottles, plastic bags, broken plastic pieces lined against the building. The porch area at the entry door had a trashcan with debris laying near it, a broken orange snow shovel, and black plastic piece, plastic bags, and paper laying in the grass to the left. On 2/19/26 at 10:00 AM met with the Nursing Home Administrator (NHA), Maintenance Director, and EVS Director. When asked who was responsible for cleaning up the debris in the parking lot. EVS stated that it was housekeeping's responsibility. Reviewed findings with the EVS Director with the NHA present on 2/19/26 at 10:03 AM by walking around the parking lot and showing her the debris. She stated that she assigns a porter everyday to clean the parking lot area. When asked who monitors if it was done or not, she stated that she does. She stated that she has not checked the area since they had snow.

Based on the review of an investigation and interviews it was determined that the facility staff failed to ensure a resident was free from verbal abuse This deficient practice was evidenced in 1 (#1) of 3 investigations reviewed for an allegation of abuse during the complaint survey.The findings include:On 02/18/26 at 11:44 am a review of the facility's self-report investigation concerning an allegation of verbal abuse towards Resident #1 revealed the alleged incident occurred on 10/02/25 during the 3:00 pm - 11:00 pm shift. On 10/05/25 during 7:00 am - 7:00 pm Resident #1 reported to Licensed Practical Nurse (LPN) Unit Manager #5 that Geriatric Nursing Assistant (GNA) #13 told them to shut up. The incident was reported at the end of the shift. GNA #13 was working during the time the incident was reported but was assigned to a different unit where Resident #1 was located. The alleged perpetrator was allowed to complete the shift.A disciplinary notice was completed on 10/05/25, the explanation of the infraction was incorrect. The form indicated GNA #13 was suspended and worked the following day on 10/06/25 7:11 am - 11:16 pm. According to the facility's follow-up investigation report GNA #13 and Resident #1 agreed that the statement made was not intended to be rude or harmful. Both acknowledged that the phrase shut up was not directed from GNA #13 to resident #1. A One-on-One Inservice was completed with GNA #13 on 10/05/25. The topic of the in-service was recorded as Resident Rights, Dignity, and Respect. The description of information covered during the in-service was documented as GNA #13 will be able to recognize the difference in culture, religion, age, gender, disability etc. GNA #13 will be able to communicate effectively with residents.On 02/18/26 at 12:30 pm a review of Resident #1 electronic health record revealed the resident's BIMS Score was 15/15 assessment review date (ARD) 09/30/25. A review of the residents' statement was dated 10/05/25 was taken by Administrator #1. The statement read, a GNA told me to shut up, but she apologized after. I don't think she meant it like that. I was just surprised at first.On 02/19/26 at 1:49 pm reviewing a review of GNA #13 employee record; she was hired on 05/30/25, her GNA certificate is active. A background check was completed on 05/30/25 with no reportable records found. Abuse & Dementia training was completed on 05/30/25. On 02/19/26 at 2:02 pm during an interview with GNA #13 the surveyor asked her to review her statement from the investigation. After reviewing the statement GNA #13 confirmed the statement was accurate and confirmed she told the resident to calm down and shut up. GNA #13 confirmed having abuse training. She verbalized she didn't mean it to come out in a bad way, and she didn't mean to shut Resident #1 up. GNA #13 verbalized because of Resident #1 reaction to her telling him to shut-up, it was verbal abuse. The resident didn't mean to shout at her. The resident was complaining about the facility, and she told him to calm down and shut up. GNA #13 verbalized the resident was anxious frequently and she was trying to calm the resident down. GNA #13 reported in their culture they try to reflect inward when having issues. She told the resident to calm down, shut up, and look inward to figure things out; the resident asked for her opinion. GNA #13 did not report Resident #1 concerns to the nurse, or a supervisor nor was the incident reported. On 02/20/26 at 10:53 am during an interview with Director of Nursing (DON) #2 the surveyor asked, how did he/she find out about the allegation of abuse. DON #2 verbalized they received a phone call from the supervisor and came to the facility to complete the investigation. Interviews were completed by staff and residents. That day they were able to complete the investigation; it was more of a cultural misunderstanding between them two. The resident asked the GNA a question; it was a cultural misunderstanding; what they would do in that situation. It was a response to a question. The resident was a two-person assist; GNA #14 was in the room assisting as well. The surveyor verbalized the investigation did not mention another GNA was present during the alleged incident nor was there a statement from the employee. Also, GNA #13 did not mention GNA #14 was in the room. On 02/20/26 at 2:11pm during a telephone interview with Resident #1 the surveyor asked the resident if there was an incident when a GNA told him to shut-up. Resident #1 verbalized GNA #13 told them to shut-up; he/she was in the chair and wanted to get back in bed. The GNA had to get the lift to put them in bed. The surveyor asked was another person in the room. The resident verbalized yes, it was a male in the room. The other GNA heard GNA #13 tell them to shut-up and made a gesture with their hand to say that should not have been said. The surveyor asked the resident did he/she ask GNA #13 for advice. Resident #1 replied no and they did not want that to happen to someone else.

Based on record review and interview, it was determined that the facility failed to develop and implement abuse policies and procedures. This was evident for 1 of 3 abuse policies reviewed. The findings include:On 2/24/26 at 1200 PM a review of the facility's Abuse, Neglect, and Exploitation policy revealed it was implemented on 2/2015 and reviewed/revised on 11/2023. Section IV. Identification of Abuse, Neglect, and Exploitation #1 read that it was considered an abuse allegation when reported by a resident, staff, or family. Section V. Investigation of Alleged Abuse, Neglect, and Exploitation, letter A read that an immediate investigation was warranted when there was suspicion of abuse, VI. Protection of the Resident letter D read that room or staffing changes were to be made, if necessary to protect the resident (s) from the alleged perpetrator. Section VII. Reporting/Response, letter A read the facility would have written procedures that included: 1. reporting of all alleged violations to the Administrator, state agency, adult protective services, and all other required agencies. 1a. immediately, but no later than 2 hours after the allegation is made. During a review of the facility's investigation file for the facility reported incident #2725522 on 2/24/26 at 10:00 AM it was revealed on the initial report form that an allegation of abuse for Resident #5 was reported to Registered Nurse (RN) #11 on 1/23/26 at 8:30 PM. The administrator was not made aware of the abuse allegation until 11 hours later by the DON on 1/24/26 at 7:30 AM. According to the report the resident told the nurse that Geriatric Nursing Assistant (GNA) #12 had rolled him/her over in bed causing them to hit their head on the bedrail. Further review revealed the email confirmation the report was submitted to the state agency on 1/24/26 at 9:25 AM by the Director of Nursing (DON). An interview with the DON on 2/25/26 at 11:32 AM revealed that she was not informed of the allegation of abuse until the following morning 1/24/26 at approximately 7:00 AM. She stated that when she interviewed RN #11 the nurse reported that she was not sure if this was an allegation of abuse. The DON reported that the employees know they can call her at any time, however this nurse failed to call immediately. Furthermore, GNA #12 continued to work the rest of her shift until 11:00 PM with vulnerable residents. On 2/25/26 at 12:13 PM the concerns were reviewed with the Nursing Home Administrator who offered no rationale for the deficient practice. Cross Reference: F609 and F610

Based on record review and review of the facility's investigation and interview it was determined that the facility staff failed to report allegations of abuse within the required timeframe. This deficient practice was evidenced in 2 (Residents #3, #5) of 5 residents reviewed for abuse allegations. The findings include: 1. On 2/24/26 at 1200 PM a review of the facility's Abuse, Neglect, and Exploitation policy revealed it was implemented on 2/2015 and reviewed/revised on 11/2023. Section IV. Identification of Abuse, Neglect, and Exploitation #1 read that it was considered an abuse allegation when reported by a resident, staff, or family. Section VII. Reporting/Response, letter A read the facility would have written procedures that included: 1. reporting of all alleged violations to the Administrator, state agency, adult protective services, and all other required agencies. 1a. immediately, but no later than 2 hours after the allegation is made. On 2/24/26 at 10:00 AM a review of the facility's investigation file for the facility reported incident #272552 revealed an initial report form. According to the initial report Resident #5 reported to Registered Nurse (RN) #11 that geriatric nursing assistant (GNA) #12 had rolled him/her over in bed and hit the resident's head on the bedrail on 1/23/26 at 8:30 PM. However, she failed to report the allegation of abuse to the Director of Nursing (DON) until 1/24/26 at 7:30 AM, 11 hours later. The confirmation email revealed the DON sent the allegation of abuse to the State Agency (SA) on 1/24/26 at 9:25 AM. An interview with the DON on 2/25/26 at 11:32 AM revealed that her expectation was for staff to report allegations of abuse to her as soon as possible. She stated that the nurse was unsure it was an allegation of abuse, but once she reported the incident to the DON, she was informed it was an allegation of abuse. The DON stated that she reported it to the SA once she was made aware. The concerns were reviewed with the Nursing Home Administrator on 2/25/26 at 12:13 PM. Cross Reference: F607 and F610 2. On 02/20/26 at 2:09 pm the surveyor received a copy of the email that was received by the facility when the final report of the investigation related to Resident # 3 was submitted. The facility staff submitted an allegation of abuse on 10/21/25. According to the email received from Administrator #1 on 02/20/26 at 2:09 pm, the 5-day final report was submitted on 10/29/25. Five working days after the initial report was submitted would have been 10/28/25. The report was submitted to the state agency a day late. On 02/20/26 at 2:47 pm during an interview with Director of Nursing (DON) #2 the surveyor asked what timeframe the results of an investigation should be submitted to the state agency. DON #2 verbalized they have 5 days to submit the follow-up investigation results.

Based on the review of the facility's investigations and interviews it was determined that the facility staff failed to complete thorough investigations of incidents reported to the state agency and failed to ensure that residents were safe by allowing an alleged abuser to continue to work with vulnerable residents. This deficient practice was evidenced in 2 (Residents #1 and #3) of 3 facility reported incident investigations reviewed during the complaint survey.The findings include: 1. On 02/20/26 at 10:53 am during an interview with Director of Nursing (DON)#2 the surveyor asked, how did they find out about the allegation of abuse concerning Resident #1 for the incident that occurred on 10/02/25 during the 3:00 pm – 11:00 pm shift and was reported by the resident to staff on 10/05/25 during 7:00 am – 7:00 pm shift. DON #2 verbalized receiving a phone call from the supervisor. After receiving the phone call, the allegation was reported to Administrator #1 and he/she came to the facility to start the investigation. Interviews were conducted of the staff and residents. That same day (10/5/25) they were able to resolve it. Geriatric Nursing Assistant (GNA) #13 on the day of the incident was providing care to Resident #1 who was a two-person assist. GNA #14 was in the room assisting. The surveyor confirmed GNA #14 was in the room during the allegation of verbal abuse. The surveyor made DON #2 aware there was not a statement in the investigation from GNA #14. DON #2 verbalized speaking with GNA #14 about the incident. 2. On 02/19/26 at 10:18 am during an interview with Director of Nursing (DON)#2 the surveyor asked to explain their process of investigating complaints or incidents related to the residents or an allegation of abuse. DON #2 verbalized they get statements from the resident, the alleged perpetrator, other resident, and employees; they remove the staff pending investigation. On 02/20/26 at 10:45 am a review of Licensed Practical Nurse (LPN) #15 statement revealed DON #2 did not ask LPN #15 if he/she called Resident #3 a cranky old [expletive]. On 02/20/26 at 11:22 am during an interview with Licensed Practical Nurse (LPN) #15 the surveyor asked to tell what happened with Resident #3. LPN #15 verbalized he/she can't tell the surveyor what happened because they didn't know anything happened. There were never any problems with Resident #3; Resident #3 always told him/her they were one of the nicest people working in the facility. The surveyor made LPN #15 aware the resident accused them of calling the resident a cranky old [expletive]. The surveyor asked LPN #15 did they call Resident #3 a cranky old [expletive]. LPN #115 denied calling the resident by the expletive. On 02/20/26 at 2:39 pm during an interview with DON #2 the surveyor asked why she didn't ask LPN #15 did they call the resident a cranky old [expletive]. DON #2 verbalized the resident said it happened around medication administration when he/she heard the nurse say that. He/she asked LPN #15 open-ended questions concerning the medication administration interaction with the resident. 3. On 2/24/26 at 1200 PM a review of the facility's Abuse, Neglect, and Exploitation policy revealed it was implemented on 2/2015 and reviewed/revised on 11/2023. Section IV. Identification of Abuse, Neglect, and Exploitation #1 read that it was considered an abuse allegation when reported by a resident, staff, or family. Section V. Investigation of Alleged Abuse, Neglect, and Exploitation, letter A read that an immediate investigation was warranted when there was suspicion of abuse, VI. Protection of the Resident letter D read that room or staffing changes were to be made, if necessary to protect the resident (s) from the alleged perpetrator. A review of the facility's investigation file for the facility reported incident #272552 on 2/24/26 at 10:00 AM revealed on the initial report from that Resident #5 reported an allegation of abuse on 1/23/26 at 8:30 PM to Registered Nurse #11. The resident reported that geriatric nursing assistant (GNA) #12 had rolled him/her over in the bed and hit their head on the bedrail. A review of GNA #12's timesheet revealed that she clocked out until 11:00 PM on 1/23/26, which indicated she worked 2 1/2 hours after the allegation of abuse. On 1/24/26 she came in at 7:30 am and clocked out at 8:30 am at which time she was suspended as reported by the Director of Nursing (DON) in a later interview. An interview with the DON on 2/25/26 at 11:32 AM revealed RN #11 failed to notify her of the allegation of abuse immediately. She stated the nurse should have called even if she was not sure it was an abuse allegation. She stated that was the reason that the GNA was allowed to continue to work that evening because she would have suspended the GNA immediately. The concerns were reviewed with the Nursing Home Administrator on 2/25/26 at 12:13 PM who offered no rationale for the deficient practice. Cross Reference: F607 and F609

Based on record review and interviews it was determined that the facility staff failed to clarify a physician's order, failed to follow a physician's order, and failed to ensure a resident received their medication as ordered. This deficient practice was evidenced in 1 (#9) of 5 medical records reviewed during the complaint survey.The findings include:1. On 02/25/26 at 11:38 am a review of Resident #9's electronic health record (EHR) revealed a change in condition note was written on 12/23/25 at 1:38 pm indicating the resident was diagnosed with Influenza A. An order was written on 12/23/2025 1:27 pm for Tamiflu Oral Capsule 30 MG Give 1 capsule by mouth two times a day (BID) for Flu for 5 Days; the order was discontinued on 12/23/2025 10:51 pm. The resident never received the medication. The surveyor received a note indicating the physician was made aware on 12/23/25 at 10:50 pm. Another order was written on 12/23/25 at 10:51 pm Tamiflu 30 MG Give 1 capsule by mouth two times a day for Flu for 5 Days. According to the medication administration record (MAR) the resident did not receive the medication.On 02/26/26 at 9:55 am the surveyor received a note indicating the MD was made aware and the medication was not received on 12/23/25 at 10:50 pm. The facility staff did not notify the physician after the medication was not received the following day; there was no documentation to verify the pharmacy was made aware.On 02/25/26 at 1:04 pm during an interview with LPN Unit Manager #10, the surveyor made them aware the resident tested positive for Influenza A on 12/23/25, was ordered Tamiflu but never received the medication. LPN Unit Manager #10 verbalized typically get medications within 24 hours. STAT medications in a 4-hour window and if the order is placed by 2 pm they will receive the medication by midnight.On 02/25/26 at 3:08 pm during a telephone interview with Physician # 20 the surveyor reported Resident #9 tested positive for Influenza A and was ordered Tamiflu x 5 day, but the resident did not receive the medication. Physician #20 verbalized the patient was in the facility a couple of months ago and was not aware they didn't get the medication prescribed. Physician #20 did not specifically recall being notified that Tamiflu was not administered. 2. On 02/25/26 at 12:21 pm further review of Resident #9's EHR revealed the facility staff received a critical lab result on 12/21/25 at 11:44 pm. The resident's blood culture in the aerobic bottle tested positive for gram + cocci. The resident was ordered on 12/22/25 at 10:22 am to receive Vancomycin 750 mg IV BID for bacteremia x 14 days. The resident received three doses. When a Vancomycin trough level was reported on 12/24/25 at 9:45 am revealed a level of 20 ug/ml which was reported as high. The Vancomycin dose was decreased on 12/24/25 at 11:02 am to Vancomycin 500 mg IV BID x 14 days. The resident did not receive any doses of the medication prior to being sent to the emergency room on [DATE]. On 02/26/25 at 9:55 am the surveyor received a note indicating the nurse notified the physician about the missed dose on 12/24/25 at 6:00 am. There was no documentation to verify the physician, or pharmacy were made aware the resident did not receive the lower dose of Vancomycin 500 my IV BID x 14 days. On 02/25/26 at 2:14 pm during an interview with LPN Unit Manager #10 who reported Resident #9 got three doses of Vancomycin 750 mg, a trough was done and the dose needed to be decreased. They didn't get the lower dose and they never received Tamiflu. On 02/25/26 at 3:04 pm during a telephone interview with Nurse Practitioner (NP) #19 the surveyor asked are they aware the resident did not receive the decreased dose of Vancomycin 500 mg IV that was ordered on 12/24/25 at 11:02 am. NP #19 verbalized not being aware the resident did not receive the intravenous antibiotic. The surveyor reported the resident was diagnosed with Influenza A but did not receive Tamiflu as ordered. NP #19 verbalized not being aware the resident did not receive Tamiflu as ordered. 3. On 02/25/26 at 11:15 pm a review of Resident #9's EHR revealed an order for Sodium Chloride (Na CL) Intravenous Solution 0.9% q shift, every shift for IV fluid and to document the amount of cc given during the entire shift. The order for IV fluids failed to include how many milliliters of IV fluids the resident should receive. The order date was 12/08/25 2:57 pm and the D/C date was 12/10/25 at 6:55 am. The surveyor made DON #2 the order was incomplete, and they nurse should have clarified how many ml the resident should receive each shift. On 12/16/26 at 2:46 pm an order was written for the resident to receive NaCl 1 Liter IV in the evening every Monday, Wednesday, Friday for high ostomy output/dehydration and to use 100 ml/hr IV, document the amount of cc given during the entire shift in numbers. A review of the medication administration record revealed (MAR) the nurses were not documenting the amount of IV fluids the resident received. During an interview with DON #2 they verbalized the amount of fluids the resident received should be written in the notes. On 02/25/26 at 3:30 pm during an interview with LPN Unit Manager #10 the surveyor asked if a resident's medication is not available on site, what do they do? LPN Unit Manager #10 verbalized if they can't get the medication prescribed they would get something that is equivalent and call the pharmacy to get a STAT dose.

Based on record review and interview it was determined that the facility staff failed to provide a resident with a food preference because it could not be offered during a Jewish milk day. This deficient practice was evidenced in 1 (#7) of 2 resident records reviewed for food preferences during the complaint survey.The findings include:On 02/19/26 at 2:25 pm a review of a complaint concerning Resident #7 nutritional needs revealed the resident requested to receive a turkey or tuna sandwich daily, but the request was not honored during their stay for rehabilitation.On 02/26/26 at 10:22 am a review of Resident #7 food preferences revealed the resident was prescribed a regular diet. On Sunday, Tuesday, Thursday, and Saturday the resident was supposed to receive a chicken salad sandwich during lunch. On Monday, Wednesday, and Friday the resident was supposed to receive a turkey sandwich. There was no food preference for a tuna sandwich.On 02/26/26 at 12:28 pm during an interview with Certified Dietary Manager #26 the surveyor asked if a resident requested a turkey or tuna sandwich daily would the kitchen staff be able to honor that request? CDM #26 verbalized the resident could receive the turkey during a meat meal and tuna during a dairy or meat meal, but not every day.

On the review of the electronic health record and interview it was determined that the facility staff failed to document when a resident received activities of daily living (ADL) assistance. This deficient practice was evidenced in 1 (#6) of 5 resident records reviewed during the complaint survey.The findings include:On 02/25/26 at 8:39 am a review of Resident #6 ADL tasks for the months of December 2025 and January 2026 revealed there were multiple GNA tasks that were not completed during both months. On 12/24 & 12/25/25 (11 pm - 7 am), 12/26/25 (7am- 3 pm), and 12/31/25 (11 pm - 7am) there was no documentation to verify if the resident received personal hygiene care. On 12/24 & 12/25/25 (11 pm - 7am) 12/26/25, (7am-3pm), and 12/31/25 (11pm-7am) there is no documentation to verify the resident was turned and repositioned. On 01/03/26 (3pm-11pm) there was no documentation to verify the resident was turned and repositioned. On 01/03, 01/11, 01/18 during 11pm - 7am shift there was no documentation to verify if the resident was bathed. There was no documentation on 01/03, 01/11, and 01/18/26 during 3pm-11pm shift to verify if the resident had an episode of bladder/bowel incontinence and if the resident received personal hygiene. On 02/25/26 at 9:42 am the surveyor reviewed Resident #6's ADL care documentation with LPN Unit Manager #5, the surveyor asked was the staff expected to document ADL care each shift. LPN Unit Manager #5 verbalized the expectation was for the documentation to be done; the documentation should have been completed by the end of the shift. Once the task is completed they should document but if not it should be done by the end of the shift. When a resident has an incontinence episode there should be documentation in the boxes. The clinical staff is responsible for ensuring the staff completes the documentation of the care that was provided. Chart reviews are done the day after the care was provided.

Based on observations and interviews it was determined that the facility staff failed to maintain infection control practices. This deficient practice was discovered during three observations of linen carts and shower rooms during the complaint survey.The findings include:On 02/18/26 at 8:31 am during observation rounds the surveyor observed a linen cart outside of room [ROOM NUMBER] with a tube of cream, shower gel, a fan, and a bag of wash cloths on top on the linen cart.On 02/18/26 at 8:43 am the surveyor observed an uncovered linen cart outside of room [ROOM NUMBER].On 02/20/26 at 10:25 am the surveyor made Unit Manager #5 aware of the uncovered linen cart and the linen cart with items on top. LPN Unit Manager #5 verbalized the linen cart should have been covered and the items should not have been on top of the linen cart.On 02/20/26 at 10:30 am while in the shower room on Sudbrook with LPN Unit Manager #5 the surveyor observed a used washcloth on the grab bar in the shower stall and two used washcloths and a towel on the floor in front of the first shower stall.LPN Unit Manager # 5 verbalized the Geriatric Nursing Assistants are supposed to clean up after using the shower room. To their knowledge Environmental Services cleans the shower room daily.

Based on record review and interview, it was determined that the facility admission agreement failed to include special characteristics and service limitations related to a kosher diet, and requested residents waive their rights as well as waive potential facility liability for personal property losses. The findings include:On 2/19/26 at 1:51 PM a review of the admission packet revealed the admission Agreement. A review of this document failed to reveal information regarding the facility's kosher diet. In addition, the document requires the resident and sponsor agree to not hold the facility responsible for injury or harm that could have been avoided if they had hired a private duty nurse.Further review revealed a Risk Acknowledgement. This form outlined the facility was not responsible for stolen, lost, or damaged personal property and were not responsible for the development of pressure sores, despite regulatory requirements prohibiting waiver of potential facility liability for losses of personal property and regulatory requirement to provide a quality of care that included treatment and services to prevent pressure sores. A separate welcome packet included a copy of the Always Available Menu included in the packet which indicated that they served tuna salad, egg salad, turkey sandwich, bologna sandwich, and pastrami sandwiches along with some other items. At the bottom of the sheet it noted, Any alternate chosen must reflect the kosher appropriate menu option (diary for dairy meal, meat for meat meal.) However, there was no other mention of the special dietary considerations in the welcome packet.An interview with the Hospital Liaison on 2/20/26 at 9:34 AM revealed that she was the person who talked to potential residents in the hospital. She stated that they do not let the residents and/or resident's family know prior to admission and in writing that they follow a kosher diet. She stated that she may mention it but does not go into any detail as to what it means unless they ask for further information. She stated, Food is food and it should not make a difference that meat and dairy cannot be served in the same meal.The Nursing Home Administrator (NHA) was asked to provide proof that the admission policy/agreement was approved at the time of the change in ownership on 2/24/26 at 10:06 AM via a phone call and it was clarified with him on 2/24/26 at 10:14 AM. He was asked on 2/25/26 at 12:19 PM for the information. However, he failed to provide the evidence.On 2/26/26 at 12:33 PM an interview with the NHA revealed he was unable to provide proof that the admission agreement was approved during the change in ownership in 2017 and confirmed that residents were not informed in writing prior to admission that they followed a kosher diet. He stated that it may be included in a brochure, but that he cannot be certain that it was given to every resident. In addition, the surveyor had asked for all information that was provided before and at the time of admission and he failed to provide such a brochure. He offered no rationale as to why the admission agreement and risk acknowledgement was not in compliance with the regulatory requirements.

Based on record review and interview it was determined the facility staff failed to make prompt efforts to resolve grievances and keep the resident/representative appropriately apprised of progress toward resolution. This was evident for 1 (#8) of 6 residents reviewed for neglect.The findings include:A complaint involving Resident #8, and Resident #8's medical record were reviewed on 9/15/25 at 11:44 AM.Resident #8 was evaluated by 2 physicians on 3/31/25 and certified to lack mental capacity to make informed medical decisions. The residents' children became his/her surrogate decision makers.The complaint indicated that on the evening of 6/4/25, one of Resident #8's children was concerned that the Residents' condition was deteriorating. They asked Staff #12 a Licensed Practical Nurse (LPN) to call an ambulance. They reported that Staff #12 refused, told them to make the call themselves, argued with the family and failed to check on the resident following their request. The complaint also indicated that an email was sent to the facility's management team and Social Worker that night and no one responded.Review of the facility's Grievance Logs at that same time revealed there were no grievances related to Resident #8 from 4/27/25 to present.In an interview on 9/16/25 at 10:35 AM the Administrator indicated there were no grievances related to Resident #8. He was made aware that the surveyor had reason to believe concerns regarding neglect were sent via email soon after Resident #8 was transferred to the hospital on 6/4/25. He indicated he would check.On 9/17/25 at 10:10 AM the Administrator was asked again and indicated he checked his email and found nothing.When asked if he received any email communication regarding concerns from the Social Worker related to Resident #8, he looked again and stated, an email was sent to Rehab and the Social Worker who forwarded it to me. When asked what was done when he received it, he indicated he wasn't sure, he'd have to look.A copy of the email was provided to the surveyor upon request. Review of the email revealed it was sent by Resident #8's family member on 6/5/25 at 4:18 AM to the Director of Rehab as well as Staff #6, the Social Work Director. Staff #6 forwarded the email to the Administrator on 6/5/25 at 12:12 PM.The email indicated the family member wanted to make a formal complaint regarding the situation that occurred on 6/4/25. It detailed their concerns regarding the events on 6/4/25 and Staff #12's lack of concern, that he became verbally aggressive, loud, disrespectful and unprofessional. Another interview was conducted with the Administrator on 9/18/25 at 8:07 AM, the Director of Nursing was also present. The Administrator confirmed he did not initiate the grievance process and did not follow up with Resident #8's representative. When asked why, he indicated, because Resident #8 was discharged .He confirmed that he is the Grievance Officer for the facility,Cross reference F 609.

Based on record review and interview it was determined the facility staff failed to report an allegation of neglect to the State Survey Agency. This was evident for 1 (#8) of 6 residents reviewed for neglect.The findings include:Resident #8's medical record and a complaint involving Resident #8, were reviewed on 9/15/25 at 11:44 AM.The complaint indicated that on the evening of 6/4/25, Resident #8's family members were concerned that the Residents' condition was deteriorating. They asked Staff #12 a Licensed Practical Nurse (LPN) to call an ambulance. The complaint indicated that Staff #12 refused, told them to call 911 themselves, argued with the family and failed to check on the resident following the request to call 911. The complainant also indicated s/he sent an email to the facility's management team and Social Worker later the same night. Review of the email revealed it was sent by Resident #8's family member on 6/5/25 at 4:18 AM to the Director of Rehab as well as Staff #6, the Social Work Director. Staff #6 forwarded the email to the Administrator on 6/5/25 at 12:12 PM.The email indicated that the family member wanted to make a formal complaint regarding the situation that occurred on 6/4/25. It detailed Staff #12's refusal to call 911, and lack of concern including but not limited to: He never came to [Resident #8's] room after I voiced my concerns or after I called for an ambulance and included that Staff #12 became very aggressive and loud when the family member questioned his lack of concern. The email included [Resident #8] is a patient at your facility and should be treated as if they were caring for their own [family], not ignored and left to die.The Administrator and Director of Nursing (DON) were interviewed on 9/18/25 at 8:07 AM. When asked why the nurse didn't call 911 per the family request. The DON stated the nurse did call 911.They confirmed that the allegation was not reported to the State Survey Agency. When asked why, the DON stated, We took it as a customer service issue but immediately saw that it had been addressed by the nurse.Further review of the medical record on 9/18/25 at 9:40 AM revealed a Change in Condition note written by Staff #12 on 6/4/25 at 22:03 (10:03 PM) which included documentation that the resident's family member called 911.The Administrator and DON were made aware that the facility failed to immediately report an allegation of neglect as required then conduct a thorough investigation.Cross Reference F 585.

Based on medical record review and interview with resident and facility staff, it was determined that the facility failed to put interventions in place to prevent the future occurrence of abuse and neglect allegations. This was evident during the review of 2 of 2 allegations of abuse reported by Resident #2.The findings include:1. Medical record review of Resident # 2 on 9/16/25 at 10:30 AM revealed allegations of abuse that occurred during the rendering of activities of daily living (ADL) that was being provided to Resident #2 on 8/23/25 and then again on 9/7/25. Resident #2 first made allegations that his/her rights were violated on 8/23/25 when s/he reported that staff changed and dressed him/her without permission. Resident #2 even stated that s/he had told the staff 'No', but they continued to change his/her shirt anyway. Resident #2 alleged that s/he was held down by the wrists and made to change his/her shirt.Resident #2 was interviewed on 9/16/25 at 12:15 PM regarding what occurred on the night of 8/23/25. S/he stated that his/her regular GNA was not scheduled, and another one came in to provide care during the night shift. Resident #2 stated that s/he agreed to have their bottom changed but said 'no' to changing of the shirt. At that, according to the resident, the GNA left and the room and returned with another GNA to assist in changing the shirt. Resident #2 verbalized to this surveyor that s/he felt assaulted, was yelling and had stated 'no.'2. On 9/7/25 another incident similar in nature occurred with staff GNA #7 during the day shift. Resident #2 alleged that GNA #7 changed [his/her] shirt without permission. GNA #7 was interviewed on 9/17/25 at 1:15 PM regarding her interactions with Resident #2 on 9/7/25. She stated that she had gone in to provide care for him/her with an orientee and they were all ok and initially Resident #2 agreed to get cleaned up and change. However, when we went to change the shirt, the resident became combative. She went on to state that maybe s/he is very specific with the way s/he wants things done. She did state further that they continued to change the resident's shirt. She went on to state that she was removed from patient care while there was an investigation into this new abuse allegation.Resident #2 was interviewed about the incident on 9/7/25 on 9/16/25 at 12:15 PM. S/he was verbally and physically upset as s/he 'stated I just reported this incident on 8/23/25 and then it happened again 2 weeks later, don't I have rights? Don't they have to ask me permission?'The concern that this resident had not one, but 2 similar allegations of abuse occur in a 2-week period with no identifying prevention was reviewed.The DON stated on 9/18/25 at 8:30 AM that notes were put in Resident #2's care plans regarding these events, however, there were no adjustments to the actual plan of care for Resident # 2 that would assist this resident and care givers in potentially working cohesively and preventing future occurrences and allegations of abuse.

Based on record review and interview with staff it was determined that upon resident admission to the facility the physician failed to address a hospital discharge plan to provide CPAP (Continuous Positive Airway Pressure) at night and to wean a resident off supplemental oxygen. This was evident for 1 (#8) of 8 residents reviewed for Quality of Care.The findings include:Resident #8's medical record was reviewed on 9/15/25 at 11:44 AM. The resident was admitted to the facility from the hospital on 3/28/25. Their diagnoses included but were not limited to Obstructive Sleep Apnea and acute respiratory failure with hypercapnia (excessive carbon dioxide in the blood).The hospital Discharge summary dated [DATE] reflected post discharge plans which included but were not limited to: continue to wean off O2 (oxygen) continue with supplemental O2 in the meanwhile Continue with CPAP at night.A CPAP (Continuous Positive Airway Pressure) machine delivers a steady stream of air through a mask to keep the users airway open during sleep and prevent pauses in breathing.The physicians' orders upon admission to the facility included Oxygen inhalation (via nasal cannula @ 2 lpm [liters per minute]).Upon Resident #8's admission, the physician failed to write an order to wean the resident off the supplemental oxygen, and for the use of CPAP at night as indicated in the hospital discharge plan.The Attending Physician, Staff #14's, Medical Visit documentation dated 3/31/25, Section H. Summary of Findings stated, Continue with O2 by nasal cannula Monitor respiratory status History of obstructive sleep apnea Continue with CPAP. However, there was no order at that time for CPAP.The note did not address the plan to wean Resident #8 off supplemental oxygen or rationale for not ordering it.On 4/9/25 an order was written for: Wean off O2. It did not indicate Resident #8's target blood oxygen saturation level.In another physician note on 4/15/25 Staff #14 noted, History of obstructive sleep apnea Respiratory status seems to be at baseline, No dyspnea (shortness of breath) on examination continue with CPAP.However, no orders were written for CPAP. There was no mention of the residents' oxygen weaning and tolerance.On 5/1/25, approximately 1 month after admission, orders were written by the physician for: C-Pap on at night for OSA (Obstructive Sleep Apnea).An interview on 9/16/25 at 10:40 AM the DON (Director of Nursing) was asked how hospital discharge plans were reconciled when residents were admitted to the facility. She explained that the physician will reconcile the orders at the time of admission if in the facility. If they are not in the building the nurse will call the physician and review with the physician via telephone. She was made aware of the hospital plan for Resident #8 and was asked why Resident #8's admission orders and assessment did not include use of CPAP at night and oxygen weaning or rationale for not ordering as per the hospital discharge plan. She indicated she was not sure and would have to check the record and get back to the surveyor. No further information was provided to the surveyor regarding this concern prior to the survey exit.The Administrator was made aware of the above concerns on 9/17/25 at 1:08 PM.Cross reference F 695.

Based on record review and interview it was determined the facility failed to develop and implement a comprehensive person-centered plan to meet the residents' needs. This was evident for 1 (#8) of 8 residents reviewed for Quality of Care.The findings include: Oxygen weaning involves the gradual reduction of supplemental oxygen to determine a patient's ability to maintain adequate oxygen saturation on room air. A common approach includes decreasing oxygen flow rates in small increments, observing for symptoms and SpO2 (blood oxygen saturation level) at rest and during activity and ensuring the patient can sustain the target SpO2.A CPAP (Continuous Positive Airway Pressure) machine is a common treatment for sleep apnea, delivering a steady stream of air through a mask to keep the patients airway open during sleep and prevent pauses in breathing.Resident #8's medical record was reviewed on 9/15/25 at 11:44 AM. The resident was admitted to the facility from the hospital on 3/28/25. Their diagnoses included but were not limited to Obstructive Sleep Apnea (OSA) and acute respiratory failure with hypercapnia (excessive carbon dioxide in the blood).A hospital Discharge summary dated [DATE] identified post discharge plans which included but were not limited to: continue to wean off O2 (oxygen) continue with supplemental O2 in the meanwhile continue with CPAP at night.A comprehensive plan of care was developed for Resident #8 on 3/31/25. However, the plan for altered respiratory status/Difficulty Breathing r/t COPD (chronic occlusive pulmonary disease), cough was not added until 4/18/25. The resident's goal was will have no complications related to SOB (shortness of breath). The plan did not identify the residents individualized care needs related to his/her use of supplemental oxygen and diagnosis of OSA.On 4/9/25 the physician ordered oxygen weaning. The Plan of Care was not updated to include a weaning plan, protocol, or the staff responsible.On 5/2/25 an intervention was added for: CPAP SETTINGS: The resident's BiPAP using home machine with settings embedded via (nose mask).The plan of care did not include individualized resident centered interventions for the provision of care related to the resident's use of the CPAP machine such as type of mask, humidification, schedules for replacing/cleaning the tubing, mask, filters, and machine support, provision of supplies and the staff responsible.The Administrator was asked to provide a copy of the facility policies, procedures and protocols related to CPAP, BIPAP and Oxygen Weaning.Review of the facility policies on 9/16/25 at approximately 8:00 AM revealed the policy for Oxygen Administration included, the resident's care plan should identify the interventions for oxygen therapy based on the resident assessment and orders. The policy did not identify the facility's protocol for oxygen weaning. An interview was conducted with the DON (Director of Nursing) on 9/16/25 at 10:40 AM. She was made aware of the above concerns and indicated that the Rehab department is responsible for weaning residents off oxygen. She was unable to explain why Resident #8's plan of care did not include oxygen therapy, an oxygen weaning plan and specific care needs related to CPAP. She indicated that she would have to check and would get back to the surveyor.The DON failed to provide any further information regarding these concerns prior to the end of the survey.The Administrator was made aware of the above concerns on 9/17/25 at 1:08 PM.Cross reference F 695.

Based on medical records review and interview with facility staff, it was determined that the facility failed to have an effective system in place to appropriately manage [MEDICATION NAME] therapy in for a resident with a history of bleeding and also failed to prevent the unnecessary administration of [MEDICATION NAME]. This was evident for 1 out of 6 residents (Resident #10) reviewed for unnecessary medication.Due to this failure, on May 5, 2016 at 3:28 PM an Immediate Jeopardy was identified related to the use of anticoagulant medication with insufficient monitoring identified during investigation of complaint MD 313. An initial plan of action was given to the survey team for review on 5/5/16 at 5:20 PM and rejected. The 2nd plan of action was given to the survey team and the Office of Health Care Quality for review at 6:30 PM. The immediate jeopardy was removed at 6:45 PM on May 5, 2016 while the survey team remained on site. After removal of the immediacy, and based on review of documentation submitted by the facility, this deficiency was found to be past non-compliance as of March 18, 2016. The findings include: On 5/5/16 Resident's #10 medical records were reviewed. This review revealed that the resident was admitted to the facility for long term care and with [DIAGNOSES REDACTED]. Review of the physician orders [REDACTED].#10 was receiving daily [MEDICATION NAME] (dose) to prevent his/her blood from clotting. The targeted physician ordered range for Resident #10's INR was 2.0 - 3.0.INR stands for international normalized ratio. The INR provides some information about a person's blood's tendency to clot (which is often described as how thin or thick their blood is). A normal INR is approximately 1.0. People taking the blood thinner [MEDICATION NAME] typically have a target INR of 2.0 to 3.0.Further review of the physician orders [REDACTED]. On 1/25/16 the physician discontinued the [MEDICATION NAME] and started the resident on [MEDICATION NAME] 1 gram intramuscularly every day for 5 days. The resident finished the course of antibiotic on 1/30/16. Many antibiotics increase [MEDICATION NAME] ' s blood-thinning ability and raise the risk of internal bleeding. People taking [MEDICATION NAME] and antibiotics must be monitored closely. Review of the [MEDICATION NAME] Anticoagulation Records from January 2016 and February 2016 revealed that the resident's dose of [MEDICATION NAME] had been 1.5 milligram (mg) every day. The INR result on 1/13/16 was 3.24. The [MEDICATION NAME] dose was held on 1/13/16 and on 1/14/16 the resident resumed the 1.5mg daily dose of [MEDICATION NAME]. The [MEDICATION NAME] records also revealed that on 2/2/16 the resident's INR was 1.4 and the [MEDICATION NAME] dose was increased to 2 mg every day. On 2/5/16 the INR was 1.81 and the resident continued to receive the 2 mg. Further review of the [MEDICATION NAME] records revealed that on 2/12/15 the resident's INR was 6.46.On 2/12/16 the nurse's note revealed that the physician was called and made aware of the PT/INR results. A telephone order was given to repeat PT/INR on 2/13/16. Review of the physician order [REDACTED]. The telephone orders failed to include an order to hold the [MEDICATION NAME] and the box on the order sheet was not checked to indicate that the nurse read the order back to the physician; verifying accuracy of the telephone order. Review of the laboratory records and the [MEDICATION NAME] anticoagulant records for 2/13/16 and 2/14/16 failed to reveal the results of the PT/INR that was ordered for 2/13/16. Review of the medication administration records (MAR) revealed that the resident received 2 mg of [MEDICATION NAME] on 2/12/16, 2/13/16 and 2/14/16 even though the INR was critically high at 6.46. Further review of the clinical record revealed the resident had her/his PT/INR obtained on 2/15/16, 2 days after it was scheduled to be done. The order to discontinue the [MEDICATION NAME] was not written until 2/15/2016 when the INR result had increased to 7.31.Further review of the medical records revealed that on 2/15/16 the resident was noted on the floor with no apparent injuries. On 2/16/2016 the resident was transferred emergently to the hospital after being examined by the physician for change in mental status, complaints of headaches and a large purple bruise noted on the left upper arm radiating down below the elbow.Review of the hospital records revealed that on the 2/16/16 admission, extensive ecchymosis was noted on the left upper extremity, bruising noted on the left lower extremity, and multiple other bruises were noted. Review of the 2/21/16 hospital discharge revealed the following statement, h/she had ecchymosis of the left upper extremity with some ecchymosis around the left knee joint as well as left ankle joint and the calf muscle area. She/He also had a lot of bleeding with ecchymosis of the skin of the back.Further review of the hospital's [MEDICAL CONDITION] consult report revealed that the resident had a thoracentesis on 2/19/2016 to remove a pleural effusion in which 850 milliliters of tea colored fluid was removed. The resident's 2/21/16 discharge summary further stated, For [MEDICAL CONDITION], the patient did not require any transfusion as hemoglobin and hematocrit remained stable during the hospital stay. However, there was a significant loss of blood while she/he was in the nursing home from previous admission to now which could be accounted by the extensive ecchymosis as well as right sided pleural effusion very likely due to hemothorax.Thoracentesis is a procedure to remove excess fluid in the space between the lungs and the chest wall. Pleural effusion is excess fluid that accumulates in the fluid filled cavity or space surrounding the lungs. [MEDICAL CONDITION] is a decrease in the amount of red blood cells in the blood. Hemoglobin and hematocrit measurements are blood tests that evaluated the amount of red blood cells in blood. Ecchymosis is a discoloration of the skin resulting from bleeding underneath, typically caused by bruising. Hemothorax is a type of pleural effusion in which blood accumulates in the fluid filled cavity or space surrounding the lungs. During an interview with Staff #3 on 5/5/16, the surveyor asked if laboratory came to the facility on the weekend. She replied that they came every single day.During an interview with the physician on 5/6/16 at 2:00 PM he revealed if the INR is high, he provides orders for vitamin K. If elevated at 3.5 - 4.5, [MEDICATION NAME] should be held and restarted at a lower dose. He also reported that an INR between 5 and 9, at the discretion of the doctors. The surveyor asked the physician if he gave the order to hold [MEDICATION NAME] and he stated, Believe me I told this nurse to stop the [MEDICATION NAME], it is not standard of practice to give [MEDICATION NAME] and Vitamin K.Prior to initiation of the survey, the facility had put certain actions including a variety of policies and structural changes in place:-On 2/15/16 the deficient practice was identified by the facility after learning that the facility staff failed to obtain a physician ordered PT/INR to be drawn on 2/13/16 and continued to administer a high risk medication [MEDICATION NAME].-On February 18, 2016 the facility enacted a voluntary 30 day admission ban on new residents taking [MEDICATION NAME] to revise and test the revisions of laboratory services and [MEDICATION NAME] administration.-The laboratory policy was revised and dated as 3/17/2016. The earliest staff training sign-in sheet on the revised laboratory policy provided to the surveyors was dated 3/18/2016. In addition, the anticoagulation policy was revised and dated March 2016. The earliest staff training sign-in sheet on the revised anticoagulation policy provided to the surveyors was dated 3/14/16. Nursing staff also received additional training by the pharmacy consultant on March 15, 2016.-[MEDICATION NAME] will be discontinued instead of being placed on hold for patients that have a clinical indication that requires that [MEDICATION NAME] be discontinued or held. If [MEDICATION NAME] is to be restarted a new order will be required. A caution note will be attached to Vitamin K stating that if Vitamin K is used [MEDICATION NAME] is to be discontinued. -The facility changed its laboratory policy to incorporate that weekend nursing staff beginning on Friday at 11 PM are responsible for calling STAT laboratory prior to finishing their shift.In summary, Resident #10 continued to be administered [MEDICATION NAME] for 3 days starting on 2/12/16 after it was discovered that the resident's INR was significantly elevated. No orders were evident to discontinue this high risk medication until 2/15/16 even after the physician was notified and medication was initiated to reverse the effects of [MEDICATION NAME]. Furthermore, when the resident's INR was ordered to be rechecked on 2/13/16, the INR was not checked until 2/15/16, 2 days later. This multi-system failure which included a failure to ensure appropriate orders were obtained, the continued inappropriate administration of a high risk medication, and failure to follow medical and laboratory monitoring orders in the management of [MEDICATION NAME] placed the resident and other residents on [MEDICATION NAME] within the facility at risk for serious harm.

Based on medical records review and interview with facility staff on 7/1/15, it was determined that the facility staff failed to have an effective system in place to monitor a resident on [MEDICATION NAME] (medication used to prevent blood from clotting). Resident #1 was prescribed and administered [MEDICATION NAME] with no documented clear and comprehensive understanding of the goals of [MEDICATION NAME] management specific to this resident even after the attending physician reviewed the chart on 6/1/15 and failed to order any labs for the monitoring of [MEDICATION NAME] therapy. In addition staff failed to consistently monitor the resident's INR (international normalized ratio). Direct care staff failed to communicate the pharmacy recommendation that was completed on 6/3/15 to monitor the resident's INR to the ordering physician and staff repeatedly administered [MEDICATION NAME] without knowing the current status of the resident's INR.These interrelated system failures resulted in Resident #1 going more than 30 days on the high-risk medication with insufficient monitoring. The failure to ensure appropriate orders were obtained, to ensure an effective process for completion of the pharmacy review process, and the continued administration of the medication without knowledge of current INR status increased the risk for serious harm for this resident. This was evident for 1 of 4 residents identified during a complaint survey. The findings include:On 7/1/15 Resident #1's medical record was reviewed. This review revealed that the resident was admitted to the facility for long term care and with [DIAGNOSES REDACTED].Review of the physician orders [REDACTED]. Further review of the anticoagulation records revealed that the resident also had INR's obtained on April 6, 9, 10, 13, and 20, 2015.On 4/6/15 the resident's INR was 3.26 and the [MEDICATION NAME] was discontinued. On 4/9/15 and 4/10/15 the INR remained greater than 3 and the [MEDICATION NAME] remained discontinued. On 4/13/15 the INR was 1.52 and an order was written for [MEDICATION NAME] 5 milligrams by mouth every day. Review of the May anticoagulation records revealed that the resident had an INR obtained on 5/4/15 and 5/18/15. On 5/18/15 the resident was ordered an additional 5 milligrams of [MEDICATION NAME] for low INR results (1.47). Further review of the physician orders [REDACTED].Review of the nursing progress note dated 5/18/15 revealed the following: INR= 1.47, MD made aware via phone, N.O. (new order) to give [MEDICATION NAME] 10 milligrams x1 and then resume [MEDICATION NAME] 5 milligram as of 5/19/15. Further review of the nurse's notes for May and June failed to reveal any additional notes on monitoring the resident's INR. Review of the medication administration records (MAR) revealed that on 5/18/15 the resident received a total of 10 milligrams of [MEDICATION NAME]. From 5/19/15 to 6/19/15, the resident continued to receive 32 doses of [MEDICATION NAME] without checking the resident's INR and without questioning why there was no INR result available.Review of a physicians order and note dated 6/1/15 revealed the following plan: 'We will continue to watch her closely. Watch the pro-time/INR and make sure everything is okay.' Despite this plan, there was no order found in the medical record or provided by the facility to the surveyor, regarding the need obtain a pro-time/INR.Further review of the resident's medical records revealed a Chronological Record of Medication Regimen Review sheet completed by the consulting pharmacist that documented the date when a medication review was completed and if recommendations were made to the physician. This review revealed that on 6/3/15 the pharmacist reviewed the resident's chart and made a recommendation to the physician. Further review of the medical record failed to reveal any documentation as to what these recommendations were and if they were addressed by the physician.On 7/1/15 at 2:10 PM surveyor requested from the Quality Assurance nurse a copy of the recommendations made for this resident for June 2015. On 7/1/15 at 2:45 PM the QA nurse stated that she had 'bad news.' She reported she was able to get the recommendation from the DON and it did not appear that the physician or anyone else was made aware of the pharmacy recommendations.Review of the 6/3/15 pharmacy recommendations to the physician revealed the following: On 5/18/15 this resident had an INR of 1.47 (sub therapeutic) that resulted in an order to give 5 mg of [MEDICATION NAME] ([MEDICATION NAME]) x1. No follow-up INR has been drawn since 5/18/15. Consider ordering an INR at this time and recheck it until it reaches the desired therapeutic range.During an interview with the QA nurse on 7/1/15 she revealed that when the DON gets the pharmacy recommendation, she gives it to the unit mangers. She had no explanation as to how or why this pharmacy review was missed.During an interview with the medical director on 7/1/15 at 7:42 PM, he acknowledged that there was a breakdown in physician services, nursing and pharmacy services.During the survey on July 1, 2015 complaint MD 572 was substantiated and at 10:50 PM an Immediate Jeopardy was determined to exist related to the use of anticoagulant medication with insufficient monitoring. It was determined that the facility failed to have an effective system in place to monitor a resident on [MEDICATION NAME].An initial plan of action was given to the survey team and the Office of Health Care Quality for review at 2:00 AM on July 2, 2015 by the facility. The immediate jeopardy was removed at 2:20 AM on July 2, 2015 after acceptance by the survey team and review by the Office of Health Care Quality.