Every finding on record at Linden Place Center for Nursing and Rehabilitation

Based on observations and staff interviews, the facility failed to maintain in good repair a resident's room door and bathroom sink in 1 of 11 resident rooms and 1 of 11 resident bathrooms on 1 of 2 halls whose room and/or bathroom was observed to have environmental concerns (Resident #48).The findings included:1) An initial observation of Resident #48's room was conducted on 1/5/26 at 1:10 PM. This observation revealed the door latch on the door to the resident's room did not secure the door so that it would remain closed. Accompanied by the facility's Maintenance Director, an observation of the door to Resident #48's room was conducted on 1/8/26 at 4:00 PM. When the Maintenance Director was shown the door latch and strike plate on the resident's door, he reported having worked on the door in the past. However, he acknowledged the repair did not appear to have fixed the problem. The Maintenance Director was observed as he attempted several times to close the door, but the door would not latch so that it would remain closed. The Director stated the door would likely need to be replaced. An interview was conducted on 1/9/26 at 3:15 PM with the facility's Administrator, Director of Nursing (DON), and Regional Nurse Consultant to discuss the environmental concerns that had been identified. When asked about the concern related to Resident #48's door not latching, the Administrator and Regional Nurse Consultant agreed that they would expect residents to be able to close the door to their room. 2) An initial observation of Resident #48's bathroom was conducted on 1/5/26 at 1:10 PM. This observation of the bathroom revealed the sink had approximately one to two inches of standing water (not draining) in the sink. Accompanied by the facility's Maintenance Director, an observation of Resident #48's bathroom sink was conducted on 1/8/26 at 4:00 PM. At that time, one to two inches of standing water (not draining) was observed at the bottom of the sink. When the Director was informed a similar observation was made of the bathroom sink on 1/5/26, he responded by stating the sink would need to be fixed to ensure it drained properly.An interview was conducted on 1/9/26 at 3:15 PM with the facility's Administrator, Director of Nursing (DON), and Regional Nurse Consultant to discuss the environmental concerns that had been identified. When asked about the concern related to Resident #48's bathroom sink, the Administrator reported that he and the Maintenance Director fixed that sink drain on the evening of 1/8/26. Upon further inquiry, the Administrator acknowledged failure of the sink to drain water did not create a homelike atmosphere.

Based on observations and staff interviews, the facility failed to: 1) Label a medication with the minimum required information (including the resident's name) stored on 1 of 2 medication (med) carts (North Hall Med Cart #2); 2) Discard expired medications stored in 1 of 1 medication storeroom (North Hall Medication Storeroom) and on 1 of 2 medication carts observed (North Hall Med Cart #2); and 3) Date medications as to when they were opened to allow for the determination of the shortened expiration date for medications stored in 1 of 1 medication storeroom (North Hall Medication Storeroom).The findings included:1. An observation was conducted on 1/5/25 at 2:45 PM with Medication (Med) Aide #1 of the North Hall Medication Storeroom. The observation revealed the following medications were stored in the Medication Storeroom:a. One (1) unopened, single-use vial of Arexy for injection (a vaccine for Respiratory Syncytial Virus or RSV) dispensed by the pharmacy on 4/4/25 for Resident #48 was stored in the medication storeroom refrigerator. The manufacturer's expiration date was 10/15/25, indicating the medication was kept past its expiration date.b. The manufacturer's storage instructions for a multi-dose vial of Tuberculin PPD (Purified Protein Derivative) injectable solution (used for skin testing in the diagnosis of tuberculosis) indicated that once opened, the product should be discarded after 30 days. One (1) opened, multi-dose vial of Tuberculin PPD injectable solution dispensed from the pharmacy on 10/10/25 was stored in the med room refrigerator. Neither the vial nor the manufacturer box it was stored in were labeled as to when the vial had been opened to allow for the determination of its shortened expiration date. A second opened, multi-dose vial of Tuberculin PPD injectable solution dispensed from the pharmacy on 11/3/25 was stored in the med room refrigerator. A pharmacy auxiliary sticker placed on the vial indicated the PPD injectable solution was opened on 11/19/25 (indicative of a shortened expiration date of 12/19/25).c. An intravenous (IV) solution of 100 milliliters (ml) of 0.9% sodium chloride (normal saline) solution compounded with 2 grams (g) of cefazolin (an IV antibiotic) was dispensed from the pharmacy on 12/22/25 for Resident #83. The pharmacy labeling placed on the IV bag indicated the stop date for this medication was 12/24/25. The pharmacy labeling also read, Discard After 12/31/25. The labeling on the IV solution revealed the medication was kept past its expiration date.d. A stock box containing 11 expired hemorrhoidal suppositories was stored on the shelf of the medication storeroom. The manufacturer's expiration date of July 2025 was printed on both the box and packaging of the individual suppositories.e. A stock box containing seven 21 milligram (mg) Nicotine Transdermal System Patches was stored on the shelf of the medication storeroom. The manufacturer's expiration date of August 2025 was printed on both the box and packaging of the individual patches, indicating the patches were expired.f. Two opened stock bottles of 500 mg Vitamin C tablets were stored on the shelf of the medication storeroom. Each of the opened bottles appeared to contain approximately 200 tablets. Both stock bottles of the Vitamin C tablets were identified as being expired. One bottle had a manufacturer expiration date of August 2025. The second bottle of Vitamin C tablets had a manufacturer expiration date of November 2025. g. One unopened, 6-ounce stock bottle of a Sore Throat Spray was observed to be stored on a shelf in the medication storeroom. The manufacturer's expiration date of the spray bottle was November 2025 (indicative of the medication being expired).On 1/5/26 at 3:12 PM, Unit Manager #2 reviewed the storeroom medications identified as having a med storage concern and confirmed the labeled information (including expiration dates) noted for the medications was accurate. Unit Manager #2 was observed as she collected these medications for removal from the medication storeroom. 2. An observation was conducted of the North Hall Medication Cart #2 on 1/5/25 at 3:20 PM with Med Aide #3. The observation revealed the following medications were stored on the medication cart:a. One - 6-ounce bottle of a Sore Throat Spray was observed to be stored on the medication cart. The spray bottle was opened and appeared to have 5.5 ounces of solution remaining in the bottle. However, the spray bottle was not labeled with a resident's name. When Med Aide #3 was asked who the bottle of Sore Throat Spray belonged to, the med aide stated that she did not know. It was also noted at that time that the spray bottle was expired with a manufacturer's expiration of December 2025.b. One - 60 milliliter (ml) bottle of 10 grams (g) per 15 milliliters (ml) lactulose dispensed from the pharmacy on 5/29/25 for Resident #6 was stored on the medication cart. The pharmacy labeling indicated this medication had a stop date of 5/30/25 and a notation made on the labeling to Discard after 11/28/25. This medication was identified as having expired.During the medication cart observation conducted on 1/5/26 at 3:20 PM, Med Aide #3 showed the expired throat spray (without the resident information on its label) and the lactulose identified as being expired. The med aide reported she did not have any questions and was observed as she pulled the medications from the med cart to share with her supervisor and/or the Director of Nursing (DON).An interview was conducted on 1/9/26 at 3:15 PM with the facility's Director of Nursing (DON), Administrator, and Regional Nurse Consultant to discuss the concerns that were identified to date. The DON acknowledged the concern about medication storage had been previously discussed and the Central Supply Clerk was identified as assuming responsibility for monitoring the expiration dates of medications stored in the medication storeroom. The nurses and medication aides on night shift were typically responsible for checking the expiration dates for medications stored on the med carts with the Unit Managers and DON herself monitoring the med carts on a weekly basis. The DON indicated that after she became aware of the issues identified in the medication storeroom and first medication cart checked during the survey, the remaining storage areas were audited to ensure there were no further concerns with the storage of medications.

Based on record review, staff and resident interviews, the facility failed to act upon group grievances, resolve repeat grievances, and/or communicate the facility's efforts to address grievances voiced during Resident Council meetings for 2 of 3 months reviewed (November 2025 and December 2025).The findings included:Resident Council minutes completed on 10/14/25 by the previous Activities Director, Activities Director #1, revealed the following grievances were expressed: staff had poor attitudes and used foul language, medications were dropped off and left in resident rooms, call lights not in reach, staff observed voicing confidential resident information in public areas, unsanitary shower rooms and bathrooms, and lack of communication regarding room changes. A review of the grievances for October 2025 revealed one grievance form completed by the Administrator on 10/14/25 that corresponded to the Resident Council minutes dated 10/14/25. This form revealed no mention of the grievances voiced by the Resident Council related to staff voicing confidential resident information in public areas, unsanitary shower rooms and bathrooms, and lack of communication regarding room changes. Multiple attempts were made to interview Activities Director #1, but attempts were not successful.Resident Council minutes completed on 11/18/25 by the current Activities Director, Activities Director #2, indicated a review of old business and follow up on grievances/concerns were read and approved as corrected. However, there was no evidence the specific grievances voiced during the 10/14/25 meeting related to staff voicing confidential resident information in public areas, unsanitary shower rooms and bathrooms, and lack of communication regarding room changes were discussed, addressed, and/or resolved. The 11/18/25 minutes noted a repeat grievance from the October 2025 Resident Council meeting related to staff being rude (previously voiced as staff having poor attitudes and using foul language). Additionally, the following new grievances were expressed: call lights not answered on 2nd and 3rd shift, bugs observed, staff turning off call lights and leaving the room without returning, residents not being told who their assigned nursing assistant was for that shift, and noise levels (staff) being too loud on the hallways. A review of the grievances for November 2025 revealed one grievance form completed by the Administrator on 11/18/25 that corresponded to the Resident Council minutes dated 11/18/25. This form revealed documentation of the concerns related to staff turning off call lights and leaving the room without returning, residents not being told who their assigned nursing assistant was for that shift, and noise levels being too loud on the hallways. However, there was no indication of an investigation, interventions, and/or a resolution to these specific grievances expressed by the Resident Council. Resident Council minutes completed on 12/16/25 by Activities Director #2 indicated a review of old business and follow up on grievances/concerns were read and approved as corrected. However, there was no evidence of the specific grievances voiced during the 12/16/25 Resident Council meeting related to staff turning off call lights and leaving the room without returning, residents not being told who their assigned nursing assistant was for that shift, and noise levels being too loud on the hallways. The 12/16/25 minutes included a repeat grievance from the October 2025 Resident Council meeting related to leaving medications in residents' rooms (previously voiced as medications being dropped off and left in resident rooms). Additionally, the following new grievances were expressed: staff not responding to residents in a timely manner, staff using personal phones while in resident rooms and on the hall, and staff rushing residents when eating. A Resident Council meeting was held on 1/7/26 at 11:00 AM with Resident #20 (the Resident Council President), Resident #5, Resident #55, Resident #11 and Resident #12. During the meeting, all residents voiced that the Resident Council had made repeated grievances month after month which had not been fully addressed or resolved. An interview with Activities Director #2 on 1/9/26 at 1:07 PM revealed that she completed the Resident Council minutes and then provided a copy of the minutes to the Administrator after each Resident Council meeting. She further indicated that the follow-up process for grievances voiced during the Resident Council meetings was for the Administrator to address all Resident Council concerns and then provide her with the follow-up so that she could review it with the Resident Council members at the next meeting. Activities Director #2 further revealed that she was not aware that the grievance follow-up that she provided to the Resident Council during the November 2025 and December 2025 Resident Council meetings did not address all the grievances that were voiced during the previous month's meeting. Activities Director #2 did not know why this had not been completed and that this was an oversight. An interview with the Administrator on 1/10/26 at 9:39 AM revealed that the Resident Council grievance process was for the Activities Director to document any Resident Council members' concerns in the minutes, and then the Administrator would initiate a grievance form. The Administrator further explained that the Resident Council grievances were discussed at the next morning meeting with all department heads and the department heads were responsible for addressing any Resident Council concerns in their areas and report the resolution to him (the Administrator). The Administrator indicated he would document the resolution on the grievance form or attach documentation to the form so that the Activities Director could follow up with the Resident Council members at their next meeting. The Administrator indicated that these actions should have been taken to address all the Resident Council members' concerns. He indicated he felt this was an oversight.

Based on observation, staff interviews and record review, the facility failed to maintain accurate and consistent advance directive information throughout both the electronic medical record and paper record kept at the nursing station for 1 of 32 residents reviewed for advance directives (Resident #96). The findings included:Resident #96 was admitted to the facility on [DATE] with cumulative diagnoses which included cancer and generalized muscle weakness.On [DATE] at 10:15 AM, a 3-ring binder containing paper copies of the residents' advance directives was observed at the nursing station. A review of Resident 96's record kept in this binder revealed it included a signed Do Not Resuscitate (DNR) form dated [DATE] and printed on bright yellow/orange-colored paper indicating the resident had a DNR status with No Expiration Date. Further review of the 3-ring advance directive binder revealed it also contained a Medical Order for Scope of Treatment (MOST) form dated [DATE] and signed by the resident's Nurse Practitioner. This MOST form indicated cardiopulmonary resuscitation (CPR) was to be attempted if the resident had no pulse and was not breathing. Resident #96's most recent Minimum Data Set (MDS) was an admission assessment dated [DATE]. A review of the MDS assessment revealed Resident #96 had moderately impaired cognition. A review of Resident #96's physician's orders in her electronic medical record (EMR) revealed an order was received on [DATE] for the resident to have a code status of CPR. The resident's care plan included an area of focus initiated on [DATE] which read, Advance Directive-Resident is a full code. An interview was conducted on [DATE] at 4:00 PM with the facility's Director of Nursing (DON) in the presence of the Administrator. During the interview, inquiry was made as to who was responsible to obtain information on advance directives for newly admitted and current residents. The DON and Administrator reported that the facility's Social Worker (SW) assumed this responsibility. An interview was conducted on [DATE] at 4:23 PM with the SW. When asked what the process involved for obtaining an advance directive for a newly admitted resident, the SW stated she would typically try to address the advance directive either on the day of or the day after the resident's admission to the facility. If the resident had intact cognition, she would go over the form with the resident. If the resident did not have intact cognition, she would involve the family as well. Once the resident or designated family member signed the advance directive, the form would be put in a physician's box kept within the Nursing Supervisor's office so the provider could review it the next day he/she was in the office. The SW stated that to her knowledge, the nursing staff completed the process of documenting and retaining the orders for a resident's advance directive.On [DATE] at 4:27 PM and upon request, the SW was accompanied as she reviewed Resident #96's DNR and MOST forms stored in the advance directive binder stored at the Nursing Station. When asked, the SW acknowledged there was potential for confusion with both forms kept in this binder. She reported she would need to follow the facility's protocol to clarify the resident's and family's wishes for her advance directive. An interview was conducted on [DATE] at 3:58 PM with Nurse #3. Nurse #3 was identified as the nurse assigned to care for Resident #96. When asked where she would look to find a resident's advance directive in the case of an emergency, she reported she would go to the first resource she could access. Nurse #3 reported she could find information on a resident's advance directive either in the 3-ring binder stored at the Nursing Station or in the resident's electronic medical record. An interview was conducted on [DATE] at 3:15 PM with the facility's Director of Nursing (DON) in the presence of the Administrator and Regional Nurse Consultant to follow up with the concern identified for Resident #96's advance directive. At that time, the DON and Regional Consultant reported the Do Not Resuscitate (DNR) form printed on bright yellow/orange-colored paper should not have been in the advance directive binder kept at the nursing station. They reported the facility did not use that form and surmised it must have come from the hospital. When asked, it was agreed that storing the two contradictory advance directives (DNR and MOST forms) in the binder containing the advance directives would be potentially confusing in the event of an emergency.

Based on staff interviews and record reviews, the facility failed to accurately code the Minimum Data Set (MDS) assessment in the areas of Preadmission Screening and Resident Review (PASRR, a review to determine if the resident needs specialized services and nursing home care) Level II status (Resident #2) and Hospice services (Resident #17). This occurred for 2 of 32 residents whose MDS assessments were reviewed (Resident #2 and Resident #17).The findings included: 1. Resident #2's electronic medical record (EMR) included a PASRR Level II Determination Notification letter issued 11/22/23 which had no expiration date. Resident #2 was admitted to the facility on [DATE] with a cumulative diagnosis which included schizophrenia and major depressive disorder. The resident's care plan included an area of focus which reported the resident had a Level II PASRR status related to a serious mental illness and related condition due to schizophrenia (Initiated 3/25/25). Resident #2's most recent annual Minimum Data Set (MDS) dated [DATE] reported Resident #2 was not considered by the state Level II PASRR process to have a serious mental illness and/or intellectual disability or related condition. An interview was conducted on 1/9/26 at 3:15 PM with the facility's Director of Nursing (DON), Administrator, and Regional Nurse Consultant to discuss concerns that had been identified to date. When asked about the failure to identify Resident #2 as having a PASRR Level II status on his 11/15/25 annual MDS assessment, the DON reported she thought it may have been a corporate MDS nurse who completed this assessment. This MDS nurse was not available for an interview. An interview was conducted on 1/10/26 at 12:45 PM with the facility's Social Worker (SW). Upon inquiry, the SW reviewed Resident #2's PASRR status and confirmed he had a PASRR Level II status. 2. Resident #17 was admitted to the facility on [DATE] with a diagnosis of cerebrovascular disease (CVA). A review of Resident #17's care plan, last updated on 06/14/2024, noted a terminal prognosis related to CVA and enrollment in hospice services. Resident # 17's physician orders dated 06/12/2024 confirmed hospice admission, and a hospice recertification (continued dates of coverage for hospice services) dated 10/27/2025 covered the period from 11/25/2025 to 01/23/2026. A review of Resident #17's hospice physician order dated 10/27/25 read in part the hospice certification period was 11/25/25 to 01/23/26. A review of Resident #17's quarterly MDS assessment dated [DATE] did not reflect hospice services. The MDS Coordinator was unavailable for interview. On 01/10/2026 at 11:25 AM, during an interview with the Director of Nursing (DON) she verified that Resident #17 was receiving hospice care and the 11/02/2025 MDS should have been coded accordingly.

Based on observations, record review, and resident interviews and staff interviews, the facility failed to develop a comprehensive care plan in the areas of use of a colostomy bag and urinary catheter (Resident #52), dialysis treatment (Resident #14), and discharge goal (Resident #65) for 3 of 32 residents whose care plans were reviewed. The findings included: 1.Resident #52 was admitted to the facility on [DATE] with diagnoses that included necrotizing fasciitis, other specified soft tissue disorders, and rectal hemorrhage. The resident was admitted with a colostomy bag and a urinary catheter. A review of Resident #52's physician orders dated 10/27/2025 revealed orders for catheter care, including checking the placement of the catheter strap every shift and monitoring urinary catheter output every shift. Physician orders dated 10/29/2025 directed staff to check and empty the resident's colostomy bag every shift and replace it as needed. A review of Resident #52's care plan dated 10/28/2025 revealed that no care plan had been developed for colostomy bag care or indwelling urinary catheter care. The admission Minimum Data Set (MDS) assessment dated [DATE] indicated that Resident #52 was cognitively intact and that she had both an indwelling urinary catheter and an ostomy bag in place. A review of Resident #52's Care Area Assessment (CAA) summary revealed it was completed on 01/10/2026 by the MDS Coordinator on 11/4/2025. Further review indicated Urinary Incontinence and Indwelling Catheter was a triggered care area. It was indicated in the CAA summary that urinary incontinence and indwelling catheter would be addressed in the care plan to minimize risks. The MDS Coordinator, who was responsible for the care plan, was not available for interview during the survey. An interview with the Director of Nursing (DON) and the Administrator was conducted on 1/10/2026 at 12:10 PM. The interview was conducted with the DON and Administrator because the Minimum Data Set (MDS) nurse was out on leave and not available for interview. During the review of Resident #52's care plan, the DON stated that a care plan should have been developed for both the colostomy bag and the indwelling urinary catheter by the MDS Coordinator and was unsure why these areas were omitted. The Administrator agreed that both the colostomy and indwelling urinary catheter should have been included in Resident #52's care plan and could not provide a reason for the omission. 2. Resident #14 was admitted to the facility on [DATE] with diagnoses that included end stage renal disease. Review of Resident #14's Physician orders showed the following orders in place: 9/29/25 Dialysis Arteriovenous (AV) shunt-Monitor Every Shift for thrill and bruit. 9/29/25 Dialysis AV shunt-Monitor Every Shift for signs and symptoms of bleeding. 9/29/25 Kidney Center Monday-Wednesday-Friday chair time at 7:05 AM. The comprehensive care plan last reviewed on 10/1/25 revealed no interventions or goals related to dialysis treatment. The admission Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #14 was cognitively intact and received dialysis treatment. An interview with Resident #14 on 1/6/26 at 12:45 PM revealed he received dialysis treatment 3 times a week since his admission to the facility. An attempt was made to interview the MDS Nurse, however she was unavailable for interview. On 1/9/26 at 9:33 AM an interview was conducted with the Director of Nursing. She indicated Resident #14 went to dialysis as ordered and that the MDS Nurse was responsible for the development of care plans. She said a dialysis care plan should have been added to Resident #14's care plan and that the MDS Nurse normally created a dialysis care plan for any resident who received dialysis treatment and that this must have been an oversight. The Administrator stated on 1/9/26 at 9:40 AM that Resident #14 should have a care plan developed which included dialysis treatment. 3. Resident #65 was admitted to the facility on [DATE] with diagnoses that included metabolic encephalopathy. An admission MDS assessment dated [DATE] revealed Resident #65 was moderately cognitively impaired and participated in discharge planning with a goal to return to the community. A social work progress note dated 12/2/25 revealed the Social Worker and Resident #65's emergency contact discussed a plan to seek placement at an assisted living facility. The comprehensive care plan dated 12/4/25 revealed no interventions or goals related to discharge planning. An interview was conducted with Resident #65 on 1/5/26 at 12:26 PM and he indicated that he requested assistance from the facility Social Worker and his emergency contact with placement in an assisted living facility or back to his home. Multiple attempts were made to interview Resident #65's emergency contact but attempts were not successful. An interview was conducted with the Social Worker on 1/7/26 at 1:30 PM. She indicated she was responsible for discharge planning and developing discharge planning care plans. The Social Worker indicated she was aware of Resident #65's request to discharge back to the community and that his emergency contact was in support of transitioning Resident #65 to an assisted living facility. The Social Worker further revealed she did not know why she did not include a discharge focus area on Resident #65's care plan and that it must have been an oversight. On 1/9/26 at 9:34 AM during an interview with the Director of Nursing, she stated the Social Worker was responsible for the development of discharge care plans. The DON further revealed that a discharge care plan should have been added to Resident #65's comprehensive care plan and that it must have been an oversight. An interview was conducted with the Administrator on 1/8/26 at 1:56 PM. The Administrator indicated that the Social Worker was responsible for discharge planning and should have had a discharge planning focus area included in Resident #65's care plan.

Based on observations, record review, resident interview and staff interviews, the facility failed to shave facial hair for 1 of 4 residents reviewed for activities of daily living (ADL) (Resident #65). The findings included:Resident #65 was admitted to the facility 11/18/25 with diagnoses that included metabolic encephalopathy, needs assistance with personal care and muscle weakness.The admission Minimum Data Set (MDS) assessment completed on 11/24/25 documented Resident #65 was moderately cognitively impaired and required supervision or touching assistance with personal hygiene needs.A care plan developed on 12/4/25 documented Resident #65 required staff supervision/touching assistance with personal hygiene and included the goal that Resident #65 would improve current level of function in ADL through the next review. Interventions included Resident #65 required assistance by staff with personal hygiene. Resident #65 was observed on 1/5/26 at 12:26 PM. Resident #65 had a full beard that was approximately an inch in length and a mustache approximately 1/2 inch in length, which covered the full top lip and curled toward the inside of his lip toward his mouth. An interview was conducted with Resident #65 on 1/5/26 at 12:27 PM and he indicated he had made several requests to the nursing assistants that he would like to have his mustache trimmed. He indicated that he was not concerned about the length of his beard only the length of the mustache as it was so long it was growing toward his mouth which bothered him and he was frustrated that nobody had assisted him with his requests. Resident #65 further revealed the nursing assistants told him that someone would come to trim his mustache, but it had been several weeks, and his mustache still had not been trimmed.An observation of Resident #65 was conducted on 1/7/26 at 10:20 AM. Resident #65 had a full beard approximately an inch in length and a mustache approximately 1/2 inch in length, which covered the full top lip and curled toward the inside of his lip toward his mouth. Nursing Assistant (NA) #1 was interviewed on 1/7/26 at 10:20 AM and she reported she had worked with Resident #65 regularly and was his assigned nursing assistant. She further revealed that Resident #65 required staff assistance for facial hair trimming and he had requested to have his mustache trimmed for a while and that it had not been done. NA #1 explained it was her understanding that because Resident #65's mustache and beard was so long it required the use of clippers and not a razor, therefore the Transportation Aide was responsible for trimming his facial hair. NA #1indicated she had reported this request to the Transportation Aide but did not recall when and did not know why it had not been done.An interview was conducted with Nurse #2 on 1/7/26 at 10:26 AM. Nurse #2 reported that she was not aware of Resident #65's requests to have his mustache trimmed but the nursing assistants normally shaved men's facial hair per the resident's preference. Nurse #2 further revealed if nursing staff felt a resident's facial hair was too long then the staff notified the Transportation Aide to come and use the clippers to trim the long facial hair. Nurse #2 reported she was not aware why Resident #65's facial had not been trimmed.An interview was conducted with the Transportation Aide on 1/7/26 at 11:51 AM and she indicated that she helped at times with trimming men's facial hair, but it was the responsibility of the nursing assistants to trim all facial hair or to notify her if her assistance was needed. The Transportation Aide revealed she was never made aware by any staff member that Resident #65 had requested to have his facial hair trimmed.The Director of Nursing (DON) was interviewed on 1/7/26 at 1:08 PM and she reported nursing assistants were responsible for providing facial hair trimming and clippers were available to all nursing staff. The DON further revealed that if the nursing assistants did not have access to the clippers for any reason or felt uncomfortable providing the assistance they were expected to notify the DON or the Transportation Aide that assistance with facial hair trimming was needed.The Administrator was interviewed by phone on 1/7/26 at 2:00 PM. The Administrator reported he did not know why Resident #65's facial hair had not been trimmed, and he expected the staff to complete all ADL care for all residents.

Based on observation, record review, and staff and Nurse Practitioner interviews, the facility failed to obtain a physician order for the treatment of a stage 3 pressure ulcer and failed to set a pressure relieving air mattress to the correct setting for 1 of 3 residents reviewed for pressure ulcers (Resident #17). The findings included:Resident #17 was admitted to the facility on [DATE] with diagnosis that included cerebral vascular disease, type 2 diabetes, hypertension, pressure ulcer of sacral region, and peripheral vascular disease.The care plan revised on 08/29/25 revealed Resident #17 had a pressure ulcer on her coccyx and was at risk for further breakdown related to failure to thrive and disease process. The goal was Resident #17's pressure ulcer would show signs of healing and remain free from infection. Interventions included assessing resident for risk of skin breakdown, keeping skin clean and dry as possible, and skin assessments as indicated. Weekly treatment documentation to include measurement of each area of skin breakdown's width, length, depth, type of tissue and exudate, administer treatments as ordered and monitor for effectiveness,The admission Minimum Data Set (MDS) dated [DATE] revealed that Resident #17 had severe cognitive impairment and was dependent for activities of daily living. Further review of the MDS indicated Resident had no rejection of care and no pressure ulcers during the assessment period. a. A review of Resident #17's weekly skin review dated 12/23/25 indicated Resident had pressure ulcers to her left buttock and sacrum.A review of the wound measurements, documented by the Wound Care Nurse on 12/23/25 were for a stage 3 pressure ulcer that measured 6.5 cm (centimeters) long, 5.0 cm wide and 0.1 cm depth on the sacrum and a stage 3 pressure ulcer that measured 2.5 cm long, 3.0 cm wide, and 0.1cm depth on the left buttock.A review of the physician orders for Resident #17 revealed and order dated 12/24/25 to cleanse the left buttock with Dakin's/normal saline, apply honey fiber to the wound bed, cover with a silicone super absorbent pad, daily and PRN (as needed) and an order dated 12/24/25 to cleanse the sacrum with Dakin's/normal saline, apply honey fiber to the wound bed, cover with a silicone super absorbent pad daily and PRN. There was no treatment order for the right buttock.A review of Resident #17's weekly pressure wound observation tool dated 12/29/25 revealed Resident had a stage 3 pressure ulcer to her left buttock, and a stage 3 to her sacrum.A review of the wound measurements, documented by the Wound Care Nurse on 12/29/25 were for a stage 3 pressure ulcer that measured 2.5 cm long, 3.0 cm wide and 0.1cm depth on the left buttock and a stage 3 pressure ulcer that measured 6.5 cm long, 5.0 cm wide, and 0.1cm depth on the sacrum.A review of Resident #17's weekly skin review dated 01/05/26 indicated Resident had a stage 3 pressure ulcer to sacrum and stage 3 pressure ulcer to left gluteal fold.A review of the wound measurements, documented by the Wound Care Nurse on 01/05/26 were for a stage 3 pressure ulcer that measured 2.0 cm long, 2.5 cm wide and 0.1cm depth on the left buttock and a stage 3 pressure ulcer that measured 6.0 cm long, 4.0 cm wide, and 0.1 cm depth on the sacrum.A review of Resident #17's weekly skin review dated 01/07/26 indicated Resident had a stage 3 pressure ulcer to right buttock. A review of the wound measurements, documented by the Wound Care Nurse on 01/07/26 were for a stage 3 pressure ulcer that measured 5.0 cm long, 4.0 cm wide and 0.1 cm depth on the right buttock. A review of Treatment Administration Record (TAR) for December 2025 and January 2026 reflected the Wound Care Nurse provided wound care to Resident #17's sacral area and left buttock beginning on 12/23/25. There was no documentation for a treatment order in December 2025 for the pressure ulcer on the right buttock.During an observation on 01/07/26 at 9:53 AM of wound care provided by the Wound Care Nurse an observation was made of pressure ulcers to Resident #17's left buttock, right buttock and sacral area. No concerns were identified with the wound care provided.During an interview with the Wound Care Nurse on 01/07/26 at 11:00 AM she indicated Resident #17 had wounds to her left buttock, right buttock and sacrum. She stated the wounds were identified on12/23/25 during a skin check. Wound Care Nurse indicated she had been providing wound care to the left buttock, right buttock and the sacrum and did not realize there was not an order in place for the right buttock. She stated, all the wounds were identified on 12/23/25 and I have been treating them all since then, I don't know what happened, just forget to put the order in, I will get an order now.A further review of the physician orders revealed an order dated 01/07/26 to cleanse the right buttock with Dakin's/normal saline, apply Santyl to slough areas, then sprinkle collagen particles on the granulated tissue, next, cover with a silicone super absorbent pad, daily and PRN (as needed).Review of Resident #17's January 2026 TAR revealed an order dated 01/07/26 to cleanse the right buttock with Dakin's/normal saline, apply Santyl to slough areas, then sprinkle collagen particles on the granulated tissue, next, cover with a silicone super absorbent pad, daily and PRN. The treatment to the pressure ulcer on Resident #17's was first documented as completed on 01/08/26.01/07/26 at 11:05 AM an interview was conducted with the Director of Nursing (DON), and she indicated she was not aware there was not an order or documentation of Resident #17's pressure ulcer to the right buttock.An interview was conducted with the Nurse Practitioner (NP) on 01/10/26 at 2:15 PM and she indicated she was aware of Resident #17's pressure ulcers to her right buttock, left buttock and sacrum, however she was not aware that there was no order in place for the treatment of the right buttock. The NP stated, I will write the order now.b. On 01/05/26 an observation was conducted of Resident #17 in bed, and the pressure-relieving air mattress was set at 350 pounds (lbs.).A review of Resident #17's medical record revealed Resident's weight on 12/04/25 was 133.5 lbs.On 01/06/26 at 8:58 AM an observation was made of Resident #17 in bed and the pressure relieving air mattress was set at 350 lbs.An interview was conducted on 01/07/26 at 10:29 AM with Nurse #2 and she indicated she was the Nurse assigned to Resident #17 on 01/07/24 and was not aware that she was responsible for checking the weight setting on the pressure-relieving mattress, but she would find out.An interview was conducted with the Wound Care Nurse on 01/07/26 at 9:57 AM and she indicated it was the Nurse on the hall's responsibility to ensure the weight set on the pressure relieving mattress was at the correct weight. Nurse #1 stated she would check Resident's weight and get the setting corrected on the pressure relieving mattress.01/07/26 at 11:07 AM during an interview the DON indicated she would provide training to the Nurses to ensure they were aware of their responsibility in making sure the setting on the pressure relieving mattresses was accurate.

Based on observations, staff interviews, and record reviews, the facility failed to post cautionary signage outside the resident's room to indicate supplemental oxygen was in use for 1 of 1 resident reviewed for respiratory care (Resident #88).The findings included:Resident #88 was admitted to the facility on [DATE] with a diagnosis of systolic (congestive) heart failure.The resident's most recent Minimum Data Set (MDS) was a quarterly assessment dated [DATE]. The MDS reported Resident #88 had severely impaired cognition. Review of the resident's electronic medical record (EMR) census revealed the resident was sent out to the hospital on [DATE] with re-entry to the facility on [DATE].Resident #88's Physician's Orders included an order received on 12/11/25 for supplemental oxygen to be provided via nasal cannula at 2 liters per minute as needed for shortness of breath to maintain an oxygen saturation rate greater than 90%. During an observation conducted on 1/5/26 at 10:15 AM of Resident #88, the resident was observed lying in bed with supplemental oxygen provided to her via a nasal cannula. There was no signage to indicate oxygen was in use on or near the entrance to the resident's room. Additional observations were made on 1/5/26 at 11:42 AM, 12:26 PM and 1:54 PM as the resident remained in her bed with supplemental oxygen provided via nasal cannula. These observations also revealed there was no signage to indicate oxygen was in use on or near the entrance to the resident's room. On 1/5/26 at 3:55 PM, a No Smoking sign was observed to be posted on the right side of the main entrance door to the facility. The sign did not specifically indicate that supplemental oxygen was in use within the facility. Resident #88's EMR included a nursing progress note dated 1/6/26 at 8:58 AM which indicated the resident was sent out to the hospital for evaluation. A Nursing Note dated 1/8/26 at 6:08 PM reported Resident #88 returned to the facility from the hospital.Resident #88's Physician's Orders included an order received on 1/8/26 for supplemental oxygen to be provided via nasal cannula at 2 liters per minute as needed for shortness of breath to maintain an oxygen saturation rate greater than 90%. An observation was conducted on 1/9/26 at 9:47 AM as Resident #88 was lying in her bed with the head of bed raised. She had supplemental oxygen provided to her via a nasal cannula. There was no oxygen signage on the door or near the entrance to the resident's room to indicate oxygen was in use.An interview was conducted on 1/9/26 at 3:15 PM with the facility's Director of Nursing (DON), Administrator, and Regional Nurse Consultant to discuss concerns identified to date, including the failure to post oxygen signage at the entrance to Resident #88's room. When asked, the DON and Administrator reported the staff member responsible for ensuring oxygen signage was posted by a resident's door was the Medical Records/Central Supply clerk. The DON confirmed the resident had returned to the facility the previous day (1/8/26) and added that being on the supplemental oxygen was fairly new for this resident.On 1/9/26 at 3:52 PM, an interview was conducted with the facility's Medical Records/Central Supply clerk. Upon inquiry, the clerk reported she has worked at the facility since 2017, but only in this position since February of 2025. When asked who was responsible to ensure oxygen signage was posted near the entrance to the room for a resident receiving supplemental oxygen, the clerk stated she thought the nursing staff was responsible for this. The clerk reported the nurses would alert her if a resident was on supplemental oxygen so she could make sure that all the necessary supplies were available on the floor to meet his/her needs. An interview was conducted on 1/9/26 at 3:58 PM with Nurse #3. Nurse #3 was identified as the hall nurse assigned to care for Resident #88's on first shift (7:00 AM - 7:00 PM). When asked who would be responsible for posting oxygen signage near the entrance to a resident's room if he/she was receiving supplemental oxygen, the nurse stated she thought it would be the hall charge nurse on each shift. When asked, Nurse #3 stated she was the hall charge nurse on this date. An interview was conducted on 1/10/26 at 11:05 AM with Unit Manager #1. When asked, Unit Manager #1 reported that if she knew in advance that a resident was being admitted with orders for the use of supplemental oxygen, she would prep the room for the resident and put up the oxygen signage. Upon further inquiry, the manager reported it was unclear to her as to who would be responsible to ensure oxygen signage was posted for a resident if the facility was not informed in advance that he/she required supplemental oxygen or for a resident who had new orders for supplemental oxygen.An interview was conducted on 1/10/26 at 9:25 AM with the facility's Nurse Practitioner (NP). During the interview, the NP confirmed that Resident #88 was using the supplemental more often than she initially did. When the NP was informed of the facility's failure to provide oxygen signage at the entrance of the resident's room, the NP stated, I do think it's important.

Based on observations, staff interviews, and record reviews, the facility failed to have a medication error rate of less than 5% as evidenced by 2 medication errors out of 25 opportunities, resulting in a medication error rate of 8% for 2 of 6 residents observed during the medication administration observations (Resident #11 and Resident #33).The findings included:1. Breo Ellipta is an aerosol powder for inhalation used for the management of chronic obstructive pulmonary disease (COPD) and/or asthma. The manufacturer's Full Prescribing Information for the Breo Ellipta inhaled medication included Administration Information. These instructions read, in part: After inhalation, the patient should rinse his/her mouth with water without swallowing to help reduce the risk of oropharyngeal candidiasis [a superficial yeast infection of the mouth, also known as oral thrush].On 1/7/26 at 8:33 AM, Medication Aide (Med Aide) #2 was observed as she prepared and administered ten (10) medications to Resident #11. The medications administered to the resident included 200 - 25 micrograms (mcg) per actuation of Breo Ellipta aerosol powder given as one puff by mouth. After Resident #11 inhaled one puff of the Breo Ellipta, Med Aide #2 offered him water to drink. The resident accepted it and was observed as he drank and swallowed the water immediately after the Breo Ellipta inhaler was administered. Med Aide #2 did not prompt the resident to rinse his mouth with water and then spit the water out after using this inhaled medication.A review of Resident #11's current orders revealed a medication order was initiated on 12/24/25 for 200 - 25 micrograms (mcg) per actuation of Breo Ellipta aerosol powder to be given as one puff by mouth one time a day for reactive airway disease. A notation was included in the order to rinse mouth and spit after use. An interview was conducted on 1/7/26 at 11:08 AM with Med Aide #2 in the presence of Nurse #2. Nurse #2 was the hall nurse assigned to care for Resident #11. During the interview, Nurse #2 pulled up Resident #11's January 2026 Medication Administration Record (MAR) and reviewed his physician's order for the Breo Ellipta. The nurse confirmed Resident #11's orders included a notation for the resident to rinse and spit after using the Breo Ellipta. When asked, Med Aide #2 recalled the resident drank and swallowed water after the Breo Ellipta was administered. She acknowledged she did not prompt him to rinse and spit the water out. Nurse #2 explained to the med aide why this was important, stating that failure of a resident to rinse/spit after using Breo Ellipta could cause thrush.An interview was conducted on 1/9/26 at 3:15 PM with the facility's Director of Nursing (DON), Administrator, and Regional Nurse Consultant to discuss the concerns that had been identified to date. When asked, the DON reported she would expect the nursing staff administering a steroid inhaler to remind the resident to rinse and spit water out after the inhaler's administration.2. On 1/7/26 at 8:28 AM, Medication Aide (Med Aide) #2 was observed as she prepared and administered four (4) medications to Resident #33. The medications administered to the resident included one tablet of a combination medication containing a multivitamin with minerals taken from a stock medication bottle stored on the medication cart. A review of Resident #33's current physician's orders revealed a medication order was initiated on 7/17/24 for a multivitamin to be given as one tablet by mouth one time a day for vitamin deficiency. An interview was conducted on 1/7/26 at 11:08 AM with Med Aide #2 in the presence of Nurse #2. Nurse #2 was the hall nurse assigned to care for Resident #33. During the interview, Nurse #2 pulled up Resident #33's January 2026 Medication Administration Record (MAR) and reviewed his physician's order for the multivitamin. At that time, Nurse #2 confirmed the order indicated Resident #33 was supposed to receive a multivitamin without the minerals added. When the med aide stated she wasn't sure there was a stock bottle on the medication cart that contained only multivitamins (without minerals), Nurse #2 stated there was. The nurse cautioned Med Aide #2, stating that she would need to look at the bottle more carefully to ensure she was pulling the right stock bottle from the medication cart prior to administering a medication.An interview was conducted on 1/9/26 at 3:15 PM with the facility's Director of Nursing (DON), Administrator, and Regional Nurse Consultant to discuss the concerns that had been identified to date. When the medication errors were discussed, the DON stated she would need to be sure the nursing staff was educated on these concerns.

Based on record review, and Ombudsman and staff interviews, the facility failed to notify the Ombudsman in writing of residents transfer to the hospital for 2 of 2 emergency hospitalization transfers reviewed for hospitalization (Resident #99 and Resident #88). The findings included:1. Resident #99 was admitted to the facility on [DATE].The nursing progress note dated 12/10/25 revealed Resident #99's was out of the facility at an appointment and was transferred to the hospital for further evaluation due to chest pain.The medical record indicated Resident #99 was discharged from the facility on 12/10/25 and did not return to the facility.The facility was unable to provide documentation regarding notification to the Ombudsman of Resident #99's transfer to the hospital.An interview was conducted with the Social Worker on 1/9/26 at 10:37 AM and revealed she was hired in October of 2025, and she had not sent the Ombudsman office any notifications regarding emergency transfers as it was not her responsibility. The Social Worker stated she did not know who was supposed to complete the notification for emergency transfers to the Ombudsman.An interview was conducted with the interim Ombudsman on 1/9/26 at 4:42PM and she indicated the facility had not notified the ombudsman office of any resident emergency transfers to the hospital since September of 2025.An interview was conducted with the Administrator on 1/9/26 at 2:01 PM who revealed he was not aware the facility had not notified the Ombudsman office of emergency transfers since September of 2025 and it was the Social Worker's responsibly to notify the Ombudsman of any emergency transfers to the hospital.2.a. Resident # 88 was admitted to the facility on [DATE].The nursing progress note dated 11/13/25 revealed Resident #88 was transferred to the hospital per family member's request for seizures.The medical record indicated Resident #88 was discharged from the facility on 11/13/25 and returned to the facility on [DATE],The facility was unable to provide documentation regarding notification to the Ombudsman of Resident #88s transfer to the hospital.b. The nursing progress note dated 12/7/25 revealed Resident #88 was transferred to the hospital for further evaluation of seizure-like activity.The medical record indicated Resident #88 was discharged from the facility on 12/7/25 and returned to the facility on [DATE].The facility was unable to provide documentation regarding notification to the Ombudsman of Resident #88s transfer to the hospital.An interview was conducted with the Social Worker on 1/9/26 at 10:37 AM and revealed she was hired in October of 2025, and she had not sent the Ombudsman office any notifications regarding emergency transfers as it was not her responsibility. The Social Worker stated she did not know who was supposed to complete the notification for emergency transfers to the Ombudsman.An interview was conducted with the interim Ombudsman on 1/9/26 at 4:42PM and she indicated the facility had not notified the ombudsman office of any resident emergency transfers to the hospital since September of 2025.An interview was conducted with the Administrator on 1/9/26 at 2:01 PM who revealed he was not aware that the facility had not notified the Ombudsman office of emergency transfers since September of 2025 and it was the Social Worker's responsibly to notify the Ombudsman of any emergency transfers to the hospital.

Based on record review and staff interviews, the facility failed to transmit Minimum Data Set (MDS) assessments within the regulated timeframe for 2 of 32 residents reviewed for MDS assessments (Resident # 1 and # 30).Findings included: 1. Resident #1 was admitted to the facility on [DATE] with diagnoses that included type 2 diabetes and hypertension. Resident #1's quarterly MDS with an assessment reference date (ARD, the last day of the look back period) of 11/14/25 was completed on 11/26/25 and had not been transmitted. The MDS coordinator was not available for interview. An interview was conducted on 01/10/26 at 11:34 a.m. with the Director of Nursing (DON). She verified Resident #1's MDS quarterly MDS dated [DATE] had not been transmitted. The DON indicated there was a glitch in the system and it should have automatically transmitted when the assessment was completed. On 01/10/26 at 11:40 a.m. an interview was conducted with the Administrator. He indicated it was his expectation for all MDS assessments to be transmitted on time. 2. Resident #30's electronic medical record (EMR) indicated the resident was admitted to the facility on [DATE] and was discharged on 9/18/25. Review of Resident #30's EMR revealed a discharge MDS with an assessment reference date (ARD, the last day of the look back period) of 9/18/25 was signed as completed by the facility's MDS nurse on 10/3/25. However, the Discharge MDS was not reported as having been transmitted or accepted by the Centers for Medicare and Medicaid Services (CMS) System. An interview was conducted on 1/6/26 at 4:00 PM with the facility's Director of Nursing (DON) in the presence of the Administrator. At that time, the DON and Administrator reported the MDS nurse was unavailable. The DON reviewed Resident #30's records and acknowledged the 9/18/25 Discharge MDS had not been transmitted to CMS. An interview was conducted on 1/9/26 at 3:15 PM with the facility's Administrator, Director of Nursing (DON), and Regional Nurse Consultant to discuss the concerns that had been identified to date. When asked about the failure to transmit Resident #30's 9/18/25 Discharge MDS, the DON reported that the MDS nurse should have been monitoring a print-out which would have shown whether the MDS assessments were successfully transmitted and accepted. Upon further inquiry, the DON reported Resident #30's Discharge MDS should have been transmitted within 14 days of the Assessment Reference Date (ARD) of 9/18/25.

Based on record review, observation, and resident and staff interviews, the facility failed to honor a residents' request to have medications administered at a time that was desired for 1 of 4 residents (Resident #64) reviewed for choices. The findings included: Resident # 64 admitted to facility on 7/16/24 with diagnoses that included chronic obstructive pulmonary disease. The quarterly Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #64 was cognitively intact. On 09/10/24 at 12:51 PM an interview was conducted with Resident #64 and he indicated he was concerned with the time he was getting his medications. He indicated he would sometimes receive his morning medications close to lunch time. Resident #64 stated, I have talked numerous times to someone here about my medications and getting them on time, and nothing has changed A review of Resident#64's September electronic medication administration record revealed morning medication times scheduled for 7:00 AM, 8:00 AM, and 9:00 AM. On 09/11/24 at 9:46 AM an interview was conducted with Resident #64 and he stated he had not received his medications yet. An interview was conducted with Nurse #4 on 09/11/24 at 11:46 AM and she indicated, Resident #64 went to the medication cart around 10:30 am and requested his medications. The Nurse indicated she was working her way to Resident #64's room, however she was running behind on the medication pass. She stated, I came in to help out and got here about 8:00 or 8:30 AM, so I'm running behind. Nurse #4 acknowledged Resident # 64's morning medications were administered late. At 11:57 AM on 09/11/24 another Interview was conducted with Resident #64 and he stated, they were making me late for bible study, so I went to ask for my medicines. He indicated he just wanted to get his medications a certain time every day without having to ask for them. On 09/11/24 at 12:00 pm and interview was conducted with the Director of Nursing (DON) and she indicated she would change Resident #64's medication times so he would get them as he preferred. An interview was conducted on 09/12/24 at 10:54 AM with the Administrator and he stated, he expected the Resident to get his medications timely. He indicated it was the Residents' right to get his medications when he wanted them, and we should honor his request.

Based on record review and interviews of the staff, physician, and nurse practitioner, the facility failed to notify the on-call nurse practitioner when a resident had a change in condition (Resident #95). This deficient practice affected 1 of 2 residents reviewed for hospitalization . Findings included: Resident #95 was admitted to the facility on [DATE] with diagnoses of diabetes, atrial fibrillation on anticoagulant, and end stage renal disease dependent on renal dialysis. On 6/12/24 at 7:30 pm Nurse #1 documented in the neurological assessment form Resident #95 had blood pressure (BP) 135/95, pulse (P) 91, respirations (R) 13, and temperature (T) 97.0. The resident was lethargic with both pupils reactive but sluggish. The resident had no motor function of all extremities and hand grasp. There was no headache, seizure, drainage from the ear or nose, or vomiting. On 9/11/24 at 2:49 pm Nurse #1 was interviewed. Nurse #1 stated she had not informed the on-call nurse practitioner (NP) on 6/12/24 at 11:30 pm when the resident had a change in her neurological status starting at 7:30 pm. Nurse #1 stated I do not think I included the pupils and lethargy information when I contacted the NP about the resident's sleepiness. The NP was informed the resident was too drowsy and sleepy to wake up for medication at 7:30 pm and 11:30 pm. Nurse #1 stated she had not thought to notify the NP about the sluggishness of the eyes, lethargy, diaphoresis, and that she had not moved her extremities. The NP directed Nurse #1 to hold the resident's evening medications. On 9/12/24 at 12:35 pm an interview was conducted with the day-shift Nurse Practitioner. The Nurse Practitioner stated she was not on call on 6/12/24. There was a high risk for bleeding when a resident was receiving anti-coagulant. The Nurse Practitioner stated she would want to be called at the time when there was a change in the resident's neurological status. The Nurse Practitioner stated the on-call service for after hours (after 5:00 pm and before 7:00 am) do not know the residents and would be solely reliant on what the nurse reported. The on-call service providers do not have access to the facility's records. On 9/12/24 at 11:30 am an interview was conducted with the Physician. The Physician stated any change in a resident's neurological status needs to be reported immediately to medical staff.

Based on record review and interviews of the staff, physician, and nurse practitioner, the facility failed to identify a resident's change in condition (Resident #95). This deficient practice affected 1 of 2 residents reviewed for hospitalization . Findings included: The resident had medical orders for scope of treatment (MOST) form dated 3/21/22 signed by a representative. Section A was for do not resuscitate. Section B was limited additional interventions: Do not intubate or mechanical ventilate but may consider less invasive airway support such as BiPAP or CPAP (oxygen mask with positive pressure), transfer to hospital if indicated, and avoid intensive care. Sections C and D were to provide antibiotics and intravenous fluids. Resident #95 was admitted to the facility on [DATE] with diagnoses of diabetes, atrial fibrillation on anticoagulant, and end stage renal disease dependent on renal dialysis. Resident #95's care plan dated 5/23/24 documented she had an impaired cognitive function and thought process, was at risk for falls, required hemodialysis, and was receiving anticoagulant for atrial fibrillation (dysrhythmia of the heart). Anticoagulant interventions were to monitor for changes in mental status, changes in vital signs, and lethargy. Resident #95 had an order dated 2/11/24 for Eliquis (anticoagulant) 2.5 mg twice a day. On 9/12/24 at 10:38 am an interview was conducted with Nurse #2. Nurse #2 stated she was assigned to Resident #95 on 6/12/24 from 7:00 am to 7:00 pm. The resident was assessed by the Director of Nursing (DON) and me up to 5:00 pm. The resident was at her mentation baseline. The resident went to dialysis at approximately 10:30 am to 4:00 pm on 6/12/24. The resident had her dialysis as scheduled. Nurse #2 stated at dialysis the resident would have had heparin anticoagulant in the dialysis solution in addition to her twice a day facility provided anticoagulant. Resident #95 had no change on my shift 6/12/24 before dialysis. I last saw the resident about 5:30 pm sitting up in her bed with her meal. On 6/12/24 at 7:30 pm Nurse #1 documented in the neurological assessment form Resident #95 had blood pressure (BP) 135/95, pulse (P) 91, respirations (R) 13, and temperature (T) 97.0. The resident was lethargic with both pupils reactive but sluggish. The resident had no motor function of all extremities and hand grasp. There was no headache, seizure, drainage from the ear or nose, or vomiting. On 6/12/24 at 11:40 pm Nurse #1 documented in the neurological assessment form Resident #95 had BP 144/105, P 93, R 14, and T not documented. The resident was lethargic with both pupils reactive but sluggish. The resident had no motor function of all extremities and hand grasp. Nurse #1 was unable to assess headache, seizure, drainage from the ear or nose, or vomiting. Nurse #1's nurses' note dated 6/13/24 at 12:20 am of Resident #95. The resident was lying in bed, unlabored breathing, diaphoretic, lethargic, and unarousable. The resident's evening medications were placed on hold due to resident acute changes and inability to arouse to swallow. The nurse practitioner was notified (of the inability to arouse and swallow medication). On 6/13/24 at 3:20 am Nurse #1 documented in the neurological assessment form. Resident #95 was unresponsive with both pupils fixed. The resident had no motor function of all extremities and hand grasp. Nurse #1 was unable to assess whether the resident had a headache, seizure, drainage from the ear or nose, or vomiting. On 9/11/24 at 2:48 pm an interview was conducted with Nurse #1. Nurse #1 stated on 6/12/24 at 7:00 pm Resident #95 had a neurological assessment every 4 hours. The resident was barely responding with labored breathing and was diaphoretic. Nurse #1 stated she could not tell if the change was neurological because the resident had received dialysis earlier that day. Residents were usually worn out after dialysis. Nurse #1 stated she passed the medication to other residents and returned to Resident #95 to administer medications at 11:00 pm. The resident was too sleepy to wake up and swallow her evening medications. The resident's pupils were responsive but slow and she would only moan when attempted to wake. The resident was not moving her extremities and was diaphoretic. Nurse #1 decided she would wait for the resident to wake up and tried again at 11:30 pm. Nurse #1 assessed Resident #95, she was still very tired, not waking up and not moving. Nurse #1 believed the resident was tired from dialysis and had not refused medication before. The resident was not talking, just moaning at 7:30 pm and 11:30 pm assessments. Nurse #1 stated she called the on-call nurse practitioner and informed her the resident was very sleepy and could not swallow evening medication. The nurse practitioner directed Nurse #1 to hold the resident's evening medications. Interview continued: Nurse #1 stated she came back at approximately 3:20 am on 6/13/24 and Resident #95 was unable to wake up and was not moving. The resident had a large amount of saliva in her mouth and her tongue was stuck on the left side and she had extreme diaphoresis. Nurse #1 tried sternal rub and was unable to wake the resident. Nurse #1 called NA #1 into the resident's room and they both could not wake the resident. Nurse #1 stated she called another nurse into the resident's room and this nurse could not wake the resident. The resident was noted to not react to sternal rub, saliva was coming out of her mouth, and her pupils were not reactive and fixed. The resident was not responding at all, she had a weird gurgling noise in her mouth. Nurse #1 stated she called the DON to inform her of the resident's status and was directed to send the resident out. Nurse #1 stated she called 911 around 3:45 am on 6/13/24. Nurse #1 further stated that something was not right with the resident, she was very diaphoretic and needing her clothes changed, and her blood glucose check was 147, but the resident was not responding to anything. She had no muscle control and fixed pupils. Nurse #1 went on to state she thought the resident was sleepy from dialysis. Nurse #1 had not suspected a neurological change because I was not at the facility all day to see the resident. Nurse #1 was aware the prior shift nurse had not observed the resident's lethargy. Nurse #1 stated she received in report the resident was at neurological baseline when she came back from dialysis at 4:30 pm on 6/12/24. The resident's mental status was normal prior to the 7:00 pm to 7:00 am shift on 6/12/24. Everything changed on my shift. Nurse #1 stated the resident's blood pressure was elevated which was not normal for her. On 9/12/24 at 10:30 am an interview was conducted with Nursing Assistant (NA) #1. NA #1 stated she was assigned to Resident #95 on 6/12/24 from 7:00 pm to 7:00 am. NA #1 stated the resident was talking to her but drowsy at 7:00 pm. NA #1 thought the resident was tired from dialysis. The resident was more quiet than normal and remained that way until the next check at 11:00 pm when the resident was not talking, and the NA thought the resident was sleeping and had not tried to wake her. NA #1 stated sometime after midnight the resident could not wake up, not sure the exact time. Around 3:00 am on 6/13/24 Nurse #1 called me into the resident's room to observe the resident. The resident was not able to wake up and not moving. Nurse #1 stated another nurse attempted to wake the resident unsuccessfully. The resident was sent out by EMS to the hospital.

Based on observations and staff interviews the facility failed to maintain clean and sanitary floors, ensure baseboards were in good repair and ensure the toilet was clean and in good repair in 2 of 3 rooms (rooms [ROOM NUMBERS]), ensure the light fixture was clean and a sink was in good repair in 1 of 3 rooms (room [ROOM NUMBER]), and maintain cleanliness and sanitation in 1 of 2 linen closets and 1of 1 dining room observed for maintenance of a sanitary and orderly interior. The findings included: Review of the Perfomance Improvement Project (PIP) worksheet dated 5/6/24 revealed the facility had decluttered resident's rooms and transitioned from contracted housekeeping services to in house. The facility documented results of their interventions as clean building, decreased pests, consistent housekeeping, deep cleaning and decluttering. To sustain improvement, the facility wrote consistent housekeeping and focus on being clutter-free, and constant contact with local pest exterminator for any pest seen. The PIP worksheet indicated it was ongoing and did not have a completion date. a. An observation of room [ROOM NUMBER] on 6/10/24 at 12:45 pm revealed a sink that was pulling away from the wall, the light fixture was full of dead bugs, the baseboards outside the bathroom were peeling away from the wall, the bathroom floor had debris and dust at the corners under the commode, a crack with an opening was noted in a corner wall of the bathroom and a dried brown material was on the commode lid. An additional observation was conducted on 6/11/24 at 11:50 am with the Administrator revealing the same findings. The Administrator stated he would have someone take care of those right away. During an interview with the resident in room [ROOM NUMBER] on 6/10/24 at 12:45 pm, the resident revealed the housekeepers came to clean everyday but did not do a thorough job. She stated there was a housekeeper that came by but the dried bowel movement on the commode lid was still there. She stated she could barely balance herself to wipe the lid or pick up something from the floor. She pointed at her light fixture and stated it was full of bugs since she got admitted and nobody came to clean it. b. An observation of room [ROOM NUMBER] on 6/11/24 at 9:30 am revealed dust or [NAME] material on the floor outside the bathroom. The baseboard was peeling away from the wall outside the bathroom. Debris was noted in the broken vinyl tile in the bathroom and dust noted on the corners of the bathroom. During an observation and interview on 6/11/24 at 12:10 pm, the room looked the same with dust or [NAME] material on the floor beside the bathroom and debris in the broken vinyl tile and dust on the corners of the bathroom. The resident occupying the room stated the housekeepers came and cleaned every day. They swept and mopped around her belongings on the floor. She stated it was hard for her to pick up because of her back hurting. She stated she could not recall if they did a deep clean in her room. c. An observation of the south hall linen closet on 6/10/24 at 4:00 pm revealed dust and dirt accumulated on two corners of the floor. A follow up observation with the Administrator of the linen closet on 6/11/24 at 11:50 am revealed the same dust and dirt on both corners of the floor. d. An observation of the dining room on 6/11/24 at 10:30 am with the Regional Nurse Consultant revealed the back of the dining room doors were covered with dust and debris. The upper part of the doors had cobwebs on them. The Nurse Consultant stated she was going to inform the Administrator and left. Further inspection revealed the back of the vending machines inside the dining room had dust and debris. The upper portion had some cobwebs. A roach bait station was observed behind the vending machine and was full of dust and debris. During an interview on 6/11/24 at 9:35 am, Environment Specialist #1 stated cleaning each resident room consisted of collecting trash, wiping surfaces with a wet rag, sweeping and mopping the floors in the rooms. She cleaned the bathrooms next by wiping in there, sweeping and mopping the floor. She was assigned to rooms [ROOM NUMBERS] and had not cleaned them at that time. During an interview on 6/11/24 at 9:55 am, Floor Technician #1 stated they swept and mopped the hallways and the dining room every day. He stated they buffed the floor in the dining room weekly. He stated he swept and mopped the dining room after lunch on 6/10/24. He has not cleaned the dining room during the interview. During an interview on 6/11/24 at 11:45 am, the Administrator stated they had an ongoing PIP on environmental services which included pest control. The goal was to provide home like, clean, pest free environment. This started in March 2024. They decluttered and threw away some of the residents' old belongings. He stated the pests were coming from the residents' clutter. The maintenance staff were filling out cracks in the walls. The staff were supposed to submit work orders online if they see bugs or things needing repairs. The Administrator stated the department heads did daily rounds and submitted work orders if they saw stuff. The housekeepers were supposed to be deep cleaning the dining rooms and residents' rooms weekly. The Administrator was shown room [ROOM NUMBER]'s condition and the light fixture full of dead flies. He stated the Regional Nurse Consultant told him about the dining room. He stated he would have someone take care of those. The Administrator provided a copy of the PIP worksheet dated 5/6/24 to the surveyor. During a discussion on 6/11/24 at around 1:40 pm, the Regional Director of Operations was informed of the findings in the resident's rooms, the linen closet and the dining room. She presented the PIP on environmental services and stated it was ongoing. She stated she was not aware of the observations with the Administrator of room [ROOM NUMBER] and its bathroom, and the linen closet in the south hall.

Based on observations, record review, resident and staff interviews, the facility failed to maintain an effective pest control program as evidenced by pests observed in 1 of 3 hallways (the hallway leading into the dining room) and in 2 of 3 residents' rooms (rooms [ROOM NUMBERS]) reviewed for pest activity. The findings included: Review of the facility's Performance Improvement Project (PIP) dated 3/3/24 in Environmental Services revealed a problem with pest control. Interventions included decluttering residents' rooms, scheduling deep cleaning of rooms, weekly exterminator rounds, care planning for residents who hoarded and daily rounding by the administrator, social worker, maintenance and environmental services. This PIP did not have a date of completion. Review of the facility's invoices from a local pest control company as follows: 4/5/24 read in part: Treated kitchen area corner tile broke with roaches, treated side exit door therapy and hallway restroom for German Roaches. 4/12/24 read in part: Kitchen at Wi-Fi area German roach activity found alive and dead. Crack and crevice treatment, void treatment. Restrooms in patient rooms: 138, 146: crack and crevice treatment. No cockroaches were found. Preventive crack and crevice treatment south nurses' station, office, and south hallways, exit doors. 4/19/24 read in part: Preventive spot treatment of hallway bathrooms, deep sink area, dishwashing area, kitchen office, kitchen area, and maintenance shop. Interior placement of bait in boiler room for American cockroaches. Please have dead roaches removed/floor cleaned under flour storage bins/table in kitchen (killed two roaches under flour bin). 4/26/24 read in part: Unoccupied residents' rooms [ROOM NUMBERS] crack and crevice treatment for ants. No ants or roaches found. Beauty salon, physical therapy, administrative office preventive spot treatment for roaches and ants. Kitchen preventive spot treatment. 5/3/24 read in part: Completed inspection and proactive spot treatment for roach activity found in kitchen, kitchen office, little locker room, behind dishwasher around pipe opening collars, and deep sink area. Completed proactive spot treatment of offices and the scheduling office. Ants reported in scheduling room. Review of the facility's PIP worksheet dated 5/6/24 revealed the results of their interventions were: cleanliness of the building, decrease in pests, consistent pest control/housekeeping, deep cleaning and de-cluttering. To sustain improvement, the facility wrote consistent housekeeping and focus on being clutter-free, and constant contact with local pest exterminator for any pest seen. The PIP worksheet indicated it was ongoing and did not have a completion date. Review of the facility's invoices from a local pest control company after the PIP follow up on 5/6/24 revealed: 5/10/24 read in part: Preventive crack and crevice treatment for ants and roaches in unoccupied rooms 104, 107, 144, 146 and southside spa. Reported ants in room [ROOM NUMBER] - crack and crevice treatment. Caulked some more in kitchen at tile crack. Crack and crevice treatment of windows for ants reported in physical therapy room. 5/17/24 read in part: Preventive spot treatment for unoccupied rooms (110, 109, 111, 137, 144 and 146), nurses stations, kitchen office, janitorial closet, behind drink machines, dining area, storage room and behind shredded dryer holder. Found and killed roaches around pipe opening collars under dishwashing machine and behind bending machine. Found one dead smokey brown roach in bathroom of room [ROOM NUMBER]. 5/24/24 read in part: Completed spot treatment of dishwashing area. Roach activity was found and treated behind pipe openings and control box. Caulked sealed off pipe openings and crevices of interior back corner, hole in floor. Seal off hole and repair damaged sheetrock at bottom wall or door frame of door leading to dining room. Hole had roach activity. Spot treatment in room [ROOM NUMBER]. 6/3/24 read in part: Inspected hallways, lobby areas, vending areas and interior traps. No observed activity at time of visit. No reported activity in patient rooms at time of inspection. a. An observation of room [ROOM NUMBER] was made on 6/10/24 at 12:45 pm revealed a fly flying around the light fixture. The room was occupied by a resident who stated she had flies flying around her face the other day and she was aggravated. She pointed to her light fixture in the room and stated it was full of dead flies since admission and she has not seen anyone clean the light fixtures. She stated her family member was going to report it. She stated she also saw brown bugs crawling out of the bathroom and thought they came from the cracks in the bathroom. The resident thought she saw the bugs after she came back from her orthopedic appointment on 6/4/24. b. An observation of room [ROOM NUMBER] was made on 6/11/24 at 9:30 am. The room was occupied at the time of the observation and the resident revealed she saw bugs coming in and out of her bathroom several times the other day (6/9/24). She told a staff but could not recall who it was. The resident has not seen anyone spray in her room. The bathroom was observed with baseboards peeling off the wall and a flattened broken vinyl tile folded over. c. An observation of common areas on 6/11/24 at 10:25 am revealed another fly circling the water sprinkler above the dining room door entrance. There were several residents in the dining room participating in activities. During an interview on 6/10/24 at 4:25 pm, Nurse Aide #1 stated a previous resident complained of seeing roaches in his room. She stated she saw roaches coming out of the linen closet the other week. She stated they submitted work orders when they see bugs. During an interview on 6/10/24 at 3:45 pm, Nurse Aide #2 stated she saw roaches and water bugs coming from the linen closet every now and then. She could not remember when she saw them last, but it was one day last week. She stated they report it to the nurses if they see them. During an interview on 6/10/24 at 4:05 pm, Nurse Aide #3 stated she saw roaches in the halls and in the residents' bathrooms when she worked third shift. She stated she saw them at the end part of May 2024. She was not aware of any residents that complained of bugs. During an interview on 6 /11/24 at 9:35 am, Environmental Specialist #1 revealed she observed live baby roaches in a resident's room that morning and killed them. She stated she also saw flies in their break room. She stated the floor technicians and maintenance take care of the pest control. She stated somebody had been spraying in the facility. During an interview on 6/11/24 at 9:55 am, Floor Technician #1 stated they mop the hallways. He stated he saw a roach in his mop bucket several weeks ago and killed it. He stated he has not seen any in the washroom lately. He stated someone came and sprayed a week after he reported it. During an interview on 6/11/24 at 3:00 pm, Medication Aide #1 revealed she saw roaches around doors the other day. She could not remember which resident rooms had them. She stated they had been reporting it, but they kept seeing them. During an interview on 6/11/24 at 11:45 am, the Administrator stated they had an ongoing PIP on environmental services which included pest control. This started in March 2024, and it was for any bugs in the facility. He stated the exterminator was on contract monthly but was changed to weekly during the first week of May 2024. He stated the receipts were records of his rounds. The facility also called the exterminator as needed. The exterminator put bait traps all over the facility. He stated the PIP was ongoing and they tried to identify residents that hoarded and decluttered and threw away some of their old belongings. He stated the pests were coming from the residents' clutter. The maintenance staff were filling out cracks in the walls. The staff were supposed to submit work orders online if they see bugs or things needing repairs. The Administrator stated the department heads did daily rounds and submitted work orders if they saw stuff. The housekeepers were supposed to be deep cleaning the dining rooms and residents' rooms weekly. The Administrator was shown room [ROOM NUMBER]'s condition and the light fixture full of dead flies. He stated he will have someone take care of those. The Administrator provided a copy of their PIP worksheet to the surveyor. During a discussion on 6/11/24 at around 1:40 pm, the Regional Director of Operations presented the PIP on pest control and stated it was ongoing. She stated she was not aware of the flies in the resident's room, the light fixture full of dead flies and the fly above the dining room door.

Based on record review and staff interviews, the facility failed to develop a comprehensive care plan that addressed a resident's individual care needs for 1 of 3 residents reviewed for comprehensive care plan (Resident #1). The facility failed to develop care plans for cognitive loss/Dementia, urinary Incontinence and Indwelling catheter, functional abilities, dehydration/fluid maintenance, dental care, pain, communication, nutritional status, and pressure ulcer/injury. Findings Included: Resident #1 was admitted to the facility on [DATE]. Diagnoses included multiple fractures and pressure ulcers. He was discharged to the hospital on 12/9/23 and did not return to the facility. Resident #1's admission Minimum Data Set (MDS) assessment dated [DATE] revealed the Care Area Assessment (CAA) summary identified care plans would be developed for cognitive loss/Dementia, urinary Incontinence and Indwelling catheter, functional abilities, dehydration/fluid maintenance, dental care, pain, communication, nutritional status, and pressure ulcer/injury. Review of the medical record revealed a nutrition care plan dated 11/8/23. There were no other care plans available for Resident #1. During an interview on 5/6/24 at 3:12 pm, MDS Nurse #1 revealed the care plans for Resident #1 had not been completed after checking Resident #1's electronic medical records (EMR). She stated she was not sure why this was not done. She referred the surveyor to another MDS Nurse (#2) who worked remotely. During a telephone interview on 5/6/24 at 3:13 pm, MDS Nurse #2 checked Resident #1's EMR and stated the comprehensive care plan was not done. She stated she was not sure what happened. She stated that she typically completed all the residents' comprehensive care plans right after she completed the MDS CAAs. She did not know how she missed it. During an interview on 5/6/24 at 3:08 pm, the Director of Nursing (DON) stated the comprehensive care plans should be based on the CAAs and completed within seven days from the resident assessment.

Based on record review, and staff interviews, the facility's Quality Assurance and Performance Improvement (QAPI) Committee failed to maintain implemented procedures and monitor the interventions that the committee put into place following the recertification and complaint investigation survey of 5/28/21 and 5/26/23 and the current complaint investigation survey of 5/6/24. This failure occurred for a repeat deficiency originally cited in the area of comprehensive resident centered care plans that was subsequently recited on the current complaint investigation survey of 5/6/24. The continued failure of the facility during three federal surveys of record shows a pattern of the facility's inability to sustain an effective QAPI Program. The findings included: This tag is cross referenced to: F656: Based on record review and staff interviews, the facility failed to develop a comprehensive care plan that addressed a resident's individual care needs for 1 of 3 residents reviewed for comprehensive care plan (Resident #1). The facility failed to develop care plans for cognitive loss/Dementia, urinary Incontinence and Indwelling catheter, functional abilities, dehydration/fluid maintenance, dental care, pain, communication, nutritional status, and pressure ulcer/injury. During a recertification and complaint investigation survey of 5/28/21, the facility failed to develop a comprehensive person-centered plan of care that included the daily use of an antipsychotic and antianxiety medication for a resident. During a recertification and complaint investigation survey of 5/26/23, the facility failed to develop a care plan with measurable goals and objectives to address nutrition for a resident. An interview was conducted on 5/6/24 at 4:40 pm with the Administrator and the Director of Nursing. The Administrator stated he headed the facility's Quality Assurance and Performance Improvement (QAPI) Committee. The committee consisted of the Director of Nursing (DON), Staff Development Coordinator (SDC), Medical Director, Pharmacist, Dietary Manager, Maintenance Director, and himself. He revealed the facility was working on falls with injuries, pest control, and recently added care plans.

Based on record review, observations, interviews with residents and staff, the facility failed to protect a resident's right to be free from employee to resident physical abuse for 1 of 1 resident investigated for abuse (Resident #13). Resident #13 had reported to the facility Nurse Aide (NA)#1 needed to feed her roommate correctly. Resident #13 alleged later the same evening NA #1 grabbed Resident #13's face very hard, squeezed her face, in a manner which scared the resident and after the incident the resident was found to have bruising on her right jawline and right cheek. The findings included: Resident #13 was admitted to the facility on [DATE] with diagnoses that included hemiplegia/hemiparesis following cerebrovascular accident (stroke), contracture of right hand and forearm, and anxiety disorder. The Minimum Data Set (MDS) dated [DATE], indicated Resident #13's cognition was intact for daily decision making and she required total assistance with activities of daily living. The assessment indicated the resident did not receive anticoagulants during the 7 days look back period. Review of the 24-hour initial report dated 8/15/22 revealed on 8/15/22 at 12:44 PM, the facility was made aware of the resident to employee abuse. The law enforcement was notified on 8/15/22 at 1:00 PM. Review of the working 5-day report dated 8/22/22 revealed the incident occurred on 8/14/22 at 10:30 PM. Resident #13 alleged she was physically abused when NA #1 grabbed and squeezed her face. The resident had bruising on her right jawline and right cheek. The report documented on 8/15/22 the administrator received the allegation that NA #1 physically abused Resident #13 when she grabbed and squeezed her face which resulted in bruising to the right side of her face. The resident was assessed by the Director of Nursing (DON) and the assessment indicated the resident had light pink bruising to the right side of her face. The physician was notified of the abuse. The local law enforcement was notified. Resident #13 had also notified the police of this allegation. NA #1 was suspended pending investigation. NA #1 denied the accusation and was unavailable for further interviews during the time of investigation. The report further indicated, after the initial investigation, the administrator and DON wrote an action plan that was reviewed by the Quality Assurance and Performance Improvement (QAPI) committee, which included the facility's medical director. The plan was implemented with the goal to prevent resident abuse. The Administrator provided the following timeline and investigation regarding the incident between NA #1 and Resident #13 on 8/15/22. On 8/14/22 at approximately 6:40 PM. Resident #13 reported to staff NA #1 did not feed her roommate. On 8/14/22 at approximately 6:45 PM the Director of Nursing (DON) investigated the grievance with no concerns noted. On 8/14/22 at some time between approximately 10:45 PM - 11:00 PM, Resident #13 contacted the police and reported abuse. Resident #13 alleged to the police while she was assisted to bed by NA #1, the NA had placed one hand over her mouth and another hand over her throat (in the area where her (surgical) mask was hanging off both ears below her [NAME]) and squeezed her face. On 8/14/22 Resident #13's skin assessment was completed by Nurse #1 with no new findings. NA #1 left the facility; Nurse # 4 asked her to leave at 10:46 PM on 08/14/22. The resident was monitored for any changes by Nurse #4. throughout the duration of the shift (8/14/22, 7:00 PM to 8/15/22, 7:00 AM). No changes were noted. On 8/15/22 at approximately 11:30 AM, Resident #13 reported the allegation to the Administrator. At 11:45 AM, the administrator notified DON about the allegation. On 08/15/22 at approximately 12:00 - 12:30 PM, the DON performed a skin assessment on Resident #13. Assessment revealed discoloration to the right side of face. Assessment indicated an approximately 1-inch light pink straight-line bruise to right jawline and approximately 1/8-inch darker pink dot shaped bruise on right side of face close to the [NAME]. The Administrator notified the Police and Medical Director of this allegation on 8/15/22 at 1:00 PM. On 8/15/23 all staff re-education was initiated on Abuse Reporting, Zero tolerance for Retaliation, Engaging with a Behavioral Resident, Signs of Staff Burnout, Honoring Resident Preferences, (specifically honor what time the resident chooses to go to bed) and Notifying the supervisor when conflicts occur with a resident. Review of the full plan of correction was done on site on 5/11/2023 given by the Administrator and DON. Review of Resident #13's chart revealed a progress note by Nurse #4 dated 8/14/22 when Resident #13 alleged physical abuse by NA #1. Resident #13 alleged NA #1 grabbed her face and neck leaving bruising on her right jaw line and right cheek. An interview was conducted on 5/11/23 at 1:50 PM and Resident # 13 stated she had made an abuse allegation regarding NA #1 sometime last summer. She recalled she had reported NA #1 for not feeding her roommate correctly. Resident #13 further stated NA #1 came to her bed and grabbed and squeezed her face so hard it scared her. She indicated she began screaming for NA #1 to leave her room. She indicated the assigned nurse came to her room when they heard her scream, and then NA #1 left the room. An attempt was made to contact NA #1 on 5/11/23 at 11:30 AM by telephone was unsuccessful, and a voice message was left for NA #1 to return a call. No return call was received. An attempt was made to contact Nurse #1 on 5/11/23 at 11:40 AM by telephone, was unsuccessful, and a voice message was left for Nurse #1 to return a call. No return call was received. During an interview with the DON on 5/11/23 at 2:30 PM, she indicated Resident #13 had a 1-inch light pink straight-line bruise to her right jawline and approximately 1/8-inch darker pink dot shaped bruise on the right side of her face close to the [NAME]. The DON stated NA #1 was suspended at the time of investigation. The NA initially denied the incident and later was unavailable for any interviews. During an interview on 5/11/2023 at 2:30 PM, the Administrator stated the facility has a zero tolerance of abuse. The Administrator further stated NA #1 was terminated from the facility. He expected all residents to be free from abuse and neglect and free from any retaliation. The Administrator indicated that the abuse allegation was substantiated. Plan of Correction from the facility received on 5/26/23: Interventions for affected resident: On 8/14/22 Resident #1 had a skin assessment completed by Licensed Nurse #1 with no findings. The nurse aide left the facility at 10:46 P.M. Licensed Nurse #1 monitored Resident #1 throughout the duration of the shift for any changes with no changes noted on 8/15/22. Resident #1 reported the allegation to the administrator. Administrator notified the Director of Nursing performed skin assessment on Resident #1 with discoloration to right side of face noted. The administrator submitted the facility report intake and nurse aide #1 was suspended pending outcome of investigation. Investigation initiated. Director of Nursing notified the Medical Director and psychiatry. The Director of Nursing obtained a new order for x-ray of Resident #1 right jaw due to bruising Resident #1 educated about risks of sleeping with personal belongings in bed. The administrator reviewed the personnel file for nurse aide #1 to validate background, certifications, and reference checks were performed on hire. Director of Nursing completed an additional certification check on nurse aide #1 to validate no substantiated findings of resident abuse, neglect, or misappropriation in a nursing Facility. Director of Nursing provided one to one education on abuse reporting to Licensed Nurse #1 and nurse aide #2 who were working on the North Hall. Interventions for residents identified as having the potential to be affected: Residents residing on North Hall with a brief interview for mental status of 8 or greater were interviewed by the Social Services Dept. to determine if they had any concerns of abuse. Residents residing on North Hall with a brief interview for mental status of 7 or below had a skin assessment completed to observe for any injury of unknown origin. The Administrator and Director of Nursing were educated by the Corporate Nurse Consultant on abuse reporting per Federal Regulations. The administrator reviewed Grievance Log for the last 90 days to validate any alleged abuse or neglect was properly reported and investigated. The administrator reviewed facility report intakes for the last 12 months to determine if there were other allegations against nurse aide #1. The administrator reviewed Risk Events for the last 90 days to validate any alleged abuse or neglect was properly reported and investigated. The administrator reviewed staffing for 8/14/22. Residents residing in the facility, with a brief interview for mental status of eight or higher, have been educated about the risks of sleeping with personal belongings in bed. Observational Angel Rounds performed for any items in the residents' bed that could be a hazard to sleep with / beside. If any items are noted, the Director of Nursing and Administrator will be notified. Systematic Change: The administrator and Director of Nursing re-educated current staff on Abuse Reporting, zero tolerance for Retaliation, engaging with a Behavioral Resident, Signs of Staff Burnout, and notifying the supervisor if conflicts with a resident occur initiated on 8/15/22. Attestations were signed by trained staff for the verbal education that was provided. Staff indicated they were trained prior to working in the facility for their next shifts. Newly hired staff received an in-service packet prior to working and this was verified by the facility trainers and orientation form. The Administrator and Director of Nursing were educated by the Corporate Nurse Consultant on abuse reporting per Federal Regulations. Social Services Director will interview five staff members per week for twelve weeks to validate staff knowledge of abuse reporting, zero tolerance for retaliation, engaging with a behavioral resident, signs of staff burnout, and notifying the supervisor if conflicts with a resident occur Director of Nursing or Nurse Supervisor will randomly review five skin assessments weekly for twelve weeks to validate there are no unexplained skin conditions are noted. The administrator will review grievances and risk events five times weekly for twelve weeks to validate any allegation of abuse or neglect is reported and investigated timely. The administrator will interview five residents with a brief interview of mental status of eight or greater per week for twelve weeks to inquire if they have felt abused or have witnessed or suspected abuse. During angel rounds once per week for twelve weeks the assigned Department Managers will observe any items in the residents' bed that could be a hazard to sleep. If any items are noted, the Director of Nursing and administrator will be notified. Weekly for twelve weeks the Director of Nursing or social worker will perform observations of staff interactions with three behavioral residents to validate interaction is appropriate. Weekly for twelve weeks the administrator and/or social worker will follow-up with three residents who made grievance reports to validate there was no staff retaliation in response to the grievance. Monitoring of the change to sustain system compliance ongoing: In the monthly Quality Assurance and Performance Improvement Meeting, the Social Worker, Director of Nursing, Department Managers, and administrator will present the findings of the interview audits. The QAPI Committee will review interview audits and make recommendations to assure compliance is maintained ongoing. QAPI Committee will determine the need for further intervention and auditing beyond three months to assure compliance is sustained ongoing. Compliance date: 8/22/2022 The Allegation of Compliance was validated on 5/11/23 when staff interviews revealed they received education on the Abuse policy and procedures, residents' rights to be free from physical abuse and neglect. The education included documentation and reporting to management immediately when they become aware of reported, suspected abuse, and/or injury. Staff were also educated on the assessment and daily checks of residents' skin impairments during personal care, using the body audit form. The body audit form would provide the location of the skin impairment with staff to circle the area on the diagram. The body audits would include measurements and description of the noted area. Nurse's Aides must submit the reports about skin and/or abuse issues daily to the Nurse/Unit Manager immediately. The Nurse would review the body audit daily to be placed in the physician and wound care notebook for further evaluation. The Unit Manager would review the body audit forms weekly to ensure all skin impairments and/or injuries were reviewed by the physician and/or wound care nurse. The report would be submitted to the Director of Nursing and the Administrator. Facility documentation revealed staff were trained on the following topics and additional training: abuse policy and procedures, residents' rights education and interviewing for abuse, nurse notification and assessment, body audit forms and physician notification of injury unknown origin. Attestations related to the abuse training were signed by trained staff for the verbal education that was provided. Staff indicated they were trained prior to working their next shifts. Newly hired staff received an in-service prior to working and this was verified by the facility trainers and orientation form. The facility alleged compliance as of 8/22/22.

Based on physician, nurse practitioner, staff, and emergency medical technician interviews, record review, and observations, the facility failed to follow nursing care plan interventions to avoid extreme heat and to anticipate the needs for one of 3 sampled residents, Resident #1, which resulted in extreme outdoor heat exposure for a duration of 2 hours. Resident #1 fell from his wheelchair onto the outdoor patio, had an altered mental status when he was discovered, and had a body temperature of 104.1 degrees Fahrenheit upon assessment by emergency medical technicians. Resident #1 was admitted to the hospital with [REDACTED]. The Immediate Jeopardy began on 07/22/2017 when Resident Care Specialist (RCS) #1 discovered Resident #1 lying on the courtyard patio near his wheelchair with a pulse rate of 113, a blood pressure of 59/39, and verbally unresponsive. Resident #1 was transported by ambulance to the local hospital where he was admitted for suspected heat stroke. The Immediate Jeopardy was removed on 07/31/2017 at 6:35 PM when the facility provided an acceptable credible allegation of compliance. The facility will remain out of compliance at a scope and severity of no actual harm with the potential of no more than minimal harm that is not immediate jeopardy (D). The facility was in the process of full implementation of corrective action at that time. Findings included: Resident #1 was initially admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the quarterly minimum data set (MDS) assessment dated [DATE] revealed Resident #1 had long term and short term memory problems and had moderate impairment with cognitive skills for daily decision making. Resident #1 also had behaviors of rejection of care present 1 to 3 days during the assessment look back period, and that he was independent with locomotion both on and off the unit. The same MDS assessment indicated he did not use a prosthesis. Extensive assistance was required for transfers and personal hygiene, and Resident #1 used a wheelchair for his mobility. His partial list of [DIAGNOSES REDACTED]. The nursing care plan for Resident #1, initiated on 01/18/2017 and last revised on 07/05/2017, revealed a problem of diabetes mellitus with a goal to be free of signs and symptoms of [MEDICAL CONDITION]. An intervention to reach this goal was, Avoid exposure to extreme heat or cold. Further review of the nursing care plan revealed on 02/27/2017, a problem of high risk for falls was added with a goal for Resident #1 to be free of falls through the review date. One of the interventions to achieve this goal was, Anticipate and meet the resident's needs. On 06/21/2017, a behavior problem of refusing to come inside out of the sun/refusing to wear sunscreen was added. The goal related to this problem was that there would be fewer episodes of refusing to come in out of the sun. One intervention included, Anticipate and meet the resident's needs. Another was, Allow the resident to make choices within the individual's decision making abilities. A nurse's note of 07/22/17 at 2:18 PM indicated Resident #1 was found lying on the ground in the courtyard on his back, and that his blood pressure assessed at the time was 59/39, his pulse was 113, and his temperature was 100.9. A situation/background/assessment/recommendation (SBAR) note dated 07/22/17 revealed Resident #1 was found lying on his back beside his wheelchair in the courtyard, and that the resident was unable to say what was happening. The note indicated that since the incident happened, the situation had gotten worse, and that he was unresponsive for his mental status. The resident was transferred to the hospital and the resident's primary care clinician was notified at 1:40 PM. The resident's guardian was notified at 2:00 PM. Review of the facility's courtyard/patio camera footage dated 7/22/17 revealed the following: On 07/22/2017 at 11:13 AM, Resident #1 was seen independently entering the enclosed courtyard area via the facility's door on the north side of the building. He navigated in his wheelchair about the courtyard on the sidewalk and on the patio by propelling himself with his left leg. There was partial shade in the courtyard from a tree located on the side of the courtyard closer to the south side of the building. Outdoor tables were located on the part of the patio closest to the door on the north side of building. Resident #1 navigated to one of the tables in the sun and sat in his wheelchair. By 12:00 noon on 07/22/2017, the resident had navigated himself to another table on the patio which was in partial sun. A staff member was seen entering the patio from the north entrance door at this time and approaching the resident, talking with him, and then exiting the patio area via the north door. There were no other staff members seen in the courtyard until 12:20 PM when a staff member was seen at a vending machine which was located at the entrance to the courtyard area. This staff member did not approach the resident or speak with him. At 12:48 PM, Resident #1 navigated to another table in the courtyard that was in partial shade. There were no staff members seen in the courtyard other than the staff member who came outside at 12:00 noon and the staff member who accessed the vending machine at 12:20 PM. No one was seen providing fluids to Resident #1 to drink between 11:13 AM and 1:14 PM. At 1:14 PM, Resident #1 was seen falling out of his wheelchair onto the patio. No further movement was noted . At 1:17 PM, a staff member was seen entering the courtyard with a male (identified as a visitor) and finding Resident #1 lying on the patio. The staff member stooped down to the resident, then stood and pointed to the south side of the building. The visitor was seen pulling the patio table away from the resident and walking back into the building. The staff member remained with the resident. Another staff member entered the patio at 1:18 PM. At 1:22 PM, a third staff member entered the courtyard with a vital signs monitor. At 1:30 PM, paramedics were seen entering the courtyard. (The camera angle did not allow a view of the resident's response to any treatment or stimulation by staff or paramedics.) The weather conditions per Weather Underground on 07/22/2017 at 12:54 PM for the facility's location was 93.9 degrees Fahrenheit with a heat index of 102.1 degrees. A review of the Emergency Medical Services (EMS) Report dated 07/22/2017 revealed the Emergency Medical Technicians (EMTs) arrived at the facility at 1:42 PM on 07/22/2017, and at 1:46 PM, the EMTs determined Resident #1 was in sinus [MEDICAL CONDITION] At 1:52 PM, the EMTs assessed Resident #1's temperature to be 104.2, and intravenous fluids were administered at 1:57 PM. The text on the report indicated the EMTs removed Resident #1's clothing to assist in cooling him, and at 1:59, a cold wet towel was placed on the resident's chest and abdomen, and ice packs were placed under the axilla (under arms.) The resident was transported at 1:58 PM to the hospital. The hospital discharge summary dated 7/24/17 revealed the primary [DIAGNOSES REDACTED]. Under this diagnosis, the summary indicated resident was admitted for suspected heat stroke, and that due to leukocytosis, fever, and elevated lactic acid, the resident was started on IV antibiotics. The suspected reason [MEDICAL CONDITION] was aspiration. His blood cultures were negative for bacteria, and his urinalysis dated 7/23/2017 showed no bacteria. The second [DIAGNOSES REDACTED].) The seventh [DIAGNOSES REDACTED]. The resident was hospitalized from [DATE] until his discharge on 7/24/17 and he was prescribed [MEDICATION NAME] (an antibiotic), one tablet by mouth twice per day per the discharge medication list. In an interview with resident care specialist (RCS) #1 on 07/27/2017 at 9:38 AM, she stated she was the RCS assigned to care for Resident #1 during the 7:00 AM to 3:00 PM shift on 07/22/2017, when the courtyard incident occurred, but she was not present when the incident occurred. RCS #1 stated she reviewed the care card (Kardex) for residents if they were new or she was not familiar with them in order to know what to do for them. She added that she knew Resident #1 and there was no need to refer to his care card and she knew he wore sunscreen daily. RCS #1 stated she provided morning care to Resident #1 after breakfast on 7/22/2017, then transferred him to his wheelchair and rolled him into the hall near the nurse's station on the south side of the building. She explained she then provided care for her other assigned residents, then checked on Resident #1 again. At that time (not sure of the exact time of day) she did not see Resident #1 in the hallway but later noted he was outside. RCS #1 stated that Resident #1 typically did not talk much, but he seemed to understand what people said to him and that he was able to feed himself. He was also able to get around the facility very well in his wheelchair by scooting himself with his feet and he enjoyed sitting outside. RCS #1 added that he was able to navigate to the courtyard whenever he wanted, and she had a concern for him the day of the incident because it was so hot. She said she saw him outside; however he generally rejected care, and she did not know how to deal with him when he refused offers to come inside. She stated she reported to the nurse that he was outside during the morning hours on 07/22/2017, but she was not sure what time she reported it. In a telephone interview on 07/27/2017 at 10:12 AM with Nurse #1 who was assigned to care for Resident #1 during the 7:00 AM to 3:00 PM shift on 07/27/2017, she stated she worked for a staffing agency and had cared for Resident #1 in the past and was familiar with his behavior. Nurse #1 explained she provided the resident his medications about 8:00 AM on 7/22/17, and that the next time she saw him was around 12:00 noon. She explained she did not recall RCS #1 reporting to her the resident was outside. She added she had to look for him and was unable to find him in his room, the dining room or lobby, but she found him outside in the courtyard at 12:00 noon. Nurse #1 indicated she needed to check his capillary blood glucose level (by finger stick) at that time to determine his sliding scale insulin dose. She stated Resident #1 refused to have his blood glucose level checked, saying, No, no, no, and that he also refused to come inside when she offered him his lunch, so she left Resident #1 outside and decided to check on him again later, although she said she never did. Nurse #1 stated about an hour later, someone summoned her to the courtyard (could not remember who it was) and she found 2 other staff members on the patio assessing Resident #1 who was lying on the patio and appeared unresponsive. She stated she immediately got her supervisor while the 2 staff members remained with the resident. On 7/27/2017 at 11:40 AM, an interview was conducted with the nurse practitioner (NP) who was on call on Saturday, 7/22/17 when Resident #1 was found on the ground on the courtyard patio. The NP stated she would expect the staff to bring the resident inside on a hot day and that she thought he was care planned for his refusals to come inside out of the sun. She explained that Resident #1 at times rejected care, but it was not very often. She stated the challenge was knowing how to deal with his refusals to come inside. The NP explained that it was sometimes necessary to be creative and act as a parent when a resident refused care or were unable to make appropriate decisions for their own well-being. The NP suggested that offering a cool drink or a snack might be used to coax the resident inside. In an interview with Resident #1's physician on 07/27/2017 at 12:00 PM, she stated she would not want the resident to stay outside for any length of time without hydration and she would expect staff to check on him every 30 minutes to an hour in order to meet his needs. In an interview with RCS #2 on 7/27/2017, she stated she was the staff member who discovered Resident #1 was in the courtyard lying on the patio on 07/22/2017 when a visitor alerted her about it. She stated Resident #1 was not assigned to her care on 07/22/2017, but she was familiar with him because she had cared for him the previous week, RCS #2 added she knew he had often enjoyed being outside. She also indicated that she knew how to care for her assigned residents by referring to the care plan. She stated when she found Resident #1 outside, she checked his radial pulse, then his carotid pulse, and it was very faint and weak. She told the visitor to go inside to get a nurse, and a short time later, a nurse and another nurse aide came with a vital signs monitor. RCS #2 stated she was unable to get a blood pressure reading on his left arm, so she removed the blood pressure cuff and applied it to his right arm below the elbow to palpate his blood pressure and it was 59/39. She explained that Resident #1 was not responding to her verbal stimulation. On 7/27/17 at 3:25 PM, an interview was conducted with the Director of Nursing (DON), the Assistant Director of Nursing (ADON), and the District Director of Clinical Services (DDCS.) The DDCS stated Resident #1 was on the ground in the courtyard for about 3 minutes before he was discovered by staff. The DON, the ADON, and the DDCS reviewed Resident #1's nursing care plan and acknowledged the staff did not follow the intervention put in place to avoid extreme heat or cold, and did not anticipate and meet the needs of the resident related to his problem of refusing to come inside out of the sun by allowing him to remain in the facility's outdoor courtyard area for a two hour period. She acknowledged he was not provided any hydration according per camera footage. On 07/31/2017 at 11:30 AM, an interview was conducted with MDS Nurse #1 and MDS Nurse #2. MDS Nurse #1 stated that there were clinical meetings held each weekday to discuss any acute episodes that have taken place with the residents, and that on Mondays, they would discuss any acute episodes that had taken place over the weekend. She stated the interdisciplinary team updated care plans on a daily basis depending on acute events that had taken place, and that the unit managers were responsible for updating the information on the Kardex and for communicating the new information to the nurses and resident care specialists. MDS Nurse #1 explained that if the unit managers were not present, then the MDS nurse was responsible for the communication, so all nursing staff should be aware of interventions in place for the resident. MDS #1 acknowledged that there was an intervention on Resident #1's care plan for him to avoid extreme heat and cold, as well as interventions to anticipate and meet the resident's needs, and to allow the resident to make choices within his decision making abilities. She also acknowledged that the resident was at risk for falls with a goal to be free of falls through the next review date, and that it also included an intervention to anticipate and meet the resident's needs. MDS Nurse #1 did not offer a reason why staff did not follow the care plan. The DDCS (present during the absence of the Administrator), the DON, and the ADON were notified of Immediate Jeopardy on 07/28/2017 at 12:25 PM. On 07/31/17 at 6:35 PM, the facility provided a credible allegation as follows: 1. The alleged Resident was admitted to Fisher Park HR on 1/20/2004 with primary [DIAGNOSES REDACTED]. On 7/22/17 at 1:14pm, resident fell out of wheelchair in the enclosed courtyard (per courtyard video camera). A certified Nursing Assistant went to the facility enclosed courtyard at 1:17pm (per courtyard video camera) after being alerted by a visitor that a resident was on the ground in the courtyard. The Nursing Assistant immediately responded and went to the courtyard. The certified Nursing Assistant determined that the resident had a pulse and was breathing but that the resident seemed to have a decrease level of consciousness. The Nursing Assistant stayed with the resident and summoned for assistance. The licensed nurse immediately responded. The nurse's initial assessment revealed and recorded Vital signs of Temperature of 100.9, pulse 113, BP 59/39. 911 was called by the licensed nursing staff and based on the camera video footage, EMS arrived at 1:30 pm. The resident's temperature was recorded by EMS of 104.2. The resident was transported to the hospital and subsequently admitted with a [DIAGNOSES REDACTED]. Additional [DIAGNOSES REDACTED]. The responsible party was notified at approximately 2:00pm. The resident returned to the facility on [DATE] with active problems [MEDICAL CONDITION], (HCC) Type 2 diabetes mellitus with neurological manifestations, Dementia without behavioral disturbance, [MEDICAL CONDITION] of multiple sites, and leukocytosis. The resident was admitted for suspected heat stroke as he presented with fever and had been outside for a 2-hour period prior. Due to the leukocytosis, fever, elevated lactic acid, he was started on IV antibiotics for suspected aspiration and then changed to [MEDICATION NAME]. A repeat chest x ray for suspected aspiration showed no active disease. Resident was treated with IV fluids for hydration, BP improved and discharge exam from hospital show BP was 134/47. The resident has not been as interested in sitting in the courtyard since return to the facility, but he is tolerating being in wheelchair short period of times. The resident was re- assessed using the BIMS (Brief Interview for Mental Status) assessment tool on 7/28/17; his scoring was 0- severe impairment. Based on the BIMS score, the resident care plans were revised by the MDS coordinator on 7/31/17 to include providing supervision when in the courtyard. Resident also has been provided a hat for courtyard use. The diabetic Mellitus and Impaired Cognitive function / dementia care plan was revised on 7/31/17 by the MDS coordinator. The MDS coordinator implemented a resident care plan for at risk for heat exhaustion on 7/31/17. The licensed nurse assigned to the resident on 7/22/17 no longer works at the facility. The certified nursing assistant assigned to the resident on 7/22/17 at the time of the incident was provided one on one re- education regarding sign and symptoms of heat exhaustion to include sweating, fatigue, headache, pale clammy skin, thirst, rapid heartbeat, dizziness, [MEDICAL CONDITION], nausea, vomiting, muscle and abdominal cramps, temperature elevation, and weakness and contact nursing staff if symptoms occur. The nursing assistant education also included offering hydration to residents that are outside more than thirty minutes by district director of clinical services on 7/31/17. 2. It was determined on 7/26/17 during an IDT ADHOC QAPI meeting that the resident had been assessed and identified with severely impaired cognition based on BIMS assessment on 11/22/16. During staff interviews on 7/24/17 it was identified that the resident routinely went to the court yard unsupervised and refused to come inside for extensive periods of time. After review of the resident care plans, the investigation of alleged event and staff interviews it was identified that the facility had failed to follow resident care plans as relates to a. Diabetic Mellitus care plans stated to avoid extreme heat or cold b. Impaired cognitive function/dementia or impaired thought processes related to determine residents needs and supervision as needed c. The care plan goal related to resident's behavior problem of refusing to come inside out of the sun and will not wear sunscreen - intervention of anticipate and meet the resident's needs (initiated 6/21/17) The facility MDS coordinator initiated an audit of the facility residents care plans to ensure that each residents identified with desire to sit in the enclosed court yard was care planned for at risk for heat exhaustion on 7/31/17 3. The facility staff (nursing, housekeeping and administrative staff) will be provided education regarding the risk of heat exhaustion for facility residents that are outside in the enclosed courtyard. This education included recognizing signs and symptoms of heat exhaustion to include sweating, fatigue, headache, pale clammy skin, thirst, rapid heartbeat, dizziness, [MEDICAL CONDITION], nausea, vomiting, muscle and abdominal cramps, elevated temperatures, and weakens and contact nursing staff if symptoms are observed. The education also included basic supervision and knowing where assigned residents are. The education will include assessing the residents in the court yard every thirty minutes for signs and symptoms of heat exhaustion and document on the courtyard monitoring tool and offering fluids appropriate hydration. The education was initiated on 7/30/17 and will be completed on 7/31/17 by the assistant director of nursing. Staff members who have not received the education will not work until they complete the education to include agency staff. The facility staff (nursing, housekeeping and administrative staff, agency staff) were provided education to refer to the resident care card to ensure that resident identified with desire to sit outsider care plan are being followed on 7/31/17 by Assisted Director of Nursing . The facility newly admitted or readmitted residents that are identified with desire to sit outside in the enclosed courtyard will be care planned for at risk for heat exhaustion by MDS coordinator. The resident care card will be updated to reflect care plans for resident at risk for heat exhaustion. On 7/31/17 at 7:45 PM, validation of the credible allegation was evidenced via interviews with nurses, resident care specialists, residents, and unit supervisors who stated they received in-service education regarding the importance of providing supervision and fluids to residents who are outside on a hot day, and the signs of heat exhaustion. Each staff member interviewed was able to names signs of heat exhaustion and demonstrated they knew to follow the resident's care plans. An observation of the facility's door to the courtyard area revealed a keypad was in place, and an alarm sounded when the door was opened. There were no residents observed in the courtyard area at the time of validation of the credible allegation.

Based on physician, nurse practitioner, staff, and emergency medical technician interviews, record review, and observations, the facility failed to provide supervision and hydration for 1 of 3 residents, Resident #1, which resulted in extreme outdoor heat exposure for a duration of 2 hours. Resident #1 fell from his wheelchair onto the outdoor patio, had an altered mental status when he was discovered, and had a body temperature of 104.1 degrees Fahrenheit upon assessment by emergency medical technicians. Resident #1 was admitted to the hospital with [REDACTED]. The Immediate Jeopardy began on 07/22/2017 when Resident Care Specialist (RCS) #1 discovered Resident #1 lying on the courtyard patio near his wheelchair with a pulse rate of 113, a blood pressure of 59/39, and was verbally unresponsive. Resident #1 was transported by ambulance to the local hospital where he was admitted for suspected heat stroke. The Immediate Jeopardy was removed on 07/31/2017 at 6:35 PM when the facility provided an acceptable credible allegation of compliance. The facility will remain out of compliance at a scope and severity of no actual harm with the potential of no more than minimal harm that is not immediate jeopardy (D). The facility was in the process of full implementation of corrective action at that time. Findings included: Resident #1 was initially admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the quarterly minimum data set (MDS) assessment dated [DATE] revealed Resident #1 had long term and short term memory problems and had had moderate impairment with cognitive skills for daily decision making. Resident #1 also had behaviors of rejection of care present 1 to 3 days during the assessment look back period, and that he was independent with locomotion both on and off the unit. The same MDS assessment indicated he did not use a prosthesis. Extensive assistance was required for transfers, personal hygiene, toilet use, and dressing, and Resident #1 used a wheelchair for his mobility. His partial list of [DIAGNOSES REDACTED]. The nursing care plan for Resident #1, initiated on 01/18/2017 and last revised on 07/05/2017, indicated Resident #1 had diabetes mellitus with a goal to be free of signs and symptoms of hyperglycemia. An intervention to reach this goal was for the resident to avoid extreme heat or cold. Further review of the nursing care plan revealed on 02/27/2017 another problem was added on 02/27/2017 for high risk for falls related to confusion, [DIAGNOSES REDACTED], poor communication/comprehension, and unawareness of safety needs. One of the interventions to address this problem was Anticipate and meet the resident's needs. On 06/21/2017 a behavior problem of refusing to come inside out of the sun/refusing to wear sunscreen was added. The goal was that there would be fewer episodes of refusing to come in out of the sun, and one intervention included, Anticipate and meet the resident's needs. Another was to allow the resident to make choices within the resident's decision making abilities. Review of the facility's courtyard/patio camera footage dated 7/22/17 revealed the following: On 07/22/2017 at 11:13 AM, Resident #1 was seen entering the enclosed courtyard area via the facility's door on the north side of the building. He navigated in his wheelchair about the courtyard on the sidewalk and on the patio by propelling himself with his left leg. There was partial shade in the courtyard from a tree located on the side of the courtyard closer to the south side of the building. Outdoor tables were located on the part of the patio closest to the door on the north side of building. Resident #1 navigated to one of the tables in the sun and sat in his wheelchair. By 12:00 noon on 07/22/2017, the resident had navigated himself to another table on the patio which was in partial sun. A staff member was seen entering the patio from the north entrance door at this time and approaching the resident, talking with him, and then exiting the patio area via the north door. There were no other staff members seen in the courtyard until 12:20 PM when a staff member was seen at the vending machine which was located at the entrance to the courtyard area. This staff member did not approach the resident or speak with him. At 12:48 PM, Resident #1 navigated to another table in the courtyard that was in partial shade. There were no staff members seen in the courtyard other than the staff member at 12:00 noon and the staff member who did not check on the resident at 12:20 PM. No one was seen providing fluids to Resident #1 to drink between 11:13 AM and 1:14 PM. At 1:14 PM, Resident #1 was seen falling out of his wheelchair onto the patio. No further movement was noted. At 1:17 PM, a staff member was seen entering the courtyard with a male (identified as a visitor) and finding Resident #1 lying on the patio. The staff member stooped down to the resident, then stood and pointed to the south side of the building. The visitor was seen pulling the patio table away from the resident and walking back into the building. The staff member remained with the resident. Another staff member entered the patio at 1:18 PM. At 1:22 PM, a third staff member entered the courtyard with a vital signs monitor. At 1:30 PM, paramedics were seen entering the courtyard. (The camera angle did not allow a view of the resident's response to any treatment or stimulation by staff or paramedics.) A nurse's note of 07/22/2017 at 2:18 PM indicated Resident #1 was found lying on the ground in the courtyard on his back, and that his blood pressure assessed at the time was 59/39, his pulse was 113, and his temperature was 100.9. A situation/background/assessment/recommendation (SBAR) note dated 07/22/2017 revealed Resident #1 was found lying on his back beside his wheelchair in the courtyard, and that the resident was unable to say what was happening. The note indicated that since the incident happened, the situation had gotten worse, and that he was unresponsive for his mental status. The resident was transferred to the hospital and the resident's primary care clinician was notified at 1:40 PM. The resident's guardian was notified at 2:00 PM. The weather conditions per Weather Underground on 07/22/2017 at 12:54 PM for the facility's location was 93.9 degrees Fahrenheit with a heat index of 102.1 degrees. A review of the Emergency Medical Services (EMS) Report dated0 7/22/2017 revealed the emergency medical Technicians (EMTs) arrived at the facility at 1:42 PM on 07/22/2017, and at 1:46 PM, the EMTs determined Resident #1 was in sinus tachycardia. At 1:52 PM, the EMTs assessed Resident #1's temperature to be 104.2, and intravenous fluids were administered at 1:57 PM. The text on the report indicated the EMTs removed Resident #1's clothing to assist in cooling him, and at 1:59, a cold wet towel was placed on the resident's chest and abdomen, and ice packs were placed under the axilla (under arms.) In an interview with the resident care specialist (RCS) #1 on 07/27/2017 at 9:38 AM, she stated she was the RCS assigned to care for Resident #1 on 07/22/2017 when the courtyard incident occurred. RCS #1 explained she did not discover the resident on the ground on 7/22/17. RCS #1 stated she provided morning care to Resident #1 after breakfast on 7/22/2017, then transferred him to his wheelchair and rolled him into the hall near the nurse's station on the south side of the building. She explained she then provided care for her other assigned residents, then checked on Resident #1 again. At that time (not sure of the exact time of day) she did not see Resident #1 in the hallway but later noted he was outside. She stated that the resident typically did not talk much, but he seemed to understand what people said to him and that he was able to feed himself. He was also able to get around the facility very well in his wheelchair by scooting himself with his feet. RCS #1 indicated she could not remember what time it was, but she observed staff members go into the courtyard. She stated it was another RCS (RCS #2) who first found Resident #1 on the ground. RCS #1 added that when she went into the courtyard after he had been discovered, she observed the resident's left arm was blue below the blood pressure cuff when RCS #2 was trying to take his blood pressure. In a telephone interview with Nurse #1 who was assigned to care for Resident #1 on 07/27/2017 at 10:12 AM, she stated she worked for a staffing agency and had cared for Resident #1 in the past and was familiar with his behavior. Nurse #1 explained she provided the resident his medications about 8:00 AM on 7/22/17, and that the next time she saw him was around 12:00 noon. She stated she had to look for him and was unable to find him in his room, the dining room or lobby, but she found him outside in the courtyard at 12:00 noon. Nurse #1 indicated she needed to check his capillary blood glucose level (by finger stick) at that time to determine his sliding scale insulin dose. She stated Resident #1 refused to have his blood glucose level checked, and that he also refused to come inside when she offered him his lunch, so she left Resident #1 outside. Nurse #1 stated about an hour later, someone summoned her to the courtyard. (Could not remember who it was.) She stated he was found on the ground in the courtyard by another staff member, but she could not recall who that staff member was. In addition, Nurse #1 said other nurse aides and nurses were with the resident assessing him, so she got her unit supervisor who helped prepare the resident for a transfer to the hospital. She stated she thought she was the one who called 911 and the nurse practitioner, but was not sure. An interview was conducted with RCS #2 on0 7/27/2017 at 12:54 PM. RCS #2 stated she was the first staff member to find Resident #1 on the ground on the courtyard patio on 7/22/17. She explained that a man who was a visitor came to her and reported he saw a resident on the ground beside his wheelchair in the courtyard, so she ran outside. RCS #2 stated she stooped down and checked Resident #1's radial pulse which was weak and fast, and she then checked for his carotid pulse which was also faint. She did not know the exact pulse rate at that time because she did not have the vital sign monitor. The resident's head was was under the table and he was mentally out per her description. She explained she could see his chest rising and falling and the resident's skin was red. RCS #2 said she asked the visitor to run inside to get the resident's nurse and that the nurse came outside shortly thereafter. Another nurse aide brought the vital signs monitor out to the courtyard, and she (RCS #2) measured his vital signs. She stated at first she was unable to get a blood pressure reading in the resident's left arm, so she removed the blood pressure cuff and placed it on his right arm below the elbow to take his blood pressure. (The resident's right arm was partially drawn at the elbow due to hemiparesis.) RCS #2 stated his arm turned purple below the cuff, but she was able to get a blood pressure reading by palpation and it was very low. RCS #2 added she could not remember the exact blood pressure reading and had no recollection of times when she entered the courtyard or when other staff members arrived, but that she stayed with the resident until paramedics arrived to take care of Resident #1. RCS #2 also stated she had observed Resident #1 fall asleep in his wheelchair outside the day before, but no one knew for certain how the resident had fallen out of his wheelchair on 07/22/2017. In an interview with the unit supervisor (US) on 07/27/2017 at 1:11 PM, she explained she was passing medications to residents when she was called to the courtyard STAT (immediately) on 7/22/17. She found Resident #1 on the ground and there were 2 nurses already present with him from the facility's south wing, as well as a nurse aide. She explained she bent down over the resident and called his name, and the resident opened his eyes, then closed them, but did not respond verbally. The US also stated the nurse aide and one of the nurses were reattempting to get the resident's vital signs. She added that one of the nurses from the staffing agency called 911 and that she herself called the nurse practitioner who was on call for the physician. An order was obtained to transport the resident to the hospital. The US was not certain of the time when she entered the courtyard area, but once she was out there, the EMS came within 5 or 6 minutes. The nurse practitioner (NP) who was notified about the resident's courtyard incident was interviewed on 07/27/2017 at 11:40 AM. The NP stated the facility called 911 before contacting her and that she provided the order to send the Resident #1 to the hospital. The NP also indicated she felt there was no long term negative impact on the resident's health after he had been exposed to the hot weather for a few hours. She stated that ideally she would expect the staff to bring the resident inside on a hot day and that staff needed to provide fluids for the resident to keep him hydrated. The NP did not provide a length of time Resident #1 should have been able to stay outside on a hot day. In an interview with Resident #1's physician on 07/27/2017 at 12:00 noon, she explained she was on vacation when Resident #1 was found on the ground outside, so the facility notified the nurse practitioner who was on call. The physician stated she learned of the incident after returning from her vacation on 7/26/17 and that she had read the emergency department report. In addition, she stated she would not want the resident to stay outside any length of time on a hot day without hydration, and that the resident may not have had the ability to make an appropriate decision to come inside. The physician stated she would expect for the resident to be checked every 30 minutes to one hour. She added that heat would affect individuals in different ways depending on physical condition and that Resident #1 commonly sat outside. On 07/27/2017 at 3:25 PM, and interview was conducted with the Director of Nursing (DON), the Assistant Director of Nursing (ADON), and the District Director of Clinical Services (DDCS.) The DDCS stated Resident #1 was on the ground in the courtyard for about 3 minutes before he was discovered by staff. The DON stated she did an investigation of the incident and that she felt the resident's temperature of 104 was incorrect, that the facility recorded his temperature to be 100.9, and that the EMS had a temperature of 101. The DON stated there were no recorded temperatures higher than 101 for Resident #1. The DON added that she felt the resident had sepsis and that was the reason for his elevated temperature on 7/22/17. The DDCS added that staff had been educated about checking on residents who are outside more often and that the facility had placed a magnetic feature on the door to the courtyard so that an alarm would sound 24 hours a day whenever a resident entered the courtyard. She explained that the alarm would encourage staff to check the courtyard for a resident and the alarm would have to be reset by a staff member. In addition, the DDCS stated that the dietary department was now keeping a cooler of water with cups in the courtyard for residents to receive fluids when the temperatures were warm. She stated she was not sure that Resident #1 would be able to help himself to the water in the cooler. A follow up interview was conducted with RCS #2 on 07/28/2017 at 4:49 PM. RCS #2 stated she thought she had her cell phone with her on 7/22/17 when she found Resident #1 lying in the courtyard outside, but she stated she did not call 911 because she wasn't certain of the protocol was for calling emergency services. On 7/31/2017 at 2:02 PM a telephone interview was completed with EMT #1 who was the lead paramedic who responded to the courtyard incident for Resident #1 on 7/22/17. EMT #1 stated he did check the resident's temperature and it was 104.1 degrees and he recorded it on the EMS report. He added that a facility staff member was with the resident, and that fire department personnel had arrived just before he did. Upon his assessment, Resident #1 was not verbally responsive but his eyes were open. He stated the resident was unaware of his presence. EMT #1 reported he administered intravenous (IV) fluids and placed ice packs under the arms and around the groin area to help reduce Resident #1's elevated body temperature. The hospital discharge summary dated 7/24/17 revealed the primary [DIAGNOSES REDACTED]. Under this diagnosis, the summary indicated resident was admitted for suspected heat stroke, and that due to leukocytosis, fever, and elevated lactic acid, the resident was started on IV antibiotics. The suspected reason for sepsis was aspiration. His blood cultures were negative for bacteria, and his urinalysis dated 7/23/2017 showed no bacteria. The second [DIAGNOSES REDACTED].) The seventh [DIAGNOSES REDACTED]. The resident was hospitalized from [DATE] until his discharge on 7/24/17 and he was prescribed Augmentin (an antibiotic), one tablet by mouth twice per day per the discharge medication list. The DDCS (present during the absence of the Administrator), the DON, and the ADON were notified of Immediate Jeopardy on 07/28/2017 at 12:25 PM. On 07/31/17 at 6:35 PM, the facility provided a credible allegation as follows: 1. The alleged Resident was admitted to Fisher Park HR on 1/20/2004 with primary [DIAGNOSES REDACTED]. On 7/22/17 at 1:14pm, resident fell out of wheelchair in the enclosed courtyard (per courtyard video camera). A certified Nursing Assistant went to the facility enclosed courtyard at 1:17 pm (per courtyard video camera) after being alerted by a visitor that a resident was on the ground in the courtyard. The Nursing Assistant immediately responded and went to the courtyard. The certified Nursing Assistant determined that the resident had a pulse and was breathing but that the resident seemed to have a decrease level of consciousness. The Nursing Assistant stayed with the resident and summoned for assistance. The licensed nurse immediately responded. The nurse's initial assessment revealed and recorded Vital signs of Temperature of 100.9, pulse 113, BP 59/39. 911 was called by the licensed nursing staff and based on the camera video footage, EMS arrived at 1:30 pm. The resident was transported to the hospital and subsequently admitted with a [DIAGNOSES REDACTED]. The nurse practitioner on call was notified of 911 being notified and of the event around 1:40 pm. The responsible party was notified at approximately 2:00pm. The resident returned to the facility on [DATE] with active problems of sepsis, (HCC) Type 2 diabetes mellitus with neurological manifestations, Dementia without behavioral disturbance, Dermatitis of multiple sites, and leukocytosis. The resident was admitted for suspected heat stroke as he presented with fever and had been outside for a 2 hour period prior. Due to the leukocytosis, fever, elevated lactic acid, he was started on IV antibiotics for suspected aspiration and then changed to Augmentin. Additional [DIAGNOSES REDACTED]. A repeat chest x ray for suspected aspiration showed no active disease. Resident was treated with IV fluids hydration, BP improved and discharge exam from hospital show BP was 134/47. The resident has not been as interested in sitting in the courtyard since return to the facility, but he is tolerating being in wheelchair short period of times. The resident was re- assessed using the BIMS (Brief Interview for Mental Status) assessment tool on 7/28/17, his scoring was 0- severe impairment. Based on the BIMS score, the resident care plans were revised by the MDS coordinator on 7/31/17 to include providing supervision when in the courtyard. Resident also has been provided a hat for courtyard use. The licensed nurse assigned to the resident on 7/22/17 no longer works at the facility. The certified nursing assistant assigned to the resident on 7/22/17 at the time of the incident was provided one on one re- education regarding sign and symptoms of heat exhaustion to include sweating, fatigue, headache, pale clammy skin, thirst, rapid heartbeat, dizziness, fainting, nausea, vomiting, muscle and abdominal cramps, temperature elevation, and weakness and contact nursing staff if symptoms occur. The nursing assistant education also included offering hydration to residents that are outside more than thirty minutes by district director of clinical services on 7/31/17. 2. It was determined on 7/26/17 during an IDT ADHOC QAPI meeting that the resident had been assessed and identified as severely impaired based on BIMS assessment on 11/22/16. During staff interviews on 7/24/17 it was identified that the resident routinely went to the court yard unsupervised and refused to come inside for extensive periods of time. After review of the medical record, the investigation of alleged event and staff interviews it was identified that the facility had failed to provide. a. Supervision when residents are in the court yard to ensure that residents are not showing signs and symptoms of heat exhaustion/ dehydration. b. Hydration cart, that included water and electrolyte fluids when outside in enclosed count yard c. Education to staff, residents and responsibly/facility visitors regarding signs of heat stroke and/or dehydration. d. The enclosed court yard entrance was rekeyed so that the alarm will sound at any time, 24 hours a day, unless the code is entered into the keypad. The code is provided to all staff members. Any resident may exit through the door to the courtyard, but an alarm will sound, and a staff member will need to silence the alarm by entering the code. There have been no other residents that presented with signs and symptoms of heat exhaustion based on the review of the monitoring tools that have been in place since 7/24/17. The facility implemented a plan to address each item that was identified during the ADHOC QAPI meeting on 7/26/17 Hydration cart with water was placed outside in enclosed courtyard on 7/24/by dietary staff. Beverages with electrolytes have been added as of 7/31/17. The facility Dietary staff was provided education regarding keeping water and electrolyte fluid in the cooler 7/31/17 by the dietary manager. The dietary staff received education regarding replenishing process of the fluids to include check before breakfast, after lunch and dinner daily. The facility posted an information sheet regarding signs and symptoms of heat exhaustion at the door in the enclosed court yard on 7/31/17 by director of Nursing The facility interviewable residents will be provided education regarding sign and symptoms of heat exhaustion to include:sweating, fatigue, headache, pale clammy skin, thirst, rapid heartbeat, dizziness, fainting, nausea, vomiting, muscle and abdominal cramps, temperature elevation, and weakness. If symptoms occur staff is to contact license nursing staff. The facility interviewable residents will be educated on using the hydration cart while sitting in courtyard with recommendations to drink electrolyte fluids from the hydration cart if they are outside greater than 2 hours. The education provided to the residents was completed on 7/31/17 by MDS coordinator on 7/31/17. The facility staff (including, nursing, housekeeping and administrative) will be provided education regarding signs and symptoms of heat exhaustion to include sweating, fatigue, headache, pale clammy skin, thirst, rapid heartbeat, dizziness, fainting, nausea, vomiting, muscle and abdominal cramps, temperature elevation, and weakens and contact nursing staff if symptoms are observed. The education also included basic supervision and knowing where assigned residents are. The education will include assessing the residents in the court yard every thirty minutes for signs and symptoms of heat exhaustion and document on the courtyard monitoring tool and offering fluids appropriate hydration. The education was initiated on 7/30/17 and will be completed on 7/31/17 by the assistant director of nursing. Staff members who have not received the education will not work until they complete the education to include agency staff. A facility staff member will provide 30 minute checks in the courtyard and document on the courtyard monitoring tool. A facility staff member will be assigned daily by the Director of Nursing. The enclosed court yard entrance was rekeyed so that the alarm will sound at any time, 24 hours a day, unless the code is entered into the keypad. The code is provided to all staff members. Any resident may exit through the door to the courtyard, but an alarm will sound, and a staff member will need to silence the alarm by entering the code. 3. The door alarm for the door that entrances the court yard will be checked daily by director of maintenance and /or manager of duty to ensure that the door alarms when opened. Daily for thirty days. An Information sheet was posted on the door that enters the enclosed court yard regarding the signs and symptoms of heat exhaustion and steps to take to avoid heat exhaustion to include hydration and notify the nursing staff if signs and symptoms occur. On 7/31/17 at 7:45 PM, validation of the credible allegation was evidenced via interviews with nurses, resident care specialists, residents, and unit supervisors who stated they received in-service education regarding the importance of providing supervision and fluids to residents who are outside on a hot day, and the signs of heat exhaustion. An observation of the facility's door to the courtyard area revealed a keypad was in place, and an alarm sounded when the door was opened. There were no residents observed in the courtyard area at the time of validation of the credible allegation.

Based on record review, and interviews with staff, and the nurse practitioner, the facility failed to notify the physician when a severe weight loss occurred for 1 of 3 sampled residents reviewed for nutrition (Resident #2) Findings included: Record review indicated Resident #2 was admitted on [DATE] with cumulative [DIAGNOSES REDACTED]. Review of the admission Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had severely impaired cognition, had a poor appetite for 2-6 days, and required supervision of one staff for eating. Review of the admission physician order [REDACTED]. ? Keflex 500 milligrams (mg) by mouth (po) twice a day for 3 additional days. This drug was used to treat the resident ' s urinary tract infection. ? [MEDICATION NAME] 4.6/24 patch once daily for the treatment of [REDACTED]. Significant nausea, vomiting, anorexia, and weight loss are associated with use; occurs more frequently in women and during the titration phase. Nausea and/or vomiting may be severe, particularly at doses higher than recommended. Monitor weight during therapy. " ? [MEDICATION NAME] sulfate 325 mg po once a day for treatment of [REDACTED]. ? [MEDICATION NAME] 0.5 mg every 8 hours prn for anxiety ? Nutritional liquid house supplements three times a day which provided 600 calories and 18 grams of protein. ? Level one (1) dysphagia diet (The level 1 diet has pureed foods prepared so foods require little to no chewing). ? Weights daily for 3 days, weekly weights times 4 then monthly weights Review of the monthly weight chart form revealed the resident ' s height was 66 inches. The monthly weight chart form indicated a weight history which included in part: 10/09/13 =150 pounds (lbs.) 10/10/13 =153 lbs. 10/11/13 =154 lbs. 10/18/13 = 148 lbs. 10/25/13 = 145 lbs. 11/01/13 = 137 lbs 11/05/13 = 135 lbs 11/06/13 = 133 lbs 11/7/13 = 135 lbs 11/8/13 = 132 lbs The 17 lbs weight loss experienced by Resident #2 from 10/09/13 to 11/06/13 equates to an 11.3 percent (%) severe weight loss during less then a one month period. Review of the nurse practitioner ' s (NP) progress notes dated 11/1/13 revealed under " physical examination " a recorded weight of 150 lbs. Interview on 12/30/13 at 1:27 PM via the phone the NP revealed she usually will get a print out of the current weights of residents and on 11-1-13 visit she only had the weight of 150 lbs. The NP indicated she was not notified of the severe weight loss. Continued interview with the NP indicated had she been made aware about the weight loss orders to address the weight loss would have included lab work and/or ordered [MEDICATION NAME] (an antidepressant drug used to stimulate the appetite). Interview on 12/30/13 at 3:19 PM with Nurse #1 indicated she had not contacted the physician or the nurse practitioner regarding the weight loss. Interview on 12/30/13 at 3:28 pm with Nurse #4 revealed she did not remember the resident and did not know if she called the physician about the weight loss. Record review revealed on 11/13/13 the resident was admitted to the hospital. Continued interview on 12/30/13 at 1:27 PM via the phone the NP indicated the hospital admitting [DIAGNOSES REDACTED]. Continued interview with the NP revealed failure to thrive had not been a previous [DIAGNOSES REDACTED]. Interview on 12/30/13 at 5:43 PM with the director of nurses revealed she expected the physician to be notified of this weight loss.

Based on record review, and interviews with staff, the consultant dietitian, and the nurse practitioner, the facility failed to implement nutritional interventions to prevent a severe weight loss for 1 of 3 sampled residents reviewed for nutrition (Resident #2) Findings included: Record review indicated Resident #2 was admitted on [DATE] with cumulative [DIAGNOSES REDACTED]. Review of the admission Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had severely impaired cognition, had a poor appetite for 2-6 days, and required supervision of one staff for eating. Review of the care plan initiated 10/17/13, which addressed nutrition, revealed in part the goals regarding an increased nutrient needs related to the healing of a left surgical incision and progression of dementia and aging. Some of the basic interventions included diet as ordered, medication as ordered, monitor meal consumption daily, monitor weights and liquid supplements between meals. . Review of the admission physician order [REDACTED]. ? Keflex 500 milligrams (mg) by mouth (po) twice a day for 3 additional days. This drug was used to treat the resident ' s urinary tract infection. ? [MEDICATION NAME] 4.6/24 patch once daily for the treatment of [REDACTED]. Significant nausea, vomiting, anorexia, and weight loss are associated with use; occurs more frequently in women and during the titration phase. Nausea and/or vomiting may be severe, particularly at doses higher than recommended. Monitor weight during therapy. " ? [MEDICATION NAME] sulfate 325 mg po once a day for treatment of [REDACTED]. ? [MEDICATION NAME] 0.5 mg every 8 hours prn for anxiety ? Nutritional liquid house supplements three times a day which provided 600 calories and 18 grams of protein. ? Level one (1) dysphagia diet (The level 1 diet has pureed foods prepared so foods require little to no chewing). ? Weights daily for 3 days, weekly weights times 4 then monthly weights Review of the monthly weight chart form revealed the resident ' s height was 66 inches. The monthly weight chart form indicated a weight history which included in part: 10/09/13 =150 pounds (lbs.) 10/10/13 =153 lbs. 10/11/13 =154 lbs. 10/18/13 = 148 lbs. 10/25/13 = 145 lbs. 11/01/13 = 137 lbs 11/05/13 = 135 lbs 11/06/13 = 133 lbs 11/7/13 = 135 lbs 11/8/13 = 132 lbs The 17 lbs weight loss experienced by Resident #2 from 10/09/13 to 11/06/13 equates to an 11.3 percent (%) severe weight loss during less then a one month period. Review of the dietitian ' s nutritional assessment dated [DATE] revealed the resident ' s estimated nutritional daily needs were 1705 calories, 69-83 grams of protein and 2045 milliliters of fluids. The dietitian indicated that there were no nutritional issues at present and " PO (by mouth) with supplementation likely adeqaute (sic) to met (sic) nutritional needs. Continued review of the assessment indicated nutrition interventions were to continue house supplements, monitor po intake, labs, weights and monitor the need for further supplementation for a nutritional goal of meal intakes of more then 75%. Review of the " Resident Meals by Day Report " form from 10/09/13 though 11/6/13 revealed the resident ' s food and fluid intakes varied from 0 percent (%) to 25 % at different meals for 58 out of 103 meals. The resident ' s food and fluid intakes were 50% at different meals for 25 out of 103 meals. Review of the medical record revealed no documentation to determine the percentage or how much of the nutritional supplement was consumed. Interview on 12/30/13 at 5:43 PM with the director of nurses (DON) revealed a computer system changed occurred in the facility and the written entry on the Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. Review of the nurse practitioner ' s (NP) progress notes dated 11/1/13 revealed under " physical examination " a recorded weight of 150 lbs. Interview on 12/30/13 at 1:27 PM via the phone the NP revealed she usually will get a print out of the current weights of residents and on 11-1-13 visit she only had the weight of 150 lbs. Review of the medical record revealed no changes or interventions to address the resident ' s severe weight loss until 11/6/13 when the [MEDICATION NAME] was discontinued. There was no evidence in the medical record to indicate the dietitian reassessed the resident ' s nutritional status. Interview on 12/30/13 at 12:27 PM with food service manager (FSM) revealed she was responsible for collecting nutritional data and sharing with the dietitian. The FSM indicated that she was on vacation from 11/4/13 through 11/12/13 when the weight loss occurred. Interview on 12/30/13 at 4:44 PM via the phone with the facility ' s consultant dietitian (RD) regarding the severe weight loss for Resident #2 revealed the facility addressed the weight loss when the [MEDICATION NAME] was discontinued on 11/6/13. The RD indicated that staff at the facility would not have notified her about the weight loss, but she would have addressed the weight loss once she did her weekly visit to the facility and obtained the weights from the computer. Continued interview revealed she was not aware of the 10/25/13, 11-1-13, 11/5/13 or the 11/6/13 weights. The RD indicated she did not conduct a reassessment after the weight loss because the weights were not in the computer. Further interview revealed the RD confirmed the facility failed to implement measures to address the resident ' s weight loss other then the discontinuation of the [MEDICATION NAME] on 11/6/13. Interview on 12/30/13 at 3:10 PM with restorative aide (RA) #1 (responsible for obtaining weights) revealed RA#2 obtained the weights on Resident #2. RA#1 revealed the procedure in the facility was to obtain the weight and verify the weight. RA #1 indicated we are suppose to notify the nurse in charge immediately of a 5 pound weight difference. Further interview revealed the restorative aide that obtains the weight would record in the computer. RA#1 indicated that RA #2 obtained all the weights for Resident #2. Attempts to interview RA #2 were unsuccessful. Interview on 12/30/13 at 3: 35 PM and 4 PM with the RA nurse #5 (nurse who oversees the restorative program) revealed RA #1 and #2 should report to the nurse and dietary manager regarding weight losses. The nurse /dietary manager would make a note in the progress notes or on the 24 hour report. Further interview with RA nurse #5 indicated that she had no notes to indicate that Resident #2 ' s severe weight loss was discussed in the weight committee. Interview on 12/30/13 at 3:19 PM nurse #1 who cared for Resident #2, revealed she did not recall being provided the weights from RA #1 or RA#2. Nurse #1 indicated that there was a period of time when Resident#2 would not eat or take her medications. An attempt to interview nursing assistant #1 (NA) who provided care to Resident #2 during the day shift was unsuccessful. Interview on 12/30/13 at 3:20 PM with Nurse #2 revealed she was not aware of the weight loss but the weight committee should have addressed the weight loss. Interview on 12/30/13 at 4:17 PM with NA #2 revealed when he was assigned to care for Resident #2 she would not eat, refused care, and became agitated quickly. NA #2 indicated she would take her supplements sometimes when she was in the mood and thought that he told Nurse #4 about the resident ' s poor meal consumption and refusing care. Continued interview on 12/30/13 at 5:43 PM with the DON revealed there was a weight committee meeting scheduled on 10/31/13 and 11/7/13 but was not held. The DON indicated in this meeting the facility would have discussed Resident #2 ' s weight loss. Further interview indicated the meetings just " fell through the cracks " and provided no other explanation why the committee did not meet.