Every finding on record at Maimonides Health Center of Virginia Beach

Based on observation, record review, and facility policy review, the facility failed to ensure two medications were not left on top of a medication cart unsecured. The facility further failed to ensure three of five medication carts observed were locked when not in sight of staff. This had the potential for the misappropriation of medications. Findings include: 1. During medication administration observation and interview on the 100 hall on 07/15/26 from 9:10 AM to 9:51 AM, a Lovenox (an anticoagulant) 40 microgram (mcg) syringe was observed sitting out on top of the medication cart, unsecured. One resident was observed wheeling past the cart in his wheelchair. The Licensed Practical Nurse (LPN)8 was in an out of sight of the medication cart at this time. LPN8 confirmed the Lovenox syringe was on top of the medication cart, unsecured, and stated, I would not leave any medications out. The resident had requested the injection be given later. It shouldn't have been left out. During an interview on 07/16/26 at 4:22 PM, the Director of Nursing (DON) stated, Medications are expected to be locked up in the cart before leaving the cart and not leaving medications on top of the medication cart. Review of the facility's policy titled, Medication Storage revised 12/25, indicated, All drugs and biologicals will be stored in locked compartments (i.e., medication carts,cabinets, drawers, refrigerators, medication rooms). During a medication pass, medications must be under the direct observation of the person administering medications or locked in the medication storage cart. 2.During an observation and interview on 07/15/26 at 9:23 AM revealed an unlocked and unattended medication cart in front of room [ROOM NUMBER]. There were no staff around the medication cart. No residents were observed to be wandering near the unlocked medication cart. Continued observation and interview 9:28 AM Licensed Practical Nurse (LPN) 6 exited room [ROOM NUMBER] and locked the medication cart. She said, I'm sorry, I thought I would be in and out. LPN 6 said the medication cart should have been locked to prevent access to those not authorized. 3.During an observation and interview on 07/15/26 at 9:32 AM revealed LPN9 in the hallway next to room [ROOM NUMBER]. LPN 9 left the medication cart unlocked and entered room [ROOM NUMBER] and closed the door. Continued observation revealed LPN9 exited room [ROOM NUMBER] at 9:34 AM. LPN placed an insulin pen in the medication cart and locked it. LPN 9 said I have problems sometimes locking the cart. 4.During an observation and interview on 07/16/26 at 5:46 AM of the nurses' station near [NAME] Hall revealed an unlocked and unattended medication cart. There were no staff within sight of the cart. There was a round white tablet in a transparent medication cup on top of the cart. At that time LPN5 exited the station's nutrition room and then went to the restroom. After LPN5 exited the restroom she identified the tablet in the medication cup as Tramadol (narcotic pain medication) 50 milligrams (mg). LPN5 locked the medication cart and took the dispensed medications to a resident. 5.During an observation and interview on 07/16/26 at 6:05 AM of the nurses' station near [NAME] Hall revealed the same medication cart near the [NAME] Hall was unlocked and unattended again. LPN5 was in a room in an adjacent hall, out of sight of the medication cart. LPN5 exited the room at 6:07 AM and went to the station's nutrition room. At 6:08 AM LPN 5 emerged from the nutrition room and locked the medication cart. The LPN confirmed the medications cart was unlocked two times, once at 5:46 AM and then again at 6:08 AM. 6.During an observation and interview on 07/16/26 at 6:10 AM of the [NAME] Hall revealed an unlocked and unattended medication cart. There were no staff within sight of the cart. No staff was seen for three minutes. At 6:13 AM LPN7 confirmed she had retrieved a medication from that unlocked/unattended medication cart recently. 7.During a continuous observation on 07/16/26 from 4:10 AM to 4:40 AM, two unattended medication carts were observed in the Blue unit. One cart was sitting next to the nurses' station in the center of the unit and one cart was sitting off to the side against the wall in the unit, both carts were unlocked. One Certified Nurse Aide (CNA) was observed entering and exiting the unit on four occasions. During an interview on 07/16/26 at 4:40 AM, Registered Nurse Supervisor (RNS) confirmed both carts were unlocked and should not be. RNS locked both carts. During an interview on 07/16/26 at 4:55 AM, Licensed Practical Nurse (LPN) 5 entered the Blue unit and stated she was the only nurse assigned to the unit. She stated medication carts should always be locked unless medications are administered. LPN 5 stated she remembered the carts were not locked and should have been. Review of the facility policy titled, Medication Storage revised December 2026 revealed, . 1. General Guidelines: .c. During a medication pass, medications must be under the direct observation of the person administering medications or locked in the medication storage area/cart.

Based on staff interview, clinical record review, secure text messaging, family interviews and review of facility documents, the facility's staff neglected to ensure a resident who was in severe abdominal pain received care and treatment in a timely for 2 of 10 residents (Resident #2 and Resident #4) in the survey sample which resulted in Harm for Resident #4. Past Non-Compliance was issued for this deficient practice.The findings include:1. 1.Resident #2 was admitted to the facility on [DATE] with diagnoses including nephrostomy tubes for urine excretion, chronic heart failure and chronic heart disease with 3 cardiac arterial bypass grafts, an artificial heart valve, and a left ventricular ejection fraction of only 26% revealing a severely weakened heart muscle. The Resident's admission weight was 120 pounds, and she used oxygen in the hospital and was ordered to be administered Oxygen at 3 liters per minute via nasal cannula as needed upon discharge. Review of the clinical record revealed nursing and physician progress notes dated 3-2-25, through 3-5-25 with the following condensed information. On 3-2-25 at 8:00 p.m., the Skilled unit nurse wrote that the Resident's son had called multiple times, and she had just answered his inquiries about his mother's weights and medication administration. The Resident's weight was 128 pounds, an increase of 8 pounds since admission. On 3-4-25 at 8:00 a.m., the Registered Nurse Practitioner (NP) wrote that an assessment of the Resident had been conducted, and she found 2+ pitting edema in the Resident's lower extremities and a 3-pound weight increase (in error). On 3-4-25 at 12:00 noon, the Physiatrist wrote that an assessment of the Resident had been conducted, and he found 3+ pitting edema in the Resident's lower extremities, and the Resident told him that she did not feel good. On 3-4-35 at 3:00 p.m., the Skilled unit nurse wrote that the Resident was short of breath and had a weight of 127.7 pounds. On 3-5-25 at 9:45 p.m., the Skilled unit nurse wrote that the Resident's son had called and complained that the Resident was weak and confused at dinner (6:00 p.m.) and he wanted her sent to the emergency room at the hospital for evaluation. The order to send the Resident was received at 10:00 p.m., however, the Resident was not sent until 1:17 a.m. (3 hours later) on 3-6-25. She did not return and expired in the hospital 2 days later on 3-8-25. Resident #2's discharge hospital orders were reviewed and revealed a hospital physician's order for labs to be drawn in 3 days, however, upon the resultant admission to the skilled nursing facility the Resident was ordered by the physician there to begin drawing labs on 1-29-25 (8 days after admission). The lab draw schedule then went on to be ordered randomly for 2-5-25, 2-8-25, 2-12-25, 2-18-25, and 3-4-25. Weights were ordered on admission, completed daily, and documented as revealed in the review of the clinical record. The hospital discharge summary did denote that if the Resident should experience a 3-pound weight gain in one day or a 5-pound weight gain in one week, that the cardiology physician should be contacted immediately. The Resident's care plan was also reviewed and revealed that worsening edema, and weight gain were to be assessed for, and the physician notified, should this issue arise as it would underscore a worsening condition. Review of the weight documents further revealed that from 2-4-25 through 2-9-25 the Residents weight increased from 121.0 pounds to 128.4 pounds in 5 days. Her weight continued to be elevated and from 2-26-25 until the Resident was discharged to the emergency room on 3-6-25 at 1:17 a.m., (7 days later). The Resident's weight stayed at its highest elevation during this week of 8.8 pounds since the admission weight of (120 pounds), ranging between 127.7 to 128.8. During the Resident's 43 day stay a gradual increase in weight, edema, and shortness of breath, all indicated a worsening condition. There is no indication that the cardiology doctor was ever notified of this, however, four medication changes were made by the skilled nursing facility physician to manage the symptoms of fluid overload. Those 4 medications follow below. 1. 1. Bumex 2 milligram (mg) every day ordered 1-21-25 through 2-21-25 (one month), 2-5-25 through 2-6-25 (2 days), then every day from 2-24-25 through discharge. 2. 2. Bumex 1 mg every day ordered 1-28-25 through 1-29-25 (2 days), and 2-18-25 through discharge every day. 3. 3. Metolazone 2.5 mg every day ordered 1-29-25 through 1-31-25 (2 days). 4. 4. Metoprolol 25 mg every day ordered 1-21-25 through 2-2-25 (12 days). A review of nursing progress notes revealed staff documentation that the Resident was noncompliant with her fluid restriction. Interviews conducted with staff and family also revealed that Resident #2 often asked others for fluids such as a roommate, family members, and dining services staff with complaints of thirst. The fluid weight gain experienced by Resident #2 was further questioned as review of the Resident's Intake and output records were reviewed and revealed a concerning revelation. The Resident was ordered to have a 1500 milliliter (ml) fluid restriction for each 24-hour day. The documents showed that upon admission on [DATE] and 1-22-25 no fluids were recorded as consumed. The Resident complained of thirst to her son frequently, and records show a pattern of not providing fluids to the bedridden Resident. The rest of the days documented during her stay of fluid consumption follow below. (January 2025) - 1-23-25 (420 ml), 1-24-25 (712 ml), 1-25-25 (240 ml), 1-26-25 (240 ml), 1-27-25 (1360 ml), 1-28-25 (1500 ml), 1-29-25 (720 ml), 1-30-25 (1490 ml), 1-31-25 (924 ml). (February 2025) - 2-1-25 (1660 ml), 2-2-25 (1440 ml), 2-3-25 (480 ml), 2-4-24 (960 ml), 2-5-25 (720 ml), 2-6-25 (900 ml), 2-7-25 (720 ml), 2-8-25 (482 ml), 2-9-25 (720 ml), 2-10-25 (1200 ml), 2-11-25 (660 ml), 2-12-25 (840 ml), 2-13-25 (480 ml), 2-14-25 (720 ml), 2-16-25 (720 ml), 2-17-25 (478 ml), 2-18-25 (420 ml), 2-19-25 (598 ml), 2-20-25 (598 ml), 2-21-25 (720 ml), 2-22-25 (716 ml), 2-23-25 (598 ml), 2-24-25 (480 ml), 2-25-25 (720 ml), 2-26-25 (720 ml), 2-27-25 (720 ml), 2-28-25 (720 ml). (March 2025) - 3-1-25 (960 ml), 3-2-25 (960 ml), 3-3-25 (716 ml), 3-4-35 (720 ml), 3-5-25 (720 ml). Only one time in January (1-28-25) did Resident #2 receive the 1500 ml of fluids allowed in her special diet. This reveals that the edema, weight gain, and shortness of breath were indeed symptoms of a worsening illness, and not related to fluid consumption nor noncompliance. The Resident's Activities of Daily Living (ADL) records were reviewed and revealed bathing and showering records. Those records indicated that Resident #2 received a bed bath only 3 times, on 1-23-25, 1-24-25, and 3-2-25. Documents recorded refusals to be bathed by the Resident only twice, on 2-10-25, and 3-1-25. No other baths nor showers were provided to Resident #2 during her entire 43-day stay in the facility. Staff members (2 LPNs licensed practical nurses and 2 CNAs Certified Nursing Assistants) on the unit where this Resident formerly resided were asked how often bathing was provided to the residents. The response by all was 2 times per week for showers or tub baths, and every day if they received bed baths. Other Residents were placed in the survey sample and reviewed for hygiene care which was found to be adequate at the time of survey. No pervasive odors, nor soiled linens on beds were found. Residents and family members were interviewed and had no issues with hygiene care being provided. A general finding of neglect based upon the other findings of withholding of goods and services required to care for this Resident is found. A preponderance of Observations, staff and family interviews, clinical record review, and facility document review indicate deficient practice in 3 specific areas of need for this Resident. Harm is not identified, as the complex comorbidities and severe cardiac illness for this [AGE] year-old Resident would have resulted in hospitalization, and likely death at a point in the near future as all available avenues of intervention had been exhausted. Notification to family members, bathing, and added fluid provision would not have improved the outcome for this Resident; however, they were required by federal regulation to be provided. On 11-17-25 at 3:00 p.m., at the end of day debriefing held with the Director of Nursing (DON), and Assistant Director of Nursing (ADON), they were informed by surveyors of the staff failure to provide goods and services required for this Resident resulting in neglect. Namely notifying the responsible party of a Resident's worsening condition, providing adequate bathing, and adequate fluids. Both stated they had nothing further to provide. 2.The facility staff failed to ensure a resident that was in severe abdominal pain received care, treatment and services to prevent complications. Resident #4 was originally admitted to the facility 6/13/25 after an acute hospital stay and discharged on 7/28/25 to an acute care facility. The current diagnoses included; Type 2 Diabetes Mellitus with hyperglycemia and Pain in Right Knee, Chronic Kidney Disease stage 4, anemia, heart failure, and Chronic Respiratory failure. Resident #4 was admitted to the facility on [DATE] after an acute hospital stay and discharged on 7/28/25 to an acute care facility. The current diagnoses included; Type 2 Diabetes Mellitus with hyperglycemia and Pain in Right Knee, Chronic Kidney Disease stage 4, anemia, heart failure, and Chronic Respiratory failure. The significant change, Minimum Data Set (MDS) assessment with an assessment reference date (ARD) of 6/13/25 coded the resident as completing the Brief Interview for Mental Status (BIMS) and scoring 10 out of a possible 15. This indicated Resident #4 cognitive abilities for daily decision making were moderately impaired. In sectionGG(Physical functioning) the resident was coded as independent with eating, requiring set up or clean up assistance with oral hygiene, requiring substantial/maximal assistance with toileting and personal hygiene and resident coded as dependent with shower/bathe self. In section J (Health Conditions) J0100-Pain Management (B) coded resident as not receiving scheduled or prn pain medications. The person-centered care plan dated 3/06/24 and revised on 6/05/25 read the resident has chronic pain r/t knees. The Goal for the resident is the resident will verbalize adequate relief of pain or ability to cope with incompletely relieved pain through 6/29/25. The interventions for the resident were as follows: Administer analgesia (Tylenol) as per orders. Give 1/2 hour before treatments or care, monitor/document for side effects of pain medication. Observe for constipation; new onset or increased agitation, restlessness, confusion, hallucinations, dysphoria; nausea; vomiting; dizziness and falls. Report occurrences to the physician, monitor/record pain characteristics (knees) and PRN: Quality (e.g. sharp, burning); Severity (1 to 10 scale); Anatomical location; Onset; Duration (e.g., continuous); Aggravating factors; Relieving factors (Revised 7/26/24). A review of the July 2025 Medication Administration Record (MAR) and Physician Order Summary (POS) revealed the following orders were received for Resident #4 during her course of pain and discomfort beginning on 7/27/25 through 7/28/25: Resident #4 received Lactulose Solution 10 GM/15ML -30 ml by mouth three times a day for constipation for 2 Days, (Hold for loose stool) on 07/28/2025 at 12:00 pm. The resident received Tylenol 325 mg 2 tablets, prn every 4 hours on 7/27/25 at 12:30 am., and on 7/28/25 at 10:19 am., On 7/28/25 bladder scan ordered for urinary retention was completed at 1:24 pm. The (MAR) revealed resident was given Albuterol Sulfate Inhalation Aerosol on 7/27/25 through 7/31/25 but seemed questionable due to the resident being discharged on 7/28/25 in the evening. On 7/28/25 at 2:58 pm., a STAT Order for Fleets Enema was given to resident rectally per order. On 7/28/25 at 11:15 am., an order for Simethicone Oral Tablet 80 MG (Simethicone) 2 tablet by mouth every 6 hours as needed for Gas pain/bloating, was ordered but not administered. On 7/28/25 at 3:02 pm., A STAT KUB was ordered for Abdominal pain/distention, was not administered due to resident being transported to the hospital at 5:19 pm. A timeline of events leading to residents' hospitalization revealed the following: A review of text messages sent on 7/28/25 from Resident #4 and her daughter/Power of Attorney read: 1:21 am, sent from Resident #4 reading: Help me. 5:56 am., the daughter responded: Hey mom, you ok? You texted me at 1 in the morning to help you. What help did you need? 6:45 am., the resident responded: I'm in pain. 7:54 am., the daughter responded: Ok press your button! what hurts?? Is it your knee? 2:28 pm., the resident responded: No stomach very bad. Help 2:28 pm., the daughter responded: Oh, that's awful. Hit that button!!!!!! 2:29 pm., the daughter responded: If (unknown name) is around ask her to get you help. If no one answers you let me know. On 7/28/25 at 12:04 am., a health status note read resident c/o abdominal pain at 11:20 pm (7/27/25). The resident was repositioned, stated she could not breathe but after repositioned she felt better, pain level went from 8 to 3-4 after repositioning and after ginger ale and her oxygen saturation was 98% on 2L N.C Resident family visited this evening and brought in donuts (Prior to complaining). The resident also ate two peanut butter and jelly sandwiches this evening. Resident is now resting with her eyes closed, fan blowing on bed side. She feels better and felt some relief from her abdominal pain. The resident is not on the BM (Bowel Movement) due list. The above health status note revealed that the resident was not on the list for bowel movement, which could indicate other issues were impending, possibly causing her abdominal pain and discomfort. A review of the Medication Administration Record (MAR) dated 7/27/25 at 12:30 am., read that Tylenol 325 mg, 2 tabs were given. On 7/28/25 at 5:52 a.m., A late entry health status note read that a Certified Nursing Assistant (CNA) reported to this writer that resident experienced an episode of vomiting and has been complaining of pain throughout the night. Upon assessment, resident was observed sitting upright in wheelchair, napping. Resident was gently awakened and assessed. Resident verbalized, My neck has been bothering me all night and I have pain over here, while pointing to the right side of her abdomen. She was unable to describe the quality of the pain and, when prompted with descriptors (pressure, sharp, burning, dull), responded, All of the above. Nurse on duty was alerted and reported that resident received analgesia at the beginning of the shift and is due for the next dose in one hour. Nurse also stated that resident was administered Milk of Magnesia approximately one hour ago. A review of Health status and nursing notes revealed the following: A review of the above nurses' and health status notes revealed that Resident #4 first complained of pain on 7/27/25 at 11:20 pm., was administered Tylenol 2 tablets 325 mg (according to the late entry note), On 7/28/25 at 5:52 am, (6 hours and 32 minutes later) the Certified Nursing Assistant reported that Resident #4 had pain and vomiting throughout the night, pointing to the right side of her abdomen. On 7/28/25 at 6:05 am. (6 hours and 45 minutes later) per health status note resident is still complaining about having abdominal pain, Miralax given for possible constipation. On 7/28/25 at approximately 10:30 am., (11 hours and 10 minutes later) the nurse practitioner came in to evaluate resident for complaining of having abdominal pain and nausea after being notified within 10 minutes by nursing staff of resident's complaints. According to the health status notes neither the on-call doctor nor the Nurse Practitioner were notified in a timely manner of resident's abdominal pain or discomfort for hours, it wasn't until 11 hours and 10 minutes later, that the NP was notified, which resulted in a delay in treatment, neglect and notification. On 7/28/2025 at 12:33 pm., a late entry health status note read: Resident's roommate notified facility staff resident still complaining of pain and shortness of breath (SOB). Vital signs were taken, Resident on 02 at 3 liters per nasal cannula. Nursing staff says she is waiting to hear from primary care provider. On 7/28/25 at 1:53 pm., according to the Medication Administration Record (MAR) resident received 2 Tylenol tablets, 325 mg. The follow-up read was ineffective with pain scale being a 6. According to the health status notes Resident #4 was still experiencing pain and discomfort since her initial complaint of pain, and was administered Tylenol 2 tablets, 325 mg at 11:20 pm, on 7/27/25 for a total of 14 hours and 33 minutes, the resident had still remained at the facility. On 7/28/2025 at 2:00 pm., Late Entry Health Status Note: Resident continues to c/o abdominal pain and right-side neck pain from previous shift and stated that lying down relieves pain some. Not able to consume breakfast. Fluid intake adequate. ADL care was provided. Resident rang call light several times between breakfast and lunch hour c/o pain. NP down to assess resident. New orders given for bladder scan and lactulose x1 along with gas-x x1. Resident stated that gas-x relieved pain minimally. Lactulose ineffective. Bladder scan shown 28cc urine. Verbal order received for resident to have foley placed. Writer disagreed and immediately went to unit. According to the health status note the Power of Attorney (POA) Responsible Party (RP), daughter was not notified of the above issues from the facility staff until 4:49 pm, on 7/28/25, which was 17 hours and 29 minutes later. According to the health status note dated 7/28/25 at 5:15 pm, Resident #4 was picked up by medical transport via ambulance to be transported to the local hospital. The POA was notified of the pick-up time. On 11/15/25 at approximately 6:15 pm, a telephone interview was conducted with the complainant Daughter/Power of Attorney (POA) concerning Resident #4. The resident's daughter said that a text message was sent to her by her mom reading I'm in pain. The daughter thought that her mother was having knee pain, but she indicated that she felt bad because her stomach was hurting. My mother's roommate later mention that my mother was crying and screaming all night long. The resident's daughter also said that she was not informed until late 7/28/25. The daughter also mentioned that the doctor at the hospital said my mom became septic due to having a perforated ulcer. On 11/12/25 at approximately 3:35 pm., an interview was conducted with Licensed Practical Nurse (LPN) #1. LPN #1 said that the resident's daughter visited her on the night of 7/27/25 and that the resident never complained of any discomfort until an hour after the daughter left. LPN #1 said that the resident complained of having a hard time breathing but he repositioned her and she also complained that her stomach was hurting. He said that the resident had eaten 2 sandwiches before her daughter arrived and ate donuts-this was after 8 pm. LPN#1 said the resident started burping and he gave her ginger ale due to her feeling nauseated. It was past 11:00 pm, when she complained of pain. I stayed until she felt better around 12:30am., then I clocked out. LPN #1 also said that when he returned on 7/28/25 to work the 3-11 shift, the nurse that he was relieving said that the resident is not better. LPN #1 also mentioned they tried to transfer the resident to the toilet, but she appeared like she was going to pass out, saying she was having discomfort with her stomach. LPN #1 also that he contacted her daughter later on 7/28/25. LPN #1 also mentioned that he approached the Nurse Practitioner (NP) and said, we should do something. On 11/17/25 at approximately 1:25 pm., an interview was conducted with Certified Nursing Assistant (CNA) #1. CNA#1 said that Resident #4 was able to make her needs known, use a call bell and able to communicate discomfort or pain. CNA #1 said that the morning the resident wasn't feeling good she reported it to the charge nurse that the resident was pointing to her belly saying she wasn't feeling well. The resident didn't want anything to eat in the morning or at lunch, I kept pushing fluids in her. CNA was asked the resident needed to have a bowel movement. CNA #1 said that the resident didn't need to go to the toilet. On 11/17/25 at approximately 3:05 pm, an interview was conducted with the ADON concerning Resident #4. The ADON said there was a delay in treatment relating to the NP waiting too late for the STAT KUB and on sending the resident to the ER. The ADON also said that the family should have been informed of the change in condition but wasn't notified until 7/28/25 at 5:15 pm. The ADON also mentioned that the DON had instructed the unit manager to speak to the NP to send the resident to the ER. On 11/17/25 at approximately 3:25 pm., an interview was conducted with LPN #4. LPN #4 said that on the 3-11 shift on the night of 7/27/25 due to eating a lot of food the resident was complaining of having pain in the back of her neck, with her hand placed on her stomach, the resident was given ginger ale and belched. LPN#4 said, We thought she had indigestion. According to the hospital admission records Resident #4 arrived at the hospital on 7/28/25 at 5:35 pm., via ambulance. The Emergency Department (ED)Triage note dated 7/28/25 at 5:54 pm read that Resident #4 presented with complaints of a low blood pressure of 91/54, abdominal pains, appearing pale and currently on 95% 02 at 4 liters per nasal cannula. A Sepsis / Febrile Neutropenia (FN) Screen - Patient assessment indicating risk for infection: Shortness of Breath, Alteration of Mental Status; Heart Rate greater 90 beats/min. Other Risk Factors of Infection: Skilled Nursing Facility. The ED note read transferred patient from stretcher to bed. Patient suddenly became nauseous then vomited coffee ground color emesis/liquid. The same day a diagnosis of Septic Shock was given at 11:58 pm. According to the medical records dated 8/06/25, Resident #4 was diagnosed as having a perforated ulcer. Febrile Neutropenia: Neutropenic fever is when there is a single oral temperature greater than or equal to 101 F (38.3 C) or a temperature greater than or equal to 100.4 F (38 C) for at least an hour. https://www.ncbi.nlm.nih.gov/books/NBK541102/ Septic shock is the last and most severe stage of sepsis. Sepsis occurs when your immune system has an extreme reaction to an infection. The inflammation throughout your body can cause dangerously low blood pressure. You need immediate treatment if you have septic shock. Treatment may include antibiotics, oxygen and medication. https://my.clevelandclinic.org/health/diseases/23255-septic-shock A peptic ulcer is an open sore in the stomach lining or the upper part of the small intestine (duodenum). An ulcer can go through all the layers of the digestive tract and form a hole. This is called a perforated ulcer. A perforated ulcer lets food and digestive juices leak out of the digestive tract. This is a serious health problem that needs urgent medical care. Symptoms of a perforated ulcer may include: Sudden, severe pain in the belly, usually in the upper area, pain spreading to the back or shoulder, nausea or vomiting, lack of appetite or feeling full, swollen belly or feeling bloated, feeling lightheaded, increased heart rate. Perforated ulcers can have serious complications. These include: Infection and inflammation of the lining of the abdomen (peritonitis), bloodstream infection (sepsis), Death. Contact your doctor right away if you have: Blood in your vomit, or vomit that looks like coffee grounds, bloody, black, or tarry-looking stools, fever of 100.4°F (38°C) or higher, or as directed by your doctor, Chills, pain that gets worse, symptoms that don't get better with treatment, or symptoms that get worse, or new symptoms. https://www.ummhealth.org/health-library/understanding-perforated-ulcers Compliance with Reporting Allegations of Abuse/Neglect/Exploitation. Date implanted: 9/24. Policy: It is the policy of this facility to report all allegations of Abuse/Neglect/Exploitation or mistreatment. Including injuries of unknown sources and misappropriation of resident property are reported immediately to the administrator of the facility and to other appropriate agencies in accordance with current state and federal regulations within prescribed timeframes. Compliance Guidelines: The facility will develop and operationalize policies and procedures for screening and training employees, protection of residents and for the prevention, identification, investigation, and reporting of abuse, neglect, mistreatment, and misappropriation of property. The purpose is to assure that the facility is doing all that is within its control to prevent occurrences. Identification: Neglect: Failure of the facility, its employees or service providers to provide goods and services to a resident that are necessary to avoid pain. All residents who had issues with pain and pain assessments were reviewed since 9/19/25. The 9/19/25 pain interventions, notifications and abuse interventions were put in place, monitored every shift by the facility staff as well as current residents, that were placed in the survey sample by the survey team presented with no issues. On 11/12/25 at approximately 12:30 pm, a brief interview was conducted with the administrator, asking if the facility had any current (2025) Performance Improvement Plans (PIPs), and Facility Related Synopsis to present to the survey team. The administrator was given 20 minutes to bring in evidence of the above requested documents. On 11/12/25 at approximately 12:53 pm, the Director of Nursing (DON) brought in a PIP. It was reviewed. There was no resident identifiable information on the PIP, no corrective action dates, no Allegation of Compliance (AOC) date. The DON said that it would be 4 weeks from 9/19/25 but later changed the date to 9/29/25. On 11/12/25 at approximately 1:47 pm, the survey team met with the DON, the Assistant Director of Nursing (ADON), and the administrator. They were asked to identify the resident in question for the PIP. The administrator said they were working on HIPAA for privacy, (The Health Insurance Portability and Accountability Act), we're calling it a POC so we can get Past Non-Compliance (PNC) 9/19/25 as our end date. The DON and the administrator meant to say 4 weeks from compliance from date. DON said that the resident's name should have been written on the PIP. The administrator said that we missed the name and date. The following five-point plan was discussed secondary to Resident #4's pain, notifications and abuse concerns: The facility identified Resident #4's care resulted in the areas of pain management, notification and abuse. The facility completed a 100 percent review of all pain assessments in the facility previous to determine like-residents. Staff education was 100 percent for all nursing staff by the Director of Nursing and ADON to educate staff on pain management, notifications and abuse. The Administrator, Director of Nursing and ADON completed weekly audits 5 times per week for 4 weeks to include pain management, notifications and abuse. All Quality Assurance and Performance Improvement (QAPI) findings will be forwarded to the QAPI committee. Corrective action was completed on 9/29/25. On 11/12/25 at approximately 4:05 pm., during the end of day meeting the DON said that the AOC date will be 9/29/25. We have not had any incidents since 9/29/25. The survey team reviewed the PNC POC documents. It was determined by the survey team through interviews, record reviews and resident observations that the above practices were not identified since 9/29/25 nor during the course of the survey from 11/12/25 through 11/17/25. On 11/17/25 at approximately 4:25 p.m., the above findings were shared with the Director of Nursing (DON), the Assistant Director of Nursing (ADON) and via telephone the local Ombudsman was present. An opportunity was offered to the facility's staff to present additional information, but no additional information was provided. It was determined that the facility implemented its Corrective Action Plan, and there was sufficient evidence that the facility corrected the noncompliance and was in substantial compliance at the time of the current survey for the regulatory requirements, F600 at Past Non-Compliance.

Based on family interview, staff interview, facility documentation review, and clinical record review, the facility staff failed to inform the the resident's representative and Nurse Practitioner of a change in condition for 2 of 10 residents (Resident #4, and #2) which resulted in harm at Past Non-Compliance, for Resident #4 in the survey sample.The findings included: 1.Resident #2 was admitted to the facility on [DATE] with diagnoses including nephrostomy tubes for urine excretion, chronic heart failure and chronic heart disease with 3 cardiac arterial bypass grafts, an artificial heart valve, and a left ventricular ejection fraction of only 26% revealing a severely weakened heart muscle. The Resident's admission weight was 120 pounds, and she used oxygen in the hospital and was ordered to be administered Oxygen at 3 liters per minute via nasal cannula as needed upon discharge. Review of the clinical record revealed nursing and physician progress notes dated 3-2-25, through 3-5-25 with the following condensed information. On 3-2-25 at 8:00 p.m., the Skilled unit nurse wrote that the Resident's son had called multiple times, and she had just answered his inquiries about his mother's weights and medication administration. The Resident's weight was 128 pounds, an increase of 8 pounds since admission. On 3-4-25 at 8:00 a.m., the Registered Nurse Practitioner (NP) wrote that an assessment of the Resident had been conducted, and she found 2+ pitting edema in the Resident's lower extremities and a 3-pound weight increase (in error). On 3-4-25 at 12:00 noon, the Physiatrist wrote that an assessment of the Resident had been conducted, and he found 3+ pitting edema in the Resident's lower extremities, and the Resident told him that she did not feel good. On 3-4-35 at 3:00 p.m., the Skilled unit nurse wrote that the Resident was short of breath and had a weight of 127.7 pounds. On 3-5-25 at 9:45 p.m., the Skilled unit nurse wrote that the Resident's son had called and complained that the Resident was weak and confused at dinner (6:00 p.m.) and he wanted her sent to the emergency room at the hospital for evaluation. The order to send the Resident was received at 10:00 p.m., however, the Resident was not sent until 1:17 a.m. (3 hours later) on 3-6-25. She did not return and expired in the hospital 2 days later on 3-8-25. This 3-5-25 interaction as documented by nursing staff revealed that the family member called the facility as the decision-making authority, and the facility did not notify him of the preceding 2 days of concerning symptoms that the Resident was experiencing. The Resident's son was interviewed on 11-17-25 at 12:00 noon, and stated he had to call them, they never called him, nor returned his calls. He further stated that he had difficulty reaching the staff, often calling multiple times a day before reaching a staff member. Weights were ordered on admission, completed daily, and documented as revealed in the review of the clinical record. The hospital discharge summary did denote that if the Resident should experience a 3-pound weight gain in one day or a 5-pound weight gain in one week, that the cardiology physician should be contacted immediately. The Resident's care plan was also reviewed and revealed that worsening edema, and weight gain were to be assessed for, and the physician notified, should this issue arise as it would underscore a worsening condition. Review of the weight documents further revealed that from 2-4-25 through 2-9-25 the Residents weight increased from 121.0 pounds to 128.4 pounds in 5 days. Her weight continued to be elevated and from 2-26-25 until the Resident was discharged to the emergency room on 3-6-25 at 1:17 a.m., (7 days later). The Resident's weight stayed at its highest elevation during this week of 8.8 pounds since the admission weight of (120 pounds), ranging between 127.7 to 128.8. There is no indication that the cardiology doctor was ever notified. On 11-17-25 at 3:00 p.m., at the end of day debriefing held with the Director of Nursing (DON), and Assistant Director of Nursing (ADON), they were informed by surveyors of the staff failure to notify the responsible party of a Resident's worsening condition, and both stated they had nothing further to provide. 2.The facility staff failed to ensure the resident's Power of Attorney/Daughter and the Nurse Practitioner were notified of resident being in severe abdominal pain. Resident #4 was originally admitted to the facility 6/13/25 after an acute hospital stay and discharged on 7/28/25 to an acute care facility. The current diagnoses included; Type 2 Diabetes Mellitus with hyperglycemia and Pain in Right Knee, Chronic Kidney Disease stage 4, anemia, heart failure, and Chronic Respiratory failure. Resident #4 was admitted to the facility on [DATE] after an acute hospital stay and discharged on 7/28/25 to an acute care facility. The current diagnoses included; Type 2 Diabetes Mellitus with hyperglycemia and Pain in Right Knee, Chronic Kidney Disease stage 4, anemia, heart failure, and Chronic Respiratory failure. The significant change, Minimum Data Set (MDS) assessment with an assessment reference date (ARD) of 6/13/25 coded the resident as completing the Brief Interview for Mental Status (BIMS) and scoring 10 out of a possible 15. This indicated Resident #4 cognitive abilities for daily decision making were moderately impaired. In sectionGG(Physical functioning) the resident was coded as independent with eating, requiring set up or clean up assistance with oral hygiene, requiring substantial/maximal assistance with toileting and personal hygiene and resident coded as dependent with shower/bathe self. In section J (Health Conditions) J0100-Pain Management (B) coded resident as not receiving scheduled or prn pain medications. The person-centered care plan dated 3/06/24 and revised on 6/05/25 read the resident has chronic pain r/t knees. The Goal for the resident is the resident will verbalize adequate relief of pain or ability to cope with incompletely relieved pain through 6/29/25. The interventions for the resident were as follows: Administer analgesia (Tylenol) as per orders. Give 1/2 hour before treatments or care, monitor/document for side effects of pain medication. Observe for constipation; new onset or increased agitation, restlessness, confusion, hallucinations, dysphoria; nausea; vomiting; dizziness and falls. Report occurrences to the physician, monitor/record pain characteristics (knees) and PRN: Quality (e.g. sharp, burning); Severity (1 to 10 scale); Anatomical location; Onset; Duration (e.g., continuous); Aggravating factors; Relieving factors (Revised 7/26/24). A review of the July 2025 Medication Administration Record (MAR) and Physician Order Summary (POS) revealed the following orders were received for Resident #4 during her course of pain and discomfort beginning on 7/27/25 through 7/28/25: Resident #4 received Lactulose Solution 10 GM/15ML -30 ml by mouth three times a day for constipation for 2 Days, (Hold for loose stool) on 07/28/2025 at 12:00 pm. The resident received Tylenol 325 mg 2 tablets, prn every 4 hours on 7/27/25 at 12:30 am., and on 7/28/25 at 10:19 am., On 7/28/25 bladder scan ordered for urinary retention was completed at 1:24 pm. The (MAR) revealed resident was given Albuterol Sulfate Inhalation Aerosol on 7/27/25 through 7/31/25 but seemed questionable due to the resident being discharged on 7/28/25 in the evening. On 7/28/25 at 2:58 pm., a STAT Order for Fleets Enema was given to resident rectally per order. On 7/28/25 at 11:15 am., an order for Simethicone Oral Tablet 80 MG (Simethicone) 2 tablet by mouth every 6 hours as needed for Gas pain/bloating, was ordered but not administered. On 7/28/25 at 3:02 pm., A STAT KUB was ordered for Abdominal pain/distention, was not administered due to resident being transported to the hospital at 5:19 pm. A timeline of events leading to residents' hospitalization revealed the following: A review of text messages sent on 7/28/25 from Resident #4 and her daughter/Power of Attorney read: 1:21 am, sent from Resident #4 reading: Help me. 5:56 am., the daughter responded: Hey mom, you ok? You texted me at 1 in the morning to help you. What help did you need? 6:45 am., the resident responded: I'm in pain. 7:54 am., the daughter responded: Ok press your button! what hurts?? Is it your knee? 2:28 pm., the resident responded: No stomach very bad. Help 2:28 pm., the daughter responded: Oh, that's awful. Hit that button!!!!!! 2:29 pm., the daughter responded: If (unknown name) is around ask her to get you help. If no one answers you let me know. On 7/28/25 at 12:04 am., a health status note read resident c/o abdominal pain at 11:20 pm (7/27/25). The resident was repositioned, stated she could not breathe but after repositioned she felt better, pain level went from 8 to 3-4 after repositioning and after ginger ale and her oxygen saturation was 98% on 2L N.C Resident family visited this evening and brought in donuts (Prior to complaining). The resident also ate two peanut butter and jelly sandwiches this evening. Resident is now resting with her eyes closed, fan blowing on bed side. She feels better and felt some relief from her abdominal pain. The resident is not on the BM (Bowel Movement) due list. The above health status note revealed that the resident was not on the list for bowel movement, which could indicate other issues were impending, possibly causing her abdominal pain and discomfort. A review of the Medication Administration Record (MAR) dated 7/27/25 at 12:30 am., read that Tylenol 325 mg, 2 tabs were given. On 7/28/25 at 5:52 a.m., A late entry health status note read that a Certified Nursing Assistant (CNA) reported to this writer that resident experienced an episode of vomiting and has been complaining of pain throughout the night. Upon assessment, resident was observed sitting upright in wheelchair, napping. Resident was gently awakened and assessed. Resident verbalized, My neck has been bothering me all night and I have pain over here, while pointing to the right side of her abdomen. She was unable to describe the quality of the pain and, when prompted with descriptors (pressure, sharp, burning, dull), responded, All of the above. Nurse on duty was alerted and reported that resident received analgesia at the beginning of the shift and is due for the next dose in one hour. Nurse also stated that resident was administered Milk of Magnesia approximately one hour ago. A review of Health status and nursing notes revealed the following: A review of the above nurses' and health status notes revealed that Resident #4 first complained of pain on 7/27/25 at 11:20 pm., was administered Tylenol 2 tablets 325 mg (according to the late entry note), On 7/28/25 at 5:52 am, (6 hours and 32 minutes later) the Certified Nursing Assistant reported that Resident #4 had pain and vomiting throughout the night, pointing to the right side of her abdomen. On 7/28/25 at 6:05 am. (6 hours and 45 minutes later) per health status note resident is still complaining about having abdominal pain, Miralax given for possible constipation. On 7/28/25 at approximately 10:30 am., (11 hours and 10 minutes later) the nurse practitioner came in to evaluate resident for complaining of having abdominal pain and nausea after being notified within 10 minutes by nursing staff of resident's complaints. According to the health status notes neither the on-call doctor nor the Nurse Practitioner were notified in a timely manner of resident's abdominal pain or discomfort for hours, it wasn't until 11 hours and 10 minutes later, that the NP was notified, which resulted in a delay in treatment, neglect and notification. On 7/28/2025 at 12:33 pm., a late entry health status note read: Resident's roommate notified facility staff resident still complaining of pain and shortness of breath (SOB). Vital signs were taken, Resident on 02 at 3 liters per nasal cannula. Nursing staff says she is waiting to hear from primary care provider. On 7/28/25 at 1:53 pm., according to the Medication Administration Record (MAR) resident received 2 Tylenol tablets, 325 mg. The follow-up read was ineffective with pain scale being a 6. According to the health status notes Resident #4 was still experiencing pain and discomfort since her initial complaint of pain, and was administered Tylenol 2 tablets, 325 mg at 11:20 pm, on 7/27/25 for a total of 14 hours and 33 minutes, the resident had still remained at the facility. On 7/28/2025 at 2:00 pm., Late Entry Health Status Note: Resident continues to c/o abdominal pain and right-side neck pain from previous shift and stated that lying down relieves pain some. Not able to consume breakfast. Fluid intake adequate. ADL care was provided. Resident rang call light several times between breakfast and lunch hour c/o pain. NP down to assess resident. New orders given for bladder scan and lactulose x1 along with gas-x x1. Resident stated that gas-x relieved pain minimally. Lactulose ineffective. Bladder scan shown 28cc urine. Verbal order received for resident to have foley placed. Writer disagreed and immediately went to unit. According to the health status note the Power of Attorney (POA) Responsible Party (RP), daughter was not notified of the above issues from the facility staff until 4:49 pm, on 7/28/25, which was 17 hours and 29 minutes later. According to the health status note dated 7/28/25 at 5:15 pm, Resident #4 was picked up by medical transport via ambulance to be transported to the local hospital. The POA was notified of the pick-up time. On 11/15/25 at approximately 6:15 pm, a telephone interview was conducted with the complainant Daughter/Power of Attorney (POA) concerning Resident #4. The resident's daughter said that a text message was sent to her by her mom reading I'm in pain. The daughter thought that her mother was having knee pain, but she indicated that she felt bad because her stomach was hurting. My mother's roommate later mention that my mother was crying and screaming all night long. The resident's daughter also said that she was not informed until late 7/28/25. The daughter also mentioned that the doctor at the hospital said my mom became septic due to having a perforated ulcer. On 11/12/25 at approximately 3:35 pm., an interview was conducted with Licensed Practical Nurse (LPN) #1. LPN #1 said that the resident's daughter visited her on the night of 7/27/25 and that the resident never complained of any discomfort until an hour after the daughter left. LPN #1 said that the resident complained of having a hard time breathing but he repositioned her and she also complained that her stomach was hurting. He said that the resident had eaten 2 sandwiches before her daughter arrived and ate donuts-this was after 8 pm. LPN#1 said the resident started burping and he gave her ginger ale due to her feeling nauseated. It was past 11:00 pm, when she complained of pain. I stayed until she felt better around 12:30am., then I clocked out. LPN #1 also said that when he returned on 7/28/25 to work the 3-11 shift, the nurse that he was relieving said that the resident is not better. LPN #1 also mentioned they tried to transfer the resident to the toilet, but she appeared like she was going to pass out, saying she was having discomfort with her stomach. LPN #1 also that he contacted her daughter later on 7/28/25. LPN #1 also mentioned that he approached the Nurse Practitioner (NP) and said, we should do something. On 11/17/25 at approximately 1:25 pm., an interview was conducted with Certified Nursing Assistant (CNA) #1. CNA#1 said that Resident #4 was able to make her needs known, use a call bell and able to communicate discomfort or pain. CNA #1 said that the morning the resident wasn't feeling good she reported it to the charge nurse that the resident was pointing to her belly saying she wasn't feeling well. The resident didn't want anything to eat in the morning or at lunch, I kept pushing fluids in her. CNA was asked the resident needed to have a bowel movement. CNA #1 said that the resident didn't need to go to the toilet. On 11/17/25 at approximately 3:05 pm, an interview was conducted with the ADON concerning Resident #4. The ADON said there was a delay in treatment relating to the NP waiting too late for the STAT KUB and on sending the resident to the ER. The ADON also said that the family should have been informed of the change in condition but wasn't notified until 7/28/25 at 5:15 pm. The ADON also mentioned that the DON had instructed the unit manager to speak to the NP to send the resident to the ER. On 11/17/25 at approximately 3:25 pm., an interview was conducted with LPN #4. LPN #4 said that on the 3-11 shift on the night of 7/27/25 due to eating a lot of food the resident was complaining of having pain in the back of her neck, with her hand placed on her stomach, the resident was given ginger ale and belched. LPN#4 said, We thought she had indigestion. Compliance with Reporting Allegations of Abuse/Neglect/Exploitation. Date implanted: 9/24. Policy: It is the policy of this facility to report all allegations of Abuse/Neglect/Exploitation or mistreatment. Including injuries of unknown sources and misappropriation of resident property are reported immediately to the administrator of the facility and to other appropriate agencies in accordance with current state and federal regulations within prescribed timeframes. Compliance Guidelines: The facility will develop and operationalize policies and procedures for screening and training employees, protection of residents and for the prevention, identification, investigation, and reporting of abuse, neglect, mistreatment, and misappropriation of property. The purpose is to assure that the facility is doing all that is within its control to prevent occurrences. Identification: Neglect: Failure of the facility, its employees or service providers to provide goods and services to a resident that are necessary to avoid pain. On 11/12/25 at approximately 12:30 pm, a brief interview was conducted with the administrator, asking if the facility had any current (2025) Performance Improvement Plans (PIPs), and Facility Related Synopsis to present to the survey team. The administrator was given 20 minutes to bring in evidence of the above requested documents. On 11/12/25 at approximately 12:53 pm, the Director of Nursing (DON) brought in a PIP. It was reviewed. There was no resident identifiable information on the PIP, no corrective action dates, no Allegation of Compliance (AOC) date. The DON said that it would be 4 weeks from 9/19/25 but later changed the date to 9/29/25. On 11/12/25 at approximately 1:47 pm, the survey team met with the DON, the Assistant Director of Nursing (ADON), and the administrator. They were asked to identify the resident in question for the PIP. The administrator said they were working on HIPAA for privacy, (The Health Insurance Portability and Accountability Act), we're calling it a POC so we can get Past Non-Compliance (PNC) 9/19/25 as our end date. The DON and the administrator meant to say 4 weeks from compliance from date. DON said that the resident's name should have been written on the PIP. The administrator said that we missed the name and date. The following five-point plan was discussed secondary to Resident #4's pain, notifications and abuse concerns: The facility identified Resident #4's care resulted in the areas of pain management, notification and abuse. The facility completed a 100 percent review of all pain assessments in the facility previous to determine like-residents. Staff education was 100 percent for all nursing staff by the Director of Nursing and ADON to educate staff on pain management, notifications and abuse. The Administrator, Director of Nursing and ADON completed weekly audits 5 times per week for 4 weeks to include pain management, notifications and abuse. All Quality Assurance and Performance Improvement (QAPI) findings will be forwarded to the QAPI committee. Corrective action was completed on 9/29/25. On 11/12/25 at approximately 4:05 pm., during the end of day meeting the DON said that the AOC date will be 9/29/25. We have not had any incidents since 9/29/25. The survey team reviewed the PNC POC documents. It was determined by the survey team through interviews, record reviews and resident observations that the above practices were not identified since 9/29/25 nor during the course of the survey from 11/12/25 through 11/17/25. On 11/17/25 at approximately 4:25 p.m., the above findings were shared with the Director of Nursing (DON), the Assistant Director of Nursing (ADON) and via telephone the local Ombudsman was present. An opportunity was offered to the facility's staff to present additional information, but no additional information was provided. It was determined that the facility implemented its Corrective Action Plan, and there was sufficient evidence that the facility corrected the noncompliance and was in substantial compliance at the time of the current survey for the regulatory requirements, F580, Past Non-Compliance.

Based on family and staff interviews, clinical record review, and facility document review, the facility staff failed to maintain hydration for one Resident (Resident #2) in a survey sample of 10 residents.The findings included: Resident #2 was admitted on [DATE]. The discharge hospital orders were reviewed and revealed a hospital physician's order for labs to be drawn in 3 days, however, upon the resultant admission to the skilled nursing facility the Resident was ordered by the physician there to begin drawing labs on 1-29-25 (8 days after admission). The lab draw schedule then went on to be ordered randomly for 2-5-25, 2-8-25, 2-12-25, 2-18-25, and 3-4-25. Weights were ordered on admission, completed daily, and documented as revealed in the review of the clinical record. The hospital discharge summary did denote that if the Resident should experience a 3-pound weight gain in one day or a 5-pound weight gain in one week, that the cardiology physician should be contacted immediately.The Resident's care plan was also reviewed and revealed that worsening edema, and weight gain were to be assessed for, and the physician notified, should this issue arise as it would underscore a worsening condition.Review of the weight documents further revealed that from 2-4-25 through 2-9-25 the Residents weight increased from 121.0 pounds to 128.4 pounds in 5 days. Her weight continued to be elevated and from 2-26-25 until the Resident was discharged to the emergency room on 3-6-25 at 1:17 a.m., (7 days later). The Resident's weight stayed at its highest elevation during this week of 8.8 pounds since the admission weight of (120 pounds), ranging between 127.7 to 128.8. During the Resident's 43 day stay a gradual increase in weight, edema, and shortness of breath, all indicated a worsening condition. There is no indication that the cardiology doctor was ever notified of this, however, four medication changes were made by the skilled nursing facility physician to manage the symptoms of fluid overload. Those 4 medications follow below.1. Bumex 2 milligram (mg) every day ordered 1-21-25 through 2-21-25 (one month), 2-5-25 through 2-6-25 (2 days), then every day from 2-24-25 through discharge. 2. Bumex 1 mg every day ordered 1-28-25 through 1-29-25 (2 days), and 2-18-25 through discharge every day. 3. Metolazone 2.5 mg every day ordered 1-29-25 through 1-31-25 (2 days). 4. Metoprolol 25 mg every day ordered 1-21-25 through 2-2-25 (12 days). A review of nursing progress notes revealed staff documentation that the Resident was noncompliant with her fluid restriction. Interviews conducted with staff and family also revealed that Resident #2 often asked others for fluids such as a roommate, family members, and dining services staff with complaints of thirst.The fluid weight gain experienced by Resident #2 was further questioned as review of the Resident's Intake and output records were reviewed and revealed a concerning revelation. The Resident was ordered to have a 1500 milliliter (ml) fluid restriction for each 24-hour day. The documents showed that upon admission on [DATE] and 1-22-25 no fluids were recorded as consumed. The Resident complained of thirst to her son frequently, and records show a pattern of not providing fluids to the bedridden Resident. The rest of the days documented during her stay of fluid consumption follows below:(January 2025) - 1-23-25 (420 ml), 1-24-25 (712 ml), 1-25-25 (240 ml), 1-26-25 (240 ml), 1-27-25 (1360 ml), 1-28-25 (1500 ml), 1-29-25 (720 ml), 1-30-25 (1490 ml), 1-31-25 (924 ml).(February 2025) - 2-1-25 (1660 ml), 2-2-25 (1440 ml), 2-3-25 (480 ml), 2-4-24 (960 ml), 2-5-25 (720 ml), 2-6-25 (900 ml), 2-7-25 (720 ml), 2-8-25 (482 ml), 2-9-25 (720 ml), 2-10-25 (1200 ml), 2-11-25 (660 ml), 2-12-25 (840 ml), 2-13-25 (480 ml), 2-14-25 (720 ml), 2-16-25 (720 ml), 2-17-25 (478 ml), 2-18-25 (420 ml), 2-19-25 (598 ml), 2-20-25 (598 ml), 2-21-25 (720 ml), 2-22-25 (716 ml), 2-23-25 (598 ml), 2-24-25 (480 ml), 2-25-25 (720 ml), 2-26-25 (720 ml), 2-27-25 (720 ml), 2-28-25 (720 ml).(March 2025) - 3-1-25 (960 ml), 3-2-25 (960 ml), 3-3-25 (716 ml), 3-4-35 (720 ml), 3-5-25 (720 ml).Only one time in January (1-28-25) did Resident #2 receive the 1500 ml of fluids allowed in her special diet. This reveals that the edema, weight gain, and shortness of breath were indeed symptoms of a worsening illness, and not related to fluid consumption nor noncompliance.On 11-17-25 at 3:00 p.m., at the end of day debriefing held with the Director of Nursing (DON), and Assistant Director of Nursing (ADON), they were informed by surveyors of the staff failure to provide adequate hydration required for this dependent Resident. Both stated they had nothing further to provide.

Based on family and staff interviews, clinical record review and facility document review the facility staff failed to provide adequate bathing and ADL care to a dependent resident (Resident #2) in a survey sample of 10 residents.The findings included.Resident #2 was admitted on [DATE] with diagnoses including nephrostomy tubes for urine excretion, chronic heart failure and chronic heart disease with 3 cardiac arterial bypass grafts, an artificial heart valve, and a left ventricular ejection fraction of only 26% revealing a severely weakened heart muscle. The Resident's admission weight was 120 pounds, and she used oxygen in the hospital and was ordered to be administered Oxygen at 3 liters per minute via nasal cannula as needed upon discharge.The Resident's Activities of Daily Living (ADL) records were reviewed and revealed bathing and showering records. Those records indicated that Resident #2 received a bed bath only 3 times, on 1-23-25, 1-24-25, and 3-2-25. Documents recorded refusals to be bathed by the Resident only twice, on 2-10-25, and 3-1-25. No other baths nor showers were provided to Resident #2 during her entire 43-day stay in the facility.Resident #2 had nephrostomy tubes and at times those are known to leak causing a need for frequent bathing. They are inserted into the lower back of a resident to provide a way for urine to flow directly from the kidneys to the outside of the body. The underlying reason for nephrostomy tube surgical insertion is due to a blockage in the normal pathway of urine exit from the body. Movement, while in bed, can compress or disrupt the skin in the areas where the tubes exit the body and interfere with the seal of the tubes in the skin. Staff members (2 LPNs licensed practical nurses and 2 CNAs Certified Nursing Assistants) on the unit where this Resident formerly resided were asked how often bathing was provided to the residents. The response by all was 2 times per week for showers or tub baths, and every day if they received bed baths.Other Residents were placed in the survey sample and reviewed for hygiene care which was found to be adequate. No pervasive odors, nor soiled linens on beds were found. Residents and family members were interviewed and had no issues with hygiene care being provided.On 11-17-25 at 3:00 p.m., at the end of day debriefing held with the Director of Nursing (DON), and Assistant Director of Nursing (ADON), they were informed by surveyors of the staff failure to provide adequate bathing required for this dependent Resident. Both stated they had nothing further to provide.

Based on staff interviews, clinical record review, and review of facility documents, the facility staff failed to provide adequate supervision to prevent accidents for 1 of 10 residents (Resident #1) in the survey sample.The findings included: The facility staff failed to provide adequate supervision to ensure Resident #1 was safe from falling while toiletingResident #1 was no longer a resident of the facility; therefore, a closed record review was conducted. Resident #1 was admitted to the facility on [DATE] after a hospital stay. The resident's diagnoses included acute kidney failure, chronic obstructive pulmonary disease, unsteadiness on feet, and chronic congestive heart failure. The 5-day Minimum Data Set (MDS) assessment with an assessment reference date (ARD) of [DATE] coded the resident as completing the Brief Interview for Mental Status (BIMS) and scoring 10 out of a possible 15. This indicated Resident #1's cognitive abilities for daily decision making were moderately impaired. A synopsis of an event dated [DATE] revealed that Resident #1 had an unwitnessed fall in the bathroom. Resident #1 was left unattended in the bathroom while toileting. The Certified Nursing Assistant (CNA) heard a noise and went into the bathroom and found Resident #1 lying on the bathroom floor. 911 was notified. Resident #1 was pronounced deceased by Virginia Beach Emergency Medical Services at the facility. A review of section GG (Functional Abilities) dated [DATE] of Resident #1's Minimum Data Set (MDS) coded Resident #1 for toileting hygiene (the ability to maintain perineal hygiene, adjust clothes before and after voiding or having a bowel movement) as dependent (helper does all of the effort. Resident does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the resident to complete the activity). A care plan problem dated [DATE] read: I have limited physical mobility r/t weakness. The goal read: I will demonstrate the appropriate use of wheelchair to increase mobility through the review date. The interventions/tasks included, I need assistance of 1 caregiver to transfer bed to chair, chair to bed, and chair to chair. A review of a Virginia Beach Emergency Medical Services Prehospital Patient Care Report dated [DATE] read, Narrative: E10 was dispatched to a cardiac arrest and arrived on-scene to find a pulse less and apneic female patient who had been placed in her hospital bed after being found deceased earlier in the day. On-scene providers explained that they believe she had fallen while attempting to use the bathroom. E10 assessed the patient and found that she was in rigor mortis and presented with no discernible pulse. Upon being presented with a valid and signed DNR, E10 pronounced the patient deceased at 0801 at the scene. See the attached DNR included under attachments. E10 subsequently cleared any addition VBEMS resources, cleared the scene, and returned to service without incident. On [DATE] at 11:52 AM an interview was conducted with the Nurse Practitioner (NP). The NP stated that she did not perform a full assessment of Resident #1 after the fall on [DATE]. The NP also stated that she did not pronounce Resident #1 deceased on [DATE]. The NP further stated that she observed a cut on Resident #1's head near the hairline with bleeding. A review of Resident #1's NP's note dated [DATE] at 9:15 AM read: (Resident name), [AGE] years old female, notification received that she died this morning. Patient was assisted to the bathroom by a staff member. She requested privacy, with staff closing the bathroom door but remaining in the patient room. A short time later a noise was heard and patient was found on the floor of the bathroom without a pulse or respirations. 911 was notified, but upon arrival a DNR was produced signed by the patient. EMS declared time of death.On [DATE] at 12:40 PM an interview was conducted with Licensed Practical Nurse (LPN) #3. LPN #3 stated that a CNA alerted her that Resident #1 was on the floor. LPN #3 also stated that she went to the room and observed Resident #1 lying on the floor in between the toilet and the shower and blood was on the floor. LPN #3 further stated that she did not complete an assessment on Resident #1 or document any information in the resident's medical record regarding this fall due to never experiencing anything like this before in her (7) seven year nursing career and being really shook up. LPN #3 lastly stated, I left the room and when I came back to the room, the Resident was in her bed. I do not know who used the hoyer lift and moved the resident to the bed. I was the charge nurse and did not tell anyone to move her to the bed. The Resident was not responding and did not have a pulse. She had blood coming from her head. She had only been here a few days and I did not know her functional abilities. The facility's Fall policy was presented on [DATE] at 11:20 AM from the Assistant Director of Nursing (ADON) without an effective date. The policy read: Do not move resident until assessment has been completed by the nurse. The Physician's Order Summary (POS) for [DATE] read: Apixaban Oral Tablet 5 MG (Apixaban) Give 1 tablet by mouth two times a day for a fib with a start date of [DATE].A review of Resident #1's nurses note (Unit Manager) dated [DATE] at 18:14:49 PM read, Late Entry: Note Text: Nurse and CNA went to resident's room at 0730 to assist the resident for her shower. Resident requested to use the toilet prior to taking a shower and asked the CNA to step out for privacy. Resident was educated to use the call bell when in need of assistance. Call bell was in place. Shortly after, CNA heard a noise indicating something had fallen. CNA immediately went to the bathroom to check the resident. At 0740, nurse was notified that resident was found lying on the bathroom floor. Nurse promptly responded and assessed the resident. Resident was unresponsive. At approximately 0803, writer was alerted about the incident. Resident had no response to verbal or tactile stimuli. Pulse and respiratory effort were absent. Blood pressure was unappreciated. Pupils were dilated and non-reactive. The resident has a Do Not Resuscitate order in place. Hoyer lift was utilized by two staff to move the resident from the floor to bed. RP/Daughter was informed of the resident's status at 0810. MD was notified at 0820. The resident was pronounced dead by [NAME] NP at 0930. Family came in the facility at 1000. Writer communicated the resident's death to the family with compassion and sensitivity. The family expressed their understanding of the DNR status and shared feeling of loss. Daughter inquired about funeral arrangements and information was provided. The body was respectfully prepared for transport. It was picked up by [NAME] Funeral Home at 1130. On [DATE] at 1:43 PM an interview was conducted with the Rehab Manager. The Rehab Manager stated that Resident #1 required supervision or touching assistance with transfers. The Rehab Manager also stated that supervision or touching assistance with transfers means that the staff should have visual contact with the resident or lay hands on the resident such as on the elbow, hand, arm, the walker, or even using a gait belt while the resident is transferring on and off the toilet. The Rehab Manager further stated that Resident #1 required supervision using her front wheeled walker while performing commode transfers. A review of Resident #1's Physical Therapy Evaluation and Plan of Treatment with a start of care date of [DATE] read: Transfers - Baseline: Supervision or touching assistance. A review of Resident #1's Occupational Therapy Evaluation and Plan of Treatment with a start of care date of [DATE] read: Toileting hygiene - Baseline: Partial/moderate assistance. Toilet/adapted commode transfers - Baseline: Supervision using front wheeled walker. On [DATE] at approximately 4:15 PM, a final interview was conducted with the Director of Nursing and Assistant Director of Nursing. An opportunity was offered to the facility's staff to present additional information. They had no further comments and voiced no concerns regarding the above information.

Based on observations, resident interviews, staff interviews, and a clinical record review, the facility staff failed to recognize and act on symptoms of an exacebation of heart failure for 1 of 20 residents (Resident #10), in the survey sample. The findings included: Resident #10 was originally admitted to the facility 3/6/2025 after an acute care hospital stay. The current diagnoses included chronic non-occlusive DVT and congestive heart failure with a reduced ejection factor of 30 percent. The admission Minimum Data Set (MDS) assessment with an assessment reference date (ARD) of 3/12/2025 coded the resident as completing the Brief Interview for Mental Status (BIMS) and scoring 5 out of a possible 15. This indicated Resident #10's cognitive abilities for daily decision making were severely impaired. An interview was conducted with Resident #10 on 4/9/25 at approximately 12:10 PM. Resident #10 stated she was with a dry cough and she needed to take some cough syrup her mother taught her to make and she had passed the recipe on to her daughter. The resident further stated the cold was not getting any better and it was unusual for the homemade cough syrup not to work. The resident stated the cough syrup normally clears a cold in just a few days and this had been going on for weeks. Resident #10 also stated the edema to her left leg was the results of a blood clot and she did not know why the right leg was swelling. An observation of the left leg, ankle and foot revealed plus two to three pitting edema and the right leg, ankle and foot revealed plus two pitting edema. The resident stated she had compression hose at one time but was told the fit was not good therefore more would be obtained but currently she did not have any. The resident was observed wearing non-skid socks which were leaving indentations into both legs. The resident stated she had not been weighed on 4/9/25 or for a few days therefore she was unaware of her current weight. An interview was conducted with the Assistant Director of Nursing (ADON) on 4/9/25 at approximately 4:40 PM. The ADON weighed the resident and the resident's weight was 149 pounds, an increase of over 3 pounds in one day. A physician's order dated 4/10/25 revealed an additional diuretic, Metolazone Oral Tablet 5 MG, Give 1 tablet by mouth one time a day for CHF, edema for 3 days, was added to the resident's treatment plan. On 4/10/25 at approximately 5:43 PM, a final interview was conducted with the Administrator, the Assistant Director of Nursing (ADON) and a Corporate Consultant. The above information was reviewed, and the ADON stated that the resident wound have ongoing assessments with interventions if needed. If you have heart failure, your heart can't supply enough blood to meet your body's needs. Symptoms may develop slowly. Sometimes, heart failure symptoms start suddenly. Heart failure symptoms may include: Shortness of breath with activity or when lying down. Fatigue and weakness. Swelling in the legs, ankles and feet. Rapid or irregular heartbeat. Reduced ability to exercise. Wheezing. A cough that doesn't go away or a cough that brings up white or pink mucus with spots of blood. Swelling of the belly area. Very rapid weight gain from fluid buildup. Nausea and lack of appetite. Difficulty concentrating or decreased alertness. Chest pain if heart failure is caused by a heart attack. (https://www.mayoclinic.org/diseases-conditions/heart-failure/symptoms-causes/syc-20373142)

Based on observations, resident interviews, staff interviews, and a clinical record review, the facility staff failed to prevent a pressure ulcer and manage care of an avoidable pressure ulcer after it was acquired for 1 of 20 residents (Resident #10), in the survey sample. The findings included: Resident #10 was originally admitted to the facility 3/6/2025 after an acute care hospital stay. The current diagnoses included chronic non-occlusive DVT and congestive heart failure with a reduced ejection factor of 30 percent. The admission Minimum Data Set (MDS) assessment with an assessment reference date (ARD) of 3/12/2025 coded the resident as completing the Brief Interview for Mental Status (BIMS) and scoring 5 out of a possible 15. This indicated Resident #10's cognitive abilities for daily decision making were severely impaired. An interview was conducted with Resident #10 on 4/9/25 at approximately 12:10 PM. Resident #10 stated she had an opened sore on her bottom and it was painful and itched, although the nurses put a bandage on it daily. The resident also stated she used a wheelchair to get around but several hours each day she sits in a reclining chair beside her window and watches the people outside. A review on the resident's person centered care plan revealed the following problem dated 3/6/25: Resident is at risk for impaired skin integrity related to deconditioning, the goal stated, the resident's skin will remain intact through out the review period, 6/17/25, the interventions stated, apply moisturizer as needed to the skin, do not massage over bony prominences and use mild cleansers for peri care/washing. The care plan failed to address the opened area to the resident's sacrum identified on 3/17/25. Based on information from a weekly skin observation tool completed on 3/12/25 Resident #10 had intact skin. The resident was identified to have a sacral pressure ulcer on the weekly skin observation tool completed on 3/17/25. The pressure ulcer measure 4.0 centimeters (cm) by 4.5 cm by 0, but the stage of the pressure ulcer was not documented. The weekly skin observation tool completed on 3/19/25 revealed the resident had an ongoing pressure ulcer to the sacrum and no further documentation was included. The 3/26/25 weekly skin observation tool revealed the resident continued to have an ongoing pressure ulcer to the sacrum and again there was no documentation such as measurements, stage, characteristics or extent of the tissue injury. No further weekly skin observation tools were observed in the clinical record, therefore an interview was conducted with Licensed Practical Nurse (LPN) #4 on 4/9/25 at approximately 12:18 PM. LPN #4 stated the resident's skin assessment was due to be performed on the next shift. An interview was also conducted with the Assistant Director of Nursing (ADON) on 4/9/25 at approximately 4:40 PM. The ADON reviewed the resident's weekly skin observation tools and stated the resident should have had a weekly skin observation completed on 4/2/25 but she was unable to locate it in the clinical record. The ADON further stated she would ensure the weekly skin observation tool was completed that evening. A weekly skin observation tool was completed on 4/9/25 and the documentation stated Resident #10's skin was intact. On 4/10/25 at approximately 11:00 AM an observation was made of Resident #10's sacral pressure ulcer with the ADON and LPN #4. The observation revealed the resident had three small openings in the crack of the buttock, the injured tissue was pink, without drainage and measured 2.5 cm by 1 cm. The sacral pressure ulcer was assessed to be a stage two. On 4/10/25 at approximately 5:43 PM, a final interview was conducted with the Administrator, the ADON and a Corporate Consultant. The above information was reviewed, and the ADON stated that the resident should have ongoing weekly skin observations and the findings should be documented on the tool, The ADON also stated the an order had been obtained for the pressure ulcer to be assessed weekly and the characteristics documented in the nurse's notes.

Based on observation and staff interviews, the facility staff failed to adhere to hand hygiene practices to help prevent the development infections for 1 of 20 residents (Resident #9), in the survey sample. The findings included: Resident #9 was originally admitted to the facility 7/27/2023 and readmitted [DATE] after an acute care hospital stay. The current diagnoses included afib, diabetes and high blood pressure. The admission significant change annual quarterly Minimum Data Set (MDS) assessment with an assessment reference date (ARD) of 2/17/2025 coded the resident as completing the Brief Interview for Mental Status (BIMS) and scoring 14 out of a possible 15. This indicated Resident #9's cognitive abilities for daily decision making were intact. On 4/9/25 approximately at 11:24 AM, an observation of wound care to the resident's sacral pressure ulcer was conducted. Licensed Practical Nurse (LPN) #7 positioned the resident on his left side with help of Certified Nursing Assistant (CNA) #7. LPN #7 sprayed the sacral wound with the dermal wound cleanser, patted the wound with four by fours, sprinkled Nyastatin powder around the wound bed, put the Hydrofera Blue on the border gauze and placed the border gauze to the resident's sacral wound. The bottom edges of the border gauze folded therefore it had to be removed and another applied to adhere to the resident's skin. LPN #7 failed to remove the gloves used to clean the wound and she failed to wash or sanitize her hand prior to handling the clean wound care supplies. An interview was conducted with LPN #7 immediately after she completed the sacral wound dressing, she acknowledged that she failed to adhere to best practice hand hygiene. On 4/10/25 at approximately 5:43 PM, a final interview was conducted with the Administrator, the Assistant Director of Nursing (ADON) and a Corporate Consultant. The above information was reviewed, and the Administrator stated that LPN #7 had been educated on hand hygiene during pressure ulcer care. Using a clean dressing technique. Step one Assemble all of your wound care supplies that you will need to change the dressing. Clean gloves (sterile gloves are not needed) A clean surface to place everything on (such as a clean piece of aluminum foil or clean paper The new bandage to be applied Saline or wound cleanser to clean the wound Several pieces of gauze to use in cleaning or wiping the wound Trash bag Step two Wash your hands with soap and warm water for 20-30 seconds. After washing and drying your hands, put on clean gloves to remove the old dressing and perform the dressing removal step. Observe if there is fluid or drainage and note the drainage or wound fluid that is on the gauze. Wounds with a lot of fluid draining from them are exuding wounds. Now clean the wound by wiping with some gauze pads and saline or wound cleanser. Wipe the wound in small circles this from the middle of the wound outward and finally the skin around the wound edge. You may need several pieces of gauze. Dispose of the dirty bandage, gauze used to clean the wound, and dirty gloves in the trash. Step three Measure the wound and record the length and width and the depth of the wound. Measuring should occur anytime the wound looks different and at least once per week. Write the measurements down so you can give them to your doctor or nurse. Step four Rewash your hands with soap and water for 20-30 seconds and dry them. Put on a new pair of clean gloves (you do not need sterile gloves). Now you will apply the new wound treatment and dressing. Your doctor may prescribe a medication to apply, such as an ointment, a gel, a liquid, or a spray. The medication should be applied as directed and, if needed, to spread it across the wound, clean cotton-tipped applicator like a Q-tip should be used. After any medication has been applied, you will place the primary dressing (this is the one that is placed in contact with the wound bed first). The primary dressing will then be covered by a secondary dressing (if one is recommended by your doctor). The dressing may have a part that sticks to the skin to hold it in place, or you may need to use tape to secure the secondary dressing. If no secondary dressing is used, you may need to secure the primary dressing with bandage tape. There are several types of dressings, each used for different reasons, and we will describe them below with some tips for correctly applying them to the wound (https://cert.vohrawoundcare.com/how-to-change-a-wound-dressing/). Hydrofera Blue CLASSIC® is a PVA foam that improves epithelialization while wicking exudate and debris from the wound bed, resulting in a multifaceted, non-toxic healing environment that kills bacteria and reduces bioburden. (https://www.woundsource.com/product/hydrofera-blue-classic)

Based on interview, clinical record review and facility documentation the facility staff failed to ensure allegations of abuse and neglect to include injuries of unknown origin, are thoroughly investigated for one (1) Resident (#1) in a survey sample of 20 Residents. The findings included: For Resident #1 the facility staff failed to thoroughly investigate a black and blue bruise to the Resident's chest area. Resident #1 was admitted to the facility on [DATE]. Diagnoses for Resident #1 included but are not limited to dementia, severe protein calorie malnutrition, major depressive disorder, age related physical debility, restlessness, dysphagia, insomnia, osteoporosis, rheumatoid arthritis and pain. Resident #1 ' s Minimum Data Set (an assessment protocol) with an Assessment Reference Date of [DATE] coded Resident #1 as unable to assess, indicating Resident #1 has severe cognitive impairment. In addition, the Minimum Data Set, coded Resident #1 as requiring 4- total dependence, on staff, for Activities of Daily Living care. Resident #1 expired in the facility on [DATE]. On [DATE] a review of the clinical record revealed the following note from RN#1: [DATE] 10:35 a.m. The above resident has an area to her chest which is black and blue will notify the nurse practitioner. Between [DATE] - [DATE] attempts times three made to contact RN #1 (who discovered the black and blue to Resident #1's chest) were met with a recording stating the phone number was unable to accept calls at this time. On the morning of [DATE] an interview was conducted with the Administrator who was asked who the Abuse Coordinator is, and he responded that he was. When asked if an injury of unknown origin should be reported to the physician, Resident Representative and the appropriate state agencies, he stated that it should be investigated and reported. At that time a request was made to the Administrator to for the investigation into this injury of unknown origin, the Administrator stated that he did not have any FRI's (Facility Reported Incidents) related to the Resident #1 and an injury of unknown origin. On [DATE] at approximately 2 p.m. an interview was conducted with CNA #2 who stated that if the CNA's find any new skin areas, either injury or skin breakdown they are supposed to immediately report it to the nurse on the floor. On [DATE] at 3:00 pm an interview was conducted with LPN #4 who stated that the facility policy is to notify the physician, and family of any injury or changes in condition for all Residents. When asked if a discolored area is described as black and blue would that be something that should be reported to the physician and family she stated that it should. When asked if a black and blue area to the chest, is found on a Resident who is nonverbal, should be of concern, she stated that it would be a bigger concern. When asked why this would be a bigger concern she stated that it could possibly be from abuse or neglect. On [DATE] at approximately 5:00 p.m. an interview was conducted the ADON who stated that it is the expectation of the facility to notify the physician and Resident Representative of any changes in the condition of the Resident to include any injury of unknown origin. The ADON was asked to provide any documents related to the injury of unknown origin. A review of the policy entitled Abuse, Neglect and Exploitation revealed the following excerpt from page 5: V. Investigation of alleged, abuse, neglect, and exploitation. A. An immediate investigation is warranted when suspicion of abuse, neglect, or exploitation, or reports of abuse, neglect or exploitation occur. B. Written procedures for investigations include: 1. identifying staff responsible for investigation. 2. Two. Caution and handle evidence that could be used in a criminal investigation (e.g., not tampering or destroying evidence) 3. Investigating different types of alleged violation. 4. Identifying an interviewing, all involved persons, including the alleged victim, alleged, perpetrator, witnesses, and others who might have knowledge of allegations. 5. Focusing the investigation on determining if abuse, neglect, exploitation, and/or mistreatment has occurred, the extent, and cause, and 6. Providing complete and thorough documentation of the investigation. On [DATE] during the end of day meeting the Administrator was made aware of the concerns and no further information was provided.

Based on interview, clinical record review and facility documentation, the facility staff failed to immediately notify the physician and also notify the Resident's Representative when there is a significant change in the resident condition for one Resident (#1) in a survey sample of 20 Residents. The findings included: For Resident #1 the facility staff failed to notify the Resident Representative of changes in skin condition, (injury of unknown origin, skin tear, possible pressure areas, and open area on shoulder). Resident #1 was admitted to the facility on [DATE] with diagnoses that included but are not limited to dementia, severe protein calorie malnutrition, major depressive disorder, age related physical debility, restlessness, dysphagia, insomnia, osteoporosis, rheumatoid arthritis and pain. Resident #1's Minimum Data Set (an assessment protocol) with an Assessment Reference Date of [DATE] coded Resident #1 as unable to assess, indicating Resident #1 has severe cognitive impairment. In addition, the Minimum Data Set, coded Resident #1 as requiring 4- total dependence, on staff, for Activities of Daily Living care. Resident #1 expired in the facility on [DATE]. On [DATE] a review of the clinical record revealed that on several occasions changes in Resident #1's condition were not reported to the Resident Representative. On [DATE] a review of the clinical record revealed the following notes from RN#1: [DATE] 10:35 a.m. The above resident has an area to her chest which is black and blue will notify the nurse practitioner. [DATE] 2:27 a.m.- This nurse noted skin tears/skin flaps on bilateral posterior wrist that had dried blood on the areas. Resident crosses arms and has been noted scratching self at times, Areas cleaned and steri strips applied, booked for medical. [DATE] 10:05 p.m. - Redden [sic] blisters noted to outside of both feet no discomfort noted. [DATE] 2:04 a.m. -Open area noted on left posterior shoulder. New treatment initiated. Left posterior shoulder- Cleanse with DWC [Dermal Wound Cleanser], pat dry, apply bacitracin and cover with a foam dressing or border gauze, Q Day. Every evening shift for wound care. Referred to medical for further orders. Will have on coming shift notify POA. On the morning of [DATE] an interview was conducted with the Administrator who stated that when he started working at the facility, he cleaned house. When asked what was meant by the phrase cleaned house, he stated that they had gotten rid of staff that were not performing to facility expectations. [DATE] at 4:00 p.m. an interview was conducted with the ADON who stated that she has only been working in the facility a month but reviewed the record and was unable to find documentation of immediate Physician and / or RP notification of changes in condition for [DATE], [DATE], [DATE], and [DATE]. A review of Resident#1's care plan revealed the following: FOCUS: Resident is at risk for impaired skin integrity r/t incontinence, r/t impaired mobility. Date Initiated: [DATE] GOAL: Resident skin will remain intact throughout the review period. Date Initiated: [DATE] Revision on: [DATE] Target Date: [DATE] Keep skin dry, clean and well lubricated Date Initiated: [DATE] Monitor skin condition daily during care and report changes Date Initiated: [DATE] INTERVENTIONS: Report to MD any signs of deterioration or significant change to area of impairment Date Initiated: [DATE] Skin Observation Date Initiated: [DATE]. A review of the policy entitled Notification of Changes dated 9/2024 read: Page 1: Policy: The purpose of this policy is to ensure the facility promptly consults the resident's physician and notified consistent with his or her authority the residents representative when there is a change requiring notification. Compliance Guidelines: Circumstances requiring notification include: 1. Accidents a. Resulting in injury b. Potential to require physician intervention. 2. Significant change in the residents physical, mental or psychosocial Condition such as deterioration in health, mental or psychosocial status that may include: a. Life -threatening conditions or b. Clinical complications 3. Circumstances that require a need to alter treatment This may include: a. New treatment b. Discontinuation of current treatment due to: i. Adverse consequences. ii. Acute condition iii. Exacerbation of a chronic condition . On [DATE] during the end of day meeting the Administrator was notified of the concerns and no further information was provided.

Based on interview, clinical record review and facility documentation the facility staff failed to implement the abuse, neglect policy for one (1) Resident (#1) in a survey sample of 20 Residents. The findings included: For Resident #1 the facility staff failed to implement the abuse policy when an injury of unknown origin was found. Resident #1 was admitted to the facility on [DATE]. Diagnoses for Resident #1 included but are not limited to dementia, severe protein calorie malnutrition, major depressive disorder, age related physical debility, restlessness, dysphagia, insomnia, osteoporosis, rheumatoid arthritis and pain. Resident #1 ' s Minimum Data Set (an assessment protocol) with an Assessment Reference Date of [DATE] coded Resident #1 as unable to assess, indicating Resident #1 has severe cognitive impairment. In addition, the Minimum Data Set Coded Resident #1 as requiring 4- total dependence, on staff, for Activities of Daily Living care. Resident #1 expired in the facility on [DATE]. On [DATE] a review of the clinical record revealed the following note from RN#1: [DATE] 10:35 a.m. The above resident has an area to her chest which is black and blue will notify the nurse practitioner. Between [DATE] - [DATE] attempts times three were made to contact RN #1 (who discovered the black and blue to Resident #1's chest) were met with a recording stating the phone number was unable to accept calls at this time. On the morning of [DATE] an interview was conducted with the Administrator who was asked who the Abuse Coordinator is, and he responded that he was. When asked if an injury of unknown origin should be reported to the physician, Resident Representative and the appropriate state agencies, he stated that it should be investigated and reported. At that time a request was made to the Administrator to for the investigation into this injury of unknown origin, the Administrator stated that he did not have any investigations related to the Resident #1 and an injury of unknown origin. On [DATE] at approximately 2 p.m. an interview was conducted with CNA #2 who stated that if the CNA's find any new skin areas, either injury or skin breakdown they are supposed to immediately report it to the nurse on the floor. On [DATE] at 3:00 pm an interview was conducted with LPN #4 who stated that the facility policy is to notify the physician, and family of any injury or changes in condition for all Residents. When asked if a discolored area is described as black and blue would that be something that should be reported to the physician and family she stated that it should. When asked if a black and blue area to the chest, is found on a Resident who is nonverbal, should be of concern, she stated that it would be a bigger concern. When asked why this would be a bigger concern she stated that it could possibly be from abuse or neglect. On [DATE] at approximately 5 p.m. an interview was conducted the ADON who stated that it is the expectation of the facility to notify the physician and Resident Representative of any changes in the condition of the Resident to include any injury of unknown origin. The ADON was asked to provide any documents related to the injury of unknown origin [DATE] at 4:00 p.m. an interview was conducted with the ADON who stated that she has only been working in the facility a month but reviewed the record and was unable to find documentation of immediate Physician and Resident Representative notification of changes in condition for [DATE]. On [DATE] a review of the policy, entitled Unexplained Injuries dated 09/2024 24 revealed the following excerpts. All unexplained injuries, including bruises, and injuries of unknown source will be investigated. Policy explanation and compliance: 1. observations of any unexplained injuries shall be reported immediately to the residence nurse. 2. Care and treatment shall be provided to the resident as needed. This includes physician, notification, implementation of physician, orders, or facility protocols. 3. An incident report shall be completed. If an allegation of abuse is made or if the injury is of unknown source reporting and investigating procedures shall be implemented in accordance with the facilities, abuse policies, and procedures. 4. An injury should be classified as injury of unknown source when both of the following conditions are met: a. The source of the injury was not observed by any person, or the source of injury could not be explained by the Resident; and b. The injury is suspicious because of: I. The extent of the injury or ii. The location of the injury (e.g , the injury is located in an area not generally vulnerable to trauma) or: iii. The number of injuries observed in one particular point of time or: iv. The incidents of injuries overtime 5. Relevant information shall be documented in the residence, medical record, including, but not limited to: a physical assessment, findings, including objective description of the injury. b. Risk factors and conditions that could cause or predisposed someone to similar signs and symptoms. c. Notification of physician and his or her response. d. Actions taken to meet the residence, immediate needs and implementation of physician orders. e. notification of resident representative. 6. The facility shall modify the residence care plan as needed to prevent reoccurrence or to stabilize, reduce, or remove underlying risk factors contributing to the injury. A review of the facility policy for Abuse Neglect and Exploitation revealed the following excerpt from page 5: Pg 5: A. The facility will have written procedures to assist staff in identifying the different types of abuse- mental/verbal abuse, sexual abuse, physical abuse and the deprivation by an individual of goods and or services. This includes staff to resident abuse and certain resident to resident altercations. Possible indicators of abuse include, but are not limited to: 1. Resident, staff or family member report of abuse 2. Physical marks such as bruises or patterned appearances such as a handprint, blet or ring mark on a residents body. 3. Physical injury of a resident, of unknown source. On [DATE] during the end of day meeting the Administrator was made aware of the findings and no further information was provided.

Based on interview, clinical record review and facility documentation the facility staff failed to ensure the timely reporting of allegations of abuse and neglect, to include injury of unknown source, for one (1) Resident (#1) in a survey sample of 20 Residents. The findings included: For Resident #1 the facility did not report an injury of unknown origin in the required timeframes. Resident #1 was admitted to the facility on [DATE]. Diagnoses for Resident #1 included but are not limited to dementia, severe protein calorie malnutrition, major depressive disorder, age related physical debility, restlessness, dysphagia, insomnia, osteoporosis, rheumatoid arthritis and pain. Resident #1's Minimum Data Set (an assessment protocol) with an Assessment Reference Date of [DATE] coded Resident #1 as unable to assess, indicating Resident #1 has severe cognitive impairment. In addition, the Minimum Data Set, coded Resident #1 as requiring 4 total dependence, on staff, for Activities of Daily Living care. Resident #1 expired in the facility on [DATE]. On [DATE] a review of the clinical record revealed the following note from RN#1: [DATE] 10:35 a.m. The above resident has an area to her chest which is black and blue will notify the nurse practitioner. Between [DATE] - [DATE] attempts times three were made to contact RN #1 (who discovered the black and blue to Resident #1's chest) were met with a recording stating the phone number was unable to accept calls at this time. On the morning of [DATE] an interview was conducted with the Administrator who was asked who the Abuse Coordinator is, and he responded that he was. When asked if an injury of unknown origin should be reported to the physician, Resident Representative and the appropriate state agencies, he stated that it should be investigated and reported. At that time a request was made to the Administrator to for the investigation into this injury of unknown origin, the Administrator stated that he did not have any FRI's (Facility Reported Incidents) related to the Resident #1 and an injury of unknown origin. On [DATE] at approximately 2 p.m. an interview was conducted with CNA #2 who stated that if the CNA's find any new skin areas, either injury or skin breakdown they are supposed to immediately report it to the nurse on the floor. On [DATE] at 3:00 pm an interview was conducted with LPN #4 who stated that the facility policy is to notify the physician, and family of any injury or changes in condition for all Residents. When asked if a discolored area is described as black and blue would that be something that should be reported to the physician and family she stated that it should. When asked if a black and blue area to the chest, is found on a Resident who is nonverbal, should be of concern, she stated that it would be a bigger concern. When asked why this would be a bigger concern she stated that it could possibly be from abuse or neglect. On [DATE] at approximately 5 p.m. an interview was conducted the ADON who stated that it is the expectation of the facility to notify the physician and Resident Representative of any changes in the condition of the Resident to include any injury of unknown origin. The ADON was asked to provide any documents related to the injury of unknown origin [DATE] at 4:00 p.m. an interview was conducted with the ADON who stated that she has only been working in the facility a month but reviewed the record and was unable to find documentation of immediate Physician and Resident Representative notification of changes in condition for [DATE]. On [DATE] a review of the policy, entitled Unexplained Injuries dated 09/2024 24 revealed the following excerpts. Policy: All unexplained injuries, including bruises, and injuries of unknown source will be investigated. Policy explanation and compliance: 1. observations of any unexplained injuries shall be reported immediately to the residence nurse. 2. Care and treatment shall be provided to the resident as needed. This includes physician, notification, implementation of physician, orders, or facility protocols. 3. An incident report shall be completed. If an allegation of abuse is made or if the injury is of unknown source reporting and investigating procedures shall be implemented in accordance with the facilities, abuse policies, and procedures. 4. An injury should be classified as injury of unknown source when both of the following conditions are met: a.The source of the injury was not observed by any person, or the source of injury could not be explained by the Resident; and b.The injury is suspicious because of: i.The extent of the injury or ii.The location of the injury (e.g , the injury is located in an area not generally vulnerable to trauma) or: iii.The number of injuries observed in one particular point of time or: iv.The incidents of injuries overtime. A review of the facility policy for Abuse Neglect and Exploitation revealed the following excerpt from page 5: Pg 5. A. The facility will have written procedures to assist staff in identifying the different types of abuse- mental/verbal abuse, sexual abuse, physical abuse and the deprivation by an individual of goods and or services. This includes staff to resident abuse and certain resident to resident altercations. Possible indicators of abuse include, but are not limited to: 1. Resident, staff or family member report of abuse 2. Physical marks such as bruises or patterned appearances such as a handprint, blet or ring mark on a residents body. 3. Physical injury of a resident, of unknown source. Pg 5. VII. Reporting / Response A. The facility will have written procedures that include: 1. Reporting of all alleged violations to the Administrator, state agency, adult protective services and to all other required agencies (e.g., law enforcement when applicable) within specified timeframes: a. Immediately but not later than 2 hours if the allegation is made, if the events that cause the allegation, involve abuse OR result in serious bodily injury, or b. Not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury . On [DATE] during the end of day meeting the Administrator was made aware of the findings and no further information was provided.

Based on interview, clinical record review and facility documentation the facility staff failed to have a written agreement with hospice before hospice care is furnished for 1 Resident in a survey sample of 20 Residents. The findings included: For Resident #1 the facility staff failed to have a hospice contract before providing hospice services to the Resident and also failed to maintain hospice records within the clinical record. Resident #1 was admitted to the facility on [DATE]. Diagnoses for Resident #1 included but are not limited to dementia, severe protein calorie malnutrition, major depressive disorder, age related physical debility, restlessness, dysphagia, insomnia, osteoporosis, rheumatoid arthritis and pain. Resident #1's Minimum Data Set (an assessment protocol) with an Assessment Reference Date of [DATE] coded Resident #1 as unable to assess, indicating Resident #1 has severe cognitive impairment. In addition, the Minimum Data Set, coded Resident #1 as requiring 4- total dependence, on staff, for Activities of Daily Living care. On [DATE] at approximately 1 p.m., a review of the clinical record revealed that Resident #1 was started on hospice services on [DATE] with Hospice Provider Other #13. The clinical revealed that the Hospice provider #13 provided services to Resident #1 from [DATE] - until she expired at the facility on [DATE]. Hospice care plan, visit notes, and medication and treatment orders initiated by hospice could not be located in the electronic health record. Employe other #8 (Medical Records) contacted the Hospice provider and obtained paper copies of all the hospice notes and orders not in the EHR. On [DATE] during the end of day meeting the Administrator (who started working at the facility in [DATE]) the ADON (who started on [DATE]) and the Corp Nurse Consultant ant were present. The Administrator stated that there were 3 hospice companies servicing the facility. A review of the three Hospice provider contracts revealed the following: Hospice Provider (Other # 11) had a contract that was signed on [DATE], Hospice Provider (Other #12)'s contract was signed on [DATE] and the third Hospice provider (Other #13)'s contract was signed on [DATE] (the first day of survey). When asked why the contract was signed only 2 days prior, the Administrator stated that he did not know where the previous Administrator had put the Hospice Contracts. He states that he reached out to the hospice company, and they did not have it, so he told them to send a new one. When asked what the communication process is, between the facility and the hospice provider, to ensure that the needs of the resident are addressed, the ADON stated that the nurses communicate with the Hospice company verbally when the nurses and cna's come to the facility and also by telephone. The Corporation Nurse Consultant stated that they needed to look into giving hospice access to the EHR On [DATE] during the end of day meeting the Administrator was made aware of the concerns and no further information was provided.

Based on observation, resident interview, staff interview, and a clinical record review, the facility staff failed to ensure medications were administered in accordance to accepted professional standards for 1 of 20 residents (Resident #9), in the survey sample. The findings included: Resident #9 was originally admitted to the facility 7/27/2023 and readmitted [DATE] after an acute care hospital stay. The current diagnoses included afib, diabetes and high blood pressure. The admission significant change annual quarterly Minimum Data Set (MDS) assessment with an assessment reference date (ARD) of 2/17/2025 coded the resident as completing the Brief Interview for Mental Status (BIMS) and scoring 14 out of a possible 15. This indicated Resident #9's cognitive abilities for daily decision making were intact. On 4/8/25 at approximately 10:54 AM, Resident #9 was observed in bed asleep. The resident did not answered when the door was knocked on. Upon entrance into the room to awaken the resident it was observed that a medication cup with approximately ten pills of various sizes and colors was on the bedside table. The resident stated he could not take them when the nurse brought them in because he had a piece of candy in his mouth and it was still in the roof of his mouth. The resident was reminded of the time and the wound care observation and he stated he would take them as soon as he finished his candy. An interview was conducted with Licensed Practical Nurse (LPN) #7 on 4/8/25 at 11:04 AM regarding the medication observed at Resident #9's bedside. LPN #7 stated the resident is non-compliant with all aspects of care and he would not accept the medications when she went in to administer them therefore they were left upon his request. LPN #7 went into the residents room and returned with an empty medication cup in her hand. She stated he had taken them. On 4/9/25 at approximately 5:43 PM, a final interview was conducted with the Administrator, the Assistant Director of Nursing (ADON) and a Corporate Consultant. The above information was reviewed, and the Administrator stated LPN #7 should not have left the resident's medications at the bedside, she should have returned them to the medication cart.

Based on interview, clinical record review, and facility documentation, the facility staff failed to ensure adequate nutrition to prevent significant weight loss for 1 Resident (#1) in a survey sample of 20 Residents. The findings included: For Resident #1 the facility failed to obtain recognize signs of significant weight loss and consult with the Registered dietician for recommendations as ordered by physician on several occasions, resulting in 29 lb. weight loss from 12/31/24 - 2/11/25. Resident #1 was admitted to the facility on [DATE]. Diagnoses for Resident #1 included but are not limited to dementia, severe protein calorie malnutrition, major depressive disorder, age related physical debility, restlessness, dysphagia, insomnia, osteoporosis, rheumatoid arthritis and pain. Resident #1 ' s Minimum Data Set (an assessment protocol) with an Assessment Reference Date of 1/9/25 coded Resident #1 as unable to assess, indicating Resident #1 has severe cognitive impairment. In addition, the Minimum Data Set, coded Resident #1 as requiring 4- total dependence, on staff, for Activities of Daily Living care. Revealed the following excerpts from the medical provider: 6/16/24 BMI 17.4-Underweight Consider dietary consult for further recs re weight/nutritional. 10/4/24 1p.m. continues to avg. 2 meals/day, weight loss, 89-->85lbs . 12/12/24 11:15 a.m.: BMI 17.2, indicating severe malnutrition. Decline in oral intake reported by nursing, 50-75%, previously75-100%. Measures to sustain intake maintained, including appropriate consistency of food/food preferences. Patient requires assistance to feed. Continue to monitor weight closely. Dietitian to follow regarding potential for weight loss and provide recommendations for nutritional support. Encourage oral intakes tolerated and assist with meals as needed. 1/10/25 - Follow up within 1 week for monitoring- Continue to monitor BMI - Consider dietary consult for further recommendations regarding weight and nutritional status. 1/15/25 GENERAL- Frail/cachectic elderly female, In no acute distress, Limited due to impaired cognition . Follow up within 1 week for monitoring- Continue to monitor BMI (19 - Underweight) - Consider dietary consult for further recommendations regarding weight and nutritional status. A review of the document entitled Nutrition Evaluation dated 1/9/25 signed by the Registered Dietician (other employee#15) revealed the following excerpts: 1 C. Most recent wt. -. [left blank] date [left blank] 3 E. BMI: Underweight/Normal weight/Obese I, II, III/ - Unable to determine Last BMI was 17.2 indicating she is underweight. F. Usual body wt. 85 lbs. G. Ideal body wt. >/= 120 lbs. L. Malnutrition Diagnosis: Detail if not present or if present detail signs/symptoms: Severe PCM [Protein Calorie Malnutrition] as noted. M. At Risk for Malnutrition: NO O. Comments: Additional notes from interview/general appearance/nursing notes/summary/etc. - Unable to determine if there have been any recent wt. changes. Documented PO intakes exceed needs making it likely that resident has maintained wt. or possibly gained. Gain would be beneficial with underweight BMI. Hx of dysphagia with no difficulties tolerating current texture documented. Current nutrition dx of severe PCM remains appropriate. 4. A Recommendations: Provide nutrition recommendation changes, diet order changes, supplement changes, enteral feed changes, etc . -No recommendations as current intake meets/exceeds EEN. Continue plan of care. On the afternoon of 4/9/25 an interview was conducted with Other #7 the current Registered Dietician, who stated that she began in [DATE]. The RD stated that she reviewed the Resident's chart and started house supplements and magic cup. A review of the clinical record revealed that Resident #1 had already been on magic cups with meals since 8/29/23 and the house shakes were not ordered until 2/14/25 the day of the Residents death. Review of the document entitled Care Plan Acknowledgement Form dated 1/17/25 at 1 p.m. signed only by the Social Worker (Other employee #3) boxes checked off were Quarterly / Annual and Comprehensive Care Plan. Written in handwriting on the upper half of the form was the following: [Resident Representative name] Via phone Are the CNA's taking time to feed her? - She takes a while. A review of the policy, entitled Comprehensive Care Plans dated September 2024 read as follows: Policy: It is the policy of this facility to develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights that include measurable objectives, and time frames to meet a residents. Medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment Policy explanation and compliance guidelines 4. The comprehensive care plan will be prepared by an interdisciplinary team, that includes, but is not limited to: a. The attending physician or non-physician practitioner design involved in the president and the residence care if the physician is unable to participate in the development of the care plan. b. A registered nurse with the responsibility for the resident. c. A member of food and nutrition services staff d. The resident and the resident representative to the extent practical. e. Other appropriate staff or professionals in disciplines as determined by the residence needs or as requested by the resident. Examples include but not limited to: 1. RAI coordinator 2. Activities Director/staff 3. Social Services Director / Social Worker 4. Licensed Therapist 5. Family member surrogate or others desired by the resident. 6. Administration 7. Discharge coordinator A review of the clinical record revealed the following excerpts from Resident #1's care plan: Focus: The resident has nutritional problem or potential nutritional problem r/t underweight, poor POI, on hospice. On hospice w/ orders for no routine weights Date Initiated: 08/01/2024 GOAL: The resident will have gradual weight gain (1-2 lbs. per month) through review date. Date Initiated: 08/01/2024 Revision on: 02/13/2025 Target Date: 04/23/2025 Cancelled Date: 02/13/2025 INTERVENTIONS: Monitor/record/report to MD PRN s/sx of malnutrition: Emaciation (Cachexia), muscle wasting, significant weight loss: 3lbs in 1 week, >5% in 1 month, >7.5% in 3 months, >10% in 6 months. Date Initiated: 08/01/2024. RD to evaluate and make diet change recommendations PRN. Date Initiated: 08/01/2024 Revision on: 02/18/2025 As evidenced by documentation of Skilled Nursing Notes in the electronic health record Resident #1 was on skilled care at the time the Focus area was entered (8/1/24) stating she was on hospice. This Resident had previously graduated from Hospice due to lack of decline and was not put back on Hospice until 2-11-25. The Goal is unattainable if you are not checking weights. The interventions are not possible without checking weights and following physician recommendations for dietary consults. On 4/10/25 during the end of day meeting the Administrator was made aware of the concerns and no further information was provided.

2. The facility staff failed to review and revise the person centerd care plan as the resident's condition changed for Resident #10. Resident #10 was originally admitted to the facility 3/6/2025 after an acute care hospital stay. The current diagnoses included chronic non-occlusive DVT and congestive heart failure with a reduced ejection factor of 30 percent. The admission Minimum Data Set (MDS) assessment with an assessment reference date (ARD) of 3/12/2025 coded the resident as completing the Brief Interview for Mental Status (BIMS) and scoring 5 out of a possible 15. This indicated Resident #10's cognitive abilities for daily decision making were severely impaired. An interview was conducted with Resident #10 on 4/9/25 at approximately 12:10 PM. Resident #10 stated she had an opened sore on her bottom and it was painful and itched, although the nurses put a bandage on it daily. The resident also stated she used a wheelchair to get around but several hours each day she sits in a reclining chair beside her window and watches the people outside. A review on the resident's person centered care plan revealed the following problem dated 3/6/25: Resident is at risk for impaired skin integrity related to deconditioning, the goal stated, the resident's skin will remain intact through out the review period, 6/17/25, the interventions stated, apply moisturizer as needed to the skin, do not massage over bony prominences and use mild cleansers for peri care/washing. The care plan failed to address the opened area to the resident's sacrum identified on 3/17/25. On 4/10/25 at approximately 11:00 AM an observation was made of Resident #10's sacral pressure ulcer with the Assistant Director of Nursing (ADON) and Licensed Practical Nurse (LPN) #4. The observation revealed the resident had three small openings in the crack of the buttock, the injured tissue was pink, without drainage and measured 2.5 cm by 1 cm. The sacral pressure ulcer was assessed to be a stage two. On 4/10/24 at approximately 5:43 PM, a final interview was conducted with the Administrator, the ADON and a Corporate Consultant. The above information was reviewed, and the Administrator stated Resident #10's care plan would be revised to address the pressure ulcer. Based on interview, clinical record review and facility documentation the facility staff failed to develop and implement a person-centered care plan that is reviewed and revised for one (1) Resident (#1) in a survey sample of 20 Residents. The findings included: For Resident #1 the facility staff failed to review and revise the care plan after injuries, skin tear, pressure areas, and failed to have the required members of interdisciplinary team input on one care plan meeting. Resident #1 was admitted to the facility on [DATE]. Diagnoses for Resident #1 included but are not limited to dementia, severe protein calorie malnutrition, major depressive disorder, age related physical debility, restlessness, dysphagia, insomnia, osteoporosis, rheumatoid arthritis and pain. Resident #1's Minimum Data Set (an assessment protocol) with an Assessment Reference Date of 1/9/25 coded Resident #1 as unable to assess, indicating Resident #1 has severe cognitive impairment. In addition, the Minimum Data Set, coded Resident #1 as requiring 4- total dependence, on staff, for Activities of Daily Living care. Resident #1 expired in the facility on 2/14/25. A review of the clinical record revealed the following progress notes: 10/22/24 2:27 a.m.- This nurse noted skin tears/skin flaps on bilateral posterior wrist that had dried blood on the areas. Resident crosses arms and has been noted scratching self at times, Areas cleaned and steri strips applied, booked for medical. 1/3/25 10:05 p.m. - Redden [sic] blisters noted to outside of both feet no discomfort noted. 1/25/25 2:04 a.m. -Open area noted on left posterior shoulder. New treatment initiated. Left posterior shoulder- Cleanse with DWC [Dermal Wound Cleanser], pat dry, apply bacitracin and cover with a foam dressing or border gauze, Q Day. Every evening shift for wound care. Referred to medical for further orders. Will have on coming shift notify POA. 2/9/25 9:42 p.m. - Call [sic] to room by CNA noted darken [sic] area under resident [sic] left foot great toe. left [sic] message for on call NP no pain noted. spoke to resident POA Daughter concern [sic] about resident [sic] health condition. Appetite poor. Drinking small sips of water. Reposition for comfort. A review of Resident #1's care plan for skin integrity read: FOCUS: Resident is at risk for impaired skin integrity r/t incontinence, r/t impaired mobility. Date Initiated: 01/23/2025 GOAL: Resident skin will remain intact throughout the review period. Date Initiated: 01/23/2025 Revision on: 02/18/2025 Target Date: 04/23/2025 Keep skin dry, clean and well lubricated Date Initiated: 01/23/2025 Monitor skin condition daily during care and report changes Date Initiated: 01/23/2025 INTERVENTIONS: Report to MD any signs of deterioration or significant change to area of impairment Date Initiated: 01/23/2025 Skin Observations Date Initiated: 01/23/2025 4/10/25 at 4:00 p.m. an interview was conducted with the ADON who stated that she has only been working in the facility a month but reviewed the record and was unable to find documentation of immediate Physician and / or RP notification of changes in condition for 10/15/24, 10/22/24, 1/3/25, and 1/25/25. When asked when care plans should be updated, she stated that when there are changes in a Resident's condition, treatment or new diagnoses the care plan should be updated, and also quarterly with the care plan meetings. A review of the policy, entitled Comprehensive Care Plans dated September 2024 read as follows: Policy: It is the policy of this facility to develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights that include measurable objectives, and time frames to meet a residents. Medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment. Policy Explanation and Compliance Guidelines: 4. The comprehensive care plan will be prepared by an interdisciplinary team, that includes, but is not limited to: a. The attending physician or non-physician practitioner design involved in the president and the residence care if the physician is unable to participate in the development of the care plan. b. A registered nurse with the responsibility for the resident. c. A member of food and nutrition services staff d. The resident and the resident representative to the extent practical. e. Staff or professionals in disciplined as determined by the residents needs or as requested by the resident. Examples include but are not limited to: I. The RAI coordinator ii. Activities Director / staff iii. Social Services Director / Social Worker iv. Licensed therapist v. Family member, surrogate or others desired by the resident. vi. Administrator vii. Discharge coordinator 5. The comprehensive care plan will be reviewed and revised by the interdisciplinary team after each comprehensive and quarterly MDS assessment. 6.The comprehensive care plan will include measurable objectives, and time frames to meet the residence needs as an identified in the residence comprehensive assessment. The objectives will be utilized to monitor the residence progress alternative interventions will be documented as needed. On 4/10/25 during the end of day meeting the Administrator was made aware of the findings and no further information was provided.

Based on observation, Resident interview, staff interview and clinical record review, the facility staff failed to ensure that the baseline care plan was person-centered and effective for one Resident ( Resident # 15) in a survey sample of 20 Residents. 1. For Resident # 15, the facility staff failed to address communication needs for a Spanish speaking resident. The findings included: For Resident #15, the facility staff failed to address communication needs for a Spanish speaking resident. Resident #15 was admitted to the facility on [DATE] with the diagnoses of, but not limited to, Sepsis, Type 2 Diabetes Mellitus, Chronic Kidney Disease Stage 3B, Essential Hypertension and Peripheral Vascular Disease, anemia. Resident #15 was admitted the day prior to the start of the survey. Therefore,no Minimum Data Set (MDS) Assessment was completed because it was too soon. indicating no cognitive impairment. Review of the clinical record was conducted on 4/92025-4/10/2025. Review of the baseline care plan revealed there was no mention of the fact that Resident # 15 spoke Spanish. There were no concerns, goals nor interventions listed for communication. During rounds on 4/8/2025 at 1:15 p.m., Resident # 15 was observed lying in the bed and facing the door. When the surveyor said hello, Resident # 15 turned to the visitor in the room and spoke in another language. The visitor stated he was the son of Resident # 15 and could translate for Resident # 15. On 4/9/2025 at approximately 1:10 p.m., Resident # 15 was observed sitting up in bed. The lunch tray was on the overbed table located at the foot of the bed. There was a staff member standing in the room. The staff member identified herself as Therapy staff and stated the resident did not want to eat. The therapy staff person stated the resident spoke Spanish but that she did not speak Spanish. The Therapy staff member pulled out her cellular phone while stating that she guessed she could try to use the phone to translate. The Resident's son was not in the room. In Spanish, the surveyor asked Resident #15 if she wanted to eat. Resident # 15 responded no. When the surveyor asked Resident #15 if she saw what was on the tray, Resident # 15 stated no. The surveyor lifted the cover on the tray and described in Spanish the foods that were on the tray, Resident # 15 said yes to the fish and potatoes that were on the tray. When the surveyor asked Resident # 15 in Spanish what she wanted to drink, she replied agua (water). She stated she did not want the tea that was on the lunch tray. There was a cup of water on the bedside table Resident # 15 was observed eating some of the fish and potatoes. On 4/9/2025 at 2:10 p.m., Resident # 15 was in the room alone. The son was not in the room. On 4/9/2025 at 4:45 p.m., Resident # 15 was observed sitting was up in the chair by the bed. The son was not in the room. On 4/10/2025 at 9:11 a.m., an interview was conducted with the Certified Nursing Assistant # 2 who stated Resident # 15 spoke Spanish but did say some words in English. Certified Nursing Assistant # 2 stated that Resident # 15's son stated he was available to translate anytime the staff needed him to do it. On 4/10/2025 at 9:18 a.m., an interview was conducted with the Certified Nursing Assistant # 6 stated she was aware that the Resident # 15 spoke Spanish and that she tried to communicate with her by pointing to objects and letting the nurses know if there was something the son needed to help convey. On 4/10/2025 at 1:15 p.m., an interview was conducted with Licensed Practical Nurse # 4 who stated it was important for the staff to be able to communicate with the Resident. Licensed Practical Nurse # 4 stated she had an app on her phone that could help to translate. On 4/10/2025 during the end of day debriefing, the Administrator, Assistant Director of Nursing and Regional Nurse Consultant were informed of the findings. The Administrator stated the facility staff could communicate with Resident # 15 by consulting with the son. The Administrator stated the staff posted the telephone number to a Translation Services line after the surveyor questioned how the staff communicated with the resident. The Regional Nurse Consultant (Corporate-1) stated it was not appropriate for the staff to utilize the son for translation of some of the concerns that might be medical or sensitive to Resident # 15. She stated the staff should use the Translation services line provided by the facility. She also stated that the couple of words Resident # 15 spoke in English did not ensure the resident understood what the staff members were saying. They stated communication needs should be addressed on the care plan. No further information was provided.

Based on resident interview, staff interview, clinical record review, the facility's staff failed to ensure residents were free of significant medication errors for 2 of 7 residents in the survey sample, Resident #7 and Resident #6. The findings included: 1. Resident #7, a post kidney transplant resident was administered 8 days of the wrong medication, Cyclophosphamide, a chemotherapy drug, instead of the prescribed Cyclosporine, a drug used to prevent organ rejection in people who have received a kidney transplant, during his short term stay for rehabilitation. Resident #7 was originally admitted to the facility 4/08/24 after an acute care hospital stay. The current diagnoses included encounter for aftercare following kidney transplant and malignant neoplasm of unspecified kidney except renal pelvis. The admission Minimum Data Set (MDS) assessment with an assessment reference date (ARD) of 04/14/24 coded the resident as completing the Brief Interview for Mental Status (BIMS) and scoring 9 out of a possible 15. This indicated Resident #7 cognitive abilities for daily decision making were moderately impaired. The Person-Centered Care Plan dated 4/10/24 read Resident #7 was receiving antibiotic therapy related to post kidney transplant. The goal for Resident #7 was for the resident to be free of any discomfort or adverse side effects of antibiotic therapy through the review date of 4/26/24. The Interventions for Resident #7 included monitor/document/report as needed (PRN) adverse reactions to antibiotic therapy: diarrhea, nausea, vomiting, anorexia, and hypersensitivity/allergic reactions (rashes, welts, hives, swelling face/throat). A review of the April 2024 Physician's order Summary (POS) read Cyclophosphamide Oral Tablet 25 MG (Cyclophosphamide) Give 4 tablet by mouth two times a day for aftercare following a kidney transplant to start on 4/09/24. A review of the April 2024 Medication Administration Record (MAR) revealed that Resident #7 received Cyclophosphamide Oral Tablet 25 MG (Cyclophosphamide) 4 tablets by mouth two times a day in error. A review of the MAR revealed that Resident #7 received a total of 8 doses of Cyclophosphamide (32 tablets) from 4/10/24-4/17/24 at 9:00 AM., and from 4/09/24-4/15/24 Resident received 7 doses of Cyclophosphamide (28 tablets) in error, at 9:00 PM., A review of the MAR revealed that Resident #7 received his first dose of the correct medication, Cyclosporine Capsule 25 MG Give 5 capsule by mouth two times a day for antirejection on 4/17/24 at 9:00 PM. Resident #7 started receiving his correct anti-rejections medication, Cyclosporine for his new Kidney 8 days after being admitted to the long-term care facility. **Cyclosporine and cyclosporine (modified) are used with other medications to prevent transplant rejection (attack of the transplanted organ by the immune system of the person who received the organ) in people who have received kidney, liver, and heart transplants. Cyclosporine is a class of medication called immunosuppressants. They work by decreasing the activity of the immune system ( https://medlineplus.gov/druginfo/meds/a601207.html#:~:text=Cyclosporine). ***Cyclophosphamide is used to treat cancer of the ovaries, breast, blood and lymph system, and nerves (mainly in children). Cyclophosphamide is also used for retinoblastoma (a type of eye cancer mainly in children), multiple myeloma (cancer in the bone marrow), and mycosis fungoides (tumors on the skin). It belongs to the group of cancer medicines called alkylating agents. Cyclophosphamide is also used for some kinds of kidney disease. Cyclophosphamide interferes with the growth of cancer cells, which are then destroyed by the body. Since the growth of normal body cells may also be affected by cyclophosphamide, other effects will also occur. Some of these may be serious and must be reported to your doctor (https://www.mayoclinic.org/drugs-supplements/cyclophosphamide-oral-route-intravenous-route/description/drg-20063307). On 7/10/24 at approximately 3:15 PM., during a phone conversation with the State Long Term Care Ombudman, it was said that the resident was admitted to the facility on [DATE], with orders for Cyclosporine. The attending physician put in the order to the pharmacy for Cyclophosphamide. The Cyclophosphamide was administered until the staff was able to verify the medication with the kidney doctor on April 17, 2024. The kidney doctor noticed the wrong med and had the resident sent to the hospital for evaluation. The hospital in turn made the change in the medication list and returned the resident to the facility. A review of the Hospital Discharge Summary dated 4/08/24, did not list Cyclosporine as a discharged medication, but read that Resident #7 was transitioned from taking one prescribed medication (Prograf) to start Cyclosporine on 3/25/24. An interview was conducted on 7/11/24 at approximately 10:45 AM., with Licensed Practical Nurse (LPN)/Unit Manager #1. LPN #1 said that the resident was admitted after 5:00 PM., on 4/08/24, the nurse that admitted the resident verified his orders and conducted an admission assessment. LPN #1 also said that the Cyclosporine was not initially listed on the resident's discharge summary until the family member asked them to call the transplant clinic on 4/16/24 concerning the resident's appointment. The Transplant Nurse asked to verify the resident's medication. It was verified as being cyclophosphamide instead Cyclosporine and were asked to send the resident immediately to the hospital so that they could conduct labs, which were okay. On 7/11/24 at approximately 1:15 PM., an interview was conducted with The Medical Doctor (MD)/Other Staff member (OSM) #3. OSM #3 said that as she was re-ordering the new medication, it was written correctly, but ordered incorrectly. The OSM stated,I ordered Cyclophosphamide instead of Cyclosporine. I made a mistake. A review of the above MD's (OSM) #3 History and Physical (H&P) dated 4/09/24 was written correctly as Cyclosporine 100mg twice daily (bid) started. When the medication was being selected, Cyclophosphamide was selected in error from the medications listed in Point Click Care (PCC) per OSM #3. On 7/11/24 at approximately 1:50 PM., an interview was conducted with Family Member (FM) #1. FM #1 said that the anti-rejection medicine was given to her on the night of Resident #7's discharge. FM #1 also said that the resident didn't get to the facility until 9:00 PM., because she transported him to the nursing facility. FM#1 said, I walked in the facility and handed the medications to the nurse giving the medications at the med cart. She assured me that she would give the medications to the resident. I found out later the facility did not take medications from the outside. FM #1 said that the following day she showed the after-visit summary to OSM #3 because the initial documentation from the hospital showed a discontinued medication on the list that had caused an adverse reaction to Resident #7 in the past. FM #1 also mentioned that she spoke to the Unit Manager (LPN #1), alerting them that the Transplant Center was trying to contact them by phone to increase the Cyclosporine. FM #1 also said the nurse called the transplant center concerning the increased Cyclosporine, and LPN#1 said he was on a chemo medication called Cyclophosphamide. The Transplant Center nurse said to send the resident to the ER. An interview was conducted on 7/11/24 at approximately, 3:15 PM., with the Medical Director. The Medical Director said the resident should have been on Cyclosporine but there was a provider error because the correct medication did not appear on the Medication Reconciliation Form from the hospital. The Medical Director said, The wife's list was accurate. We caught the error within 12 hours and sent the resident to the hospital to get labs, labs were good. On 7/11/24 at approximately 4:08 PM., a phone call was made to Resident #7 concerning the above complaint. Resident #7 said that he felt awkward about receiving the wrong medication for his new kidney, It was a rough ride. According to the DON and Administration, no one had been admitted to the facility with transplant organs. On 7/11/24 at approximately 4:25 PM., a phone call was made to Other Staff Member/OSM #6 at the pharmacy company. OSM #6 said that they received a request to process Cyclophosphamide from the facility on 4/09/24, but in turn had to clarify the medication for tablets because the pharmacy needed to change the medication to capsules. A review of the electronic shipping manifest dated 4/09/24 read Cyclophosphamide 25 mg, give 4 tablets by mouth twice daily Permission to change to capsules. On 4/15/24 at 2:00 PM., an order was reviewed/written by the Kidney Transplant Center that read, increase Cyclosporin 125 mg twice daily. According to the MAR Resident #7 was still receiving Cyclophosphamide in error even after the Transplant Center had verified the correct medication. A review of the After-visit Summary Medication list dated on 4/08/24 at 7:00 PM., read Cyclosporine 25 mg 4 capsules by mouth twice daily (Morning and Evening). The last time given at the hospital was on 4/08/24 at 10:50 AM. A review of the Medication Error Report dated 4/16/24 read that during medication verification with the kidney transplant nurse, a medication error was identified. The medication in error was Cyclophosphamide 25 mg, give 4 tablets twice daily. The correct medication Cyclosporine 25 mg, give 4 tabs to equal 100mg twice daily. The Transplant Medical Doctor (MD), and the facility MD were notified as well as family member. Resident #7 was taken to the hospital for further testing. According to the progress report dated 4/16/24 at 12:36 PM., Resident #7 was sent to the local hospital due to a medication discrepancy to be evaluated with ongoing monitoring, family was made aware. According to the progress note dated on 4/17/24 at 12:18 AM., Resident #7 returned from the hospital with a new prescription for Cyclosporine 25 mg take 5 capsules twice daily. On 7/11/24 at approximately 5:25 PM., the above findings were shared with the Administrator and Director of Nursing. An opportunity was offered to the facility's staff to present additional information, but no additional information was provided. 49455 2) For Resident #6 the facility failed to administer ordered anti-seizure medication for three (3) days which was a significant medication error. Resident #6 was admitted to the facility on [DATE], status post right hip replacement from an acute care hospital. Diagnoses for Resident #6 included but are not limited to right hip replacement, hypertension, diabetes mellitus, and seizure disorder. Resident #6's personal centered care plan dated 10/18/2023, noted a focus on seizure disorder with an intervention to administer medications per order. Resident #6's order summary dated 10/17/23 has Phenobarbital (luminal) 32.4 mg to be administered at bedtime for seizure disorder. Review of Resident #6's medical administration record (MAR) for October 2023, documented the medication not being available on 10/17/23, 10/18/23, and 10/19/23. On 10/20/23 at 4:19 AM a progress note was written and indicated that nursing staff called and left a message for pharmacy on 10/20/23 at 8:30 PM about phenobarbital not being available for medication administration. Pharmacy called back at on 10/20/23 3:45 AM and stated they did not have a script on file to dispense medication. Review of a pharmacy shipping manifest reflects Resident #6's medication being shipped on 10/20/23 at 12:23 PM and signed for by facility staff on 10/20/23. Resident #6 received the first dose of Phenobarbital the night of 10/20/23. Resident #6 missed three (3) doses of Phenobarbital. Review of the facility emergency cubex contents were reviewed and Phenobarbital was not available at the facility. An interview was held on 7/11/24 at approximately 12:30 PM with the Assistant Director of Nursing/Educator (ADON). The ADON shared that the process when a resident is admitted with a medication requiring a script to be sent to the pharmacy is: 1) day shift, the onsite provider will fax the script to the pharmacy or 2) off shift, the nurse must call the on-call provider and they have the capability to send the script to the pharmacy. The ADON indicated, either way, the nurse should call the pharmacy to confirm that the script was received. The ADON shared that the turnaround time to receive medications should be no longer than 12 hours and in the interim the nursing staff should see if the needed medication is in the emergency medication supply The ADON shared if it is not in the emergency medication supply the nurse should notify the practitioner that the medication is unavailable, get an order to discontinue the medication or put it on hold, and/or get a substitute. The ADON also shared that nursing staff should notify the resident and responsible party if applicable of all changes made. An interview was held on 7/11/24 at approximately 1:05 PM with one of the facilities Medical Doctors. When asked what the risk were for a resident missing anticonvulsive medication for 2-5 days. The Doctor shared that it depends based on the resident's current medical condition, comorbidities, etc., but having a seizure was certainly possible. The facility Medication Administration Policy was reviewed. There was no noted approved by, effective, or revision dates. The policy read, .medications will be administered in accordance with the orders . Phenobarbital is used to control seizures. (https://medlineplus.gov/druginfo/meds/a682007.html) The above findings were shared with the Administrator and the Director of Nursing on 7/11/2024 at approximately 5:25 PM. No further information was provided prior to the conclusion of the survey.

Based on family interview, staff interview, facility documentation review, and clinical record review, the facility staff failed to respect and honor a resident's right to remain a full code for 1 of 7 residents in the survey sample, Resident #6. The findings included: For Resident #6, the facility staff entered an order for the resident to become a do not resuscitate/do not intubate (DNR/DNI) after the resident was admitted from the hospital as a full code and expressed wishes to remain a full code. On 7/11/24 at 3:35 PM the Administrator and The Director of Nursing were not able to find a signed DNR to support the order placed on 10/18/23-10/23/23 for Resident #6 being a DNR/DNI. Resident #6 was admitted to the facility on [DATE], status post right hip replacement from an acute care hospital. Diagnoses for Resident #6 included but are not limited to right hip replacement, hypertension, diabetes mellitus, and seizure disorder. The quarterly Minimum Data Set (MDS) assessment with an assessment reference date (ARD) of 10/24/23 coded the resident as completing the Brief Interview for Mental Status (BIMS) and scoring 15 out of a possible 15. This indicated Resident #6 cognitive abilities for daily decision-making were independent. Resident #6's personal centered care plan dated 10/18/2023, did not include a code status focus, intervention, or goal. Review of Resident #6's discharge summary from the hospital, discharge instructions from the hospital, and report sheet from the facility all dated 10/17/23 and notes the resident was a full code. The order summary for Resident #6 included an order dated 10/18/23 to change the resident to a DNR/DNI and an order dated 10/23/23 to change the resident back to a full code. An interview was conducted over the phone with Family Member (FM) #2 on 7/10/24 at approximately 3:05 PM. FM #2 shared that the doctor spoke with Resident #6 on 10/18/23 about changing her code status from full code to DNR/DNI. Resident #6 replied no thanks. FM #2 said the doctor proceeded to tell the resident that 30% of hip replacements ends up dying anyway. FM #2 said the resident told the doctor No repeatedly and the doctor left the unsigned DNR/DNI document with the resident. FM #2 asked facility staff for a printout of Resident #6 orders on 10/23/23 to verify medication compliance and saw that Resident #6 was listed as being a DNR/DNI. When FM #2 asked staff to see the signed DNR/DNI document to support the order, they did not have one.FM #2 shared with the nursing staff that Resident #6 did not agree to be a DNR/DNI. The resident's order was changed back to her wishes of being a full code. Resident #6 was receiving dialysis at the time of this interview and was unavailable. An interview was conducted with Licensed Practical Nurse (LPN) #1 on 7/11/24 at approximately 10:50 AM. When asked who speaks with new residents about their code status and advanced directives, she replied, the social worker. An interview was conducted with The Admissions Director on 7/11/24 at approximately 11:15 AM. Who shared her part in residents admissions does not require her to know code status. An interview was conducted with Assistant Director of Nursing (ADON) on 7/11/24 at approximately 12:30 AM. The ADON shared that residents usual come in as a full code from the hospital unless they have a DNR already complete. The ADON voiced that the Doctor would have the conversation with the resident about code status and not the social worker. When asked had she ever witnessed any doctor suggest to a resident that they should change their code status to a DNR, the ADON shared that she had never witnessed it, but in meetings it has been discussed that a doctor may make that suggestion. An interview was held on 7/11/23 at approximately 1:05 PM with one of the facilities medical doctors. This doctor hared that she would not make a suggestion for a resident to become a DNR, but she would make their options very clear. An interview was conducted on 7/11/24 at approximately 2:40 PM with the Social Service Director who shared she does not see the residents until 72 hours after they are admitted to the facility. The facility's your rights and protections as a nursing home resident policy was reviewed with an effective date of 4/14/2003. The policy read, .The right to participate in the decisions that affect your care .To create advanced directives. The above findings were shared with the Administrator and the Director of Nursing on 7/11/2024 at approximately 5:25 PM. No further information was provided prior to the conclusion of the survey.