Every finding on record at Larkin Chase Center

Based on observation, interview and record review, it was determined that the facility failed to develop and implement resident-centered care plans for residents' urinary catheters and activities. This was evident for 4 (#10, #71, #3 , and #20) out of 32 residents reviewed during an annual survey. The findings include: A Care Plan is used in nursing facilities to summarize a resident's health conditions and care needs. It is used to ensure resident's needs are met and consistent care is provided to the resident based on those needs. 1. During a review of medical records for Resident #10 on 7/01/2026 at 12:09 PM it was discovered that the Resident's care plan included Resident requires indwelling catheter that was initiated on 4/27/2026. A review of the doctor's orders revealed the orders for Resident #10 to have a urinary catheter had been discontinued on 5/01/2026. There was no additional documentation showing that Resident #10 had a current urinary catheter. During an interview with Registered Nurse (RN) #22 on 7/02/2026 at 10:06 AM she confirmed that Resident #10 no longer had a urinary catheter and that it had been removed. She advised the Unit Managers are responsible for maintaining and updating the Care Plans for the Residents. During an interview with Unit Manager #29 on 7/02/2026 at 10:13 AM she reported the nursing care plans should be updated with any changes the Resident experiences, which would include having a urinary catheter placed or removed. She advised the care plans are continually updated and changes are made within 24 hours when there is a change in a Resident's care. She reviewed the chart for Resident #10 and confirmed that the Resident did not currently have a urinary catheter and advised the catheter should have been resolved and removed from his/her care plan. During an interview with Senior Director of Nursing #21 on 7/06/2026 at 7:15 AM she reported that the care plans are updated with any changes the Resident experienced and every 90 days. She confirmed that the urinary catheter should have been removed from the care plan for Resident #10. 2. During a review of medical records for Resident # 71 on 7/06/26 at 11:21 AM it was discovered that the Resident's care plan included Resident requires indwelling catheter that was initiated on 6/07/2026. A review of the resident orders revealed the previous orders for a urinary catheter had been discontinued and there were no current orders for Resident #71 to have a urinary catheter. An additional review of the Progress Notes for Resident #71 revealed the urinary catheter was removed on 6/09/2026. During an interview with Unit Manager #29 on 7/06/2026 at 11:56 AM she advised the nursing care plans should be updated with any changes the Resident experiences. She reviewed the chart for Resident #71 and confirmed that the Resident did not currently have a urinary catheter, it had been discontinued and advised the care plan should have been updated. 3. On 06/29/2026 at 11:27 AM, during a three-hour observation period. Resident #3 was noted to be looking at the walls and kept falling asleep. No television was on, no activity staff were present, and no suitable activity items had been left in the room for the resident to use. During an interview on 07/01/2026 at 9:43 AM, the Activity Assistant #34 detailed her daily routine regarding one-to-one room visits for dependent residents. Her routine included checking on residents to encourage participation in group activities and offering individual engagement, such as playing music, coloring, or providing companionship. However, the Activity Assistant #34 revealed that she was unable to personalize residents' meaningful activities. Specifically, she noted challenges with incorporating preference assessments and care plan information into their daily activity needs. Additionally, she stated that her daily documentation was using a paper notebook to all one-to-one visits, but this practice ended in April which was about only half the residents had daily visits. She reported that she has been unable to document these visits in the electronic system; consequently, there has been no documentation of one-to-one visits since May 2026. On 07/01/2026 at 10:03 AM, joined interview with the Activity Director #35 confirmed that one-to-one visits are expected to dependent residents daily. She was aware that current activity services lack meaningful activities for those residents and that there are deficiencies in no accurate documentation. On 07/01/2026 at 12:30 PM, record review noted that the Activity Director #35 assessed Resident #3's Recreation Assessment on 5/26/26. The assessment included the following preferences: - Personal Choice: Choosing their own clothes and bed time. - Activities: Engaging in news and discussions, watching sports, attending Baptist services, playing cards, watching TV, play Jazz, Blues, and 60s music were noted as somewhat important. In Resident #3's care plan also includes offering specific preferences, such as play cards, watching sports channel and family visits. A final interview was conducted on 07/01/26 at 3:36 PM, to discuss the findings regarding Activity Services. During the meeting, the Administrator agreed that the facility failed to incorporate resident preferences into daily activities and noted that daily visits have been inconsistent. He confirmed that he will follow up with Activity Services to ensure that personalized activities are established and implemented. Furthermore, he has committed to ensuring that proper documentation is maintained moving forward, and to correct the all above identified practice deficiencies. 4. On 06/29/2026 at 10:52 AM, Resident #20 was awake and sitting up in bed, starring out the window. There were no activity materials at the bedside, and no activity staff were present at that time. Surveyor attempted to interview the resident during the morning and again later that afternoon; however, the resident did not respond on either occasion. During an interview on 07/01/2026 at 9:43 AM, the Activity Assistant #34 detailed her daily routine regarding one-to-one room visits for dependent residents. Her routine included checking on residents to encourage participation in group activities and offering individual engagement, such as playing music, coloring, or providing companionship. However, the Activity Assistant #34 revealed that she was unable to personalize residents' meaningful activities. Specifically, she noted challenges with incorporating preference assessments and care plan information into their daily activity needs. Additionally, she stated that her daily documentation was using a paper notebook to all one-to-one visits, but this practice ended in April which was about only half the residents had daily visits. She reported that she has been unable to document these visits in the electronic system; consequently, there has been no documentation of one-to-one visits since May 2026. On 07/01/2026 at 10:03 AM, joined interview with the Activity Director #35 confirmed that daily one-to-one visits are expected to dependent residents and she was aware that current activity services lack meaningful activities for those residents and that there are deficiencies in no accurate documentation. On 07/01/2026 at 12:46 PM, record review noted that the Activity Director assessed Resident #20's preferences on 04/07/26. The assessment included the following preferences: - Personal Choice: Choosing their own clothes, taking care of personal belongings, having snacks between meals, setting their own bedtime, and having phone access in a private space. - Activities: Following the news, reading books, listening to jazz, live music, and the radio, visiting with animals/pets, participating in group activities, dancing, spending time in the fresh air when weather permits, and attending interdenominational religious services. In Resident #20's care plan also includes offering specific preferences, such as listening to jazz music, watching game shows, and working outside garden. A final interview was conducted on 07/01/26 at 3:36 PM, to discuss the findings regarding Activity Services. During the meeting, the Administrator agreed that the facility failed to incorporate resident preferences into daily activities and noted that daily visits have been inconsistent. He confirmed that he will follow up with Activity Services to ensure that personalized activities are established and implemented. Furthermore, he has committed to ensuring that proper documentation is maintained moving forward, and to correct the all above identified practice deficiencies.

Based on record review and staff interview, the facility failed to ensure that an identified irregularity in a resident's monthly medication regimen review (MRR) was adequately addressed by the ordering physician (Physician #38) and appropriately followed up by facility staff. This was evident for 1 (Resident #2) of 5 residents reviewed for drug regimen review. The findings include:On 07/01/2026 at 2:00PM, a record review revealed that Resident #2 had orders to receive amiodarone (a medication used to control heart rhythm) 200 mg and amiodarone 500 mg. On the MRR dated 3/29/2026, Pharmacist #39 documented 2 recommendations to the physician: (1) clarification regarding an allergy to Benadryl, and (2) clarification regarding whether the concurrent amiodarone 200 mg and 500 mg orders represented a loading dose (a large dose of medication given at the beginning of treatment to rapidly achieve an optimal drug level in the bloodstream) or if both doses were intended to continue for daily therapy. The MRR showed that Physician #38 responded only to the Benadryl clarification. Review of Resident #2's record failed to identify documentation that facility staff followed up with the physician to obtain clarification regarding the amiodarone dosage. The Director of Nursing (DON) was absent for part of the survey and Registered Nurse (RN) #21 was acting in that role on those days. On 07/02/2026 at 2:30PM, in an interview with RN #21, this surveyor requested clarification on the process involved with the MRR. RN #21 stated the pharmacist reviewed each resident's medication orders monthly. If the pharmacist has recommendations, he/she emails the MRR form to the team, which includes the unit manager and the Director of Nursing, who then prints the MRR. The paper copy of the MRR is then given to the ordering physician who reviews the recommendations and either changes the orders or indicates in writing why they want to order to remain. The form is then given back to the team and reviewed. RN #21 stated if the physician does not address one or more items on the MRR, it is the team's responsibility to review it and then contact the physician. Requested the documentation that this process was followed for Resident #2. On 07/06/2026 at 1:45 PM, in an interview with the DON and RN #21, reviewed findings related to missing documentation. No additional information was given to the survey team that showed that Physician #38 responded to the amiodarone concern or was followed up with by nursing staff.

Based on medication administration observation, medical record review, and staff interviews, it was determined that licensed facility staff failed to maintain a medication error rate of less than five percent during the medication pass observation. This was evident for 3 Residents (#17, #22, and #38) of 4 residents observed. A total of 28 medication administration opportunities were reviewed, resulting in a medication error rate of 10.71%.The findings include: 1). On 07/01/2026 at 8:26 AM during a medication administration observation with Registered Nurse (RN) #5, was observed crushing Resident #17's medications; Aspirin chewable 81mg one (1) tablet, Baclofen 20mg 1 tablet, Dantrolene Sodium 25mg 1 tablet, Famotidine 20mg 1 tablet, Gabapentin 300mg 1 capsule, Multivitamin 1 tablet, Propranolol 10 mg 1.5 tablets, Senna 8.6mg 1 tablet, and Thiamine 100mg 1 tablet, administering them mixed in applesauce. On 07/01/2026 at 9:17 AM review of Resident #17's physician orders and Medication Administration Record (MAR) with Registered Nurse (RN) #5 revealed no physician's order or instructions indicating that the medications were to be crushed prior to administration. On 07/01/2026 at 9:20 AM an interview with RN #5 confirmed that Resident #17's medications were crushed and mixed with applesauce prior to administration. RN #5 further stated that Resident #17 normally takes his/her medications crushed. Review of facility Medication Administration General Guidelines Policy dated 01/26 page 2 of 6 on 07/01/2026 at 9:30 AM revealed on Section 7.1 item 5a. states the need for crushing medications is indicated on the resident's orders and the MAR so that all personnel administering medications are aware of the this need and the consultant pharmacist can advise on safety an alternatives, if appropriate, during Medication Regimen Reviews. On 07/01/2026 at 9:50 AM an interview with the Director of Nursing (DON)#21 regarding crushed medications revealed that medication orders must include instructions indicating that medications may be crushed. The DON #21further stated that the expectation is for nursing staff to notify the physician if a resident is unable to swallow medications. 2). On 07/01/2026 at approximately 8:39 AM the surveyor observed medication administration with RN #5 on the North Wing for Resident #22. Review of the physician's orders revealed an order for Humalog Solution 100 units/mL, inject 4 units subcutaneously with meals for the treatment of Type 2 Diabetes Mellitus. The order further directed staff to obtain a finger-stick blood glucose reading prior to insulin administration and notify the physician if the blood glucose level was less than 70 mg/dL or greater than 400 mg/dL. The finger-stick blood glucose checks were scheduled for 7:30 a.m., 11:30 a.m., and 4:30 a.m. At approximately 8:50 AM the surveyor observed that Resident #22 had completed breakfast, and the breakfast tray had already been removed by staff. At approximately 8:55 AM, RN #5 obtained the resident's finger-stick blood glucose level and subsequently administered the ordered Humalog insulin after the meal had been completed. On 07/01/2026 at approximately 8:58 AM during an interview RN #5 stated that, per the physician's order, Resident #22's blood glucose level should be checked at 7:30 AM and the ordered Humalog insulin should be administered with the resident's meal. RN #5 further stated that Resident #22's breakfast tray was delivered between 7:30 AM and 8:00 AM and that the resident had already finished eating before the blood glucose level was checked and the ordered Humalog insulin was administered. 3). On 07/01/2026 at 7:49 AM during a medication administration observation on the North Wing, Resident #38 had a physician's order for insulin lispro, inject 10 units with meals. The surveyor observed RN #22 enter Resident #38's room carrying an insulin flex pen labeled with another Resident (#8's) name and prepare to administer the insulin to Resident #38. Before the medication was administered, the surveyor asked RN #22 whose insulin flex pen she was about to administer. RN #22 looked at the label and stated, This is not for this resident. RN #22 then left the room, checked the medication cart, and stated, The resident's insulin is not in the cart. Let me check the medication room. RN #22 returned with a vial of insulin labeled for Resident #38 and presented it to the surveyor prior to administering the medication. Due to the surveyor's intervention, the insulin flex pen labeled for another resident was not administered to Resident #38. On 07/01/2026 at 8:30 AM during an interview, RN #22 stated that insulin flex pens are resident-specific and should not be shared between residents. RN #22 further stated, Resident #38's insulin was not in the medication cart. On 07/01/2026 at 9:27 AM during an interview, DON #21 stated that insulin flex pens are resident-specific, individualized for each resident, and are not to be shared among residents. The DON stated that staff are expected to verify the resident's identity and the medication label prior to administration to ensure the correct insulin is administered to the correct resident. On 07/02/2026 at 1:35 PM DON#21 submitted documentation of an in-service education. The sign-in sheet indicated that RN #22 received education on the Five Rights of Medication Administration on 07/01/2026.

Based on record reviews and interviews it was determined that the facility failed to demonstrate the presence of required quality assurance committee members at Quality Assurance Process Improvement (QAPI) meetings. This was evident in 7 of 13 QAPI meetings (June 2025, July 2025, August 2025, September 2025, October 2025, November 2025 and December 2025) reviewed during the recertification survey.The findings include: During a review of the attendance sheets for June 2025 through June 2026 QAPI meetings on 7/06/2026 at 8:30 AM it was revealed that the attendance sheets were not fully completed to confirm the attendees that were present. The QAPI meeting attendance sheets had 3 columns: Column 1 was Title of the position which included Administrator, Medical Director, Director of Nursing and the Infection Preventionist. The title of Column 2 was Attended which included a box to be checked if the member had attended. Column 3 was labeled as Members Signature Required and included a blank space. During continued review of the QAPI meeting attendance sheets it was discovered that the meetings held on 6/17/2025, 7/17/2025. 8/21/2025, 9/18/2025, 10/16/2025, 11/20/2025 and 12/18/2025 had checks in Column #2 for staff that attended by title but had no names or signatures listed in Column #3 which was labeled Members Signature Required. During an interview with Nursing Home Administrator #1 on 7/06/2026 at 8:41 AM he confirmed that the attendance sheets represented who was at the meetings and that the meetings held on 6/17/2026, 6/17/2025, 7/17/2025. 8/21/2025, 9/18/2025, 10/16/2025, 11/20/2025 and 12/18/2025 did not identify the names of the attendees at the QAPI meeting and had no signatures as required by the sign in sheet. During a review of the facility Center Quality Assurance Performance Improvement Process policy on 7/06/2026 at 2:33 PM it stated that Documentation for each meeting must include Agenda, Sign-in sheet and minutes

Based on record review and interview, the facility failed to thoroughly investigate an allegation of verbal abuse for 1 (Resident #2) of 2 residents reviewed for abuse investigations. The findings include:On 7/1/26 at 2:50 PM, a review of the facility reported incident (FRI) #2974437 was initiated. The report indicated that Licensed Practical Nurse (LPN) #25 argued with and stated That's what's wrong with people in America, they want things done immediately, when a family member reported an hour-long delay in pain medication administration for Resident #2. Further review of the FRI revealed a witness statement by Registered Nurse (RN) #33 that confirmed what LPN #25 said. Additional review of the FRI documents revealed an interview between the Administrator and LPN #25 where it is documented that LPN #25 had said the statement was not intended in the way that it was interpreted. In the report investigation, it is stated that other residents who may have had contact with LPN #25 denied any such experiences. However in the witness statements, one resident had remarked that LPN #25 was snappy, a statement which was not included in the investigation report. The facility also failed to include in the documentation that RN #33 witnessed the alleged event and provided his/her account. The conclusion of the investigation stated, The allegation was unable to be verified because interviews with other residents who may have had contact stated they had no similar experiences and the perpetrator stated his words were misinterpreted. The report cites Not applicable (N/A) for any corrective action for the employee. 07/02/2026 at 1:08 PM, in an interview with the Administrator regarding the FRI investigation, this surveyor questioned the missing information about witness statements in the report. He admitted that was an error, and he interviewed staff but failed to include the information. When questioned why the report from the resident interviews did not include the one resident statement that LPN #25 could be snappy, his response was that it was discussed and found to be differences in culture, but could not say why he did not include that statement in the investigative report. When asked about RN #33's witness statement not being included in the investigative report, he did not have an answer. When asked to provide documentation of any corrective action taken as a result of this incident, he produced documents for facility - wide training on customer service, but no specific corrective action for LPN #25. When asked if this witness statement had proven the complainant's allegation, he agreed.

Based on observations, interview, and record review, it was determined that the facility failed to ensure that staff interacted with residents in a courteous, respectful and responsive manner. This was evident for 1 (Resident #71) of 1 Resident monitored for a dignified existence and 1 (Resident #2) of 2 residents investigated for abuse. The findings include: 1) During an observation on 7/06/2026 at 12:03 PM Resident #71 was observed hunched over while being pushed in a wheelchair at a moderate pace through the hallway near the North Wing Nursing Station by Occupation Therapy Assistant (OTA) #30. During continued observation it was noted that the legs of Resident #71 were observed to be bent at the knees with the legs being dragged on the floor below the seat of the wheelchair, his/her ankles were flexed backwards with the tops of his/her toes dragging on the floor. Additional observation revealed there were no footrest attached to the wheelchair. OTA #30 continued with transporting Resident #71 to the North Wing Dining room. During an interview with OTA #30 on 7/06/2026 at 12:04 PM she reported she was returning Resident #71 from therapy. She advised she needed a wheelchair so she grabbed the first one she could find for Resident #71. She reported the wheelchair didn't have any leg rest attached when she chose it for Resident #71 and advised there were no other chairs available. During an interview with Director of Rehab #31 on 7/06/2026 at 12:15 PM she reported the expectation for using leg rest with wheelchairs was that if the resident can self-propel themselves, leg rest are not required and if the resident is unable to self-propel themselves, they should have leg rest on their wheelchair. During an interview with Occupational Therapist #32 on 7/06/2026 at 12:26 PM she reported the expectations are for Residents that can't control their legs to have leg rest on their wheelchair because we don't want them dragging on the floor. She advised she had provided therapy to Resident #71 previously and advised the Resident was totally dependent on staff, the resident would not be able to lift his/her legs and did not have the ability follow commands. She confirmed that Resident #71 cannot self-propel his/herself and that she/he should have had the leg rests on the wheelchair for transport when leaving therapy. She reported we try to make sure everyone has leg rest. She confirmed that leg rest are not always available as some leg rest go missing and we have to find new ones. 2) On 7/1/26 at 2:50 PM, a facility reported incident (FRI) #2974437 was reviewed. The report indicated that Licensed Practical Nurse (LPN) #25 argued with and stated That's what's wrong with people in America, they want things done immediately, when a family member reported an hour-long delay in pain medication administration for Resident #2. Further review of the FRI revealed a witness statement by Registered Nurse (RN) #33 that confirmed what LPN #25 said. On 07/02/2026 at 11:08 AM, in a record review of employee file for LPN #25, it is noted that he/she completed online continuing education for customer service and effective communication as well as culturally competent care on 4/9/26. On 07/02/2026 at 1:08 PM, in an interview with the Administrator and after review of residents file, he confirms that there is evidence that LPN #25 made these statements in front of residents.

Based on review of resident medical records and interview with facility staff, it was determined that the facility failed to evaluate and document the clinical appropriateness of administering an antibiotic in which the resident had a documented allergy. This was evident for 1 (Resident #2) of 4 residents reviewed for antibiotic stewardship. The findings include:On 06/30/2026 at 11:07 AM, in a record review, Resident #2 was noted to have a documented allergy to penicillin. The review also revealed a progress note written 6/22/2026 by Resident #2's physician (Physician #38) that indicated an infection was present and required treatment with an antibiotic. Physician #38 ordered the antibiotic Augmentin (an antibiotic which is a combination of two different medications, one of which is penicillin-based). The record failed to acknowledge Physician #38's intent for a Penicillin-based antibiotic, despite the documented allergy to penicillin. On 07/01/2026 at 2:00PM, ongoing record review failed to indicate that the allergy was discussed or clarified with Resident #2 or Physician #38 prior to administration. A medication alert was acknowledged and signed by Licensed Practical Nurse #25; however, the record failed to document any communication between nursing staff and the physician questioning the safety of the order. On 07/02/2026 at 2:30PM, in an interview with Registered Nurse #21, she indicated that when a possible allergy to a medication exists, the ordering provider should document the reason they are ordering the medication despite the allergy. If it is not documented by the provider, the nurse who accepts the order should have reviewed the potential allergy risk with the provider and documented that conversation.

Based on record reviews and interviews, it was determined that the facility failed to ensure a resident's Preadmission Screening and Resident Review (PASRR) form was completed correctly on admission to the facility. This was evident for 1 (Resident #71) of 2 Residents reviewed for PASARR screening during the recertification survey. The findings include:Preadmission Screening and Resident Review (PASRR) is a federal mandate designed to prevent the inappropriate placement of individuals with Serious Mental Illness (SMI) or Intellectual/Developmental Disabilities (ID/DD) in nursing facilities. Everyone who applies for admission to a nursing facility must be screened for evidence of serious mental illness (MI) and/or intellectual disabilities (ID), developmental disabilities (DD), or related conditions.During a review of medical records for Resident #71 on 7/02/2026 at 12:00 PM it was discovered that the Resident had a diagnosis of dementia with psychotic disturbance and major depressive disorder upon admission into the facility. Continued review of medical records for Resident #71 showed the PASRR upon admission identified the medical diagnosis of slow heart rate (Bradycardia), Acute Kidney Failure and a blood clot in the leg and no mental illness diagnosis was found listed.During an interview with Regional Social Worker #4 on 07/01/2026 at 2:41 PM she reported the PASRR would be reviewed by the facility when the Resident is admitted and the PASRR would be resubmitted if the Resident had a Mental Illness or Mental Disability diagnosis that was not found on the admission PASRR. She confirmed that the Mental Illness Diagnosis of 'unspecified dementia, 'unspecified severity with psychotic disturbance' and 'major depressive disorder, single episode, unspecified' should have been identified on the PASRR for Resident #71.During an interview with Regional Social Worker #4 on 7/02/2026 at 10:50 AM she reported that she completed a new PASRR for Resident #71 since the mental illness diagnosis were not on the initial PASRR, she advised it was completed by the hospital and should have been redone after admission since there were no mental illness diagnosis listed on the PASRR.

Based on interview and record review, the facility failed to implement a toileting schedule for 1 (Resident #2) of 1 resident reviewed for bowel and bladder incontinence. The findings include: On 06/29/2026 at 12:38 PM, in an interview with Resident #2, he/ she reported they must wait extended times for toileting. He/she reported needing staff assistance to get to the bathroom and therefore he/she is unable to use the toilet independently. He/she reported believing they would be continent of both bowel and bladder if they were able to get to the toilet but instead have been encouraged by staff to use a brief for urination. He / she said that the staff do not help him/her to the toilet throughout the day at routine intervals. On 06/30/2026 at 11:46 AM, in a record review of the toileting documentation completed by Certified Nursing Assistants (CNAs), Resident #2 has been listed as continent 1/3 of all shifts and incontinent 2/3 of all shifts. The care plan intervention listed the resident was to be assisted to the toilet at scheduled times (also called a toileting schedule) and that staff were to discuss and plan bathroom schedules with the resident. The record fails to show that a toileting schedule has been followed since admission. Review of the Minimum Data Set (MDS) documentation for assessments dated 4/7/26 and 6/8/26 revealed that a trial of a toileting schedule had not been attempted by the facility. On 07/01/2026 at 9:46 AM, in an interview CNA #36 reported that Resident #2 knows when he/she needs to use the toilet, and that he/she is not on a toileting schedule. CNA #36 reported that, for those residents on a toileting schedule, it is noted in the medical record under tasks for the CNAs to sign off that the toileting schedule was done. CNA toileting documentation was almost always completed once a shift (about every 8 hours). On 07/06/2026, at 1:02PM in an interview with the unit manager (RN #29), also stated if a person is on a toileting schedule, then it is on the tasks portion of electronic medical record and documented every 2 hours by the CNA's that the resident was toileted. On 07/06/2026 at 1:45 PM, in an interview with the Director of Nursing (DON) this surveyor requested documentation that Resident #2 had been on a toileting schedule. The DON agreed that the care plan indicated the resident should be on a toileting schedule, but the MDS stated one had not been instituted and the CNA tasks do not include a toileting schedule.

Based on review of resident medical records and interviews with facility staff, it was determined that the facility failed to address a significant weight loss for a resident. This was evident for 1 (Resident #11) of 1 resident reviewed for nutrition during recertification survey process.The findings include: On 06/29/2026 at 2:09 PM review of Resident #11's medical record revealed the resident was admitted to the facility on [DATE] with diagnoses of dementia, diabetes mellitus, hypertension, and multiple chronic wounds. Surveyor review of the facility's documented weights from admission through 06/28/2026 (39 days after admission) revealed the following: - 05/20/2026 – 169.0 lbs. - 05/21/2026 – 174.8 lbs. - 05/22/2026 – 173.9 lbs. - 06/09/2026 – 178.4 lbs. - 06/12/2026 – 181.9 lbs. - 06/22/2026 – 185.5 lbs. - 06/23/2026 – 154.1 lbs. 06/28/2026 – 146.7 lbs. The documented weights reflected an increase of 16.5 pounds over 33 days, from 169.0 lbs. on 05/20/2026 to 185.5 lbs. on 06/22/2026. The following day, within 24 hours, the documented weight decreased 31.4 pounds, from 185.5 lbs. to 154.1 lbs. Between 06/23/2026 and 06/28/2026 (5 days), the documented weight decreased an additional 7.4 pounds to 146.7 lbs., representing a total documented weight loss of 38.8 pounds over 6 days. On 07/02/2026 at 10:58 AM interview with Certified Dietitian (CD) #18 revealed the facility's weight monitoring process includes weights upon admission, re-weighing the following day, weekly weights for four weeks, and monthly weights thereafter. The CD stated residents with wounds or a history of weight loss are monitored more frequently as clinically indicated. The CD#8 stated she assessed Resident #11 on 05/27/2026, with an average meal intake of approximately 70%, and requested a re-weight on 06/25/2026. The CD#8 further stated weight changes or variances are communicated to her by nursing staff. Review revealed no documentation that the resident's weight variance was addressed. On 07/02/2026 at 11:18 AM review of the Nutritional Assessment completed on 05/27/2026 revealed the resident was identified as having increased nutritional needs related to extensive wounds. Interventions included Protein Liquid supplementation, and a house shake twice daily to support wound healing and meet the resident's nutritional needs. On 07/02/2026 at 11:21 AM surveyor review of the resident's current dietary intake documentation revealed the resident's average oral intake was 89% of meals. On 07/02/2026 at 11:48 AM interview with Unit Manager (UM) #29 revealed residents are weighed on admission, re-weighed the following day, then weekly for four weeks and monthly thereafter. The UM stated significant weight changes are reviewed during weekly interdisciplinary weight meetings attended by the Certified Dietitian (CD), Director of Nursing (DON), Nurse Practitioner (NP), and Unit Manager (UM). She further stated that when a significant weight variance is identified, the charge nurse verifies the weight by re-weighing the resident, notifies the physician, CD, and resident representative, initiates a change-in-condition assessment, updates care plan, implements physician orders, and nursing staff document residents' meal intake daily. On 07/02/2026 at 12:16 PM surveyor review of Resident #11's medical record with UM #29 revealed no Change in Condition assessment had been completed for the resident's significant weight variance and no documentation of notification to the physician or resident representative. UM #29 stated the facility's expectation is for nursing staff to complete a Change in Condition assessment and notify the physician and resident representative of significant weight variances. The UM acknowledged the required documentation was not completed. On 07/02/2026 at 2:09 PM interview with DON #21 revealed that the Interdisciplinary Team (IDT) is responsible for updating and revising resident care plans. The DON further stated that nutrition-related care plans are updated and revised by the CD. On 07/02/2026 at 2:22 PM surveyor review of the resident's medical record with the DON #21 revealed there was no change in condition assessment initiated in response to the resident's weight variations. The review also revealed no care plan was initiated or revised to address the resident's weight loss/gain. On 07/02/2026 at 2:28 PM the CD stated that nutrition care plans are completed and updated by the Dietitian. On 07/06/2026 at 1:05 PM review of medical record revealed after surveyor's intervention, nutrition care plan for weight loss related to increased nutrient needs for wound healing despite improved oral intake as evidenced by severe 13.6% weight loss over 41 days, stage 3 pressure injury, diabetic foot ulcer and need for increase oral nutrition supplement revision on 7/3/2026. On 07/06/2026 at 2:19 PM DON #2 reported to the surveyor that there was no Dietitian or nursing documentation indicating weekly weight meetings were held, the resident's weight variances were addressed, or a plan of care was implemented related to the resident's weight loss.

Based on observations, record review, and staff interview, it was determined that the facility failed to ensure medications and medical supplies were routinely monitored for expiration dates and expired items were removed from stock. This was evident by 2 out of 2 medication storage rooms observation during the recertification survey process.The findings include:On [DATE] at 7:02 AM observation of the South Wing medication room with the Director of Nursing (DON) #21 revealed expired medication and medical supplies. Resident #62 had one bag of Ceftriaxone 2 g/100 mL in Normal Saline Solution (NSS), IV every 24 hours, Lot #2503030, with an expiration date of [DATE]. During the observation, the DON#21 stated the medication had been discontinued on [DATE]. Observation also revealed one Zyno Medical Administration Set, Lot #2504073, expired [DATE], and four Zyno Medical Administration Sets with an expiration date of [DATE].On [DATE] at 7:18 AM observation of the North Wing medication room with the DON #21 revealed four Zyno Medical Administration Sets, Lot #2505059, expired [DATE]; five Zyno Medical Administration Sets, Lot #2502037, expired [DATE]; and one iHealth COVID-19 Antigen Rapid Test Kit, Lot #245CO20627, expired [DATE].During a review of the facility's Medication Storage Policy, dated 01/2026, page 3 of 3, on [DATE] at 7:30 AM, Section 4.1, Item 14, revealed that Outdated, contaminated, discontinued, or deteriorated medications are immediately removed from stock and disposed of according to medication disposal procedures. On [DATE] at 7:45 AM interview with DON #21 regarding medication and medical supply storage revealed that all medications and medical supplies are expected to be properly labeled and routinely checked for expiration dates. The DON stated that medications and medical supplies should be stored according to facility policy and manufacturer instructions, and expired items should be promptly removed from storage. On [DATE] at 2:01PM the DON#21 informed the surveyor that education for nursing staff regarding the proper labeling, storage, and monitoring of medications and medical supplies had been initiated and was ongoing.On [DATE] at 2:27 PM the DON#21 provided the surveyor with a medication storage audit report completed on [DATE] for the South and North Wing medication rooms.

Based on interviews, observation and record review, the facility failed to ensure food was served at an appropriate and palatable temperature for 1 of 1 trays reviewed for palatability. The findings include:On 06/29/2026 at 12:38 PM, in an interview with Resident #2, he/she reported that the food is always cold and mealtimes are not consistent. On 06/30/2026 at 08:42 AM, review of a list of mealtimes revealed that the noon meal tray line was documented to begin at 11:45 AM with the first tray cart delivered to nursing units at 12:00 PM, noting that delivery times could vary by up to 10 minutes. On 07/02/2026 at 11:50 AM, in an observation of the kitchen and tray line, FSD #20 stated that the tray line would begin in approximately 5 minutes. FSD #20 reported the menu, that day, would be soft chicken taco, fajita vegetables and corn. On 07/02/2026 at 12:08 PM, in an observation of the tray line, the thermal pallets ( inserts used in institutions that are heated and placed under preheated plates to keep meals hot) were noted to be sitting on the tray line table, outside of the warming unit. The surveyor touched some of the pallets and noted that while ones freshly removed from the heater were quite hot, other pallets had been out of the heater longer and had cooled to the point of being comfortable to touch. The plates had also been removed from their heater in stacks and were placed on the tray line table. They were also only slightly warm to the touch. At that time, the surveyor also observed District Food Service Director (DSFD) #19 request the line staff only pull the plates and pallets out of their warmers for just one cart at a time to preserve their heat. Staff began returning pallets to the warmers. On 07/02/2026 observed the following: At 12:11 PM, the surveyor requested for a test tray to go in the tray line. At 12:20 PM, the test tray was placed in the food cart.At 12:21 PM, the DFSD #20 assisted in obtaining food temperatures from the test tray. The pureed chicken, pureed bread, pureed fajita vegetables, and mashed potatoes each measured about 135 degrees Fahrenheit. At 12:28 PM, the meal tray cart was delivered to the nursing unit.At 12:33 PM, the first meal tray was removed from the cart.At 12:35 PM, the second meal tray was removed from the cart.At 12:36 PM, the third meal tray was removed from the cart. At 12:37 PM, additional staff arrived to assist with delivery of meal trays.At 12:42 PM, additional administrative staff arrived to assist with delivery of meal trays At 12:54 PM, after all resident trays had been delivered, the test tray was removed from the meal cart and food temperatures were rechecked immediately. The pureed chicken, pureed bread, pureed fajita vegetables, and mashed potatoes each measured 109 degrees Fahrenheit. In an interview with DSFD #19, he expressed concern regarding the amount of time that was taken for staff to deliver the trays, and stated that this extended time makes the food cold and unpalatable. At 12:56 PM, the surveyor tasted the food items on the test tray. They all tasted unpalatably cool.

Based on interview and record review, it was determined that the facility failed to provide consistent medical necessary (post-stroke) rehabilitation to residents includes but is not limited to physical Therapy, occupational therapy or speech therapy needs. This was evident for 1 (#57) of 2 residents reviewed for the rehabilitation during an annual survey. The findings include:Post-stroke rehabilitation is an inpatient programs generally require at least 3 hours of active therapy per day, 5 days a week after a new stroke. The most rapid neurological recovery occurs during the acute and subacute phases (Days 1 to 90), making this a crucial window for intensive rehabilitation. During an interview on 06/30/26 at 9:51 AM, Resident #57 expressed deep concern regarding their post acute care. The resident experienced an acute stroke that affected their speech and functioning on one side of their body. They noted that their rehabilitation sessions stopped over two weeks ago, and they have not been informed of the medical reason for this interruption. A record review conducted on 6/30/26, at 2:10PM revealed that Resident #57 was admitted to the facility on [DATE]. The admission followed a hospital stay for an acute left cerebellar hemorrhage, which resulted in right-side paralysis, aphasia, and a cognitive communication deficit. Resident #57 was admitted primarily for intensive post-stroke rehabilitation and has been motivated, cooperative, and making steady progress. Upon further review, Physician #37 ordered the re-certification of Occupational and Physical Therapy (OT/PT) on 05/29/26. The order specified that the patient should continue to receive skilled OT/PT 5 times a week for 4 weeks, with skilled services to include therapy treatment, self-care, neuro re-education, group therapy, and discharge planning. Additionally, on 06/03/26, Physician #37 ordered the re-certification of Speech Therapy 5 times per week for 30 days for communication treatment, patient/caregiver education, and discharge planning. However, all rehabilitation services were abruptly discontinued on 06/16/26. Regarding the inquiry with the Administrator on 07/02/26, at 8:46 AM, he stated that it would be virtually impossible for the rehabilitation staff to not provide ongoing services. The Administrator indicated that he would locate the therapists' documentation and not yet received a response. On 07/02/26 at 9:33 AM, an interview was conducted with the Rehabilitation Director #31 who noted she began working at the facility last week, stated that Resident #57's rehabilitation began on 5/1 and 5/4, but all services were subsequently ended on 6/15/26. She agreed that there should be no gaps in the resident's rehabilitation therapies. During the final interview on 07/02/2026 at 3:45PM with the Administrator and shared above concerns. He agreed that the rehabilitation staff failed to provide consistent, medically necessary post-stroke rehabilitation to Resident #57. The Administrator confirmed he will follow up with the rehab staff to correct this deficient practice.

Based on observation and staff interviews, the facility failed to follow appropriate infection control practices during medication administration. This was evident for 1 (Resident #38) of 4 residents observed during the medication administration observation.The findings include:Medication administration is the process of preparing and administering medications in accordance with professional standards of practice to ensure the right resident, right medication, right dose, right route, right time, right documentation, right reason, right response, and the resident's right to refuse, while adhering to infection prevention and control practices and physician orders.On 07/01/2026 at 7:49 AM during a medication administration observation on the North Wing, Resident #38 had a physician's order for insulin lispro, inject 10 units with meals. The surveyor observed RN #22 enter Resident #38's room carrying an insulin flex pen labeled with another Resident (#8's) name and prepare to administer the insulin to Resident #38.Before the medication was administered, the surveyor asked RN #22 whose insulin flex pen she was about to administer. RN #22 looked at the label and stated, This is not for this resident. RN #22 then left the room, checked the medication cart, and stated, The resident's insulin is not in the cart. Let me check the medication room. RN #22 returned with a vial of insulin labeled for Resident #38 and presented it to the surveyor prior to administering the medication. Due to the surveyor's intervention, the insulin flex pen labeled for another resident was not administered to Resident #38.On 07/01/2026 at 8:30 AM during an interview, RN #22 stated that insulin flex pens are resident-specific and should not be shared between residents. RN #22 further stated, Resident #38's insulin was not in the medication cart.On 07/01/2026 at 9:27 AM during an interview, DON #21 stated that insulin flex pens are resident-specific, individualized for each resident, and are not to be shared among residents. The DON stated that staff are expected to verify the resident's identity and the medication label prior to administration to ensure the correct insulin is administered to the correct resident.On 07/02/2026 at 1:35 PM DON#21 submitted documentation of an in-service education. The sign-in sheet indicated that RN #22 received education on the Five Rights of Medication Administration on 07/01/2026.

Based on interview, record review, and facility policy review, the facility failed to ensure a STAT (a Latin word, statim, which meant immediately or without delay) chest x-ray was completed as ordered and timely provider notification of a critical and abnormal laboratory test values for 1 (Resident #7) of 3 sampled residents reviewed for a change in condition. On [DATE], Resident #7 experienced a change in condition and a nurse practitioner (NP) ordered a STAT chest x-ray and STAT laboratory tests to rule out pneumonia and assess for other possible underlying causes of the resident's change in condition. The STAT chest x-ray was not completed on [DATE]. The blood specimen was collected for the laboratory tests, which revealed the resident had a high critical sodium level of 161 millimoles per liter (mmol/L). This critical laboratory value was communicated to the facility nursing staff on [DATE]; however, the provider was unaware of the results until [DATE]. After review of the resident's clinical status and laboratory test results, concern was expressed by the providers for the resident's deterioration and agreed the resident required transfer to the hospital for further evaluation and management at a higher level of care. Resident #7 was transferred to the local hospital around 11:30 AM. Resident #7 arrived at the hospital and was noted to be hypotensive (low blood pressure) with agonal respirations. Cardiopulmonary resuscitation (CPR) was initiated when the resident was noted not to have a pulse. The resident remained pulseless despite multiple rounds of CPR and expired at 12:38 PM. It was determined the facility's non-compliance with one or more requirements of participation had caused, or was likely to cause, serious injury, serious harm, serious impairment, or death to residents. The Immediate Jeopardy (IJ) was related to 483.25 Quality of Care, F684, Quality of Care at a scope and severity of J. The IJ began on [DATE] when the facility failed to complete an ordered STAT chest x-ray and promptly notify the provider of a critical and abnormal laboratory test values for Resident #7.The survey team notified the Administrator, Director of Nursing, and four clinical advisors of the IJ and provided the IJ template on [DATE] at 11:00 AM. A removal plan was requested. The facility's removal plan was accepted by the state survey agency on [DATE] at 8:34 PM. The IJ was removed on [DATE], after the survey team performed onsite verification that the removal plan had been implemented. Noncompliance for F684 remained at a lower scope and severity of D, isolated/no actual harm with the potential for more than minimal harm.Findings included: A facility policy titled, NSG122 Change in Condition: Notification of, revised [DATE], specified: Policy A Center must immediately inform the patient, consult with the patient's physician, and notify, consistent with their authority, the patient's representative, where there is: * An accident involving the patient which results in injury and has the potential for requiring physician intervention; * A significant change in the patient's physical, mental, or psychosocial status (that is, a deterioration in health, mental or psychosocial status in either life-threatening conditions or clinical complications); * A need to alter treatment significantly (that is, a need to discontinue or change an existing form of treatment due to adverse consequences, or to commence a new form of treatment); or * A decision to transfer or discharge the patient from the Center. When making notification of above, the Center must ensure that all pertinent information is available and provided upon request to the physician. Purpose To provide appropriate and timely information about changes relevant to the patient's condition. A Face Sheet indicated the facility admitted Resident #7 on [DATE]. According to the Face Sheet, the resident has a medical history that included atherosclerotic heart disease, paroxysmal atrial fibrillation, encephalopathy, vascular dementia, traumatic subdural hemorrhage, hypertension, and cognitive communication deficit. A quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of [DATE], revealed Resident #7 had a Brief Interview for Mental Status (BIMS) score of 11, which indicated the resident had moderate cognitive impairment. Resident #7's Progress Notes, written by NP #6 and dated [DATE] at 11:17 AM, revealed the NP was requested to evaluate the resident for acute respiratory distress. The Progress Notes indicated the resident had difficulty breathing with the use of their accessory muscles, had lung crackles, and an oxygen saturation of 93-96% on room air. Per the Progress Notes, the NP ordered a treatment plan to include a STAT chest x-ray, STAT laboratory tests including a comprehensive metabolic panel (CMP), magnesium level, and a complete blood count (CBC) with differential to rule out pneumonia and assess for other possible underlying conditions.Resident #7's Order Details, revealed a physician's order dated [DATE] at 11:12 AM, for a STAT chest x-ray. Resident #7's Order Details, revealed a physician's order dated [DATE] at 11:15 AM, for a STAT CMP, magnesium level, and a CBC with differential. Resident #7's medical record revealed no evidence to indicate the STAT chest x-ray ordered on [DATE] was completed. Resident #7's laboratory test result report revealed a blood specimen was collected from the resident on [DATE] at 5:11 PM for CMP, magnesium level, and CBC with differential. Per the result, the resident's sodium level registered high critical at 161 mmol/L; the resident's blood urea nitrogen (BUN) registered high at 55 milligrams per deciliter (mg/dL); the resident's magnesium level registered high at 2.9 mg/dL; and the resident's white blood cell (WBC) count registered high at 29.68 10 cubed microliter (uL). Resident #7's Progress Notes, written by NP #6 and dated [DATE] at 11:51 AM, revealed Patient was seen today for follow-up of ongoing acute respiratory distress for which stat laboratory tests, chest X-ray, and DuoNeb treatments were ordered yesterday [[DATE]] due to increased work of breathing and clinical decline. Results of the stat laboratory tests obtained today [[DATE]] were reviewed and showed significant abnormalities, including markedly elevated WBC of 29.68 BUN of 55 consistent with acute kidney injury, and severe hypernatremia with sodium of 161. These findings are concerning for worsening condition with dehydration, possible infection, and renal impairment. The patient was started on half-normal saline at 124 cc (cubic centimeters) per hours for a total of 2 liters for hydration and sodium correction. Patient assessed at bedside awake at time, lethargic and showing clinical decline. [His/Her] vital stable with blood pressure 127/75 heart rate 64 temperature 96.6 oxygen 97 on room air. The provider discussed the patient's condition and abnormal laboratory results with [Resident #7's Attending Physician], who was in house at the time of evaluation. After review of the clinical status and labs, he expressed concern for the patients deterioration and agreed that the patient requires transfer to the hospital for further evaluation and management at a higher level of care. Resident #7's Order Details revealed a physician's order dated [DATE] at 11:27 AM, that specified to transfer the resident to the nearest emergency room due to critical laboratory values and an elevated WBC count. Resident #7's Emergency Department Provider Note, dated [DATE], revealed Per EMS [emergency medical services], they were called to the patient's rehab facility due to decreased oxygen saturation. On arrival, patient was noted to be hypotensive with agonal respirations. EMS established IO [intraosseous] access and began giving fluids. They began bagging the patient and then patient lost pulses. CPR [cardiopulmonary resuscitation] was started at 11:55 AM. Patient received 4 doses of epinephrine. [Resident #7] was noted to be asystole on the monitor. Per the Emergency Department Provider Note, Patient remained pulseless and asystole with cardiac standstill on ultrasound despite multiple rounds of CPR and medications. Given this, decision was made to terminate resuscitation efforts. Time of death 12:38 PM. During an interview on [DATE] at 11:28 AM, the Director of Nursing (DON) stated the facility did not have a written policy that provided guidance to staff on STAT orders, but there was a mutual expectation that STAT orders should be completed within four hours. During a telephone interview on [DATE] at 1:01 PM, the x-ray vendor representative stated the vendor received an order for an x-ray for Resident #7 on [DATE] and when the technician arrived at the facility to complete the x-ray, they were not able to complete the order because Resident #7 had already been sent to the emergency room. The x-ray vendor representative stated the vendor did not receive an order for a STAT chest x-ray on [DATE]. During a follow-up telephone interview on [DATE] at 11:57 AM, the x-ray vendor representative stated the vendor had eight hours to complete an x-ray, if it were ordered STAT. During a telephone interview on [DATE] at 3:10 PM, the laboratory vendor representative stated the laboratory vendor received an order for Resident #7 on [DATE] at 11:20 AM, the laboratory collected the blood specimen at 3:30 PM, and the results were reported to the Evening Nursing Supervisor at 8:57 PM on [DATE]. During an interview on [DATE] at 1:00 PM, the Evening Nursing Supervisor stated she did recall receiving a telephone call about Resident #7's critical and abnormal laboratory values. The Evening Nursing Supervisor stated she did not think it was her who the laboratory called. During an interview on [DATE] at 10:32 AM, NP #6 stated she was not aware the chest x-ray was not completed and the facility should have contacted the provider when the critical laboratory test results came in. NP #6 stated had she been notified the evening of [DATE] when the resident's laboratory test results were received, she would have sent the resident to the hospital. During a follow-up interview on [DATE] at 11:06 AM, the DON stated the nurses were responsible for following up on STAT orders, notifying the provider if laboratory tests and/or x-rays were not completed, and reporting all critical laboratory values immediately. The DON stated when Resident #7's critical laboratory test results were received, the facility should have reported the results to the on-call provider. The DON confirmed she was unaware Resident #7's critical laboratory test results were not reported to the provider. During a telephone interview on [DATE] at 10:44 AM, the Medical Director (MD) stated the expectation was for providers to be notified immediately of any change in a resident's condition, all critical laboratory test results, or if an order could not be carried out. According to the MD, he felt the outcome for Resident #7 would have been the same regardless of when the resident was sent to the hospital. During an interview on [DATE] at 4:12 PM, the Administrator stated he expected provider notification whenever there was a change in a resident's condition, including when critical laboratory test results were received or when laboratory or x-ray orders could not be completed. The facility submitted a removal plan that was accepted by the state survey agency on [DATE] at 8:34 PM. The removal plan indicated the following: F684 - Quality of Care: Removal Plan This Plan of Removal is in response to the identification of Immediate Jeopardy communicated by the survey team on [DATE]. The Facility respectfully submits this Plan of Removal (POR) pursuant to Federal and State regulatory requirements.Corrective Action Identification of residents affected or likely to be affected: The facility took the following actions to address the citation and prevent any additional residents from suffering an adverse outcome. Resident #7 is no longer admitted to the facility; therefore, a corrective action cannot be completed. Current residents presenting with a change in condition, as per Policy NSG122 Change in Condition: Notification of were reviewed by the DON and clinical regional nurses to ensure the following: (1) notification of change in condition to medical provider (2) new orders documented (if applicable) by [DATE]. On [DATE] at 6:44 PM, only three current residents presented a change in condition. Actions to prevent occurrence/reoccurrence: The facility took the following actions to prevent an adverse outcome from occurring. The DON and/or designee educated licensed nurses including agency nurses working on [DATE] on notification to the medical provider regarding a change in condition (Policy NSG122 Change in Condition: Notification of). Licensed nurses including agency nurses not working and not on leave or vacation on [DATE] will be re-educated by [DATE]. The education will be added to the agency nurse's orientation packet and provided prior to the start of the first shift worked. The DON and/or designee will review the clinical assessment, eINTERACT Change in Condition Evaluation to verify notification to the medical provider daily x3, weekly x4, then monthly x2. The Administrator will review the results of the audits in a weekly ad hoc quality assurance performance improvement (QAPI) to ensure compliance has been achieved and sustained. All corrections were completed on [DATE]. The immediacy of the IJ was removed on [DATE]. The IJ was removed on [DATE] at 10:00 AM after the survey team verified the facility's implementation of the removal plan as follows: Step 1 - Staff education on STAT orders and change-in-condition protocolRemoval Plan Action: Licensed nurses, including agency staff, were to receive immediate education on:-STAT order completion and escalation (4-hour threshold)-Notification requirements for abnormal findingsSurvey Team Verification: The survey team reviewed sign-in sheets and confirmed training was provided on [DATE] and supplemented through phone in-services between [DATE] and [DATE] for staff not present. Education materials were added to the agency nurse orientation packet.The survey team interviewed licensed nurses across all shifts between [DATE] and [DATE]. All staff accurately described:-STAT order protocol (completion within 4 hours, or call provider if delayed)-Notification thresholds for abnormal labs-Process for escalating orders that cannot be implemented Step 2 - Change-in-condition and STAT escalation auditsRemoval Plan Action: Daily audits were initiated to confirm provider notification and correct implementation of new orders for identified changes in condition. Planned frequency: daily x3, weekly x4, monthly x2. Survey Team Verification: The team reviewed completed audits for [DATE] and [DATE] documenting nine instances of a change in condition, all with timely notification and documented follow-up. Step 3 - QAPI MonitoringRemoval Plan Action: Weekly ad hoc QAPI meetings to confirm compliance trends and sustainability. Survey Team Verification: The team reviewed minutes from the [DATE] QAPI meeting, which included review of change of condition logs, and staff education compliance. The DON and Administrator demonstrated ongoing monitoring systems. The survey team validated through record review and interviews with nurses across all shifts plus the DON and the Market Clinical Lead, that the immediate jeopardy removal plan was fully implemented and systemic corrections were in place.

Based on interview, record review, and facility policy review, the facility failed to promptly notify the provider of a critical and abnormal laboratory test values for 1 (Resident #7) of 3 sampled residents reviewed for a change in condition. On [DATE], Resident #7 experienced a change in condition and a nurse practitioner (NP) ordered STAT (a Latin word, statim, which meant immediately or without delay) laboratory tests to rule out pneumonia and assess for other possible underlying causes of the resident's change in condition. The blood specimen was collected for the laboratory tests, which revealed the resident had a high critical sodium level of 161 millimoles per liter (mmol/L). This critical laboratory value was communicated to the facility nursing staff on [DATE]; however, the provider was unaware of the results until [DATE]. After review of the resident's clinical status and laboratory test results, concern was expressed by the providers for the resident's deterioration and agreed the resident required transfer to the hospital for further evaluation and management at a higher level of care. Resident #7 was transferred to the local hospital around 11:30 AM. Resident #7 arrived at the hospital and was noted to be hypotensive (low blood pressure) with agonal respirations. Cardiopulmonary resuscitation (CPR) was initiated when the resident was noted not to have a pulse. The resident remained pulseless despite multiple rounds of CPR and expired at 12:38 PM on [DATE]. It was determined the facility's non-compliance with one or more requirements of participation had caused, or was likely to cause, serious injury, serious harm, serious impairment, or death to residents. The Immediate Jeopardy (IJ) was related to 483.10 Resident Rights, F580, Notification of Changes at a scope and severity of J. The IJ began on [DATE] when the facility failed to promptly notify the provider of a critical and abnormal laboratory test values for Resident #7.The survey team notified the Administrator, Director of Nursing, and four clinical advisors of the IJ and provided the IJ template on [DATE] at 11:00 AM. A removal plan was requested. The facility's removal plan was accepted by the state survey agency on [DATE] at 8:34 PM. The IJ was removed on [DATE], after the survey team performed onsite verification that the removal plan had been implemented. Noncompliance for F580 remained at a lower scope and severity of D, isolated/no actual harm with the potential for more than minimal harm.Finding included: A facility policy titled, NSG122 Change in Condition: Notification of, revised [DATE], specified: Policy A Center must immediately inform the patient, consult with the patient's physician, and notify, consistent with their authority, the patient's representative, where there is: * An accident involving the patient which results in injury and has the potential for requiring physician intervention; * A significant change in the patient's physical, mental, or psychosocial status (that is, a deterioration in health, mental or psychosocial status in either life-threatening conditions or clinical complications); * A need to alter treatment significantly (that is, a need to discontinue or change an existing form of treatment due to adverse consequences, or to commence a new form of treatment); or * A decision to transfer or discharge the patient from the Center. When making notification of above, the Center must ensure that all pertinent information is available and provided upon request to the physician. Purpose: To provide appropriate and timely information about changes relevant to the patient's condition. A Face Sheet indicated the facility admitted Resident #7 on [DATE]. According to the Face Sheet, the resident has a medical history that included atherosclerotic heart disease, paroxysmal atrial fibrillation, encephalopathy, vascular dementia, traumatic subdural hemorrhage, hypertension, and cognitive communication deficit. A quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of [DATE], revealed Resident #7 had a Brief Interview for Mental Status (BIMS) score of 11, which indicated the resident had moderate cognitive impairment. Resident #7's Progress Notes, written by NP #6 and dated [DATE] at 11:17 AM, revealed the NP was requested to evaluate the resident for acute respiratory distress. The Progress Notes indicated the resident had difficulty breathing with the use of their accessory muscles, had lung crackles, and an oxygen saturation of 93-96% on room air. Per the Progress Notes, the NP ordered a treatment plan to include a STAT chest x-ray, STAT laboratory tests including a comprehensive metabolic panel (CMP), magnesium level, and a complete blood count (CBC) with differential to rule out pneumonia and assess for other possible underlying conditions.Resident #7's Order Details, revealed a physician's order dated [DATE] at 11:12 AM, for a STAT chest x-ray. Resident #7's Order Details, revealed a physician's order dated [DATE] at 11:15 AM, for a STAT CMP, magnesium level, and a CBC with differential. Resident #7's laboratory test result report revealed a blood specimen was collected from the resident on [DATE] at 5:11 PM for a CMP, magnesium level, and CBC with differential. Per the results, the resident's sodium level registered high critical at 161 mmol/L; the resident's blood urea nitrogen (BUN) registered high at 55 milligrams per deciliter (mg/dL); the resident's magnesium level registered high at 2.9 mg/dL; and the resident's white blood cell (WBC) count registered high at 29.68 10 cubed per microliter (uL). Resident #7's Progress Notes, written by NP #6 and dated [DATE] at 11:51 AM, revealed Patient was seen today for follow-up of ongoing acute respiratory distress for which stat laboratory tests, chest X-ray, and DuoNeb treatments were ordered yesterday [[DATE]] due to increased work of breathing and clinical decline. Results of the stat laboratory tests obtained today [[DATE]] were reviewed and showed significant abnormalities, including markedly elevated WBC of 29.68 BUN of 55 consistent with acute kidney injury, and severe hypernatremia with sodium of 161. These findings are concerning for worsening condition with dehydration, possible infection, and renal impairment. The patient was started on half-normal saline at 124 cc [cubic centimeters] per hours for a total of 2 liters for hydration and sodium correction. Patient assessed at bedside awake at time, lethargic and showing clinical decline. [His/Her] vital stable with blood pressure 127/75 heart rate 64 temperature 96.6 oxygen 97 on room air. The provider discussed the patient's condition and abnormal laboratory results with [Resident #7's Attending Physician], who was in house at the time of evaluation. After review of the clinical status and labs, he expressed concern for the patients deterioration and agreed that the patient requires transfer to the hospital for further evaluation and management at a higher level of care. Resident #7's Order Details revealed a physician's order dated [DATE] at 11:27 AM, that specified to transfer the resident to the nearest emergency room due to critical laboratory values and an elevated WBC count. Resident #7's Emergency Department Provider Note, dated [DATE], revealed Per EMS [emergency medical services], they were called to the patient's rehab facility due to decreased oxygen saturation. On arrival, patient was noted to be hypotensive [low blood pressure] with agonal respirations. EMS established IO [intraosseous] access and began giving fluids. They began bagging the patient and then patient lost pulses. CPR [cardiopulmonary resuscitation] was started at 11:55 AM. Patient received 4 doses of epinephrine. [Resident #7] was noted to be asystole on the monitor. Per the Emergency Department Provider Note, Patient remained pulseless and asystole with cardiac standstill on ultrasound despite multiple rounds of CPR and medications. Given this, decision was made to terminate resuscitation efforts. Time of death 12:38 PM. During a telephone interview on [DATE] at 3:10 PM, the laboratory vendor representative stated the laboratory vendor received an order for Resident #7 on [DATE] at 11:20 AM, the laboratory collected the blood specimen at 3:30 PM, and the results were reported to the Evening Nursing Supervisor at 8:57 PM on [DATE]. During an interview on [DATE] at 1:00 PM, the Evening Nursing Supervisor stated she did recall receiving a telephone call about Resident #7's critical and abnormal laboratory values. The Evening Nursing Supervisor stated she did not think it was her who the laboratory called. During an interview on [DATE] at 10:32 AM, NP #6 stated the facility should have contacted the provider when the critical laboratory test results came in. NP #6 stated had she been notified the evening of [DATE] when the resident's laboratory test results were received, she would have sent the resident to the hospital. During an interview on [DATE] at 11:06 AM, the Director of Nursing (DON) stated the nurses were responsible for reporting all critical laboratory values immediately. The DON stated when Resident #7's critical laboratory test results were received, the facility should have reported the results to the on-call provider. The DON confirmed she was unaware Resident #7's critical laboratory test results were not reported to the provider. During a telephone interview on [DATE] at 10:44 AM, the Medical Director (MD) stated the expectation was for providers to be notified immediately of all critical laboratory test results. According to the MD, he felt the outcome for Resident #7 would have been the same regardless of when the resident was sent to the hospital. During an interview on [DATE] at 4:12 PM, the Administrator stated he expected provider notification whenever there was a change in a resident's condition, including when critical laboratory test results were received. The facility submitted a removal plan that was accepted by the state survey agency on [DATE] at 8:34 PM. The removal plan indicated the following: F580 - Notification of Change: Removal PlanThis Plan of Removal is in response to the identification of Immediate Jeopardy communicated by the survey team on [DATE]. The facility respectfully submits this Plan of Removal (POR) pursuant to Federal and State regulatory requirements. Corrective Action Identification of residents affected or likely to be affected: The facility took the following actions to address the citation and prevent any additional residents from suffering an adverse outcome. Resident #7 is no longer at the facility; therefore, corrective action cannot be completed for this resident. Current residents with orders for laboratory values were reviewed by the DON and regional clinical nurses to ensure the following: (1) results were received (2) notification of results was communicated to the medical provider (3) results were reviewed by a medical provider (4) documentation of recommendations and/or new orders by medical provider after review of laboratory values were present in the electronic medical chart will be completed by [DATE] Current residents presenting with a change in condition, as per Policy NSG122 Change in Condition: Notification were reviewed by the DON and regional clinical nurses to ensure the following: (1) notification of change in condition to medical provider (2) new orders documented by [DATE]. On [DATE] at 6:44 PM, only three current residents presented a change in condition. Actions to prevent occurrence/reoccurrence:The facility took the following actions to prevent an adverse outcome from occurring. Steps for communication pertaining to critical laboratory values will be as follows:-The licensed nurse receiving the critical lab value will notify the covering physician of the lab values when results are received from the contracted lab.-Laboratory vendors will call the facility with critical lab results. If unable to reach a licensed nurse or medical provider within two hours, the call will be escalated to the DON and Administrator.-The DON and/or designee educated licensed nurses including agency nurses working on [DATE] on reporting laboratory results to the medical provider. Licensed nurses including agency nurses not working on [DATE] will be re-educated by [DATE]. The education will be added to the agency nurse's orientation packet and provided prior to the start of the first shift worked. During the daily clinical morning meeting, the DON and/or designee will notify the medical provider of unreviewed abnormal laboratory results and document the intervention in a progress note daily x3, weekly x4, then monthly x2. The Administrator will review the results of the audits in a weekly ad hoc quality assurance performance improvement (QAPI) to ensure compliance has been achieved and sustained. All corrections were completed on [DATE].The immediacy of the IJ was removed on [DATE]. The IJ was removed on [DATE] at 10:00 AM after the survey team verified the facility's implementation of the removal plan as follows: Step 1 - Review of all residents with pending or completed lab ordersRemoval Plan Action:The facility stated that leadership (including the DON and Market Clinical Lead) reviewed all residents with recent or pending lab results to confirm provider notification occurred and corrective interventions were in place. Survey Team Verification: The survey team reviewed a random sample of five residents from the lab review list. Records confirmed that abnormal lab values were reviewed by providers and corresponding orders were implemented. Interview with the Market Clinical Lead confirmed the audit process, provider notification, and documentation in progress notes. Step 2 - Daily Audits for Notification ComplianceRemoval Plan Action:The DON initiated daily audits to confirm timely provider notifications and correct documentation of abnormal findings across labs. Survey Team Verification: The survey team reviewed completed audits from [DATE] and [DATE]. Audits included checks for abnormal lab reporting and follow-up actions. Interviews with the DON confirmed audit findings were validated during daily clinical meetings, and escalation protocols were in place for discrepancies. Step 3 - Education to licensed nurses on change-in-condition and lab reportingRemoval Plan Action:The facility provided immediate education to licensed nurses (including agency staff) on:STAT order escalation and 4-hour thresholdAbnormal lab result notification Survey Team Verification:Education sign-in sheets were reviewed for sessions conducted on [DATE], with supplemental one-on-one in-services completed by [DATE]. Interviews with staff across all shifts confirmed correct understanding of: Step 4 - Process fix and QAPI integration for lab order workflowRemoval Plan Action:The facility implemented a reconciliation process to prevent lab integration errors (facility's determined root cause of initial IJ), requiring the night shift to compare the daily lab manifest against active order listings with results reviewed during the morning clinical meeting. Facility leadership also initiated ad hoc QAPI review of the IJ plan. Survey Team Verification: The survey team interviewed the Market Clinical Lead, who demonstrated the new workflow for lab manifest cross-checks and presented the QAPI minutes from [DATE], which documented the IJ plan of removal review. The team verified documentation of education, process updates, and ongoing monitoring mechanisms. The survey team validated through record review and interviews with nurses across all shifts plus the DON and the Market Clinical Lead, that the immediate jeopardy removal plan was fully implemented and systemic corrections were in place.

Based on interview, record review, and facility policy review, the facility failed to ensure there was an order to perform wound care when Resident #6 was identified to have an in-house acquired Stage 2 pressure ulcer. The facility further failed to ensure an order to perform wound care was transcribed and implemented for Resident #9's in-house acquired Stage 3 pressure ulcer; notify the Lead Registered Dietician of the resident's new pressure ulcer; and ensure there was not inconsistencies in how the resident's pressure ulcer was assessed and documented. These failures affected 2 (Resident #6 and Resident #9) of 3 sampled residents reviewed for pressure ulcer/injury.Findings included: A facility policy titled, NSG236 Skin Integrity and Wound Management, revised 09/15/2025, revealed PURPOSE To provide safe and effective care to promote optimal skin health, prevent injuries, and promote healing within the context of what matters most to all patients. The policy specified, 6.7 Notify interdisciplinary team members for a comprehensive approach to care including prevention and wound treatments, as indicated and 6.13 Implement special wound care treatments/techniques, as indicated and ordered. 1. A Face Sheet indicated the facility admitted Resident #6 on 02/02/2026. According to the Face Sheet, the resident had a medical history that included diagnoses of left femur fracture, fracture of the right lower leg, and orthopedic aftercare. Per the Face Sheet, Resident #6 discharged home on [DATE]. An admission Minimum Data Set (MDS), with an Assessment Reference Data (ARD) of 02/09/2026, revealed Resident #6 had a Brief Interview for Mental Status (BIMS) score of 15, which indicated the resident had intact cognition. The MDS indicated the resident was at risk of developing pressure ulcers/injuries and had no unhealed pressure ulcers/injuries. Resident #6's Care Plan Report included a focus area initiated 02/11/2026, that indicated the resident was at risk for skin breakdown due to decreased mobility. Resident #6's Skin Issues note completed by the Skin Health Team Lead (SHTL) and dated 03/06/2026 at 9:45 AM, indicated the resident was found to have a Stage 2 pressure ulcer on their right posterior lower leg that measured 8.93 centimeters (cm) in length and 5.43 cm in width. Resident #6's Skin Issues note completed by the SHTL and dated 03/12/2026 at 2:57 PM, indicated the resident's Stage 2 pressure ulcer on their right posterior lower leg measured 10.51 cm in length and 7.17 cm in width. Resident #6's Order Recap Report, for the timeframe 02/01/2026 - 03/31/2026, revealed an order dated 03/18/2026 to start on 03/19/2026, that directed staff to clean the resident's right posterior lower leg with wound cleanser, pat try, apply xeroform gauze, and cover with a foam dressing every other day and as needed. Resident #6's Treatment Administration Record [TAR] for the time frame 03/01/2026 - 03/31/2026, revealed the transcription of an order with a start date of 03/19/2026, to cleanse the resident right posterior lower leg with wound cleanser, pat dry, apply xeroform gauze, and cover with a dressing every other day. Per the TAR, Licensed Practical Nurse #31 initialed the TAR to indicate she provided wound care as ordered to the resident on 03/19/2026. During an interview on 04/09/2026 at 9:01 AM, the SHTL stated Resident #6 developed an in-house acquired pressure ulcer to their posterior right lower leg related to a device the resident had on their leg. The SHTL stated wound care to the resident's posterior leg was performed daily. The SHTL reviewed Resident #6's medical record and confirmed wound care orders were not implemented for the resident's Stage 2 pressure ulcer until 03/18/2026, the day before the resident discharged home. According to the SHTL, she could not say why there were no wound care orders prior to 03/18/2026 even though the resident's pressure ulcer was identified on 03/06/2026. During an interview on 04/13/2026 at 8:33 AM, the Director of Nursing stated she was not sure about Resident #6's Stage 2 pressure ulcer development. During an interview on 04/13/2026 at 4:12 PM, the Administrator stated residents' wounds must be monitored and documented appropriately. 2. A Face Sheet indicated the facility admitted Resident #9 on 08/05/2025. According to the Face Sheet, the resident had a medical history that included a diagnosis of hemiplegia and hemiparesis following nontraumatic subarachnoid hemorrhage affecting left non-dominant side. A quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 02/17/2026, revealed Resident #9 had a Brief Interview for Mental Status (BIMS) score of 10, which indicated the resident had moderate cognitive impairment. The MDS indicated the resident was not at risk of developing pressure ulcers/injuries and had no unhealed pressures ulcers/injuries. Resident #9's Care Plan Report included a focus area initiated 08/07/2025, that indicated the resident was at risk for skin breakdown related to incontinence, limited mobility, and a pressure ulcer on their right gluteus/sacral area, left heel, and left lateral ankle. Interventions directed the staff to complete a weekly wound assessment to include measurements and description of the wound status (initiated 08/07/2025). Resident #9's eINTERACT SBAR [Situation Background Assessment Recommendation] Summary for Providers note completed by the Evening Nursing Supervisor and dated 01/06/2026 at 4:53 PM, revealed During wound round and skin assessment, resident was found with MASD [moisture-associated skin damage] on the left gluteal area. The wound Doctor ordered to cleanse the wound with generic wound cleanser; pat dry and happy [apply] med honey + calcium alginate and cover with dry dressing. Resident #9's Order Recap Report for the timeframe 08/01/2025 - 04/30/2026, revealed no evidence of the transcription of an order dated 01/06/2026, to cleanse the resident's wound with generic wound cleanser, pat dry, apply med honey + calcium alginate, and cover with dry dressing. Resident #9's Treatment Administration Record [TAR] for the timeframe 01/01/2026 - 01/31/2026, revealed no evidence of the transcription of an order dated 01/06/2026, to cleanse the resident's wound with generic wound cleanser, pat dry, apply med honey + calcium alginate, and cover with dry dressing. Resident #9's Skin Issues note completed by the Director of Nursing (DON) and dated 01/28/2026, indicated the resident had in-house acquired MASD on their left gluteus that measured 1.07 centimeters (cm) in length and 1.53 cm in width, with no undermining or tunneling and 100% granulation tissue. Resident #9's Progress Notes electronically signed by the Wound Physician and dated 01/28/2026, indicated the resident had a Stage 3 pressure ulcer on their sacrum that measured 1 cm by (x) 0.5 cm x 0.1 cm with no exudate and 50% granulation tissue and 50% epithelization. Resident #9's Skin Issues note completed by the Skin Health Team Lead (SHTL) and dated 03/09/2026, indicated the resident had in-house unstageable pressure ulcer due to slough and eschar on their left gluteus that measured 5.31 cm in length and 4.53 cm in width and wound healing had stalled. Resident #9's Progress Notes electronically signed by the Wound Physician and dated 03/10/2026, indicated the resident had a Stage 3 pressure ulcer on their sacrum that measured 2 cm x 1 cm x 0 cm with no exudate and 50% granulation tissue and 50% epithelization. Resident #9's Skin Issues note completed by the SHTL and dated 03/16/2026, indicated the resident had in-house unstageable pressure ulcer due to slough and eschar on their sacrum that measured 8.34 cm in length and 5.79 cm in width and the wound characteristics had improved. Resident #9's Progress Notes electronically signed by the Wound Physician and dated 03/17/2026, indicated the resident had a Stage 3 pressure ulcer on their sacrum that measured 4 cm x 3 cm x 0 cm with no exudate and 50% granulation tissue and 50% epithelization and the wound progress was listed as Deteriorating. Resident #9's Progress Notes electronically signed by the Wound Physician and dated 03/31/2026, indicated the resident had a Stage 3 pressure ulcer on their sacrum that measured 3.5 cm x 1.5 cm x 0.1 cm with moderate exudate and 50% granulation tissue and 50% epithelization and the wound progress was listed as Improving. Resident #9's Skin Issues note completed by the SHTL and dated 04/01/2026, indicated the resident had in-house unstageable pressure ulcer due to slough and eschar on their sacrum/left glute that measured 7.46 cm in length, 6.41 cm in width, and 0.3 cm in depth, with 10% epithelial tissue, 70% granulation tissue, and 20% slough, with light serosanguineous exudate (bloody drainage) and the wound progress was listed as improved. Resident #9's Order Recap Report for the timeframe 08/01/2025 - 04/30/2026, revealed an order dated 01/25/2026, to cleanse the resident's left gluteal wound with wound cleanser, pat dry, apply hydrogel, and cover with a gauze and foam dressing daily. Per the Order Recap Report, this order ended on 02/09/2026. Resident #9's Order Recap Report for the timeframe 08/01/2025 - 04/30/2026, revealed an order dated 03/26/2026, to cleanse the resident's sacral wound with wound cleanser, pat dry, apply plurogel to the wound bed, then calcium alginate, and cover with a foam dressing every day and as needed. Per the Order Recap Report, this order was discontinued on 04/03/2026. Resident #9's Order Recap Report for the timeframe 08/01/2025 - 04/30/2026, revealed an order dated 04/03/2026, to cleanse the resident's sacral wound with wound cleanser, pat dry, apply calcium alginate, and cover with a foam dressing one time only for one day and every day shift. During an interview on 04/09/2026 at 3:17 PM, Resident #9's Emergency Contact stated they were unaware the resident had a wound on their sacrum since 01/2026. The Emergency Contact stated they were called last week (03/29/2026 - 04/04/2026) and told of the resident's wound, so they were under the impression the wound had just developed. During an interview on 04/09/2026 at 3:21 PM, the Lead Registered Dietician (RD) stated she was not familiar with Resident #9. The Lead RD reviewed Resident #9's medical record and stated that it did not look like the facility implemented any new orders when the resident's wounds developed. The Lead RD stated the resident's diet with their protein needs was appropriate, but she would have expected the facility to notify her the resident developed wounds. The Lead RD stated now that she knew the resident had wounds, she would reassess the resident's nutritional needs. During an interview on 04/13/2026 at 8:33 AM, the Director of Nursing (DON) stated the facility had skin meetings where they discussed the status of residents' wound; however, they did not do a deep dive into the residents' wounds to determine if the orders were appropriate or implemented. The DON stated she was not sure why the facility staff did not document Resident #9's pressure ulcer as a Stage 3 as the Wound Physician did. The DON stated she was not able to state why orders were missed to treat the resident's pressure ulcer. The DON stated she expected wound care orders to be implemented and if not, discussed with the provider. During an interview on 04/13/2026 at 4:12 PM, the Administrator stated residents' wounds must be monitored and documented appropriately.

Based on interview, record review, document review, and facility policy review, the facility failed to ensure staff assigned to care for a resident was interviewed once the resident voiced an allegation of neglect for 1 (Resident #1) of 8 sampled residents reviewed for abuse.Findings included: A facility policy titled, OPS300 Abuse Prohibition, revised 11/14/2025, indicated 7.7 Initiate an investigation within 24 hours of an allegation of abuse that focuses on: 7.7.1 whether abuse or neglect occurred and to what extend; 7.7.2 clinical examination for signs of injuries, if indicated; 7.7.3 causative factors; and 7.7.4 interventions to prevent further injury. 7.8 The investigation will be thoroughly documented within the Risk Management Portal. Ensure that documentation of witnessed interviews is included. A Face Sheet revealed the facility admitted Resident #1 on 07/02/2025. According to the Face Sheet, the resident had a medical history that included a diagnosis of muscle weakness. A quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 12/29/2025, revealed Resident #1 had a Brief Interview for Mental Status (BIMS) score of 15, which indicated the resident had intact cognition. The undated Facility Reported Incident [FRI] Follow-Up Investigation Report Form completed by the Director of Nursing (DON) indicated on 02/14/2026 and 02/15/2026, Resident #1 stated they were left in bed without a bath or assistance, a female geriatric nurse aide (GNA) was rough when she provided care to them, and their call light was turned off. The facility investigation file contained statements from two registered nurses and GNA #5. The facility staffing assignments revealed GNA #10 was assigned to Resident #1 on 02/13/2026 and 02/14/2026 during the 11:00 PM to 7:00 AM shift, and GNA #13 was assigned to Resident #1 during the 11:00 PM to 7:00 AM shift on 02/15/2026. During an interview on 04/03/2026 at 10:49 AM, Resident #1 stated the incident occurred during the 11:00 PM to 7:00 AM shift and they could not remember the employee's name. During an interview on 04/06/2026 at 4:26 PM, the DON stated during an investigation the facility typically interviewed the primary care staff assigned to the resident at a minimum. During an interview on 04/06/2026 at 4:43 PM, the Administrator stated abuse investigations should be thoroughly investigated to determine the thoroughness of the investigation.

Based on interview, record review, document review, and facility policy review, the facility failed to timely report an allegation of abuse to the state survey agency for 1 (Resident #5) of 8 sampled residents reviewed for abuse.Findings included: A facility policy titled, Abuse Prohibition, revised 11/14/2025, revealed, 7. Immediately upon receiving information concerning a report of suspected or alleged abuse, mistreatment, or neglect, the Administrator or designee will perform the following 7.1 Enter allegation into PCC [Point Click Care] Risk Management Portal. 7.2 Report allegations involving abuse (physical, verbal, sexual, mental) not later than two (2) hours after the allegation is made. A Face Sheet revealed the facility admitted Resident #5 on 12/04/2025. According to the Face Sheet, the resident had a medical history that included a diagnosis of muscle weakness. A quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 02/09/2026, revealed Resident #5 had a Brief Interview for Mental Status (BIMS) score of 13, which indicated the resident had intact cognition. The Facility Reported Incident [FRI] Initial Report Form submitted by the Administrator and dated 03/19/2026, indicated on 03/19/2026 at 9:30 AM, the Director of Nursing notified the Administrator of an allegation of sexual abuse alleged by Resident #5. Per the FRI Initial Report Form, Housekeeper #2 alleged she saw Housekeeper #1 enter Resident #5's room and hug and kiss the resident. According to the FRI Initial Report, this allegation of abuse was reported to the state survey agency on 03/19/2026 at 12:13 PM. During an interview on 04/02/2026 at 1:41 PM, the Administrator stated his expectation was that any allegation of abuse must be reported immediately.

Based on interview and record review, the facility failed to obtain consent prior to the use of psychotropic medications for 2 (Resident #6 and Resident #7) of 14 sampled residents. The findings included: 1. A Face Sheet revealed the facility admitted Resident #6 on 02/02/2026. According to the Face Sheet, the resident had a medical history that included diagnoses of anxiety disorder and primary insomnia. An admission Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 02/09/2026, revealed Resident #6 had a Brief Interview for Mental Status (BIMS) score of 15, which indicated the resident had intact cognition. The MDS indicated the resident used an antianxiety medication during the last seven days. Resident #6's Care Plan Report included a focus area initiated 02/11/2026, that indicated the resident was at risk for complications related to the use of psychotropic drugs. Interventions directed staff to provide informed consent to resident or healthcare decision maker (initiated 02/11/2026). Resident #6's Order Recap Report for the timeframe 02/01/2026 - 03/31/2026, revealed an order dated 02/04/2026, for clonazepam oral tablet 0.5 milligram (mg), give one tablet by mouth one time a day for anxiety; this order was discontinued on 03/09/2026. Per the Order Recap Report, there was an order dated 03/09/2026, for clonazepam oral tablet 0.5 mg, give one tablet by mouth one time a day for anxiety. Resident #6's Medication Administration Record [MAR] for the timeframe 02/01/2026 - 02/28/2026 and 03/01/2026 - 03/31/2026, revealed the staff administered clonazepam to the resident as ordered. Resident #6's Psychotropic Medication Administration Disclosure located in the resident's medical record was blank. During an interview on 04/09/2026 at 12:46 AM, Registered Nurse #29 stated she knew psychotropic medications required consent prior to use and remembered Resident #6 could not sign their own consent but did not recall reviewing the psychotropic consent with the resident. During an interview on 04/03/2026 at 3:32 PM, Licensed Practical Nurse #30 stated psychotropic medications needed consent prior to use. During an interview on 04/13/2026 at 1:30 PM, the Director of Nursing confirmed that Resident #6 did not have consent for the psychotropic medication, and consent should have been obtained. During an interview on 04/13/2026 at 4:12 PM, the Administrator stated psychotropic medications required consent prior to use according to federal guidelines. 2. A Face Sheet revealed the facility admitted Resident #7 on 10/25/2025. According to the Face Sheet, the resident had a medical history that included diagnoses of major depressive disorder and primary insomnia. A quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 02/01/2026 revealed Resident #7 had a Brief Interview for Mental Status (BIMS) score of 11, which indicated the resident had moderate cognitive impairment. The MDS indicated the resident used an antidepressant medication during the last seven days. Resident #7's Care Plan Report included a focus area initiated 11/03/2025 and revised 03/19/2026, that indicated the resident was at risk for complications related to the use of psychotropic drugs. Resident #7's Order Recap Report for the timeframe 10/01/2025 - 03/30/2026, revealed an order dated 12/07/2025, for escitalopram oxalate oral tablet 20 milligrams, give one tablet by way of the gastrostomy tube at bedtime for depression. Resident #7's Medication Administration Record [MAR] for the timeframe 03/01/2026 - 03/31/2026, revealed the staff administered escitalopram oxalate to the resident as ordered. Resident #7's Psychotropic Medication Administration Disclosure located in the resident's medical record was blank. During an interview on 04/13/2026 at 1:30 PM, the Director of Nursing confirmed the resident did not have consent for psychotropic medications and stated consent should have been obtained when the medication was started. During an interview on 04/13/2026 at 4:12 PM, the Administrator stated psychotropic medications required consent prior to use according to federal guidelines.

Based on medical record review and staff interviews, it was determined the facility: 1) failed to implement a safe and effective system to ensure that a resident that experienced a fall with a head injury, Resident #3, received ongoing assessment for neurological changes, failed to notify the physician when the resident presented with a significant change in mental status following a fall with a head injury, failed to utilize footrests when propelling Resident #3 in the wheelchair, 2) failed to rule out a head injury when Resident #5 presented with a significant change in mental status following an unwitnessed fall; and 3) failed to ensure that Resident #3, who had a history of [REDACTED]. The failure of the facility staff to monitor the neurological status of a resident that sustained a fall resulting in a head injury, the failure of the facility staff to notify the physician when a resident presented with a significant change in mental status following a fall with a head injury, and the failure to rule out a head injury in a resident presenting with a significant change in mental status following an unwitnessed fall resulted in placing the residents at risk of further injury and death. The failure to recognize changes in mental status following a head injury and promptly reporting those changes for Resident #3 to the physician, and the failure to initiate neurological assessments following a head injury resulted in determination by the Maryland Office of Health Care Quality (OHCQ) that a condition of Immediate Jeopardy existed for F 309. The facility was notified of the Immediate Jeopardy at 4:55 P.M. on 4/13/17. The facility developed a plan sufficient to remove immediacy which was reviewed and accepted at 8:18 P.M. on 4/13/17 while the surveyor remained onsite. The plan of removal included: - Immediately upon identification of the immediate jeopardy the Risk Management System fall logs were reviewed from the dates of February 1, 2017 through April 13, 2017. - For residents identified from February 1, 2017 through April 13, 2017 with an unwitnessed fall or a fall with a head injury, medical records were reviewed for ongoing evaluation and monitoring consistent with the resident risk factors and fall circumstances to review that any signficant change from the resident's baseline pre-fall were identified and communicated to the Practitioner and addressed through appropriate protocols. No other residents identified through the review. - The current clinical staff were instructed on the Falls Care Delivery Process, Notification of Change in Condition, Appropriate Documentation of Neurological Assessment, and the Physician Notification Template. This Education will be ongoing until 100% of the clinical staff are educated on these policies and protocols. - There will be an Emergency Ad Hoc Quality Improvement Meeting within 24 hours to review the issue, monitoring, and on-going plan to address the identified issue. - All falls will be reviewed by the Center Nurse Executive or Designee for ongoing evaluation and monitoring consistent with resident risk factors and fall circumstances to review that any significant change from the resident's basline pre-fall were identified and communicated to the Practitioner and addressed through appropriate protocols. - The findings of the above will be provided by the Center Nurse Executive or Designee and reviewed by the Quality Improvement committee, monitoring for the next three months or until sustained compliance and managed by the Center Executive Director. The findings include: 1. The facility failed to implement a safe and effective system to ensure that a resident that experienced a fall with a head injury, Resident #3, received ongoing assessment for neurological changes, failed to notify the physician when the resident presented with a significant change in mental status following a fall with a head injury, failed to utilize footrests when propelling Resident #3 in the wheelchair. Resident #3 is a [AGE] year old admitted to the facility on [DATE] following a hositalization for intractable pain resulting from a compression fracture. The resident was admitted to the facility for rehabilitation and pain management. The resident's medical record was reviewed on 4/11/17 and 4/13/17. Review of the hospital history and physical dated 2/10/17 revealed that the resident was alert and oriented to person, place and time. Medical record review revealed that on 2/15/17 the resident's attending physician at the facility peformed a history and physical on the resident at the time of admission to the facility. The physician documented that the resident's judgment and insight were appropriate and the resident was oriented to person, place, month and year. Review of the facility's incident investigation revealed that on 2/17/17 at 10:50 P.M. the resident was seated in his/her wheelchair in the dayroom when the assigned Geriatric Nursing Assistant (GNA) attempted to wheel the resident to his/her room. The resident leaned forward and fell to the ground. The resident sustained [REDACTED]. The Nurse Practitioner was notified and gave an order to send the resident to the hospital emergency department for further evaluation. Interview of the GNA, Staff #5, on 4/11/17 at 12:29 P.M. revealed that the GNA was not assigned to care for the resident on the evening of 2/17/17, but was assigned to transport the resident to his/her room that evening. The GNA stated that he/she unlocked the wheelchair and let the resident know he/she was being pushed in the wheelchair to his/her room. When asked where the resident's feet were when the GNA pushed the resident in the wheelchair, the GNA demonstrated that he/she asked the resident to hold his/her feet up off of the floor. The GNA failed to utilize footrests which placed the resident at risk of a fall if the resident had put his/her feet on the floor while being transported in the wheelchair. Medical record review revealed on 2/18/17 at 4:00 A.M. the nurse documented that the resident returned to the facility from the emergency department with sutures to the forehead. Review of the emergency department discharge instructions revealed that the resident was diagnosed with [REDACTED]. The resident received sutures to the [MEDICAL CONDITION]. A computerized tomography (CT) scan of the head was negative. Hospital discharge instructions included waking the resident every 2 hours to check for warning signs of a concussion, bruising, or bleeding in the brain which could appear later. It was also instructed that the resident get prompt medical attention for repeated vomiting, severe or worsening headache or dizziness, unusual drowsiness, or unable to awaken as usual, confusion or change in behavior or speech, memory loss, blurred vision, convulsion, increasing scalp or face swelling, redness, warmth or pus from the swollen area or fluid drainage or bleeding from the nose or ears. When the resident returned to the facility at 4:00 A.M. there was no documented evidence that the physician was notified or that interventions were initiated to wake the resident every 2 hours as instructed by the emergency department discharge instructions. Additionally, there was no documented evidence that the facility staff initiated neurological assessments when the resident returned to the facility. Neurological assessments include assessing level of consciousness, pupil response, hand grasps, movement of extremities and pain response. Review of the facility's policy and procedure revealed that neurological assessments are to be performed when a patient sustains an injury to the head and/or has an unwitnessed fall. The neurological assessments are to be performed every 30 minutes x 2 hours; every 1 hour x 4 hours; every 4 hours for 24 hours, which is a total of 30 hours. Review of the Neurological Assessment Flow Sheet revealed that nurses documented the following at 7:30 A.M., 8:00 A.M. 8:30 A.M., 9:00 A.M., 9:30 A.M. 10:30 A.M. 11:30 A.M: sleeping/vs (vital signs) stable. At 12:30 P.M. the nurse documented on the Neurological Assessment Flow Sheet that the resident was sleeping, awake/vs stable, and at 4:30 P.M. the nurse documented that the resident was sleeping/vs stable. At no time between 4:00 A.M. when the resident returned to the facility through 4:30 P.M. did nursing document that they attempted to wake the resident or assess the resident's neurological status. On 2/18/17 the nurse documented the following entry in the progress notes: resident noted at the nursing station in jerry (geri) chair sleeping comfortably, no signs of distress or discomfort noted, reported he fall (fell ) at night, laceration noted on the forehead with sutures, no bleeding, no drainage, no bruising, no swelling noted, v/s taken is within normal limit(s), range of motion done, no screaming, (he/she) was taken to the room by nursing assistant for am care at noon time, resident light was on at a time, writer answers he requested for water to drink, never complain(ed) of pain, neuro check continues, at 2:50 P.M., urinary bag was empty (emptied) by writer, no sign of distress, fall precaution in place, no discomfort. That is the only documented assessment by nursing and did not include an assessment of the resident's neurological status. On 4/11/17 at 12:20 P.M. the Licensed Practical Nurse (LPN) Charge Nurse for the Northside Unit, Staff #1, was interviewed. Staff #1 stated that he/she worked 7:00 A.M. - 3:30 P.M on 2/18/17 and was assigned to care for the resident. Staff #1 stated that the resident slept all day and was sleepy most of the time. Staff #1 asked why neurological checks were not done and he/she stated I don't know what to say. Most of the time (the resident) was sleeping. Staff #1 stated that the resident's urinary drainage bag was emptied at 2:50 P.M. and the resident was sleeping at that time. On 4/11/17 at 12:45 P.M. the Geriatric Nursing Assistant (GNA), Staff #2, was interviewed. Staff #2 stated that he/she worked on 2/17/17 at 7:00 A.M. - 10:00 P.M. and on 2/18/17 at 7:00 A.M. - 3:30 P.M and was assigned to care for the resident. Staff #2 stated that on 2/17/17 the resident was alert and talking, could tell staff if he/she wanted to use the bathroom, his/her speech was clear and he/she was not sleepy. Staff #2 stated that when he/she came to the facility on [DATE] the resident was at the nursing station in the gerichair and he/she was sleeping. The GNA stated that he/she tried to awaken the resident 2 times when he/she was providing morning care and when he/she gave the resident breakfast. The GNA stated that day the resident had to be fed and the day before, the resident fed himself/herself. When asked if the resident was talking the GNA stated that the resident did not talk and was so sleepy. When asked if the resident was hard to arouse the GNA stated kind of. When asked if there was a change from 2/17/17 to 2/18/17 the GNA stated of course, yes. On 4/11/17 at 1:07 P.M. the GNA, Staff #3, was interviewed. Staff #3 stated that he/she worked on 2/18/17 at 3:00 P.M. - 11:30 P.M. and was assigned to care for the resident. Staff #3 stated that when he/she came to the facility on [DATE] the resident was in the gerichair in his/her room. Staff #3 stated that the resident was not talking and was moving like he/she did not want to be in the gerichair. Staff #3 stated that the resident had no clear language, and was unable to tell Staff #3 his/her name. On 4/11/17 at 1:20 P.M. the nursing supervisor, Staff #4, was interviewed. Staff #4 stated that he/she worked on 2/18/17 at 7:00 A.M. - 3:30 P.M. Staff #4 stated he/she recalls getting report that the resident returned from the emergency department that morning. Staff #4 stated from what I got in report, (he/she) had been up most of the night and was sleepy most of the shift. When asked about the facility's policy for performing neurological checks on residents with head injuries, Staff #4 stated I don't think I know the answer to that. Staff #4 stated that nothing was brought to his/her attention regarding any concerns related to the resident during his/her shift. Medical record review revealed that on 2/18/17 at 7:00 P.M. the nurse documented that the resident had a change in condition. The symptoms include: Unresponsiveness 02/18/2017 in the afternoon. On 2/18/17 at 10:46 P.M. the nurse documented the following entry: Note: Resident was observed without pulse and respirations; resident was a full code therefore Code Blue system activated and Basic Life Support measures initiated, 911 called; ACLS (advanced cardiac life support) measures initiated - EKG monitor, [MEDICATION NAME] administration and intubation; Resident continued in (asystole) heart rhythm with no pulse and respirations; (Resuscitation) measures ended at 1837 (6:37 P.M.). The resident was not transferred to the hospital, but pronounced by the EMTs. On 4/12/17 at 9:50 A.M. the resident's attending physician was interviewed after having an opportunity to review the resident's medical record. The physician stated that there is no doubt the resident was awake and alert and oriented to person, place and time on 2/15/17. The physician further stated I know this man definitely had a change after the fall and staff did not notify anyone. The physician stated that she had discussed the death with the staff, but prior to surveyor intervention, had not reviewed the resident's medical record. The physician further stated that had she been notified of the resident's change in condition, she would have followed up with another CT scan and/or sent the resident out. The physician agreed that this was a problem. Review of the facility's incident investigation report revealed that the resident experienced an unexpected death. The nurse documented that the resident prior had a regular day . no unusual occurences prior. Had a normal day. The facility staff failed to recognize that there had been a significant change in the resident's medical condition leading up to the resident's unexpected death and, as of 4/13/17, the facility had taken no action to prevent further occurrences of a similar nature affecting other residents. 2. The facility failed to rule out a head injury when Resident #5 presented with a significant change in mental status following an unwitnessed fall. Resident #5 is an [AGE] year old resident who was admitted to the facility on [DATE] following a hospitalization for a fall at home resulting in a pubic ramus fracture. The resident's medical record was reviewed on 4/13/17. Medical record review revealed that the resident was seen and examined by the Nurse Practitioner on 3/29/17 and the Physician on 4/4/17. The Nurse Practitioner and Physician documented that the resident's judgment and insight were appropriate and the resident was alert and oriented to person, place, month and year. Medical record review revealed that on 4/5/17 at 11:13 P.M. the resident was noted lying on the floor by the bed. The resident was assessed with [REDACTED]. The Nurse Practitioner was notified of the fall at 1:05 A.M. The facility staff initiated neurological assessments at the time of the fall. Medical record review revealed that on 4/6/17 the resident was evaluated by the physician. The time is unknown, though the entry in the progress note was before 7:30 A.M. The physician documented that the resident was being seen at the request of the family for altered mental status. According to nursing staff the resident had an episode of increased confusion the previous evening. The physician further documented that over the last 12 hours the resident had become increasingly confused and at times agitated. The physician documented that the resident is usually awake, alert and interactive and able to answer questions. The resident was described as drowsy, opens eyes, but does not seem to make a lot of sense when speaking. The resident was unable to cooperate with a neurological exam secondary to lethargy. The physician documented the resident had nonsensical speech and at times becomes quite agitated. The physician ordered stat (right away) laboratory blood work and a stat urinalysis with culture and sensitivity. Medical record review revealed that the last neurological assessment that was done by nursing on 4/6/17 at 5:45 P.M. Nursing had discontinued neurological assessments 6 1/2 hours after the resident sustained [REDACTED]. On 4/13/17 at 2:00 P.M. the Certified Occupational Therapy Assistant (COTA), Staff #6, was interviewed. Staff #6 worked with the resident on 4/6/17. Staff #6 stated that prior to 4/6/17 the resident answered questions appropriately, cooperated with therapy and followed commands. Staff #6 stated that on 4/6/17 there was a drastic change in the resident's mental status. Staff #6 stated that the resident was unable to answer questions comprehensively, was unable to follow commands and was alert to name only. Staff #6 stated he/she reported his/her concerns to the nursing staff. Medical record review revealed that on 4/6/17 at 5:00 P.M. the nurse documented that the physician was notified that the resident had an elevated blood sugar. The physician gave an order to administer 2 units of insulin 1 time. Medical record review revealed that on 4/7/17 during rounds the resident was noted unconscious and difficult to arouse The resident's blood sugar was low and blood pressure elevated. The physician gave an order to send the patient to the hospital emergency department urgently. Interview of facility staff that cared for the resident on 4/6/17 (COTA and GNA) revealed that the resident had a significant change in mental status on 4/6/17. Despite the resident's significant change in mental status following an unwitnessed fall, the facility staff failed to continue to perform neurological assessments and failed to have the resident evaluated for a possible head injury. 3. The facility failed to ensure that Resident #3, who had a history of [REDACTED]. Resident #3 was admitted to the facility on [DATE] for rehabilitation after being hospitalized for [REDACTED]. The resident's medical record was reviewed on 4/11/17 and 4/13/17. Medical record review revealed, the physician that examined the resident in the hospital described the resident's pain as mainly along the low back with [MEDICAL CONDITION] to the upper buttock region and is exaggerated with any change in position. Review of the hospital physician's physical exam of the resident revealed: Patient prefers sitting with (his/her) knees flexed. Pain left lumbar region with straight leg raise on the right. Patient screamed out in pain when head of bed adjusted to sit (him/her) up. (He/she) could not sit (himself/herself) up further in bed. Medical record review revealed that the attending physician at the facility performed a history and physical of the resident on 2/15/17. The physician documented that the resident does admit to some discomfort in the lower back with movement. The physician's plan for the management of the resident's pain related to the compression fracture was to continue with [MEDICATION NAME] as well as [MEDICATION NAME] 400 mg. every 8 hours with food and with physical therapy to improve mobility and functionality. Medical record review revealed that the resident did not have a physician's orders [REDACTED]. The resident did have physician's orders [REDACTED]. 2 tablets every 6 hours as needed for mild pain. Medical record review revealed that the resident was evaluated by the Physical Therapist on 2/16/17. The Physical Therapist documented that intermittent, lower back pain was present and described as 1 out of 10 at rest and 6/10 with movement. On a scale of 1 to 10, 0 = pain free; 1 - 3 = mild pain; 4 - 6 = moderate pain; and 7 - 10 = severe pain. The Physical Therapist documented that the resident's complaint of pain was communicated with nursing. Medical record review revealed that the resident was evaluated by the Occupational Therapist on 2/16/17. The Occupational Therapist documented that the resident had constant pain of the lumbar spine and described as 6 out of ten at rest and 8 out of 10 with movement. Further review of the resident's medical record revealed [REDACTED]. or administered any pain medication to the resident on 2/16/17.

Based on observation, review of the maintence work log, facility investigation, resident family and facility staff interviews, it was determined that the facility failed to provide a safe environment for residents, resulting in a injury (resident #4). The finding included the following: During investigation of complaint # MD 786 and interview with the resident's family on 2/26/14 and 2/27/14, it was revealed that the head board over the bed that was attached to the wall fell off the wall on 1/30/14 at 9 PM, as the GNA ( Geriatric Nursing Assistant) was raising the bed to provide incontinence care. The head board struck the resident in the head causing a laceration. This required 7 staples to the scalp. Review of the maintence work log on 2/27/14 at 11 AM, revealed two work order requests (dated 1/22/14) for the following: room 111 A-please check wall board, falling off continuously and room 111 B-console above the bed is not securely attached to the wall. A work order, dated 1/30/14, documented a lose head board in room 115. Review of the facility investigation, interview with the director of nursing and the administrator on 2/27/14 and at 12:00 PM, revealed the facility was unaware of how the head board fell off the wall. During interview with the maintence director and facility staff at 12:30 PM on 02/27/14, it was revealed the head boards come off the wall when the bed is lifted too close to the wall. In addition, when the surveyor reviewed the facility maintenance work order log, observed and interviewed additional residents and facility staff, it was evident that 22 additional residents remained at risk for safety in 11 bedrooms with the wall boards. The task was extended and the findings resulted in Immediate Jeopardy for the potential harm to the remainder of the residents with the head boards over the bed. The facility abated the Immediate Jeopardy on 02/27/14 at 7:04 PM. The facility removed all the head boards from rooms 101-116.

Based on medical record and facility investigation interview review, observations, and facility staff interview, the facility staff failed to transfer resident #7 with a two (2) person assist, as noted on the resident's care kardex for safety. This resulted in the resident falling out of the sling face first to the floor. The resident sustained [REDACTED]. The findings included the following. On 3/28/11, the surveyor interviewed the ADM and DON as well as toured the facility and observed the resident. The surveyor requested the facility staff's investigation. Hoyer lifts, or mechanical lifts, are devices used to transfer heavy or completely dependent patients. The lifts are designed to protect both patient and worker from injury during transfer. According to the Center for Disease Control (CDC), first reports of employee muscle injury dropped 35% after implementing the use of mechanical lifts. However, improper use of a Hoyer lift can still result in minor to severe injury to the patient. Nurses and nurse aides must learn about the proper use of the Hoyer lift. At 10:30 AM on 3-28-11,resident #7 was observed lying in her bed. She was centered in her bed and positioned on her back. The surveyor reviewed the facility staff investigation report file. On 1/4/11 at 10 AM, according to the facility reported incident report the resident was transferred by 1 GNA, geriatric nursing assistant, (GNA #3), via the Hoyer to her wheel chair and slipped out onto the floor head first. The resident sustained [REDACTED]. The resident required total care and required 2 persons for transfers. GNA #3 was suspended, and it was noted that she would be terminated. Her record of counseling was reviewed by the surveyor. The type and description of current specific behavior/ performance/ conduct requiring counseling read: " Failure to adhere to facility protocol when using the Hoyer lift. While transferring a resident from bed to wheelchair, resident slipped out of chair and fell . This could have been prevented if there was a second staff member present" . GNA #3 commented that she was sorry and would not repeat this. The facility administration counseled and educated GNA #3 and other staff members, and retained GNA #3. At 11 AM, the surveyor interviewed the Director of Nursing, nurse #2. Nurse #2 stated that GNA #3 was the resident's regular GNA and had used bad judgment. She had transferred the resident daily and this day failed to wait for assistance. The resident was medicated for pain as a judgment on the facility staff's part and she did receive sutures to the forehead. She added that GNA #3 was suspended, not terminated. She did receive counseling and in-servicing. At 11:46 AM, the surveyor again interviewed nurse #2. She stated that GNA #3 stated/ admitted that she had transferred the resident by herself and that's when the resident fell . She added that the other nursing staff determined that the transfer was done with 1 person because of what they saw when they got to the resident ' s room. They saw that GNA #3 was by herself with the resident and the resident was face down on the floor. The surveyor reviewed the remainder of the facility staff investigation and the resident's medical record. The facility staff investigation revealed the following: The self report form, dated 1/5/11, noted that on 1/4/11 at 10 AM GNA #3 was providing activity of daily living (ADL) care for resident #7. The resident was transferred via a Hoyer lift from the bed to her wheel chair. The resident slipped out of the chair, during the transfer, and landed on the floor head first. The resident sustained [REDACTED]. The resident was noted to require total care and 2 persons for transfers. GNA #3 was suspended and all staff were re-educated on transferring policies and procedures. Copies of mandatory in-services dated 1/7/11, 1/8/11, and 1/10/11 for Hoyer lift transfers noted that 2 staff members must be present when the Hoyer lift is used. A paper with the sign in sheets read, "Two staff members must be present at all times when a Hoyer lift is being used. Failure to comply will result in disciplinary actions". On 1/4/11 GNA #3 wrote a witness statement. The GNA wrote that she provided care for resident #7 on 1/4/11. She wrote that she transferred the resident to her wheel chair; she slipped from the chair and fell face down from the same chair. She hit her forehead and when she picked her up she saw a big cut, and ran and informed the charge nurse. The charge nurse immediately informed the supervisor and the others in charge. GNA #3 wrote that she was sorry and sympathized with the resident. There are written statements from nurse #4, #5, #6, and #7 that the resident was assessed for pain and first aid was given; pressure was applied and the area was cleansed with normal saline solution (NSS),, and a dressing was applied. Nurse #4 observed the resident and assessed the laceration to be about 10 centimeters and noted that the resident was alert and nodding to questions regarding pain. Nurse #7 described the laceration as "deep " . The resident was then transferred to the ER. The surveyor reviewed the medical record for the following: The face sheet revealed that resident #7 was admitted to the facility on [DATE] and her [DIAGNOSES REDACTED]. Her date of birth is 10/20/1953. The physician's orders [REDACTED]. The minimum data set (MDS), done 12/24/10, prior to the transfer and fall, noted that the resident was totally dependent for transfers and required 2 persons assistance. On 1/4/11, the date of the transfer and fall, the nursing notes revealed that at 3:30 PM, the resident had stitches at the hospital and would be returning. There were no nursing notes prior to this time; however, a concurrent review was noted at the time of the fall. There were 2 pain evaluations done on 1/14/11, no time was noted on the pain evaluation sheets. The first noted a fall as the reason for the evaluation and that the resident was started on Tylenol 650 mg every 8 hours every shift for 5 days for pain. The second, also for a fall, noted a laceration on the resident's forehead and was incomplete for someone cognitively impaired. The resident was noted to be on routine Tylenol 325 mg every 12 hours. On 3/28/11 the DON was asked about the time of the pain evaluations and she stated that they were not timed and done per shift. The surveyor reviewed the emergency room notes from the hospital. The notes described a large forehead laceration wound noted to be 15 centimeters. The resident had CTs with contrast of the brain and cervical spine because of trauma. The sutures were to be removed in 10 days. At 7 PM, the resident returned to the facility accompanied by her family. The resident's forehead was assessed to be slightly swollen and she had 19 stitches. Her right arm was also noted to be swollen and warm to the touch; the physician ordered an X-ray of the right arm in the morning to rule out a fracture. In addition, the physician ordered Tylenol 650 milligrams (mgs) every 8 hours for 5 days for pain. At the time the resident was noted to deny pain. On 1/5/11 at 7:30 AM, the X-ray technician was noted to state that he could only obtain an X-ray of the right humerus (bone from the shoulder to the elbow), because the resident's arm was contracted (reduced movement in the joint), and suggested a CT scan. The X-ray report noted a normal humerus and the MD were notified on 1/5/11. At 2 PM, an order was obtained for a CT of the right elbow and that was scheduled. On 1/6/11, the resident's right arm remained hard and swollen. On 1/7/11 at 2:30 PM, the day nurse reported that the resident had been out for a CT scan of the right hand, forearm and elbow. On 1/10/11 at 11:43, the CT results were faxed to the facility. The study was less than optimal due to the contractions in the right arm. However, there were no displaced fracture or dislocation appreciated. The CT was noted to be done because of trauma to the right side. On 1/11/11 at 10:30 PM, the right arm swelling is noted to be decreasing gradually. On 1/14/11 at 3:30 PM, 10 days later, the Unit Manager was not able to remove all of the stitches (only 5) as the resident was uncooperative. At 10:30 PM, the stitches were removed without problem and the resident's family and the UM were informed. On 3/28/11 at 1:10 PM the DON, nurse #2, was interviewed by the surveyor. She stated that the GNAs refer to the resident care kardex on the unit for direction when transferring residents. The DON, nurse #2, stated that she would get a copy of the resident's. She added that the care cardex noted that the resident was a Hoyer lift transfer with 2 persons on the day of the fall. The surveyor reviewed the care kardex with the UM, and it confirmed what the DON had stated. There was no additional information at the time. The facility staff failed to transfer the resident with the assistance of 2 persons, via the Hoyer lift. GNA #3 transferred the resident from the bed to the wheel chair by herself. This resulted in the resident falling face first to the floor during the transfer. She sustained a 15 cm. laceration which required 19 stitches. The resident's right arm was also assessed and treated for [REDACTED].