Every finding on record at Marcella Post Acute

Based on resident interview, staff interview, clinical record review, and facility document review, the facility staff failed to ensure effective pain management was provided for one resident, Resident #28 (R28), out of a survey sample of 42 residents. Specifically, the facility failed to administer the resident's prescribed pain medication as ordered. As a result, R28 experienced withdrawal symptoms, causing actual harm and discomfort. The findings included:On 5/17/26 at 10:30 am, an interview was conducted with R28. During the interview R28 stated, my morphine was not available to be given so oxycodone was ordered one time in the morphine place but that didn't help my pain like the morphine did and I had withdrawal symptoms because I went without the morphine. R28 stated that his morphine order had to be changed because morphine extended release 15mg tablets were not available and were on back order with the pharmacy. On 5/19/26 a clinical record review was conducted. R28's care plan was reviewed and read in part, .Administer analgesia as per orders. Observe for effectiveness and s/sx [signs and symptoms] of side effects. Report abnormal findings to practitioner. Document findings and interventions. Date Initiated: 01/16/2026. R28's progress notes were reviewed. On 1/20/26 a progress note was written and read in part, MORPHINE SUL TAB 15MG ER [extended release] Give 1 tablet by mouth two times a day related to PAIN, UNSPECIFIED.Resident given 10mg of oxycodone PRN [as needed]. A progress note that was written by the NP and was dated 2/26/26 read in part, .Previously, the patient [R28] experienced an acute opioid withdrawal episode on 01/20/2026 when his MS Contin 15 mg twice daily supply was interrupted and he went without medication for 44 hours, presenting with diaphoresis and withdrawal symptoms. He was bridged with oxycodone until his MS Contin refill arrived from the pharmacy. At pain management follow-up on 01/22/2026, all withdrawal symptoms had resolved, and his pain was well-controlled on MS Contin 15 mg twice daily and Lyrica 25 mg at night along with over-the-counter alpha lipoic acid supplement for radicular pain. R28's medication administration records were reviewed for January 2026. R28 was not administered his pain medication, MS Contin 15 mg on January 19th or 20th. R28 missed four doses and was without his MS Contin for 48 hours. R28 received a dose on January 18th at bedtime and received the next dose on January 21st at 8:00 am. While R28 was without his pain medication, MS Contin 15 mg twice daily the NP gave a onetime order dated 1/20/26 at 1:01 pm, which read in part, .oxycodone HCl Oral Tablet 5 MG (Oxycodone HCl) *Controlled Drug* Give 2 tablet by mouth one time a day for Pain One time dose. On 5/17/26 at 10:45 am, an interview was conducted with the Director of Nursing (DON). The DON stated R28's morphine extended release was on back order so a different morphine was ordered, The DON said, there was a gap when we couldn't get the morphine and was working to get another pain med [medication]. On 5/19/26 at 11:00 am, an interview was conducted with the nurse practitioner (NP). The NP said, I expect them to get pain medication from stat box and if not available to let me know we will get something if they are in pain right now my goal is to get the medicine right now. The NP stated that the new pharmacy was more difficult; however, the NP stated, the facility does have a big enough stat box and if the stat box does not have enough, I will order something else until their medications arrive. The NP stated that R28 is followed by pain management. The NP said, I don't expect anyone on schedule pain management to go without medications. The nurses brought it to my attention and R28 just kept saying he didn't want to go into withdrawal; however, the NP said, I don't know if he actually had symptoms. The NP stated that the staff needs to make sure his medications were available because he likes to have his medications. The NP said, I was told that the pharmacy delivery was a two-day turnaround, but you may want to check with the staff about that. On 5/19/26, a facility document review was conducted. The facility document titled, Pain Assessment and Management, read in part, The purposes of this procedure are to help the staff identify pain in the resident, develop interventions consistent with the resident's goals and needs, and address the underlying causes of pain. Evaluate for possible physiological signs of pain, including a. increased blood pressure; b. tachycardia; c. increased respirations; d. diaphoresis; e. anorexia; or f. somnolence. Establish a treatment regimen that is specific to the resident based on consideration of the following: a. The resident's medical condition; b. Current medication regimen; c. History of addiction or opioid use disorder; d. Nature, severity, and cause of the pain; e. Course of the illness; and f. Treatment goals. The facility documentation titled, Pain - Clinical Protocol, read in part, .The provider and staff will identify individuals who have pain or who are at risk for having pain. This includes reviewing known diagnoses and conditions that commonly cause pain, for example, degenerative joint disease, rheumatoid arthritis, osteoporosis (with or without vertebral compression fractures), diabetic neuropathy, oral or dental pathology, and post-stroke syndromes. b. It also includes a review for any treatments the resident currently is receiving for pain, including complementary and non-pharmacologic treatments. 3. Staff will provide a comfortable environment and appropriate physical and complementary interventions, example, local heat or ice, repositioning, massage, and the opportunity to talk about chronic pain. 4. If the some provider determines opioid medication is an appropriate option for managing acute, sub-acute, or cases chronic pain in the resident, the lowest possible effective dose is prescribed for the shortest time possible with ongoing staff monitoring for effectiveness and adverse effects. 5. Combining opioids and benzodiazepines is avoided. If prescribed concomitantly, the resident will be carefully monitored for respiratory depression, risk of falling, cognitive impairment/confusion, daytime fatigue, and delirium. On 5/19/26 at 2:42 pm, a meeting was held with administrator, director of nursing, vice president of operations, vice president of clinical services, and the regional director of clinical services. They were informed of the above concerns. They were made aware of the pain medication that was not administered due to unavailability, pharmacy could not fill the medications, the morphine order had to be changed, R28 went 2 days without the pain medication and had withdrawal symptoms. No additional information was provided prior to the exit conference.

Based on staff interview, clinical record review, and facility document review, the facility staff failed to protect one resident, Resident #36 (R36) from a resident-to-resident altercation out of a survey sample of 42 residentsThe facility staff failed to protect R36 from a resident-to-resident altercation occurring on 11/13/25, which resulted in a left thumb fracture thus constituting harm to R36. The facility staff failed to identify and/or implement appropriate interventions, supervision, and monitoring to prevent the altercation.The findings included:A facility policy titled, Abuse, Neglect, Exploitation and Misappropriation Prevention Program, revised April 2021, specified, Residents have the right to be free from abuse, neglect, misappropriation of resident property and exploitation. On 5/18/26, a review of the incident report detailing the altercation between R36 and another resident was completed. The incident report read in part, .the perpetrator [name redacted] entered R36's [name redacted] room and struck him on the chest. Residents were separated immediately. R36 [name redacted] was evaluated by the provider. No emergent treatment was needed. Perpetrator [name redacted] was placed under 1:1 supervision until local law enforcement can determine next steps. On 5/18/26, a review was conducted of the perpetrator's clinical record. A progress note dated 11/13/2025 at 1:45 PM, read, Resident was observed to be in another resident's room at approximately 11:40am when staff heard yelling out and a thud, staff responded to noise and found that resident struck another resident [R36] in the chest. Staff tried to redirect him [perpetrator] out of the room when he continued to be aggressive towards staff. Resident exited the room and was provided 1:1 by staff members and kept on unit and walked with resident. Resident was given prn [as needed] ativan without success. At approximately 1220 [12:12 pm] Sheriffs responded and entered the unit, upon approach and speaking with resident he became aggressive resulting in sheriffs detaining resident and escorting out of the building. Paramedics arrived and assessed resident and he was transported to [name redacted] emergency room via Sheriffs vehicle for evaluation at 1330 [1:30 PM]. Resident Representative [name redacted] was updated throughout the incidence and of the outcome. Following the altercation, R36 was ordered an x-ray to his left hand due to pain. The results of the 11/13/25 Xray revealed one of the views suggested a nondisplaced vertical fracture involving the proximal radial corner of the first distal phalanx. R36's clinical record included a subsequent physician's progress note that read in part, .the patient was being treated for a left thumb fracture following a reported physical assault in the facility. He was wearing a splint and receiving pain management with Tylenol and hydrocodone-acetaminophen as needed. On 5/19/26 at 10:52 am, an interview was conducted with the Director of Nursing (DON). The DON stated that when the perpetrator was showing aggressive behaviors, we had him on frequent monitoring. She said, Psychiatrist was seeing him, we did hourly behavior watch, and monitored his behavior. He punched his roommate's television and after this behavior on October 14, 2025 we moved him to a private room, so he would not have a roommate. The DON stated that when this incident happened with R36 that 911 was called and the perpetrator was taken out of the facility by the police. The DON stated she called APS (adult protective services) for guidance with the situation and they instructed her to call the police. She stated that they implemented one on one supervision until the police arrived to detain the perpetrator. The DON said, EMS [emergency medical services] evaluated [name redacted] the perpetrator and then the police took him to the emergency room. The DON stated that R36 was upset and was mad about the situation. She stated that he was seen immediately by the provider. She stated that R36 said, he hit him in the chest and then he stated he put his hand up and was hit in the hand. The DON stated that pain management was involved due to the pain R36 was having after the altercation. She stated that we were arranging for the nurse practitioner and counseling services to see R36. The DON stated that R36 said, don't let him back in here and I want to press charges. The DON stated that they were providing him with reassurance, that the perpetrator was out of the building and was not going to come into R36's room anymore. On 5/19/26 at 2:42 pm, an end of day meeting was held with the Administrator, the Director of Nursing (DON), [NAME] President of Clinical Services, [NAME] President of Operations and the Regional Director of Clinical Services. They were informed of the concerns with R36's incident with a resident-to-resident altercation. The DON said, it was sad, never want to see that happen. We have a responsibility to protect the resident. We tried to find an appropriate placement. She stated that they did a plan of correction for past noncompliance. On 5/19/26 the past noncompliance plan of correction was provided and was as follows: Quality Assurance Performance Improvement Plan - Post Acquisition Past Noncompliance Abuse/Neglect/Exploitation/Misappropriation Facility Name: [name redacted]Date of Ownership Change: September 11th, 2025 1. Statement Regarding Change of Ownershipa. The current ownership was not involved in the clinical operations, staffing practices, or systems in place prior to this date. Therefore, while we acknowledge the survey findings, the current entity cannot retroactively correct deficient practices that may have occurred before the acquisition date.b. Post transition the facility conducted acomprehensive operational and clinical review to assess compliance with federal participation requirements and to implement systems necessary to ensure resident safety and regulatory compliance. 2. Corrective Measures Implementeda. Staff Education i. Education topics included:1. Definitions of Abuse. Neglect, Exploitation, and Misappropriation2. Mandatory reporting requirements3. Investigation timelines4. Immediate resident protection procedures5. Non-retaliation6. Documentation 3. Monitoring and Quality Assurance Plan a. Audit Processb. i. The Director of Nursing or designee will conduct a weekly audit of ten risk events to ensure appropriate identification of abuse allegations.ii. The Director of Nursing or designee will audit abuse event reports weekly to ensure timely reporting and investigation. iii. The Director of Nursing or designee will conduct weekly audits of newly hired staff personnel records to ensure appropriate background and licensure/certification checks are in place. Quality Assurance Performance Improvement (QAPI) Oversight i. The results of the audits will be reviewed during monthly QAPI Committe meetings. ii. The QAPI Committee will review and make recommendations to address the findings of the audits.iii. The audits will continue until the QAPI Committee has determined that there is substantial compliance at which time they may decrease the frequency of the interviews or resolve them. iv. An Ad Hoc QAPI Committee Meeting has been held to review this QAPI Plan. Staff education signature sheets were provided along with the education given, the audits were provided, and QAPI [quality assurance and performance improvement] minutes were provided for review. On 5/19/26, a review of the plan of correction (POC) for the resident-to-resident altercation that involved R36 was conducted. After the review by the team, the POC was accepted for past noncompliance and the administrative staff was notified. No additional information was provided prior to exit conference.

Based on observation, staff interview, policy review and facility document review, the facility staff failed to maintain all mechanical, electrical, and patient care equipment in safe operating condition. The findings included:The facility policy titled, Personal laundry Handling and Processing Policy with a reviewed date of 2/1/25 read in part, Lint traps should be checked, brushed and cleaned at least every hour unless state/local requirements prescribe more frequent attention. Lint trap cleanings should be documented on the Lint Trap Cleaning Log.The facility synopsis of events was reviewed and read in part, .concerning the fire that occurred Thursday January 22, 2026, there were no negative outcomes/injuries resulting from this incident. At approximately 9:22 AM Thursday January 22, 2026, the fire alarm went off. Maintenance Director went directly to the fire alarm panel to see where the alarm was originating from. Staff alerted Maintenance Director on the way to the fire and when entering the laundry room, there was smoke coming from dryer #3. Maintenance Director quickly grabbed the fire extinguisher and opened the lint trap doors to see embers of lint. The lint embers were extinguished and an all clear was notified. In the conclusion, the report stated, Following the incident, the excess of lint build up was found to be the result of new linen towels and washcloths being laundered at the facility. This required more frequent cleaning of the lint trap. (Environmental Services District Manager) also implemented 2-hour rounds completed by the Environmental Services Director. A new wiring harness was purchased and installed, tested without issues. On 5/17/26 at 4:10 PM The Maintenance Director was interviewed and stated, The lint trap hadn't been cleaned like it was supposed to. They are supposed to clean it or empty it every hour. There were no flames or anything, just heavy smoke, the fire alarm sounded and the fire department responded, all of that went smoothly and as it should have. The Maintenance Director stated the laundry staff are supposed to empty the trap every hour and his department takes it apart and thoroughly cleans it each week. On 5/17/26 at 4:24 PM the Director of Environmental Services was interviewed. She stated the lint trap is supposed to be emptied every hour. She stated, The one working that morning didn't do it. We have this log we fill out every time we do it, and she had filled out the log for her whole shift which was 5:00 am to 1:00 PM and it was only 9:40 AM. She was terminated. Now the staff check it every hour and I check it every two hours. When asked to clarify if she is checking the lint traps or the log she stated she is checking both. She provided the log for the surveyor to review and opened each lint trap on the three dryers for observation as well. No concerns were identified. The area behind the machines was checked as well with no concerns identified. On 5/17/26 at 4:43 PM the District Manager for the company was interviewed and stated, During orientation, new employees get educated on the process of checking the lent traps. Since the fire all the laundry staff received corrective actions, and the manager is to check the traps at least every 2 hours and ensure the log is being kept accurately. On 5/18/26 at 5:35 PM the survey team met with the Administrator, Director of Nursing, Assistant Director of Nursing, Staff Development Coordinator, Regional [NAME] President of Operations and Regional Director of Clinical Services. This concern was reviewed with them at that time. No further information was provided to the survey team prior to the exit conference.

Based on observation, resident interview, family interview, staff interview, and facility document review, the facility staff failed to maintain an effective pest control program to address and prevent the presence of insects throughout the facility. The findings included: The facility staff failed to maintain an effective pest control program to address the presence of cockroaches, ants, and other insects within resident care areas. On 05/17/2026 at 10:05 AM, during an interview on the [NAME] unit with Resident #59, the surveyor observed a brown insect near the resident's bed. The insect crawled toward the closet and disappeared. The resident reported issues with cockroaches, gnats, flies, and ants. During this observation, a second insect was observed crossing the floor across from the area where the first insect had been observed. The surveyor was able to capture the insect in a napkin. Resident food items were observed to be covered or stored in their original containers. The Director of Nursing (DON) was shown the insect and stated she could not confirm what type of insect it was. On 05/17/2026 at 10:35 AM, during an interview, Resident #29 stated they had water bugs and roaches, and they had previously requested facility staff to pull the bed from the wall to prevent an insect from crawling into the bed. During initial tour on 05/17/2026, Resident #149 reported concerns regarding insects in their room. On 05/17/2026 at 11:27 AM, Resident #3 stated they had observed roaches a few nights prior and little, tiny ants had come out with their meal tray. The residents stated that the ants had been killed; however, they were not provided a replacement meal tray. On 05/17/2026 at 2:20 PM, during an interview with a family member of Resident #50, this family pointed out a dead brown insect in the air conditioning unit on the wall and behind the bed. The family member also reported observing ants in the windowsills and stated they did not believe the residents' room had been cleaned enough. On 05/18/2026, during a resident council meeting, residents expressed concerns regarding insects being in ice machines and stated at night you can hear creatures in the ceiling, and they are in the vents. The resident council also stated there were issues with ants. On 05/18/2026 at 1:12 PM, the surveyor observed small ants on a snack cart brought from the kitchen the previous day and placed in the conference room. On 05/18/2026 at 2:30 PM, on the [NAME] unit a live water bug was observed in the bed with Resident #111 by Licensed Practical Nurse (LPN) #4. The resident was observed to be yelling and the Assistant Director of Nursing assisted with getting the insect from the resident's bed. On 05/19/2026 at 10:56 AM, the surveyor observed a live brown insect resembling a cockroach that measured 1 and 1/4 inches in length underneath the ice machine on the [NAME] unit. On 05/19/2026 at 12:00 PM, during an interview with the facility exterminator, this staff identified the insect found under the ice machine as an American cockroach. The exterminator stated the facility received weekly extermination services with additional services as needed. Regarding live activity this staff stated he saw water bugs (American cockroaches), and ants on some of the units in the windowsills. The exterminator stated logs were maintained at each nurse's station and reviewed during service visits. Review of the pest control invoices revealed that an exterminator had provided services to the facility twenty-one times between 02/04/2026-05/13/2026 and treatment had been provided for roaches and/or ants. Random review of pest control log sheets revealed documented reports of ants, spiders, and water bugs. On 04/18/2026 the facility staff documented roaches above curtain, ceiling, and walls. Additional entries included reports of ants on dressers, inside dressers, on all the walls and behind the baseboards. On 04/19/2026 the facility staff documented roaches, spiders, and ants in whole room. Review of the 04/22/2026 pest control invoice revealed the facility had been treated for insects using Suspend Polyzone, Nibor D Foam + IGR, Vendetta Roach Bait, First Strike Soft Bait, and Optigard. The most recent pest control invoice provided to the survey team was dated 05/13/2026, four days prior to the survey team entering the facility. Documentation indicated the facility had been treated with Suspended Polyzone, Contrac Bait Blox, Vendetta Roach Bait, Niban Granular Bait, and Advion Ant Gel. These concerns were discussed with the facility's administrative staff throughout the survey process. No additional information regarding these concerns was provided to the survey team prior to the exit conference.

Based on observation, interview and facility document review, the facility staff failed to ensure each resident receives three meals daily, at regular times comparable to normal mealtimes in the community or in accordance with resident needs, preferences, requests, and plan of care. The findings included:On 5/17/2026 at 9:05 AM during the initial kitchen tour the staff were still on the tray line. The dietary aide #1 stated they were prepping cart #7 of 9 carts. At 9:25 AM the dietary aide stated they were prepping the last cart. When asked about tray delivery times the aide stated, Our goal is to have the last cart out the door by 9:00 AM but that doesn't always happen, it depends on what else we have going on day to day and sometimes it just takes longer. The last tray cart left the kitchen at 9:50 AM. This cart was for the 400 hall. When asked about staffing the aide stated, We usually have three aides and one cook. When asked if that is the normal number of staff they stated, Yes, that's what we have every day. There were three aides and one cook working. The cook was asked what time the tray line for lunch starts and he stated to return at 11:30 AM in order to observe the tray line for lunch. On 5/17/26 at 11:25 AM there were three residents on the [NAME] unit still eating breakfast and several other residents still had breakfast trays in their room. Two of the three residents stated it was fairly normal for breakfast to be that late and that when it was that late, each consecutive meal would be late as well. We probably won't get supper until 8:00 or after.On 5/17/26 at 11:30 AM there were four additional staff members in the kitchen at this time. A District Manager, another corporate employee, the Dietary Manager and a fourth aide. The tray line was not ready. The District Manager stated they needed 15 more minutes. At 12:05 PM the tray line was still not ready. The District Manager stated to return at 12:30PM. The tray line was not ready until 12:40PM. The last cart was finished and loaded at 2:00 PM.On 5/18/26 at 2:38 PM another member of the survey team observed the residents on the 400 hall still did not have lunch trays. This surveyor spoke to the Administrator who stated, I just went down there. The trays were on the cart outside the kitchen door, no one pushed them up there, I guess they were busy doing something else. The last tray on the cart was passed at 2:48 PM leaving many residents on the unit still eating lunch after 3:00 PM. On 5/18/26 the Dining Services District Manager was interviewed at 2:00 PM. When asked about staffing they stated, Our goal is to have four aides and one cook on each shift. Unfortunately, that is rarely happening, we don't have enough people. We did just have a job fair and had a lot of interest so we are hopeful that staffing will improve soon. The District Manager stated the department had been short staffed since she took over the building in March. The District Manager provided a Cart Delivery Log. When asked if the log was current and accurate they stated, It is and we are definitely really late today. The log stated that the last breakfast trays should be delivered to the 400 hall by 8:55 AM and the last lunch trays should be delivered by 1:10 PM daily. For the dinner meal, the last trays should be delivered by 6:15 PM each evening.On 5/18/26 at 2:40 PM the Administrator was interviewed. When asked if they were aware of a staffing problem in the Dietary Department they stated, I am aware of those concerns, and they did recently have a job fair with over 60 applicants, so they are actively working on the issue.5/18/26 at 4:11 PM Certified Nursing Assistant C.N.A. #12 was interviewed and stated that one night there had been a night that he was unable to give showers because the dinner trays didn't get served until 9:00 PM and his shift ended at 10:30PM. On 5/18/26 at 5:35 PM the survey team met with the Administrator, Director of Nursing, Assistant Directors of Nursing, the Regional Director of Clinical Services and the Regional [NAME] President of Operations. This concern was discussed with them at that time.On 5/19/26 the lunch trays arrived on the 400 hall at 1:36 PM.05/19/2026 at 3:09 PM C.N.A #8 was interviewed. They stated that staffing was sometimes hectic, meals are often really late, so you don't know when or when not to do a shower. They stated a couple of months ago, they were getting dinner trays around 7 or 7:30 PM.No further information was provided to the survey team prior to the exit conference.

Based on observation, staff interview and facility document review, the facility staff failed to store, prepare, distribute and serve food in accordance with professional standards for food service safety in the facility kitchen and in two of three nutrition rooms ([NAME] and [NAME]). The findings included:1.The facility policy entitled, Food Storage: Cold Foods with a revision date of 02/2023 was reviewed and read in part, 5. All foods will be stored wrapped or in covered containers, labeled and dated and arranged in a manner to prevent cross contamination. On 05/17/2026 at 10:43 AM during the initial kitchen tour the walk-in cooler was checked. A raw purple onion cut in two pieces was stored in a food storage bag that was not labeled or dated. The onion was in a box with four stacks of sandwich cheese each wrapped in plastic wrap. One of the packages of cheese was not labeled or dated. There was a large bag of chopped lettuce that had been cut or torn open and left open, it was not sealed. The lettuce was wilted and brown around the edges. The manufacturer date on the bag read, packed date 04/28/2026. There was no label indicating when the bag was opened or when it was due to be discarded. There was a cole slaw kit that was not opened with a best by date of 5/15/26. There was a bundle of fresh parsley that was not in a bag or any type of container with a label on it that read 05/08/2026 use by 05/15/2026. There was a box containing eight (8) sausage patties with a use by date of 05/15/2026. In the dry storage area, there was a bag of sandwich bread that had been secured by tying a knot in the bag but below the knot the bag had been ripped open, and the bread was exposed to the air. The bread was hard. There was no label on the bread. The policy entitled, Food Storage: Dry Goods with a revision date of 2/2023 was provided and read in part, All packaged and canned food items will be kept clean, dry and properly sealed. The employee who identified themselves as the cook stated they were in charge. The cook was shown the above items and stated they would discard all the items. The cook agreed that the onion and the cheese should have been labeled and the other items were out of date. The cook was shown the bread and stated it should not have been ripped open, it should have been sealed and stated it would be discarded. On 5/18/26 at 5:35 PM the survey team met with the Administrator, Director of Nursing, [NAME] President of Operations, Regional Director of Clinical Services and Assistant Directors of Nursing. The above concerns were discussed with them at that time. No further information was provided to the survey team prior to the exit conference. 2. The facility policy entitled Foods Brought by Family/Visitors with a revision date of March 2022 was reviewed and read in part, 5. Food brought by family/visitors that is left with the resident to consume later is labeled and stored in a manner that it is clearly distinguishable from facility prepared food. a. non-perishable foods are stored in re-sealable containers with tight fitting lids. Intact fresh fruit may be stored without a lid. b. Perishable foods are stored in resealable containers with tightly fitting lids in a refrigerator. Containers are labeled with the resident's name, the item and the use by date. 6. The nursing staff will discard perishable foods on or before the use by date. 7. The nursing and/or food service staff will discard any foods prepared for the resident that show obvious signs of potential foodborne danger (for example mold growth, past due package expiration dates). On 5/18/2026 at 9:45 AM the resident refrigerator in the [NAME] nutrition room was checked. The top shelf of the refrigerator was covered in brown and purple sticky substances that had leaked down the back of the refrigerator to the bottom and settled under the drawers. There was a white birthday cake with a resident name on it dated 5/13, a brown bag with a resident name on it dated 5/9/26, a white Styrofoam food box with writing that was not legible. Certified Nursing Assistant (C.N.A.) #2 was interviewed and stated they did not know who was responsible keeping the refrigerator clean or for discarding out of date items, but the policy is after three days, the food is to be discarded. C.N.A. #2 stated she was going to discard the questionable items and clean the refrigerator. Licensed Practical Nurse (LPN) #13 was interviewed and stated it is the nursing departments responsibility to make sure the refrigerator is kept clean and that outdated food is discarded. There isn't one person assigned to it, we should all be checking it and making sure it's clean. On 5/18/26 at 10:15 AM, the resident refrigerator in the [NAME] nutrition room was checked. There was a Subway bag that was sealed with no date or name on it. There was an Olive Garden bag with a receipt attached that was dated 5/12/26. There was a freezer bag with what looked like cheesecake with no name or date and a grocery bag that was tied up dated 5/4-5/7. LPN #5 was interviewed and stated, Nursing is responsible to make sure everything is dated and thrown away after three days. LPN #5 discarded the items of concern. On 5/18/26 at 5:35 PM the survey team met with the Administrator, Director of Nursing, [NAME] President of Operations, Regional Director of Clinical Services and Assistant Directors of Nursing. The above concerns were discussed with them at that time. No further information was provided to the survey team prior to the exit conference.

Based on staff interview, clinical record review, and facility document review, the facility staff failed to ensure the highest practicable well-being for 8 or 42 residents, Residents #29, #55, #165, #175, #15, #3, #4, and #72. The findings include: 1. For Resident #29, the facility staff failed to administer provider ordered medications. These medications were available at the facility in the over the counter (OTC) mediation supply or available in the Med Bank (back up supply) for administration. Resident #29's diagnoses included quadriplegia, anxiety disorder, paralytic ileus, neuromuscular dysfunction of bladder, and cervical disc disorder. Section C (cognitive patterns) of Resident #29's admission Minimum Data Set (MDS) assessment with an Assessment Reference Date (ARD) of 02/17/2026 included a Brief Interview for Mental Status (BIMS) score of 15, indicating the resident was cognitively intact. The Resident's comprehensive care plan included an intervention to administer medications as ordered. Review of the clinical record revealed that the nursing staff documented the code 22 on the Medication Administration Records (MARs) indicating Drug/Treatment Not Administered, for the following medications: 03/18/2026, Melatonin. Mag Oxide, Vitamin B12, and Thera-M multivitamin. 03/19/2026, Melatonin, Mag Oxide, Vitamin B 12, Thera-M multivitamin, and Lorazepam. 03/21/2026, Melatonin and Lorazepam. 03/22/2026, Melatonin and Lorazepam. 03/24/2026, Simethicone. On 03/20/2026, Lorazepam was marked on the MAR as administered; however, corresponding nursing progress notes documented the medication was on order. On 04/19/26, Simethicone was documented on the MAR as administered, while nursing notes indicated the medication was .waiting on arrival. Additional nursing documentation revealed the following: On 03/19/2026 the nursing staff documented Vitamin B12 was not available, physician aware. On 03/22/2026 the nursing staff documented Melatonin was not available. On 03/24/2026 the nursing staff documented Simethicone was not available. Review of the facility's OTC medication list and Med Bank inventory provided to the survey team confirmed the above medications were available in the OTC supply of Med Bank backup supply. On 05/20/2026 at 2:38 PM during a meeting that included the Administrator, Director of Nursing, Regional [NAME] President of Operations, Assistant Director of Nursing, Staff Development Coordinator, and Regional Nurse, the issue regarding Resident #29's medications not being administered while being available in the OTC supply or Med Bank was reviewed. The facility policy titled Administering Medications stated, in part, .Medications are administered in accordance with prescriber orders. No additional information regarding this issue was provided to the survey team prior to the exit conference. 2. For Resident #55, the facility staff failed to administer provider ordered medications. These medications were available at the facility in the over the counter (OTC) mediation supply or available in the Med Bank (back up supply) for administration. Resident #55's diagnoses included, dysphagia, diabetes, depression, and vascular dementia. Section C (cognitive patterns) of Resident #55's quarterly Minimum Data Set (MDS) assessment with an Assessment Reference Date (ARD) of 02/16/2026 included a Brief Interview for Mental Status (BIMS) score of 3, indicating severe impairment in cognitive skills for daily decision making. The Resident's comprehensive care plan included an intervention to administer medications as ordered. A review of the clinical record revealed that the nursing staff documented the code 22 on the Medication Administration Records (MARs) indicating Drug/Treatment Not Administered, for the following medications: O3/18/2026, Cholecalciferol and Levothyroxine, 03/19/2026, Cholecalciferol. 03/22/2026, Carvedilol. 03/28/2026, Levothyroxine, Carvedilol, and Sertraline. 03/29/2026, Carvedilol. The MARs had been coded with an 11 for Vitals Outside of Parameters for the following medications: 03/22/2026, Sertraline and Levothyroxine. There was no provider ordered parameters for either of these medications. Corresponding nursing documentation revealed the following: 03/18/2026, Cholecalciferol and Levothyroxine, medication(s) unavailable. 03/19/2026, Cholecalciferol, not available, physician aware. 03/22/2026, Carvedilol, Sertraline, and Levothyroxine, medication(s) not available, reordered from pharmacy. 03/28/2026, Levothyroxine, Sertraline, and Carvedilol medication not on cart. During an end of the day meeting on 05/18/2026 at 5:35 PM, that included the Administrator, Director of Nursing, Regional [NAME] President of Operations, Nurse Consultant, and Assistant Director of Nursing the issue with Resident #55's provider ordered medications not being administered was reviewed. The facility policy titled Administering Medications stated, in part, .Medications are administered in accordance with prescriber orders. No additional information regarding this issue was provided to the survey team prior to the exit conference. 3. For Resident #165, the facility staff failed to administer provider ordered medications. These medications were available at the facility in the over the counter (OTC) medication supply or available in the Med Bank (back up supply) for administration. Resident #165's diagnoses convulsions, diabetes, and spondylolisthesis. Section C (cognitive patterns) of Resident #165's quarterly Minimum Data Set (MDS) assessment with an Assessment Reference Date (ARD) of 03/03/2026 included a Brief Interview for Mental Status (BIMS) score of 15, indicating the resident was cognitively intact. The Resident's comprehensive care plan included an intervention to administer medications as ordered. Review of the clinical record revealed that the nursing staff documented the code 22 on the Medication Administration Records (MARs) indicating Drug/Treatment Not Administered, for the following medications: 03/18/2026, Calcium with Vitamin D and Mag Oxide. 03/19/2026, Calcium with Vitamin D and Mag Oxide. 03/20/2026, Calcium with Vitamin D. 03/21/2026, Calcium with Vitamin D, Thera-M Multivitamin, and Oxycontin extended release. 03/22/2026, Calcium with Vitamin D and Oxycontin extended release. 03/23/2026, Calcium with Vitamin D. 03/26/2026, Calcium with Vitamin D. 03/30/2026, Calcium with Vitamin D. Corresponding nursing documentation revealed the following: 03/18/2026, Mag Oxide waiting on delivery, Nurse Practitioner aware. 03/19/2026, Mag Oxide awaiting delivery. 03/20/2026, Calcium with Vitamin D not available. 03/21/2026, Calcium with Vitamin D waiting on arrival from pharmacy. 03/22/2026, Calcium with Vitamin D medication unavailable at this time. 03/22/2026, Calcium with Vitamin D medication unavailable at this time. For the medication Famotidine the MARs had been coded with a 2 for Drug/Treatment Refused on 03/18/2026 at 4:00 PM. On 03/18/2026 at 4:56 PM the nursing staff documented Famotidine.waiting on delivery, np [Nurse Practitioner] aware. During an end of the day meeting on 05/18/2026 at 5:35 PM, that included the Administrator, Director of Nursing, Regional [NAME] President of Operations, Nurse Consultant, and Assistant Director of Nursing the issue with Resident #165's provider ordered medications not being administered was reviewed. The facility policy titled Administering Medications stated, in part, .Medications are administered in accordance with prescriber orders. No additional information regarding this issue was provided to the survey team prior to the exit conference. 4. For Resident #175, the facility staff failed to complete physician ordered blood sugar (BS) monitoring and failed to obtain weekly weights as ordered. This was a closed record review. Resident #175's diagnoses included Clostridium difficile, diabetes, and protein-calorie malnutrition. Section C (cognitive patterns) of Resident #175's admission Minimum Data Set (MDS) assessment with an Assessment Reference Date (ARD) of 06/13/2024 included a Brief Interview for Mental Status (BIMS) score of 3, indicating severe impairment in cognitive skills for daily decision making. The comprehensive care plan identified the areas of potential for weight change and diabetes. The clinical record included the following provider orders: 06/07/2024: Sliding scale Lispro insulin four times daily. 06/08/2024: Weigh resident on admission and weekly for four weeks. 06/08/2024: Glucometer checks four times daily. Review of Medication Administration Records (MARs) and Treatment Administration Records (TARs) revealed nursing staff had placed a = in the administration blocks for the weights on 06/11/2024 and 06/18/2024. In addition, for insulin administration and BS monitoring, nursing staff documented a = in the administration blocks on 06/10/2024 at 4:30 PM. The clinical record did not contain supporting documentation that would have corresponded with the code of = or to indicate why the weights and/or BS were not completed. On 05/20/2026 at 8:20 AM, the surveyor requested additional information from the Regional Nurse regarding the missing weights and BS checks. At 9:50 AM, the Regional Nurse stated the weights had not been obtained and they did not know why the BS was not obtained on 06/10/2024. On 05/20/2026 at 2:38 PM during a meeting attended by the Administrator, Director of Nursing, Regional [NAME] President of Operations, Assistant Director of Nursing, Staff Development Coordinator, and Regional Nurse, the issue regarding Resident #175's missing weights and BS monitoring was reviewed. No additional information regarding this issue was provided to the survey team prior to the exit conference. 5. For Resident #15, the facility staff failed to apply a Lidocaine pain patch as ordered by the medical provider on two separate occasions. A Lidocaine patch is a medicated topical patch used to treat pain and discomfort by numbing the area. A facility policy titled, Unavailable Medication, dated June 2021, specified In the event that a medication ordered for a resident is noted to be unavailable near or at the time it is to be dispensed, nursing staff shall a. Contact the pharmacy regarding the unavailable medication. B. Attempt to obtain the medication from the facility's automated medication dispensing system or emergency kit. An admission Record indicated the facility admitted Resident #15 on 2/03/22. According to the admission Record the resident had a medical history that included Alzheimer's Disease, adult failure to thrive, and unspecified pain. A significant change Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 2/09/26, revealed Resident #15 had a Brief Interview for Mental Status (BIMS) score of 5 out of 15 indicating the resident was severely cognitively impaired. Resident #15's comprehensive person-centered care plan included a focus dated 2/13/26, that indicated the resident had potential for pain related to contractures and being bedbound. Interventions directed staff to administer analgesia as per orders. Resident #15's medical provider orders included an order dated 12/10/25 for a Lidocaine 4% patch to the right knee topically every 24 hours for pain. A review of Resident #15's April 2026 Medication Administration Record (MAR) revealed a Lidocaine 4% patch was not applied to the resident's right knee on 4/24/26 and 4/25/26. A nursing progress note dated 4/24/26 at 2:18 PM indicated that the Lidocaine 4% patch was not applied because facility ran out. A 4/25/26 10:10 AM nursing progress note indicated the Lidocaine 4% patch was not available. The Director of Nursing (DON) was interviewed on 5/19/26 at 9:35 AM. The DON stated the Lidocaine patch was absolutely available and the nurse knew that. The DON stated Lidocaine patches are part of the house stock medications. The DON provided the facility over the counter (OTC) house stock medication inventory list which included Lidocaine 4% Pain Patches. On 5/19/26 at 5:02 PM, the facility administrative team including the Administrator and DON were informed of the concern regarding staff failing to apply Resident #15's Lidocaine 4% patch as ordered on 4/24/25 and 4/25/26. No further information was provided prior to the exit conference on 5/20/26. 6. For Resident #3, the facility staff failed to follow up on a medical provider order for Keflex 500mg in a timely manner. The order was received during an emergency room visit on 5/14/26 and was not addressed until 5/17/26. The facility staff also failed to administer medications as ordered by the medical provider on multiple occasions during the months of March 2026 and April 2026. An admission Record indicated the facility admitted Resident #3 on 10/19/23. According to the admission Record, the resident had a medical history that included chronic obstructive pulmonary disease (COPD), insomnia, vitamin D deficiency, hypomagnesemia, chronic kidney disease, atherosclerotic heart disease, and type 2 diabetes mellitus. A quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 4/22/26, revealed Resident #3 had a Brief Interview for Mental Status (BIMS) score of 15 out of 15 which indicated the resident had intact cognition. During an interview on 5/17/26 at 11:34 AM, Resident #3 stated she went to the emergency room last week after a fall and found out she had a UTI (urinary tract infection). The resident stated she has not received an antibiotic since the ER visit. An Encounter Summary for 5/14/26 indicated Resident #3 was seen at a local emergency department following a fall and complained of dysuria without fever, hematuria and urgency. Resident #3 was diagnosed with acute cystitis with hematuria and given Keflex 500 mg in the ED and prescribed Keflex 500 mg by mouth every 6 hours for 7 days. A nursing progress note dated 5/14/26 at 8:19 AM specified Resident returned from the ED [emergency department] at 0600 [6:00 AM]. Resident returned with new orders for a dx [diagnosis] UTI. Licensed Practical Nurse (LPN) #7, the writer of the 5/14/26 progress note was interviewed on 5/20/26 at approximately 1:00 PM. LPN #7 stated she called and left a message for the on-call PACE provider around 7:45 AM on 5/14/26 but failed to document in the clinical record. LPN #7 stated she passed the information along in report to the next shift. According to Resident #3's clinical record, the order for Keflex was not followed up on again until 5/17/26. A 5/17/26 1:11 PM nursing progress note indicated PACE on call was contacted regarding order for Keflex 500 mg for UTI. On call stated they would call the provider about the order and have them review it. A nursing progress note dated 5/18/26 at 11:37 AM indicated a follow-up call was placed to PACE and an order for Keflex 500 mg three times a day for 10 days was received. Resident #3 received the first administration of Keflex following the 5/14/26 ER visit on 5/18/26 at 1:50 PM. Resident #3's comprehensive person-centered care plan included a focus area dated 5/14/26 indicating the resident was on pain medication therapy. Interventions directed staff to administer medications as ordered. Resident #3's medical provider orders included an order dated 6/09/25 for Gabapentin 100 mg by mouth three times a day related to pain. A review of Resident #3's March 2026 and April 2026 Medication Administration Records (MARs) revealed Gabapentin was not administered on 3/22/26 12:00 PM, 3/22/26 9:00 PM, 3/23/26 12:00 PM, 4/09/26 12:00 PM, 4/10/26 12:00 PM, and 4/11/26 6:00 AM. Corresponding nursing progress notes on 3/22/26, 3/23/26, 4/10/26, and 4/11/26 indicated the staff needed a new script and/or were awaiting the arrival of the medication from the pharmacy. Resident #3's medical provider orders included an order starting 12/03/25 and discontinued on 5/08/26 for Melatonin 10 mg by mouth at bedtime related to insomnia. A review of Resident #3's March 2026 MAR revealed Melatonin was not administered 3/18/26 and 3/22/26. Corresponding nursing progress notes indicated Melatonin was not available for administration. Resident #3's medical provider orders included an order with a start date of 12/03/25 for Montelukast 10 mg by mouth one time a day for COPD and allergic rhinitis. A review of the April 2026 MAR revealed Montelukast was not administered on 4/13/26. A corresponding nursing progress note indicated Montelukast was not administered because staff were awaiting the arrival of the medication from the pharmacy. Resident #3's medical provider orders included orders starting on 12/03/25 for Mag Oxide 400 mg by mouth one time a day related to hypomagnesemia, Vitamin D3 1,000 units by mouth one time a day related to vitamin D deficiency, and Nitrofurantoin 100 mg by mouth one time a day for UTI prophylaxis. A review of the March 2026 MAR revealed Mag Oxide, Vitamin D3, and Nitrofurantoin were not administered on 3/18/26. Corresponding nursing progress notes indicated staff were waiting on delivery from the pharmacy. A review of the in-house facility medication supply (Med Bank) inventory list indicated Gabapentin 100 mg, Montelukast 10mg, and Nitrofurantoin 100 mg were available in the facility for administration. The facility in-house Over the Counter (OTC) house stock supply inventory list indicated Melatonin 10 mg, Mag Oxide 400 mg, and Vitamin D3 1,000 were present in the facility for resident administration. A facility policy titled, Unavailable Medication, dated June 2021, specified In the event that a medication ordered for a resident is noted to be unavailable near or at the time it is to be dispensed, nursing staff shall a. Contact the pharmacy regarding the unavailable medication. B. Attempt to obtain the medication from the facility's automated medication dispensing system or emergency kit. On 5/19/26 at 5:02 PM the facility administrative staff including the Administrator and Director of Nursing, were informed of the concerns regarding the delay in addressing Resident #3's Keflex order and multiple medications that were available but not administered. No further information regarding these concerns was provided prior to the exit conference on 5/20/26. 7. For Resident #4 (R4), the facility staff failed to follow the medical providers order for the administration of the oral medication Metoprolol Tartrate, used to treat elevated blood pressure (BP). An admission Record indicated the facility admitted R4 on 10/02/25. According to the admission Record, the resident had a medical history that included heart failure unspecified, chronic atrial fibrillation and atherosclerotic heart disease. The quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 4/9/2026, revealed R4 had a Brief Interview for Mental Status (BIMS) score of 14 out of 15, which indicated the resident had intact cognition. R4's current medical provider orders included an order dated 4/29/2026 for Metoprolol Tartrate tablet 100mg (milligrams), give 1 tablet by mouth two times a day for elevated blood pressure, hold for systolic blood pressure (SBP) <110 (less than 110); pulse<60 (less than 60). A review of R4's May 2026 Medication Administration Record (MAR) revealed Metoprolol Tartrate was administered on three separate occasions when R4's systolic blood pressure was less than 110. Metoprolol Tartrate was administered on 5/04/26 evening shift with a BP of 109/73, 5/06/26 evening shift with a BP of 106/84, and 5/14/26 with a BP of 102/68. A facility policy titled, Administering Medications, with a revision date of April 2019, specified 12. When indicated, validate physician ordered parameters prior to medication administration. On 5/20/26 at 2:38 PM during a meeting with the facility administrative staff including the Administrator and Director of Nursing, the facility was informed of staff failing to follow the medical provider orders for the administration of Metoprolol Tartrate. No further information was presented prior to the exit conference on 5/20/26. 8. For Resident #72, the facility staff failed to administer the medication Hydralazine PRN (as needed) for blood pressure (BP) greater than 160 as ordered by a medical provider. Resident #72's diagnoses list included a diagnosis of essential (primary) hypertension. The most recent quarterly minimum data set (MDS) with an assessment reference date (ARD) of 04/09/2026 assigned the resident a brief interview for mental status (BIMS) summary score of 15 out of 15 for cognitive abilities, indicating the resident was cognitively intact. A medical provider orders dated 12/02/2025 indicated Resident #72 was prescribed Hydralazine 10 mg (ten milligrams) 1 (one) tablet by mouth every 6 (six) hours as needed for elevated BP SBO (Systolic Blood Pressure) (the top number in a blood pressure reading that measures the pressure in your arteries when your heart beats) >160 (greater than one-hundred sixty). A review of the April 2026 MAR (medication administration record) disclosed Resident #72's BP readings were noted as follows on the following dates: 04/20/2026-172/79 - Hydralazine was not administered. 04/21/2026-161/72 - Hydralazine was not administered. 04/22/2026-161/72 - Hydralazine was not administered. 04/27/2026-161/72 - Hydralazine was not administered. 04/28/2026-168/59 - Hydralazine was not administered. A review of the May 2026 MAR disclosed Resident #72's BP readings were noted as follows on the following dates: 05/04/2026-168/71 - Hydralazine was not administered. 05/10/2026-165/82 - Hydralazine was not administered. 05/11/2026-165/82 - Hydralazine was not administered. On 05/19/2026 at 10:48 AM, the Director of Nursing was interviewed and stated the expectation is for the provider orders to be followed for medication administration. This concern was discussed at the end-of-day meeting on 05/19/2026 at 5:02 PM with the Administrator, Director of Nursing, Staff Development Coordinator, Assistant Director of Nursing #1, Assistant Director of Nursing #2, Regional Nurse, [NAME] President of Clinical Services, and Assistant Administrator. A facility policy titled, Administering Medications with a revision date of 04/2019 specified, Medications are administered.as prescribed. Under the heading Policy Interpretation and Implementation item #4 read in part, Medications are administered in accordance with prescriber orders. Item #11 read in part, The following information is checked/verified for each resident prior to administering medications.b. Vital signs, if necessary. No further information was provided prior to exit on 05/20/2026.

Based on observation, staff interview, and facility document review, the facility staff failed ensure safe and secure storage of medications and biologicals for 1 of 33 sampled residents (Resident #28), #1 of 3 medication storage rooms ([NAME]), 1 of 6 medication carts ([NAME]) and 1 treatment cart ([NAME]). Findings included:1.The facility staff failed to ensure medications and biologicals were not expired in one of three medication storage rooms. The policy entitled, Medication Labeling and Storage with a revision date of February 2023 read in part, 2. Nursing staff is responsible for maintaining medication storage and preparation areas in a clean, safe and sanitary manner. 3. If the facility has discontinued, outdated or deteriorated medications or biologicals, the dispensing pharmacy is contacted for instructions regarding returning or destroying these items. On [DATE] at 12:04 PM the medication storage room on the [NAME] Unit was checked with Licensed Practical Nurse (LPN) #12. In the medication refrigerator was a box labeled Flublok Influenza vaccine with ten (10) single dose prefilled syringes 0.5 mls (milliliters) each with an expiration date of [DATE]. A second unopened box containing Flucelvax 2025-2026 Formula with an expiration date of [DATE] was also in the refrigerator. LPN #12 stated, I don't understand this, I feel like this one just arrived from pharmacy a few days ago. LPN #12 was asked to verify the expiration dates on each box and agreed that each one was expired and would be disposed of according to the facility policy. On [DATE] at 5:35 PM the survey team met with the Director of Nursing, Administrator, Assistant Director of Nursing, Regional Director of Clinical Services, and the [NAME] President of Operations. This concern was discussed with them at that time. No further information was provided to the survey team prior to the exit conference. 2. For the facility, the facility staff failed to ensure the safe and secure storage of medications and biologicals for (1) one treatment cart on the [NAME] unit and (1) one of (6) six facility medication carts. A facility policy entitled, Security of Medication Cart with a revision date of [DATE] read in part, The medication cart must be secured during medication passes. Under the heading Policy Interpretation and Implementation item #1 read, The nurse must secure the medication cart during the medication pass to prevent unauthorized entry. Item #3 read in part, .the cart should be parked in the hallway against the wall with the doors and drawers facing the wall. The cart must be locked. Item #4 read, Medication carts must be securely locked at all times when out of the nurse's view. An observation on the [NAME] unit on [DATE] at 11:12 AM revealed a treatment cart (a mobile workstation used to store and transport medical supplies such as ointments, creams, wound care supplies, etc .) was unattended and unlocked in the hallway with the drawers not against the wall. A pair of scissors was observed to be opened lying on top of the cart. Licensed Practical Nurse #1 (LPN#1) locked the cart and stated she was not using the cart. Licensed Practical Nurse #2 (LPN#2) came out of a resident room and stated he was using the cart. An observation on the [NAME] unit on [DATE] at 11:54 AM revealed a medication cart (a secured cart used to organize and dispense daily scheduled pills, liquids, and prescriptions) was unattended and unlocked in front of the nurses' station with the drawers/doors facing outward. Licensed Practical Nurse #10 (LPN#10) stated it was her cart and agreed she had left it unlocked. These concerns were discussed at the pre-exit meeting on [DATE] at 2:38 PM with the Regional Director of Operations, Administrator, Director of Nursing, Assistant Director of Nursing #1, Assistant Director of Nursing #2, Regional Nurse, Assistant Administrator, and Staff Development Coordinator. No further information was provided prior to exit on [DATE]. 3. The facility staff failed to provide a locked storage box for Resident #28 's (R28) self-administered medications. On [DATE] at 11:00 am, an interview was conducted with the director of nursing (DON). The DON stated that R28 did not self-administer medications and the nurses administer his medications. On [DATE] at 12:02 pm, an observation was made of R28's room and no lock box for his self-administered medication was observed. R28 had medications observed on his overbed table that was in front of him. On [DATE] at 12:10 pm, an interview was conducted with R28. He said, I am in my right mind, and the facility didn't offer a locked box I haven't heard anything about that. On [DATE], a review of a facility document was conducted. The facility documentation titled, Medication Labeling and Storage, read in part, . The facility stores all medications and biologicals in locked compartments under proper temperature, humidity and light controls. Only authorized personnel have access to keys. 4. containing Compartments (including, but not limited to, drawers, cabinets, rooms, refrigerators, carts, and boxes) medications and biologicals are locked when not in use, and trays or carts used to transport such items are not left unattended if open or otherwise potentially available to others. On [DATE] at 2:42 pm, an end of day meeting was held with the administrator, the director of nursing, the vice president of operations, the regional director of clinical services and the vice president of clinical services. They were informed of the above concerns and the VP of operations and DON stated they thought he had one in his room. They were informed we didn't observe one in his room and R28 stated he had never been provided a lock box for his medications. On [DATE] the VP of operations stated that he provided R28 with a lock box for his self-administered medications and that R28 placed the medications in the lock box and the key to the lock box was given to R28.

Based on resident interview, staff interview, clinical record review, and facility document review, the facility staff failed to ensure provider ordered medications were available for administration for 5 of 42 residents, Residents #29, #50, #55, #165, and #3. 1. For Resident #29, the facility staff failed to ensure the provider ordered medications Peridex, Saccharomyces, and Benefiber were available for administration. Resident #29's diagnoses included quadriplegia, anxiety disorder, paralytic ileus, neuromuscular dysfunction of bladder, and cervical disc disorder. Section C (cognitive patterns) of Resident #29's admission Minimum Data Set (MDS) assessment with an Assessment Reference Date (ARD) of 02/17/2026 included a Brief Interview for Mental Status (BIMS) score of 15, indicating the resident was cognitively intact. The Resident's comprehensive care plan included an intervention to administer medications as ordered. Clinical record review revealed facility nursing staff documented code 22 on the Medication Administration Records (MARs) indicating Drug/Treatment Not Administered, for the following medications: Peridex Mouth/Throat Solution, 03/11/2026, 03/28/2026, and 03/29/2026. Saccharomyces probiotic, 03/18/2026. Benefiber, 04/15/2026, 04/20/2026, 04/30/2026, and 05/05/2026. Review of the over-the-counter medication list and Med Bank list revealed these medications were not listed as being available for administration. Additional nursing documentation revealed the following: 03/18/2026: Peridex medication not on cart, reordered. 03/29/2026: Peridex reorder pending. 04/15/2026: Benefiber waiting on delivery. On 05/20/2026 at 2:38 PM during a meeting that included the Administrator, Director of Nursing, Regional [NAME] President of Operations, Assistant Director of Nursing, Staff Development Coordinator, and Regional Nurse, the concern regarding Resident #29's medications not being administered due to unavailability was reviewed. The facility policy titled Administering Medications stated, in part, .Medications are administered in accordance with prescriber orders. Facility policy titled, Unavailable Medication stated in part, In conjunction with the contracted pharmacy, the facility will make every effort to ensure that a medication ordered for the resident is available to meet their needs. No additional information regarding this issue was provided to the survey team prior to the exit conference. 2. For Resident #50, the facility nursing staff failed to ensure the provider ordered medication Alfuzosin extended-release tablet was available for administration. Resident #50's diagnoses included Parkinson's disease and benign prostatic hyperplasia. Section C (cognitive patterns) of Resident #50's quarterly Minimum Data Set (MDS) assessment with an Assessment Reference Date (ARD) of 05/04/2026 included a Brief Interview for Mental Status (BIMS) score of 3, indicating severe impairment in cognitive skills for daily decision making. The Resident's comprehensive care plan included an intervention to administer medications as ordered. Clinical record review revealed that the nursing staff documented code 22 on the Medication Administration Records (MARs) on 05/09/2026 indicating Drug/Treatment Not Administered, for the following medication: Alfuzosin extended-release oral tablet. A corresponding nursing progress note dated 05/09/2026 documented that Alfuzosin was not available in Pixis (back up supply), awaiting supply from pharmacy. Review of the over-the-counter medication list and Med Bank list revealed this medication was not listed as being available for administration. On 05/20/2026 at 2:38 PM during a meeting that included the Administrator, Director of Nursing, Regional [NAME] President of Operations, Assistant Director of Nursing, Staff Development Coordinator, and Regional Nurse, the concern regarding Resident #50's medication not being administered due to unavailability was reviewed. The facility policy titled Administering Medications stated, in part, .Medications are administered in accordance with prescriber orders. Facility policy titled, Unavailable Medication stated in part, In conjunction with the contracted pharmacy, the facility will make every effort to ensure that a medication ordered for the resident is available to meet their needs. No additional information regarding this issue was provided to the survey team prior to the exit conference. 3. For Resident #55, the facility nursing staff failed to ensure the provider ordered medications Januvia and Lantus insulin were available for administration. Resident #55's diagnoses included diabetes and vascular dementia. Section C (cognitive patterns) of Resident #55's quarterly Minimum Data Set (MDS) assessment with an Assessment Reference Date (ARD) of 02/16/2026 included a Brief Interview for Mental Status (BIMS) score of 3, indicating severe impairment in cognitive skills for daily decision making. The Resident's comprehensive care plan included an intervention to administer medications as ordered. Clinical record review revealed nursing staff documented code 22 on the Medication Administration Records (MARs) indicating Drug/Treatment Not Administered, for the following medications: Lantus insulin on 03/02/2026 Januvia on 03/28/2026 A corresponding nursing progress note dated 03/28/2026 documented that Januvia was not on the medication cart and had been reordered by the nurse. Review of the over-the-counter medication list and Med Bank list revealed these medications were not listed as being available for administration. During an end of the day meeting on 05/18/2026 at 5:35 PM, that included the Administrator, Director of Nursing, Regional [NAME] President of Operations, Nurse Consultant, and Assistant Director of Nursing the issue with Resident #55's provider ordered medications not being available for administration was reviewed. The facility policy titled Administering Medications stated, in part, .Medications are administered in accordance with prescriber orders. Facility policy titled, Unavailable Medication stated in part, In conjunction with the contracted pharmacy, the facility will make every effort to ensure that a medication ordered for the resident is available to meet their needs. No additional information regarding this issue was provided to the survey team prior to the exit conference. 4. For Resident #165, the facility staff failed to ensure the provider ordered medication Oxcarbazepine was available for administration. Resident #165's diagnoses included convulsions and diabetes. Section C (cognitive patterns) of Resident #165's quarterly Minimum Data Set (MDS) assessment with an Assessment Reference Date (ARD) of 03/03/2026 included a Brief Interview for Mental Status (BIMS) score of 15, indicating the resident was cognitively intact. The Resident's comprehensive care plan included an intervention to administer medications as ordered. Clinical record review revealed that the nursing staff documented code 22 on the Medication Administration Records (MARs) indicating Drug/Treatment Not Administered, for the following medication: Oxcarbazepine, 03/18/2026 and 03/19/2026. Additional nursing documentation revealed the following: 03/18/2026: Oxcarbazepine medication not on cart and waiting on delivery, Nurse Practitioner made aware. 03/19/2026: Oxcarbazepine on order. Review of the over-the-counter medication list and Med Bank list revealed this medication was not listed as being available for administration During an end of the day meeting on 05/18/2026 at 5:35 PM, that included the Administrator, Director of Nursing, Regional [NAME] President of Operations, Nurse Consultant, and Assistant Director of Nursing the issue with Resident #165's provider ordered medication not being available for administration was reviewed. The facility policy titled Administering Medications stated, in part, .Medications are administered in accordance with prescriber orders. Facility policy titled, Unavailable Medication stated in part, In conjunction with the contracted pharmacy, the facility will make every effort to ensure that a medication ordered for the resident is available to meet their needs. No additional information regarding this issue was provided to the survey team prior to the exit conference. 5. For Resident #3, the facility staff failed to ensure insulin Glargine YFGN, Buspirone, and Calcium Citrate D3 200-25 Petites were available for administration. Insulin Glargine YFGN is a long-acting insulin used to lower blood sugar, Buspirone is used to treat anxiety, and Calcium Citrate D3 is a supplement used to prevent and/or treat low blood calcium and support bone health. An admission Record indicated the facility admitted Resident #3 on 10/19/23. According to the admission Record, the resident had a medical history that included type 2 diabetes mellitus, generalized anxiety disorder, vitamin D deficiency, hypocalcemia, and chronic kidney disease. A quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 4/22/26, revealed Resident #3 had a Brief Interview for Mental Status (BIMS) score of 15 out of 15 which indicated the resident had intact cognition. Resident #3's current comprehensive person-centered care plan included focus areas that indicated the resident used anti-anxiety medication, anti-depressant medication and had diabetes mellitus. Interventions directed staff to administer anti-anxiety medication, anti-depressant medication and diabetes medication as ordered. Resident #3's medical provider orders included an order starting 12/03/25 for Glargine YFGN 100 units/ml inject 40 units subcutaneously at bedtime related to diabetes mellitus. A review of Resident #3's March 2026 Medication Administration Record (MAR) revealed Glargine YFGN was not administered on 3/24/26. A corresponding nursing progress note dated 3/24/26 at 10:18 PM indicated the medication was reordered. Resident #3's medical provider orders included an order dated 3/25/26 for Buspirone 7.5 mg by mouth three times a day for major depressive disorder. A review of Resident #3's April 2026 MAR revealed Buspirone was not administered on 4/18/26 at 12:00 PM. A corresponding nursing progress note dated 4/18/26 at 11:17 AM documented staff were waiting on arrival from the pharmacy. Resident #3's medical provider orders included an order starting 12/03/26 for Calcium Citrate plus D3 200-250 Petites for hypocalcemia. A review of Resident #3's March 2026 MAR revealed Calcium Citrate plus D3 was not administered on 14 occasions, 3/18/26 morning and evening, 3/19/26 morning and evening, 3/20/26 morning and evening, 3/21/26 morning, 3/22/26 morning and evening, 3/23/26 morning and evening, 3/24/26 evening, 3/26/26 morning, and 3/27/26 evening. Corresponding nursing progress notes on 3/18/26, 3/19/26, 3/20/26, 3/21/26, 3/22/26, 3/23/26, 3/26/26, and 3/27/26 indicated the medication was unavailable for administration. On 5/20/26 at 2:38 PM the facility administrative staff including the Administrator and Director of Nursing, were informed of the concerns regarding the multiple medications that were not administered as ordered. No further information regarding these concerns was provided prior to the exit conference on 5/20/26.

Based on resident interview, family interview, staff interview, clinical record review, and facility document review, the facility staff failed to ensure a complete and accurate clinical record for 4 of 33 residents, Resident #50, #55, #175, and #8. The findings include:1. Resident #50's clinical record did not include documentation to indicate the resident had received a shower and/or bed bath. Resident #50's diagnoses included Parkinson's disease, diabetes, and dementia. Section C (cognitive patterns) of Resident #50's admission Minimum Data Set (MDS) assessment with an Assessment Reference Date (ARD) of 05/04/2026, included a Brief Interview for Mental Status (BIMS) score of 3, indicating severe impairment in cognitive skills for daily decision making. Section GG (functional abilities) was coded to indicate the resident was dependent on staff assistance for showers. The clinical record did not include any documentation to indicate this resident had received any showers/baths since admission to the facility in April 2026. During an interview conducted on 05/17/2026 at 2:17 PM, a family member expressed concerns regarding this individual receiving showers/baths. On 05/19/2026 at 9:30 AM, the Staff Development Coordinator and Assistant Director of Nursing reviewed the clinical record with the surveyor and were unable to locate documentation indicating the resident had received a shower or bath since admission. During an interview on 05/19/2026 at 10:00 AM with Certified Nursing Assistants (CNAs) #3 and #7, CNA #7 stated there were times when they did not have enough staff to provide residents with showers or baths. On 05/19/2026 at 10:05 AM, Resident #50 stated he had a shower about once or twice and reported receiving a few bed baths. On 05/20/2026 the facility staff provided the survey team with a copy of their policy titled, Charting and Documentation. This policy read in part, All services provided to the resident, progress toward the care plan goals, or any changes in the resident's medical, physical functional or psychosocial condition, shall be documented in the resident's medical record. On 05/20/2026 at 2:38 PM, during a meeting that included the Administrator, Director of Nursing, Regional Nurse Consultant, Assistant Administrator, and Regional [NAME] President of Operations the above issue was reviewed. No further information regarding this issue was provided to the survey team prior to the exit conference. 2. Resident #55's clinical record included numerous unsigned entries or holes on the March 2026 Medication Administration Record (MAR), indicating nursing staff failed to document for the administration of prescribed medications and/or treatments. Resident #55's diagnoses included dysphagia, diabetes, chronic kidney disease, and aphasia. Section C (cognitive patterns) of Resident #55's quarterly Minimum Data Set (MDS) assessment with an Assessment Reference Date (ARD) of 02/16/2026 included a Brief Interview for Mental Status (BIMS) score of 3, indicating Resident #55 was severely impaired in cognitive skills for daily decision making. A review of the clinical record identified the following medications and/or treatments that lacked documentation of administration by the facility nursing staff: 03/06/2026, Atorvastatin, Calcium Antacid Chew, Docusate Sodium, enteral feeding order, Lantus insulin, Latanoprost eye drops, Levothyroxine, Carvedilol, Ferrous Sulfate, Acetaminophen, crush medications, Lactulose, blood glucose monitoring, and Lispro Insulin. 03/07/2026, Acetaminophen and Lactulose. 03/09/26, Cholecalciferol, Januvia, Levothyroxine, Sertraline, Carvedilol, Ferrous Sulfate, Acetaminophen, crush medications, Lactulose, blood glucose monitoring, and Lispro Insulin. 03/14/2026, crush medications and enteral feed order. 03/15/2026, Acetaminophen and Lactulose. On 05/18/2026 at 5:35 PM during an end of the day meeting that included the Administrator, Director of Nursing, Regional [NAME] President of Operations, Regional Nurse Consultant, and the Staff Development Coordinator the missing documentation was reviewed. On 05/20/2026 the facility staff provided the survey team with a copy of their policy titled, Charting and Documentation. This policy read in part, All services provided to the resident, progress toward the care plan goals, or any changes in the resident's medical, physical functional or psychosocial condition, shall be documented in the resident's medical record. No further information regarding this issue was provided to the survey team prior to the exit conference. 3. For Resident #175, the facility staff failed to document meal intakes. This was a closed record review. Diagnoses included acute kidney failure, clostridium difficile, gastro-esophageal reflux disease, benign prostatic hyperplasia, diabetes, and protein-calorie malnutrition. Section C (cognitive patterns) of Resident #175's admission Minimum Data Set (MDS) assessment with an Assessment Reference Date (ARD) of 06/13/2024 included a Brief Interview for Mental Status (BIMS) score of 3, indicating Resident #175 was severely impaired in cognitive skills for daily decision making. Section G (functional abilities) was coded to indicate the resident required partial/moderate assistance for this task. A review of the clinical record identified missing documentation for meal intakes on the following dates. Breakfast: 06/11/2024, 06/18/2024, and 06/23/2024. Lunch: 06/11/2024, 06/15/2024, and 06/18/2024. Dinner: 06/11/2024 and 06/20/2024. On 05/20/2026 the facility staff provided the survey team with a copy of their policy titled, Charting and Documentation. This policy read in part, All services provided to the resident, progress toward the care plan goals, or any changes in the resident's medical, physical functional or psychosocial condition, shall be documented in the resident's medical record. On 05/20/2026 at 2:38 PM, during a meeting that included the Administrator, Director of Nursing, Regional Nurse Consultant, Assistant Administrator, and Regional [NAME] President of Operations the issue with the missing documentation was reviewed. No further information regarding this issue was provided to the survey team prior to the exit conference. 4. Resident #8's medication orders did not accurately describe what the medications were given for. Diagnoses for Resident #8 (R8) included diabetes, congestive heart failure, chronic pain, post-traumatic stress disorder, and end stage renal disease on dialysis. The most current MDS (minimum data set) was a quarterly assessment with an ARD (assessment reference date) of 4/16/26. R8 was assessed with a cognitive score of 15 indicating cognitively intact. R8's physician medication orders were reviewed and documented Monitoring as the reason the medications were being given instead of a diagnosis. The medications included: Mirtazapine (typically given for depression), Pregabalin (typically given for anticonvulsant and help pain), Prazosin (typically given for hypertension), and Ranexa (typically given for cardiovascular concerns). On 5/19/2026 at 1:53 p.m. the director of nursing (DON) reviewed the medications in question and verbalized that a diagnosis should be attached to each medication order and would look into it. On 5/19/2026 at 4:15 p.m. the DON presented documentation regarding proper diagnoses for the medications in question and verbalized that the physician's orders would be updated to ensure proper documentation. On 5/19/2026 at 5:25 p.m. the above finding was presented to the administrator and DON. No other information was presented prior to exiting on 5/20/26.

Based on resident interview, staff interview, clinical record review, and facility document review, the facility staff failed to maintain adequate staffing levels to consistently meet resident needs. The findings include: The facility staff failed to ensure consistent adequate staffing levels to meet individual resident needs. Review of payroll-based journal (PBJ) staffing data for quarter one 2026 (October 1-December 1, 2025) revealed the facility triggered for one star staffing and excessively low weekend staffing. This data is collected and reported to The Centers for Medicare & Medicaid Services (CMS) by the facility staff on a quarterly basis. During the survey process, interviews were conducted with cognitively intact residents and resident representatives. Concerns were expressed regarding facility staffing and delayed response times when answering call lights. Resident council minutes for 03/2026-05/2026 documented concerns related to staff using personal phones while providing care, staff speaking in an unprofessional manner, daily care interactions with aides, and one resident reportedly being asked to make their own bed. On 05/18/2026 at 10:00 AM, during an interview, Certified Nursing Assistant (CNA) #4 stated they were expected to pass ice/water twice a shift; however, there were occasions when this task could not be completed due to not having enough help. A resident group meeting was conducted on 05/18/2026 at 2:09 PM. Residents reported that when the facility changed ownership several staff left, those that remained were burned out, some don't care, and evening shift was the worst. The group shared concerns about having a difficult time having their briefs changed at night. The CNA's say give me a minute and do not return. If you are a transfer and require use of the Hoyer lift you have to be the last one to be put to bed. Residents also stated that they hardly ever receive ice water, often requiring resident to request it or obtain it independently. On 05/18/2026 at 4:11 PM, during an interview with CNA #12 regarding showers, CNA #12 stated there was one incident where dinner trays did not come out until 9:00 PM and they did not have time to give showers as their shift ended at 10:30 PM. Resident #107 had reported that on a night shift in May 2026 there was a delay in receiving their pain medication, and their call light was not answered in a timely manner. During an interview with the Director of Nursing (DON) on 05/19/2026 at 9:15 AM the DON stated they had a nurse to call out that would have been assigned to this hallway on night shift, they usually have two nurses on this hallway. There was a three-hour window between 2:00 AM and 5:00 AM where there was only one nurse, it was during this timeframe that the call light to Resident #107's room went off several times requesting pain medication. The DON stated it had been reported that no one would come to the room or answer the call light. The staff were re-educated on call light responseOn 05/19/2026 at 3:09 PM, during an interview, CNA #8 stated sometimes it was hectic, meals were delayed, so you don't know when or when not to do a shower, a couple months ago the residents were getting dinner around 7:00 or 7:30 PM. CNA #8 stated a couple of residents may not have been changed, last round not being completed due to meals being late, we have to feed people, document etc . CNA #8 reported this occurred in the fall around October and November during the transition from one company to another and stated, I guess it was hectic for them. On 05/19/2026 at 5:00 PM, during an end of the day meeting with the administrative staff the concerns regarding inconsistent access to water and ice were discussed. The Director of Nursing (DON) stated water, and ice are passed every shift. Throughout the survey, no staff member was observed to pass ice/water to the residents of the facility. Each unit did include a functioning water bottle filling station available for resident/staff use. On 05/20/2026 at 9:40 AM, during an interview regarding staffing concerns, the DON stated they had a weekly call with Human Resources to discuss strategies, advertisements, employee surveys, and use social media platforms such as LinkedIn and Indeed. The DON also stated referral bonus had increased, shift incentives were offered, they did not utilize agency staff as it appeared to affect the regular staff. On 05/19/2026 at 5:40 PM and again on 05/20/2026 at 2:38 PM, meetings were conducted that included the Administrator, DON, Regional [NAME] President of Operations, Assistant Director of Nursing, Assistant Administrator, Regional Nurse, and Staff Development Coordinator the issue with staffing was reviewed. Review of the facility assessment Appendix B staffing guidelines indicated staffing levels were adjusted based on multiple factors, including shifts in resident census, acuity, outbreaks, and admission or discharge volume. At the time of entrance, the census was 165. Staffing levels on 05/17/2026 (entrance) were noted to be within the facility's stated guidelines. No additional information regarding staffing concerns was provided by the facility staff prior to the exit conference.

Based on observation, staff interview and facility document review, the facility staff failed to employ sufficient staff to safely and effectively carry out the functions of food and nutrition services. The findings included:On 5/17/2026 at 9:05 AM during the initial kitchen tour the staff were still on the tray line. The dietary aide #1 stated they were prepping cart #7 of 9 carts. At 9:25 AM the dietary aide stated they were prepping the last cart. When asked about tray delivery times the aide stated, Our goal is to have the last cart out the door by 9:00 AM but that doesn't always happen, it depends on what else we have going on day to day and sometimes it just takes longer. The last tray cart left the kitchen at 9:50 AM. This cart was for the 400 hall. When asked about staffing the aide stated, We usually have three aides and one cook. When asked if that is the normal number of staff they stated, Yes, that's what we have every day. There was three aides and one cook working. The cook was asked what time the tray line for lunch starts and he stated to return at 11:30 AM in order to observe the tray line for lunch. On 5/17/26 at 11:25 AM there were three residents on the [NAME] unit still eating breakfast and several other residents still had breakfast trays in their room.On 5/17/26 at 11:30 AM there were four additional staff members in the kitchen at this time. A District Manager, another corporate employee, the Dietary Manager and a fourth aide. The tray line was not ready. The District Manager stated they needed 15 more minutes. At 12:05 PM the tray line was still not ready. The District Manager stated to return at 12:30PM. The tray line was not ready until 12:40PM. The last cart was finished and loaded at 2:00 PM. On 5/18/26 at 2:38 PM another member of the survey team observed the residents on the 400 hall still did not have lunch trays. This surveyor spoke to the Administrator who stated, I just went down there. The trays were on the cart outside the kitchen door, no one pushed them up there, I guess they were busy doing something else. The last tray on the cart was passed at 2:48 PM leaving many residents on the unit still eating lunch after 3:00 PM. On 5/18/26 the Dining Services District Manager was interviewed at 2:00 PM. When asked about staffing they stated, Our goal is to have four aides and one cook on each shift. Unfortunately, that is rarely happening, we don't have enough people. We did just have a job fair and had a lot of interest so we are hopeful that staffing will improve soon. The District Manager stated the department had been short staffed since she took over the building in March. On 5/18/26 at 2:40 PM the Administrator was interviewed. When asked if they were aware of a staffing problem in the Dietary Department they stated, I am aware of those concerns, and they did recently have a job fair with over 60 applicants, so they are actively working on the issue.5/18/26 at 4:11 PM Certified Nursing Assistant C.N.A. #12 was interviewed and stated that one night there had been a night that he was unable to give showers because the dinner trays didn't get served until 9:00 PM and his shift ended at 10:30PM. On 5/18/26 at 5:35 PM the survey team met with the Administrator, Director of Nursing, Assistant Directors of Nursing, the Regional Director of Clinical Services and the Regional [NAME] President of Operations. This concern was discussed with them at that time. On 5/19/26 the lunch trays arrived on the 400 hall at 1:36 PM. 05/19/2026 at 3:09 PM C.N.A #8 was interviewed. They stated that staffing was sometimes hectic, meals are often really late, so you don't know when or when not to do a shower. They stated a couple of months ago, they were getting dinner trays around 7 or 7:30 PM. No further information was provided to the survey team prior to the exit conference.

Based on observation, resident interview, staff interview and clinical record review, the facility staff failed to ensure accurate minimum data set (MDS) assessments for two (2) of 42 sampled residents, Resident #2 and Resident #36. Findings included: 1. For Resident #2, the facility staff coded the resident as having a limb restraint on the 03/21/2026 quarterly minimum data set (MDS), when the resident did not have a limb restraint. Resident #2's diagnosis list indicated diagnoses, which included, but not limited to, bilateral osteoarthritis of knee, muscle weakness, morbid obesity, and abnormalities of gait and mobility. The most recent quarterly minimum data set (MDS) with an assessment reference date (ARD) of 03/21/2026 assigned the resident a brief interview for mental status (BIMS) summary score of 15 out of 15 for cognitive abilities, indicating the resident was cognitively intact. A review of Section P (Restraints and Alarms) was coded to indicate the resident had a limb restraint used less than daily. On 05/17/2026 at 10:51 AM, Resident #2 was observed and interviewed and stated they did not have any type of restraints. No restraints were observed at the time of the interview/observation. A review of a medical provider orders did not disclose an order for a limb restraint. On 05/18/2026 at 1:23 PM, the MDS Coordinator (MDSC) was interviewed and reviewed the MDS for Resident #2 dated 03/21/2026, Section P (Restraints and Alarms). The MDSC stated the resident does not have any restraints and there are no restraints used in the facility and this was entered in error. The MDSC stated a modification of the MDS would be completed. This concern was discussed on 05/18/2026 at 5:35 PM at the end of day meeting with the Administrator, Director of Nursing, Regional Director of Operations, Staff Development Coordinator, Assistant Director of Nursing #1, Assistant Director of Nursing #2, Infection Preventionist, Regional Nurse, and [NAME] President of Clinical Services. A review of Centers for Medicare & Medicaid Services Long-Term Care Facility Resident Assessment Instrument (RAI) 3.0 User's Manual Version 1.20.1 October 2025, read in part (p. P-3) under the heading Steps for Assessment item #1 read, Review the resident's medical record (e.g., physician orders, nurses' notes, nursing assistant documentation) to determine if physical restraints were used during the 7-day look-back period. No further information was provided prior to exit on 05/20/2026. 2. For Resident#36 (R36), the facility staff failed to ensure an accurate assessment related to the resident's dentition status. The resident was observed to be edentulous (without teeth). On 5/17/26 at 11:30 am, an interview was conducted with the resident, R36. He said, meat is not chopped up. R36 stated that he has no natural teeth and said, sometimes I could not chew the meat and not chopped up for me. On 5/19/2026 at 11:58 am, a second interview was conducted with R36. During the interview, R36 stated that he had dentures at home but has no natural teeth. On 5/19/26 at 4:37 pm, an interview was conducted with a registered nurse, RN2. RN2 was a minimum data set (MDS) coordinator. She reviewed R36's Quarterly MDS dated [DATE] and stated that he was not coded for the broken or loose fitting full or partial dentures. She was not aware that he had no natural teeth which makes it difficult for him to chew some foods. On 5/19/26, a clinical record review was conducted. R36's Quarterly MDS that was dated 3/26/26 was reviewed. Section L - Oral/Dental Status L0200. Dental ↓ Check all that apply A. Broken or loosely fitting full or partial denture (chipped, cracked, uncleanable, or loose) F. Mouth or facial pain, discomfort or difficulty with chewing. These areas were left blank and the resident had dentures and difficulty with chewing some foods by him not having any natural teeth. The facility staff were not aware he had no natural teeth and had dentures that were at his home. On 5/19/26, a facility document was reviewed. The facility documentation titled, Resident Assessments, read in part, .10. Assessments are completed by staff members who have the skills and qualifications to assess relevant care areas and who are knowledgeable about the resident's strengths and areas of decline. 11. All persons who have completed any portion of the MDS resident assessment form must sign the document attesting to the accuracy of such information. 12. Information in the MDS assessments will consistently reflect information in the progress notes, plans of care, and resident observations/interviews. On 5/19/26, an end of day meeting was conducted with the administrative and corporate staff and they were informed of the above concerns. No additional information was provided prior to the exit conference.

Based on staff interview, clinical record review, and facility document review, the facility staff failed to review and revise the comprehensive person-centered care plan for 1 of 33 current sampled residents, Resident #4. The findings included; For Resident #4 (R4), the facility staff failed to revise the comprehensive person-centered care plan (CPCCP) following the discontinuation of a foley catheter.An admission Record indicated the facility admitted R4 on 10/02/25. According to the admission Record, the resident had a medical history that included heart failure unspecified and retention of urine unspecified. The quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 4/9/2026, revealed R4 had a Brief Interview for Mental Status (BIMS) score of 14 out of 15, which indicated the resident had intact cognition.R4's medical provider orders included an order dated 1/06/2026, to remove foley catheter: void trial, bladder scan every 8 hours and as clinically indicated.On 5/19/2026, a review of R4's comprehensive care plan revealed a focus area dated 12/17/2025 that indicated the resident had an indwelling urinary catheter. Focus, goals and interventions initiated on 12/17/2025 regarding an indwelling catheter remained active on the resident's care plan.During an interview on 5/20/26 at approximately 10:20 AM, the MDS Nurse stated this error occurred during a time of transition with the electronic computer system and the foley should have been removed from the care plan. Facility policy titled Care Plans, Comprehensive Person-Centered with a revision date of 3/2022, specified, 11. Assessments of residents are ongoing, and care plans are revised as information about the residents and the residents' conditions change.On 5/20/26 at 2:38 PM during a meeting with the facility administrative staff including the Administrator and Director of Nursing, the facility was informed of staff failing to revise R4's care plan.No further information was presented prior to the exit conference on 5/20/26.

Based on observation, staff interviews, resident interviews, clinical record reviews, and facility document reviews, the facility staff failed to develop and implement a comprehensive person-centered care plan for four residents, Resident #28 (R28), Resident #36 (R36), Resident #8 (R8), and Resident #9 (R9) out of a survey sample of 42 residents. The findings included:1.The facility staff failed to develop a care plan to address the use for R28's CPAP (continuous positive airway pressure) machine and develop interventions related to R28's hoarding behaviors within the resident's room. On 5/17/26 at 10:30 am, an observation of R28's room was conducted. Observation of his room was like hoarding behaviors. He had personal items packed in bags and boxes that was stacked at the end of his bed and on both sides of his bed. He had metal racks that were placed at the side of his bed that was full of his personal belongings. His overbed table was in front of him while in the bed and he had personal items on the overbed table that was stacked and was hard to see the resident in the bed while talking with him. There was a CPAP machine observed sitting on a table at the bedside. On 5/17/26 at 11:00 am, an interview was conducted with the director of nursing (DON). She stated they had offered bins to pack his belongings. She stated that they have offered for aides to come and clean R28's rooms but he declines. DON stated that the towels and sheets piled up at the end of his bed in bags was his special linen. On 5/18/26 at 2:00 pm, an interview was conducted with a certified nursing assistant, CNA3, She said, His room is an issue. Really tight difficult for us to work. That is all his belongings. On 5/18/26, a clinical record review was conducted. During the review, R28's care plan was reviewed and he had no care plan intervention about his CPAP machine. On 5/19/26 at 4:40 pm, an interview was conducted with a licensed practical nurse that was a Minimum Data Set (MDS) coordinator, LPN15. She said, we had to start fresh and as time goes it will get better. LPN15 stated that it was a new process that was started and the floor nurse do the care plans now. 2. The facility staff failed to develop a care plan to address that R36 has no natural teeth. On 5/17/26 at 11:30 am. an interview was conducted with the resident, R36. R36 stated he was diabetic and said, sometimes my meat is not chopped up. R36 stated he has no teeth and sometimes cannot chew the meat. He said. I get choked on the food coughing when eating not sitting upright enough. On 5/18/26, a clinical record review was conducted. R36's care plan was reviewed and no care plan was developed about him having no natural teeth, that he has dentures at his home, and having problems with chewing foods sometimes due being edentulous. His quarterly MDS dated [DATE] was reviewed and did not have him coded with dentures or difficulty with chewing. R36's nutritional assessment dated [DATE] was not accurate with him being edentulous. The section of R36's nutritional assessment was left unmarked by edentulous. On 5/18/26, a review of facility document was conducted. The facility documentation titled, Care plans, comprehensive person centered, read in part, A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident. 7. The comprehensive, person-centered care plan: a. includes measurable objectives and timeframes; b. describes the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being. On 5/19/26 at 4:40 pm, an interview was conducted with a licensed practical nurse that was a Minimum Data Set (MDS) coordinator, LPN15. She said, we had to start fresh and as time goes it will get better. LPN15 stated that it was a new process that was started and the floor nurse do the care plans now. On 05/19/2026, during an end of the day meeting that included the Administrator, Director of Nursing, Regional [NAME] President of Operations, Regional Nurse, Staff Development Coordinator, and Assistant Director of Nursing. They were informed of the above concerns. No additional information was provided prior to the exit conference. 3. Resident #8 (R8) did not have a resident centered care plan for dialysis. Diagnoses for R8 included diabetes, congestive heart failure, chronic pain, and end stage renal disease on dialysis. The most current MDS (minimum data set) was a quarterly assessment with an ARD (assessment reference date) of 4/16/26. R8 was assessed with a cognitive score of 15 indicating cognitively intact. Review of R8's dialysis care plan (section of interventions) was not resident specific to location or type of dialysis port. On 5/19/2026 at 8:51 a.m. license practical nurse (LPN #6, MDS coordinator) reviewed the care plan and verbalized that the care plan was not specific to resident access site or what type of access R8 had and should be on the care plan. On 5/19/2026 at 5:07 p.m. during an end of day meeting, the director of nursing (DON) and administrator were informed of the above findings. On 5/20/2026 at 9:30 a.m. the DON verbalized that the care plan is not patient specific and the facility staff are currently going through them regarding this. No other information was presented prior to exiting the facility on 5/20/26. 4. For Resident #9, the facility staff failed to develop a comprehensive care plan (CCP) for enhanced barrier precautions. Resident #9 had a pressure ulcer and an implanted central venous catheter for dialysis access. Resident #9's diagnoses included chronic kidney disease, diabetes, and pressure ulcer of sacral region. Section C (cognitive patterns) of Resident #9's quarterly Minimum Data Set (MDS) assessment with an Assessment Reference Date (ARD) of 04/24/2026 included a Brief Interview for Mental Status (BIMS) score of 6, indicating severe impairment in cognitive skills for daily decision making. Section M (skin conditions) coded the resident as having a stage III pressure ulcer. Section O (special treatments, procedures, programs) was coded to indicate the resident received dialysis. On 05/16/2026, during initial tour the surveyor observed signage outside the resident's room for enhanced precautions. During the record review, the surveyor did not find any information on the CCP to indicate this resident was on enhanced precautions. On 05/18/2026 at 1:08 PM, Licensed Practical Nurse (LPN) #4/MDS Coordinator reviewed Resident #9's CCP and stated they were unable to locate a Care Plan (CP) for enhanced precautions. LPN #4 confirmed that the resident should have had a CP in place for enhanced precautions. On 05/18/2026 at 5:35 PM, during an end of the day meeting that included the Administrator, Director of Nursing, Regional [NAME] President of Operations, Regional Nurse, Staff Development Coordinator, and Assistant Director of Nursing the above issue was reviewed. On 05/18/2026, the facility staff updated Resident #9's CCP to include the area of enhanced precautions related to dialysis and wound. No additional information regarding this issue was provided to the survey team prior to the exit conference.

Based on staff interview and clinical record review, the facility staff failed to provide written notification regarding the reason(s) for transfer and/or discharge to the resident and/or the resident's representative(s) and failed to offer a bed hold for 1 of 42 residents, Resident #175.The findings include: Resident #175 was transferred to a higher level of care on 06/24/2024. The facility staff were unable to provide documentation showing written notification of the reason(s) for transfer and/or discharge was provided to the resident and/or resident representative. In addition, the facility staff could not provide evidence that a bed hold was offered. This was a closed record review.Resident #175's diagnoses included pneumonitis, atrial fibrillation, acute kidney failure, alcohol dependence, clostridium difficile, gastro-esophageal reflux disease, benign prostatic hyperplasia, hypotension, gout, diabetes, and protein-calorie malnutrition. Section C (cognitive patterns) of Resident #175's admission Minimum Data Set (MDS) assessment with an Assessment Reference Date (ARD) of 06/13/2024 included a Brief Interview for Mental Status (BIMS) score of 3, indicating severe impairment in cognitive skills for daily decision making.The clinical record included a progress note dated 06/24/2024 stating Resident #175 had been transferred to a local hospital.During the record review, the surveyor was unable to locate documentation showing written notification of the reason(s) for transfer or discharge was provided to the resident and/or resident representative, or documentation indicating a bed hold had been offered.On 05/20/2026 at 9:50 AM, during an interview, the Regional Nurse stated they did not have any paperwork for this individuals discharge.During a meeting on 05/20/2026 at 2:38 PM that included the Administrator, Director of Nursing, Regional [NAME] President of Operations, Assistant Director of Nursing, Regional Nurse, and Staff Development Coordinator the above findings were reviewed.No additional information regarding this issue was provided to the survey team prior to the exit conference.

Based on staff interview, clinical record review, and facility document review, the facility staff failed to maintain documentation that an alleged violation of neglect was thoroughly investigated for one (1) of 42 sampled residents, Resident #63. The findings included:A facility policy titled, Abuse, Neglect, Exploitation and Misappropriation Prevention Program with a revision date of 04/2021, specified, Residents have the right to be free from.neglect. Under the heading, Policy Interpretation and Implementation Item #1 specified, Protect residents from.neglect.by anyone including.a. facility staff. Item #2 read, .Implement policies and protocols to prevent and identify.b. neglect of residents. Item #6 specified, Provide staff orientation and training/orientation programs that include topics such as.identification and reporting of abuse. Item #8 read, Identify and investigate all possible incidents of.neglect. Item #9 specified, Investigate and report any allegations within timeframes required by federal requirements. Item #11 specified, Establish and implement QAPI (quality assurance performance improvement) review and analysis of reports, allegations or findings of.neglect. Resident #63's diagnosis list indicated diagnoses that included, but were not limited to, adult failure to thrive, dementia severe with mood disturbance, Parkinson's disease, and major depressive disorder. The most recent significant change minimum data set (MDS) with an assessment reference date (ARD) of 02/24/2026, assigned the resident a brief interview for mental status (BIMS) summary score of 5 out of 15 for cognitive abilities, indicating the resident was severely impaired in cognition. A review of Resident #63's clinical record disclosed the following: A nursing fall progress note dated 05/19/2025 at 11:05 PM, revealed a CNA notified the nurse that Resident #63 was on the floor and assistance was needed. The resident was observed on the floor lying face down. The resident was turned over and lacerations were noted to the resident's forehead, right knee and right hand. Requested a facility synopsis of events. On 05/18/2026 at 3:51 PM, the Director of Nursing (DON) stated they did not have a FRI (facility reported incident) because the resident's medical condition was the cause of the fall. On 05/20/2026 at 12:47 PM, the DON provided two facility documents titled, Fall Investigation and Incident/Accident Report and stated they could not locate the witness statement forms and were only able to locate the fall investigation and incident/accident summary for the incident. A review of these facility documents disclosed the resident fell out of bed during ADL (activities of daily living) care on 05/19/2025 and it was noted the resident was sent to the ER (emergency room at hospital) for further evaluation. Interventions that were implemented after the incident were noted as environmental changes and staff education. A review of a medical provider fall investigation summary note dated 05/20/2025 read in part, .fall from bed with injury to forehead and femur fx (fracture).staff providing care to resident and rolled [resident] to the side and positioned [resident] in the middle of the bed and while cleaning [resident] began shaking and rolled out of bed.Staff Interviews: See attached statement forms.roommate interviewed.[Resident across the hall name omitted] was interviewed.See attached statement for interview. Witness statements could not be located for further review. A review of a hospital Discharge Summary dated 05/28/2025 read in part, .was in a nursing home and had a fall from there. Seems the bed was elevated when [resident] was being changed then [resident] fell from an elevated position and hit.head where had a laceration that required suturing and suffered a right femoral neck fracture and required hemiarthroplasty (a surgical procedure that replaces only half of a hip joint with a prosthetic implant). On 05/20/2026 at 12:55 PM, Certified Nursing Assistant #10 (CNA#10) was interviewed and stated she assisted after the resident's fall. CNA#10 recalled Resident #63 was a one-person assist at the time and she recalled the bed being at approximately stomach height to a CNA when she entered the room. CNA#10 stated that she wrote a statement after the incident that night. CNA#10 did not recall Certified Nursing Assistant #11 (CNA#11) (the resident's assigned CNA during the incident) leaving the room to collect supplies. She recalled that CNA#11's statement read that CNA#11 was facing the resident's back and providing care to the back/bottom area of the resident. Attempted to contact Certified Nursing Assistant #11 (CNA#11) who was assigned to the resident on 05/19/2025 and was caring for the resident at the time of the fall. A voicemail and call-back number were provided to CNA#11's voice messaging service. A returned call was not received. Requested and received evidence of CNA#11's education after the incident as noted in the Fall Investigation summary. The Director of Nursing (DON) provided evidence CNA#11 received education on Perineal Care on 06/04/2025. The DON stated the Licensed Practical Nurse assigned to Resident #63 at the time of the fall was no longer employed by the facility. No other facility staff who cared for Resident #63 in May 2025 continued to be employed by the facility at the time of the investigation and/or were available for interview. This concern was discussed at the pre-exit meeting on 05/20/2026 at 2:38 PM with the Regional Director of Operations (RDO), Administrator, Director of Nursing, Assistant Director of Nursing #1, Assistant Director of Nursing #2, Regional Nurse, Staff Development Coordinator, and Assistant Administrator. The RDO stated when the new company went into place, a concern had been identified for the facility not maintaining completed investigation files for incidents/facility reported incidents and a QAPI (quality assurance performance improvement) had been completed for a plan of correction and implemented to address this issue. The Plan of Correction (POC) had a completion date of 03/13/2026 and read as follows: 1.Statement Regarding Change of Ownershipa. The current ownership was not involved in the clinical operations, staffing practices, or systems in place prior to this date. (Date of Ownership Change: 09/11/2025) Therefore, while we acknowledge the survey findings related to pressure injuries/wounds occurring under prior ownership, the current entity cannot retroactively correct deficient practices that may have occurred before the acquisition date.b. Post transition the facility conducted a comprehensive operational and clinical review to assess compliance with federal participation requirements and to implement systems necessary to ensure resident safety and regulatory compliance. 2.Coorective Measures Implementeda. Staff Education i. Education topics included: 1. Definition of reportable incidents 2. Federal and State reporting timelines 3. Immediate notification requirements 4. Documentation standards 5. Investigation initiation and completion requirements 6. Protection of residents during investigations 7. Administrator/Director of Nursing reporting requirements 3. Monitoring and Quality Assurance [NAME]. Audit Processi. The Administrator or designee will audit incident reports weekly to ensure timely identification and completion of facility reported incidents.ii. The Administrator or designee will audit reportable events and investigation files weekly to ensure completion and accuracy of facility reported incidents.b. Quality Assurance Performance Improvement (QAPI) Oversight i. The results of the audits will be reviewed during monthly QAPI Committee meetings. ii. The QAPI committee will review and make recommendations to address the findings of the audits. iii. The audits will continue until the QAPI Committee has determined that there is substantial compliance at which time they may decreased the frequency of the interviews or resolve them. iv. An Ad Hoc QAPI Committee Meeting has been held to review this QAPI Plan. v. This QAPI Plan has been reviewed with the Medical Director 4. Conclusiona. Current ownership cannot retroactively correct clinical practices that occurred prior to acquisition.b. Systems necessary to ensure compliance related to facility reported incidents and management were implemented by the alleged date of compliance, and monitoring mechanisms are in place to ensure ongoing compliance and sustained performance improvement. 5. Allegation of Compliancea. The facility alleges compliance with this plan on 03/13/2026. A review of the credible evidence for the POC on 05/20/2026 disclosed education had been completed addressing reportable events, internal investigations, maintenance of investigation files, and utilization of a Red Folder Reportable Investigation Content Checklist. Further review of the credible evidence disclosed weekly audits were performed from 03/11/2026 through 04/15/2026 for facility incidents/investigations and that proper protocol/procedures were implemented for maintenance of documentation files. On 05/20/2026 at 5:59 PM the Regional Director of Operations (RDO), Administrator (ADM), Regional Nurse (RN), and Director of Nursing (DON) were interviewed. The ADM stated that the Abuse Coordinators for the facility are the Administrator, Director of Nursing, and Regional Nurse. The ADM stated there is a two-hour window when incidents occur and staff contact the ADM, initiate a FRI (facility reported incident) and contact law enforcement if warranted. The ADM stated the DON and RDO are called at the time of the investigation. The DON stated they look at the staff schedule and depending on the allegations, statements are obtained if necessary and residents, resident roommate(s), and family/visitors are interviewed if the need is indicated. The DON stated they will also check things in the system and facility cameras if needed. The ADM and DON both concurred before a five-day follow-up is completed, they call the team to discuss the incident and they have a check list, Red Folder they utilize. They check the employee files, inform regional support, and the file is sent to the regional team. Education will typically follow and they utilize a risk tracker system on the computer and maintain a hard copy of the incident file. The ADM and DON both agreed they attended a master training class when the facility changed ownership, which was a two-day training event. During this training, education and process expectations were reviewed and received for implementation of the incident/investigation processes, Red Folder Reportable Investigation Content Checklist, and maintenance of completed investigations/files. No further information was provided prior to exit on 05/20/26. This deficiency was cited as past non-compliance.

Based on observation, resident interview, staff interview, clinical record review, and facility document review, the facility staff failed to ensure a clean, comfortable and homelike environment for 2 of 33 current sampled residents, Resident #3 and Resident #111.The findings included: 1. For Resident #3, the facility staff failed to repair the overbed light resulting in the light remaining on from 5/13/26 until 5/18/26 affecting the resident's sleep. An undated facility policy titled, Maintenance Service, specified The maintenance department is responsible for maintaining the buildings, grounds, and equipment in a safe and operable manner at all times. An admission Record indicated the facility admitted Resident #3 on 10/19/23. According to the admission Record, the resident had a medical history that included schizophrenia, post-traumatic stress disorder, panic disorder, and insomnia. A quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 4/22/26, revealed Resident #3 had a Brief Interview for Mental Status (BIMS) score of 15 out of 15 which indicated the resident had intact cognition. During an interview on 5/17/26 at 11:27 AM, Resident #3 stated the cord to her overbed light had broken off and the light would not turn off and had been on for a couple of days. Resident #3 stated it was hard for her to sleep with the light on at night. She stated the nurses had turned in a maintenance order. Upon observation, the overbed light was on and the cord was detached and laying on the overbed table. On 5/18/26 at 8:30 AM, the overbed light was still on and the pull cord remained on the overbed table. The facility Maintenance Director (FMD) was interviewed on 5/18/26 at 8:53 AM. The FMD stated he had a maintenance request to repair Resident #3's overbed light. The FMD provided a copy of Work Order #1301 which indicated the work order was created on 5/13/26 at 2:24 PM for a light string behind bed missing. On 5/19/26 at 5:02 PM, the facility administrative staff including the Administrator and Director of Nursing were notified of the concern regarding Resident #3's overbed light. The Regional Director of Operations stated when the FMD went to the resident's room on Friday, the light was off. The FMD was interviewed again on 5/20/26 at 9:29 AM. The FMD stated he went into Resident #3's room on Friday afternoon (5/15/26) to fix the light and then realized the entire switch was pulled out. FMD stated it was at the end of the day and due to the number of items in the room and the resident had to be out of bed, it was too late in the day, and he did not have time to fix it. Resident #3 was interviewed again on 5/20/26 at approximately 9:55 AM and stated there was no way to turn the light off after the cord broke and she had a heck of a time sleeping. No further information was presented prior to the exit conference on 5/20/26. 2. Resident #111 (R111) room was unclean. Diagnoses for R111 included diabetes, respiratory failure, peripheral vascular disease, and hemiplegia. The most current MDS (minimum data set) was a quarterly assessment with an ARD (assessment reference date) of 3/16/26. R111 was assessed with a cognitive score of 13 indicating cognitively intact. On 5/17/2026 at 11:24 a.m. R111 was interviewed. During the interview it was noted R111's floor had food wrappers and food crumbs under the bed and near to a trashcan under the sink, a sticky dried liquid substance was on the floor next to the bed, a white powder substance was on the floor behind the head of the bed, and R111's over-bed table had food debris and was stained with dried liquids. R111 verbalized one of the housekeepers (described as a male) does a very good job of cleaning, but other housekeepers barely mop the floor and the overbed table hasn't been cleaned in months. R111 verbalized trying to keep the overbed table wiped off but does not have any cleaning items and uses a paper towel. On 5/18/26 at 10:45 a.m. the room was observed again and noted the same concerns as the day before. R111 said that housekeeping had not touched her room and they don't clean on weekends. (5/17/2026 was a Sunday). On 5/18/2026 at 3:50 p.m. R111's room was observed and had been cleaned except for the white powder on the floor behind the head of the bed. R111 commented that the housekeeper cleaned the overbed table which never gets done. On 5/18/2026 at 5:39 p.m. the above finding was presented to the administrator, director of nursing (DON), and regional director of operations. On 5/19/2026 at 9:41 a.m. the regional director verbalized R111 doesn't want room decluttered and refuses to allow housekeeping to mess with anything in the room. R111's care plan was then reviewed and did not indicate behaviors of refusals to clean room. The regional director verbalized that there is another care plan and would get the care plan. The regional director presented a copy of the care plan (not on the active/current care plan). The care plan indicated R111 refuses care indicating R111 refused to go to a scheduled dental appointment. The care plan did not document refusals to clean room or had interventions for refusing to clean room. No other information was presented prior to exiting the facility on 5/20/26.

Based on staff interviews, clinical record reviews and facility document reviews, the facility staff failed to treat one resident with respect and dignity. Specifically, the facility failed to protect and promote the rights of one resident, Resident #181 (R181) by applying multiple briefs with incontinence care, out of a survey sample of 42 residents. The findings included:The facility staff failed to ensure one resident received individualized incontinence care by applying multiple briefs at one time for R181. On 5/18/26 at 3:45 pm, an interview was conducted with a certified nursing assistant, CNA13. She said, I didn't double brief him. CNA13 stated that when she went into the room R181 was doubled briefed and she told the daughter that she did not put two briefs on him. CNA13 stated she had never seen his daughter do incontinent care on R181 and the only supplies the daughter would ask for was a towel to wipe off his face at times. CNA13 said, when they came to me about this double brief it made me cry I don't do that but don't know how it was there I didn't put it on him. On 5/19/26 at 10 am, a telephone interview was conducted with a licensed practical nurse, LPN14. She stated that the previous shift had to do the double briefing. LPN14 stated that she hadn't seen anyone go into R181's room from second shift. She stated she was standing at the medication cart in the hallway right outside R181's room. LPN14 said, when I went in the room he was double briefed I removed the outer brief from the resident I didn't want to tamper with evidence so I left the soiled brief that was against his skin that was under the outer brief and told the aide he needed to be changed. She stated that she didn't give the daughter any incontinent supplies and when she entered the room R181's daughter was just sitting in the room. LPN14 said, the brief against his skin was soiled could see it and he had not received care from out shift. She stated that she was in orientation, so she reported it to the charge nurse that evening. LPN14 said, the daughter was really upset management was looking into the incident but never asked me any questions about it. On 5/19/26, a clinical record review was conducted. A progress note was reviewed that LPN14 had written on 2/25/26. She had wrote that the daughter was upset that R181 had two briefs on and that she had went in the room and assisted the daughter to remove the outer brief and then had the CNA to go to his room and do incontinence care. On 5/19/26, a facility document was reviewed. The facility documentation titled, Activities of Daily Living (ADL), Supporting, read in part, .Residents are provided with care, treatment, and services as appropriate to maintain or improve their ability to carry out activities of daily living (ADLS). Residents who are unable to carry out activities of daily living independently receive the services necessary to maintain good nutrition, grooming, and personal and oral hygiene. On 5/19/26 at 2:42 pm, an end of day meeting was conducted with the administrator, director of nursing, vice president of operations, vice president of clinical services, and the regional director of clinical services. They were informed of the above concerns. No additional information was provided prior to exit conference.

Based on staff interview and clinical record review, the facility staff failed to complete a Level I Preadmission Screening and Resident Review (PASRR) for 1 of 33 residents, Resident #55. The findings include: The facility staff failed to fully complete a Level I PASRR, section 5 was left blank. A PASRR is a federally required screening process that screens individuals for mental illness and intellectual/developmental disabilities before they are admitted to a Medicaid-certified nursing facility. Resident #55's diagnoses included, dysphagia, diabetes, depression, and vascular dementia. Section C (cognitive patterns) of Resident #55's quarterly Minimum Data Set (MDS) assessment with an Assessment Reference Date (ARD) of 02/16/2026 included a Brief Interview for Mental Status (BIMS) score of 3, indicating severe impairment in cognitive skills for daily decision making. The resident's admission date was 01/24/2022. Review of the clinical record revealed a Level I PASSR dated 01/24/2022. Section 5, titled RECOMMENDATION (Either a or b must be checked.) had not been completed. On 05/18/2026 at 1:10 PM, the Director of Nursing (DON) was informed that the resident's Level I PASRR was incomplete. On 05/18/2026 at 5:35 PM, during an end of the day meeting that included the Administrator, DON, Regional [NAME] President of Operations, Regional Nurse, Staff Development Coordinator, and Assistant Director of Nursing the incomplete PASRR was reviewed. Prior to the exit conference, facility staff provided the surveyor with a copy of a PASRR containing a timestamp of 12/23/2021, which predated the PASRR under review. No additional information regarding this issue was provided to the survey team prior to the exit conference.

Based on a complaint investigation, observations, clinical record review, staff, resident and family interviews and facility documentation, the facility staff failed to ensure 1 of 6 residents (R#1) in the survey sample were free of significant medication errors. Resident #1 was not administered 6 doses of two different anticonvulsant medications, which resulted in unrelieved [MEDICAL CONDITION] and hospitalization . The findings included: Resident #1 was originally admitted to the nursing facility 6/24/1991 with [DIAGNOSES REDACTED]. The resident was hospitalized from [DATE] to 4/2/12 for acute [MEDICAL CONDITION] and readmitted to the nursing facility 4/2/12 at 3:40 pm. Resident #1 experienced unrelieved active [MEDICAL CONDITION] on 4/3/12 at 7:07 pm and was hospitalized 4 days. She returned to the nursing home on 4/7/12. The most recent Minimum Data Set (MDS) was an annual dated 1/4/12 and coded the resident with a BIMS score of 12 (moderately impaired cognitive performance). The resident was coded with [MEDICAL CONDITION]. The care plan dated 1/11/12 identified Resident #1 with a [MEDICAL CONDITION] disorder and risk for compromised quality of life. The goals of the staff were the resident would maintain therapeutic levels of anti-convulsant medication and would have no negative outcomes related to outcomes related to use of ant-convulsant medication. Some of the approaches the staff would take to accomplish these goals included administer medications per order. Upon readmission to the nursing facility on 4/2/12, Resident #1 had the following orders for anti-convulsants: [MEDICATION NAME] (anti-convulsant) 600 milligrams (mg) by mouth (PO) every morning (9:00 am). [MEDICATION NAME] 400 mg PO at every bedtime (9:00 pm). [MEDICATION NAME] (anti-convulsant) 60 mg PO three times (TID) a day (9:00 am, 1:00 pm and 5:00 pm). The Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. The MAR indicated [REDACTED]. The nurse's notes dated 4/2/12 at 3:40 pm through 4/2/12 at 11:00 pm did not reference the anticonvulsant medications were not administered per physician orders [REDACTED]. RN#3 was not available for interview. The nurse's note dated 4/3/12 at 12:00 am did not identify medication transcription problems by Licensed Practical Nurse (LPN) #7 who was responsible to perform 24 hour chart checks. LPN #7 was not available for interview. The nurse's note dated 4/3/12 at 10:00 am indicated the resident received her medications per MD orders by the 7/3 assigned LPN #5. There were no additional entries on this shift. LPN #5 was not available for interview. The following nurse's notes dated 4/3/12 at 7:07 pm through 10:44 pm were written by the assigned 3/11 Licensed Practical Nurse (LPN) #6: The nurse's notes dated 4/3/12 at 7:07 pm indicated the resident had a 5 minute [MEDICAL CONDITION] and the on-call physician was made aware. It was noted at the time of this phone call, the physician was told Resident #1 missed the [MEDICATION NAME] and the [MEDICATION NAME] doses and they did not arrive from the pharmacy. The physician instructed the nurse to administer 600 mg of [MEDICATION NAME] now (sic) 10-15 minutes after [MEDICAL CONDITION] activity stopped, and half of the 9:00 pm dose, as well as [MEDICATION NAME] 60 mg now 10-15 minutes after [MEDICAL CONDITION] activity stopped and 80 mg of [MEDICATION NAME] at 12:00 midnight. The nurse's notes dated 4/3/12 at 7:22 pm indicated Resident #1 began [MEDICAL CONDITION] activity. At 7:30 pm, the on-call physician was made aware the resident had an additional [MEDICAL CONDITION] 8 minutes and her oxygen saturation level was 89%. It was noted the physician said the oxygen saturation level was okay, but if the resident had not stopped seizing in 15 minutes; send to the emergency room (ER). The nurse's notes dated 4/3/12 at 7:35 pm revealed 911 was called, oxygen was started on the resident and she was transferred to the local ER at 7:40 pm. The nurse's notes dated 4/3/12 at 10:44 pm referenced a late entry for 7:14 pm. The note indicated [MEDICATION NAME] was pulled from the facility's stat box and [MEDICATION NAME] from the resident's previous medications located on another unit. The anti-convulsant medications were never administered due to constant [MEDICAL CONDITION] activity. The local hospital History and Physical (H&P) dated 4/3/12 indicated the resident presented in the ER and admitted to the hospital with [REDACTED]. The H&P further indicated the resident was loaded with [MEDICATION NAME] 4 mg (Anti-anxiety) and [MEDICATION NAME] 1500 mg (anti-convulsant) intravenously (IV). The resident was unresponsive and underwent endotracheal intubation. An EEG suggested continuous sharp wave activity. The endotracheal tube serves as an open passage through the upper airway. The purpose of endotracheal intubation is to permit air to pass freely to and from the lungs in order to ventilate the lungs. Endotracheal tubes can be connected to ventilator machines to provide artificial respiration. This can help when a patient is unconscious and by maintaining a patent airway. It is often used when patients are critically ill and cannot maintain adequate respiratory function to meet their needs. The endotracheal tube facilitates the use of a mechanical ventilator in these critical situations (medicinenet.com/endotracheal_intubation/article.htm). An interview was conducted with the Responsible Party (RP) on 4/17/12 at approximately 12:00 pm. She stated she was called by the ER to get permission to intubate the resident because she was a do not resuscitate (DNR). She said, "She had a grand-mal [MEDICAL CONDITION] and she hadn't had one of those in years. I was terrified. She had to spend several days in intensive care." A grand mal [MEDICAL CONDITION] - also known as a tonic-clonic [MEDICAL CONDITION] - features a loss of consciousness and violent muscle contractions. Grand mal [MEDICAL CONDITION] is caused by abnormal electrical activity throughout the brain. Most of the time grand mal [MEDICAL CONDITION] is caused by [MEDICAL CONDITION]. Many people who have a grand mal [MEDICAL CONDITION] will never have another one. However, some people need daily anti-[MEDICAL CONDITION] medications to control grand mal [MEDICAL CONDITION] (mayoclinic.com/health/grand-mal-[MEDICAL CONDITION]). On 4/18/12 at 10:00 am, an interview was conducted with the C Wing Unit Manager. She stated she She stated RN#3 (3/11 on 4/2/12) should have notified the physician when the anti-convulsants had not arrived from the pharmacy in a timely manner and asked if they could be obtained from the facility's STAT box or given at the next pharmacy run 11:00 pm and reschedule the doses. She said the pharmacy could have been called to send over the medications on a STAT run and they were also on call 24 hours/day. Other delivery run times were 2:00 am, 10:00 am and 7:30 pm. She stated LPN #5 (7/3 on 4/3/12) could have called the pharmacy for a STAT run, called the MD to let him know the resident had not received the anti-convulsions and/or obtained medications from the STAT box. C Wing charge nurse, LPN #1 joined the aforementioned interview on 4/18/12 at 11:00 am. She stated she helped to readmit the resident to the skilled unit (AC Wing) on 4/2/12 at 3:40 PM. The AC Wing Unit Manager said she verified the orders with the MD on the same day at 5:30 PM. They stated the pharmacy did not refill the anti-convulsants because they had already been filled and were on another unit (D Wing non-skilled unit), they just sent newly ordered medications. LPN #1 stated she was on the phone with the pharmacy about not having the anti-convulsants on 4/3/12 at approximately 1:30 pm, when she told the assigned LPN #5 to go to D Wing and retrieve the medications the resident needed. She said LPN #5 came back from D Wing with multiple medication cards and was under the impression Resident #1 received her anti-convulsants. LPN #1 stated she was not aware the resident did not get the anti-convulsants on 4/2/12. She stated the following morning 4/4/12 when 11/7 shift gave report, she was informed Resident #1 was sent out to the hospital for [MEDICAL CONDITION] activity. The Acting Director of Nursing (ADON) was interviewed on 4/18/12 at 12:55 pm. She stated it was okay to use the medications from another unit as long pharmacy was notified some of the medications of the resident's on another unit was used until new arrival of recent admission's medications. She also stated the facility preferred the medications are popped from the cards on the unit where they were housed to avoid any confusion upon delivery to the unit where the resident resided. She said the medications the resident needed were in the STAT box with the exception of the PO [MEDICATION NAME], which was in the narcotic box on the D-Wing medication cart. She further stated, the medications could have been sent over STAT from the pharmacy on 4/2/12 to start evening administration of anti-convulsants. She said the physician was not informed the resident missed the anti-convulsants until she started non-stop [MEDICAL CONDITION] activity on 4/3/12 at around 7:00 pm. On 4/18/12 at approximately 4:50 pm, an interview was conducted with the Administrator and the ADON. The Administrator stated the problem regarding Resident #1 not getting the physician ordered anti-convulsants was two fold; an internal and an external problem. Internally, involving the nursing staff not obtaining the medication via the STAT box, from the other unit or STAT from the pharmacy based on their 24 hour availability. In addition, the physician was not made aware of the missed medications. She stated the right decisions were not made and the answer was "education and more education". She stated the external factor involved the pharmacy technician's familiarity with the resident's medications, who decided not to send medication that had already been filled, but were in the building on D-Wing where the resident previously resided. She stated she ask their consulting pharmacy to address the issue. The facility policy and procedures entitled Medication and Treatment Administration dated 12/9/11 indicated the facility "strives to adopt best practices in medication/treatment administration to assure accurate and timely administration of physician orders". COMPLAINT DEFICIENCY

Based complaint investigations, observations, clinical record reviews, staff, resident and family interviews, and facility documentation, the facility staff failed to ensure care and services were provided for 8 of 10 residents in the survey sample (R#9, #1, #2, #3, #4, #5, #6 and #10). Facility staff failed to provide the necessary care for Resident's #9, #1, #2, #3, #4, #5 and #6 who were residents with [MEDICAL TREATMENT] shunts/catheters which resulted in a surgical left forearm amputation for R#9. Additionally, the facility staff was unable to demonstrate and vocalize a working knowledge of the care of residents with shunts/catheters which placed R#1, #2, #3, #4, #5, #6 in Immediate Jeopardy (IJ) with the likelihood to cause serious harm or death to them receiving care in the facility. A licensed nurse signed off completion of a treatment and dressing change to Resident #1's right foot, which had not been done. The facility staff failed to administer eye drops according to the physician's orders [REDACTED]. The findings included: 1. Resident #9 was admitted on [DATE] to C-Wing with [DIAGNOSES REDACTED]. edition). The Admission-Readmission Nursing assessment dated [DATE] indicated there was port-a-catheter (referring to the CVC) in the right chest, 100% right eye [MEDICAL CONDITION], high blood pressure, chronic [MEDICAL CONDITION] and type II diabetes mellitus. An arterial venous (AV) shunt/fistula was inserted by the vascular surgeon on 11/18/11. The resident had both accesses, but no orders to use the AV shunt for [MEDICAL TREATMENT]. Resident #9 was transferred to the local hospital from the vascular surgeon's office on 11/28/11 and did not return to the nursing facility. On the Minimum Data Set (MDS) assessment dated [DATE] Resident #9 scored 15 on the Brief Interview for Mental Status (BIMS), which indicated intact cognitive status. She was assessed with [REDACTED]. She was coded to have no behavioral symptoms. She was assessed to require extensive assistance from one staff for bed mobility, transfer, locomotion on the unit, dressing and toilet use. She was independent with set up only for eating and personal hygiene. She needed supervision with set up only for bathing. She had no impairment in upper or lower extremity. Mobility devices included a walker and wheelchair. She was coded occasionally incontinent of urine and always continent of bowel. Active [DIAGNOSES REDACTED]. She was coded for [MEDICAL TREATMENT]. Resident #9's current care plan dated 11/7/11 identified [MEDICAL CONDITION] with a port-a-cath in the "left" chest (incorrectly identified area, actually in the right chest) and [MEDICAL TREATMENT] three times per week on Tuesday, Thursday and Saturday at a local [MEDICAL TREATMENT] center. The care plan was updated on 11/18/11 to include placement of a fistula in the left arm. The goal was that the resident would continue to participate in [MEDICAL TREATMENT] without preventable complications and/or crisis. Some of the approaches the staff would use to accomplish this goal included check and record bruit (swishing sound heard with a stethoscope of blood flowing through an artery, (Mosby's Medical Dictionary, 6h edition) and thrill (a fine vibration felt over the flow of blood, such as through an AV fistula, Mosby's Medical Dictionary, 6th edition); immediately report any changes to the physician and [MEDICAL TREATMENT] center. Report any change in color or swelling to shunt or port-a-cath site. The care plan noted the resident complained of numbness in the left hand on 11/22/11 and special orders were written to monitor the site every 2 hours and treatment per physician's orders [REDACTED]. Physician orders [REDACTED].(7/3 and 3/11); document adverse findings and follow-up in the nursing notes. These orders were not transcribed to the Treatment Administration Record (TAR), but there was a nurse's signature verifying transcription of the [MEDICAL TREATMENT] orders. Upon insertion of the AV fistula on 11/18/11, the post-op fistula care that was faxed to the nursing facility from the vascular specialist indicated monitoring to the area to include coolness, tingling, numbness of the fistula arm; if any redness, tenderness, excessive drainage or swelling appears along the length of the fistula report it to the vascular physician immediately. Report fever, chills or inability to fell thrill over the fistula. According to an interview with the C-Wing Registered Nurse (RN) Unit Manager (UM) on 12/7/11 at 1:00 pm, she stated the orders to care for the [MEDICAL TREATMENT] site upon admission, on 10/31/11, should have been transcribed to the TAR, and would apply to the AV shunt in addition to the vascular surgeon's post operative instructions, which were not on the TAR. The nurse's noted dated 11/22/11 11:00 am, indicated the restorative nurse aide called the C-Wing RN UM because Resident #9 complained of "not being able to feel good with her fingers from the wrist down on the left side." The notes referenced, upon the UM's assessment, the resident was unable to make a fist with the left hand and could only raise the left arm 3 inches off the bed. Arm was noted to have [MEDICAL CONDITION], no palpation of the thrill, but bruit was heard. Lower arm and fingers cool to touch. The Nurse Practitioner (NP) was noted to have instructed the nursing staff to monitor the resident and await a return call from the [MEDICAL TREATMENT] center. On 11/22/11 physician orders [REDACTED]. If swelling in left arm increases lightly wrap with ace bandage from elbow down to armpit. [MEDICATION NAME] (Narcotic pain reliever) 5/325 milligrams (mg) was increased from i (one) tab to ii (two) tabs by mouth every 4 hours. An appointment was scheduled for Monday 11/28/11 at 10:00 am with the vascular surgeon. The nurse's notes dated 11/23/11 indicated the resident had [MEDICAL TREATMENT] on the same date. No notation of any other adverse problems with the access sites (CVC or AV), a written assessment of left arm/hand or complaints from the resident. On 11/24/11, the nurse's notes indicated at 2:00 pm Resident #9 was sent via regular medical transport to the local Emergency Department (ED) for continued "numbness and unable to move left hand". On 11/24/11 timed for 9:00 pm, the nurse's notes indicated the resident returned to the facility with no new orders. [MEDICATION NAME] 5 milligrams (mg)/325 mg was administered for pain at 8:30 pm with no further complaints of pain. The Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. Nurse's notes for the same date timed at 9:30 pm indicated the resident returned from the emergency room with no new orders and the ER reported the resident would have another appointment set for left arm shunt replacement and the facility would be contacted in the next couple of days. On 11/25/11 all nurse's notes indicated no complaints of pain, discomfort, swelling or significant changes, but the MAR indicated [REDACTED]. Although the nurse's notes indicated otherwise, physician orders [REDACTED]. The MAR indicated [REDACTED]. On 11/26/11 at 5:00 pm, the nurse's notes indicated the resident returned from [MEDICAL TREATMENT]. Complaints of left arm pain continued and routine [MEDICATION NAME] was administered with no pain voiced by the resident at 6:00 pm. The nurse's notes on 11/27/11 indicated the resident received the scheduled [MEDICATION NAME] and that the left arm was checked every 2 hours absent of pain and swelling. The nurse's notes dated 11/28/11 at 12:45 am; only vital signs were recorded by LPN #7. At 1:00 am, LPN #7 documented the following narrative nurse note: "patient refused [MEDICATION NAME] after nurse called her name three times to awaken her and touched right hand, accused nurse of taking ring. Called nurse thief and liar using foul language. Patient then begin (sic) to accuse nurse of taking 2 rings off finger and attempting to replace them while asleep. Left arm warm to touch. Strong Bruit heard." The next nurse's note dated 11/28/11 was written by LPN #7 on 6:45 am: "pt. accepted pain med. Left arm accessed (sic). Nail beds noted purple. Patient unable to grip with hand. Bruit still heard upon auscultation. Skin warm to touch. Weak thrill felt. No c/o (complaints of) pain in area." Another entry directly written under the aforementioned note (illegible time) indicated "ADON aware of left arm accessment (sic). Reported to 7/3 shift." On 11/28/11 at 9:20 am LPN #3 noted the resident continued to have numbness of the left hand, nail beds bluish/purple in color, no range of motion (ROM). A call was placed to the vascular surgeon's office to see if appointment could be moved up from 11:20 am. The office informed the LPN, R#9's appointment was for a vascular study at 10:00 am. The LPN documented a bruit and thrill was present. On 11/28/11 at 1:00 pm, LPN#3 called the vascular surgeon's office and was informed Resident #9 was being admitted to the local hospital "something to do with fistula." The local hospital records indicated Resident #9 was admitted as an inpatient on 11/28/11 at 1:09 pm from the vascular surgeon's office. The vascular surgeon indicated in the History and Physical dated 11/28/11 at 2:13 pm he had been aware of the initial numbness and tingling, but was not informed of the progression of this to the current state and told the resident she required immediate intervention. According to an operative note dictated by the aforementioned vascular surgeon, on 11/28/11 at 5:59 pm, Resident #9 had procedures that included a left upper extremity arteriogram (an X-ray film of an artery, The Merck Manual, 19th edition) , ligation (Tying off a blood vessel or duct with a suture or wire, Mosby's Medical Dictionary, 6th edition) of the AV graft and fasciotomy (surgical incision into area of muscle, tendon, connective structures of the body, Mosby's Medical Dictionary, 6th edition) of the left upper forearm. Pre and postoperative [DIAGNOSES REDACTED]. Dictionary, 6th edition), left upper extremity, status [REDACTED]. Steal is a a clinical condition caused by arterial insufficiency and ischemia distal to a [MEDICAL TREATMENT] AV fistula or graft due to diversion of blood into the fistula or graft. Signs and symptoms of Steal include hand pain, numbness/tingling, pale cold hand, diminished or absent pulses, poor capillary refill and weakness (Fistula First. org, National Vascular Access Improvement Initiative). The aforementioned operative note also indicated the vascular surgeon had documented notes that the resident had motor and sensory function on 11/22/11, four days post placement of the AV graft, and some limited tingling and numbness in the hand, no palpable thrill in the graft, but an audible bruit. The surgeon noted a radial pulse was palpable according to the nursing notes he reviewed. He noted the resident was observed in theER on [DATE] because of some feeling of weakness. His notes indicated the ER physician concluded there was no gangrene, but the resident had limited motor function, the sensory function was intact, and the hand was viable and pink with some delayed sluggish capillary refill, but a radial artery signal was auscultated with Doppler (a hand held diagnostic tool to study blood flow in arteries and veins, Mosby's Medical Dictionary, 6th edition). The AV graft was noted to be open at the time. He noted subsequent to that, she was discharged back to the nursing facility where there were no calls made to update of any worsening changes in the resident's hand or forearm. The vascular surgeon further noted Resident #9 was seen in his office for a scheduled office visit on 11/28/11 with black fingers a frankly ischemic gangrenous hand with no motor or sensory function. The notes indicated the resident was told she had to be admitted to the hospital for the aforementioned operative procedures. The surgeon stated he took her to the operating room as soon as he could. Three procedures were performed: 1) 11/28/11 AV ligation and fasciotomy; 2) 12/1/11 amputation to mid forearm with washing out of the wound; and, 3) 12/2/11 further amputation to below the elbow joint. A hospital consultation from an orthopedic surgeon on 12/2/11 concluded the forearm appeared to be non-salvageable and upon discussions with the vascular surgeon, he recommended amputation at the level of viable musculature. It was noted this procedure may require a secondary return if the intraoperatively demarcation line of viability was not well defined. On 12/6/11 at 3:45 pm, and interview was conducted with Resident #9. She was observed in the local hospital in bed. Her left arm appeared to have been amputated to just below the elbow, dressed and wrapped in gauge. A significant amount of red blood was observed at the base of the stump onto a blue Chux (brand name) pad and left sleeve of hospital gown. As she spoke, she gestured with the left upper arm stump. She stated she had been telling the nurses at the nursing facility about her left hand pain, but mostly they gave her pain pills. She stated a few days after the shunt was placed in her arm, she complained of pain and tingling and only one nurse (gave the first name of C-Wing Unit Manager) actually checked her hand and arm (see above assessment 11/22/11), but no one else did. She stated if she could have seen clearly (stated she was blind in the right eye) maybe she would have been able to tell the nurses what her hand looked like. She described the pain as a "constant bee sting". She said, "I don't understand how it got to the point, they had to cut my arm off. Oh God! Look at me. I went to the doctor and he was shocked at how my arm looked. He said he had to work on me straight away. I never thought this would happen, but I have to make adjustments." She further stated, "The night before I went to the doctors (11/28/11) I worse night ever and my arm felt like a lead pipe. The nurse did not pay any attention to what I was saying to her. She acted like she was mad at me. She ignored me!" She concluded by raising the left arm stump, "I want you to tell the nurse's my hand is hurting now." This writer informed the nurse of her complaints of pain. The nurse came into the room and reminded her it was phantom pain, but would give her some medication. On 12/6/11 at 4:15 pm, the vascular surgeon was interviewed at the bedside of Resident #9. He stated when he saw the resident during the schedule visit on Monday 11/28/11; he was not prepared to see what he saw. He said the resident's fingers were completely necrotic and not viable and blisters on forearm and hand. He stated he called the nursing home and asked them why the condition of the resident's hand was not brought to my attention sooner; he could have tied it off. He said the facility told him they first saw the condition of the hand and fingers at around 6:00 am that morning (11/28/11). He further stated, "But even if I believed that they first saw her fingers in that condition and their story is correct; at 6:00 am why didn't they just send her to the ER by 911. The ED doctors and I would have seen her immediately! This is what I do for a living and based on my assessment of her hand, this could not have happened suddenly. By just doing good assessments of the residents, regardless of what the problem was, and close monitoring of residents on [MEDICAL TREATMENT], especially one with complaints; further studies could be done. At best, by the time a body part like the arm, hand and fingers start losing oxygen, the clock starts ticking and I probably have a 12 hour window to try and turn things around and restore adequate circulation, but this process began at least 48 hours prior my evaluation on her on 11/28/11." During this interview, the vascular surgeon stated there were varying degrees of Steal syndrome and if he could get to a patient soon enough, he may be able to prevent further progression of the syndrome. He said Steal syndrome was characterized by the AV graft "stealing" or taking blood to the venous system, reversing the flow of blood absent sufficient circulation below the AV graft to the arm and hand. He said by the time the resident was seen, the Steal study proved to be futile because the extremity was dead. He stated, he tried to save the extremity, but to the best interest of the resident, to avoid other circulatory and infectious complications, and based on other professional consultation; amputation of the left forearm was inevitable. He stated most residents on [MEDICAL TREATMENT] have diabetes, [MEDICAL CONDITION] (sensation problems) and circulatory problems and are vulnerable to Steal syndrome and Resident #9 had all three. He said, "I have seen this from the community to the ED or my office, but never from a nursing home. All they had to do was monitor and make good assessments. I would make the diagnosis. I find this to be gross negligence on their part." He stated the staff needed further training on basic nursing assessments to include those residents on [MEDICAL TREATMENT] and if necessary, he would be glad to assist them. On 12/7/11 at approximately 1:15 pm, an interview was conducted Administrator (ADM), Director of Nursing (DON) and the Assistant Director of Nursing (ADON). The administrator stated, the investigation of the event was complete as of 12/6/11 and there was nothing different with the resident's left extremity until suddenly observed at 6:45 am on 11/28/11, when the nurse in charge of the resident saw Resident #9's left nail beds were purplish and she was unable to grip with her hand, but a bruit was heard and a thrill was present. The ADM stated the charge nurse then ask someone to come take a look at the hand, as well as the ADON. The ADM stated she and her staff fully read the chart and investigated the matter with the conclusion that everything that could have been done was done and the only critical issue was the resident was not sent out 911 on 11/28/11 at 6:45 am when it was first discovered her fingernails were discolored. She stated the two nurses involved were LPN #7 (off going 11/7 nurse) and LPN #3 (11/28/11 oncoming 7/3 nurse) and the DON did a verbal counseling with them. During the above interview, in the presence of the ADM, the ADON was interviewed at 1:20 pm. The ADON stated she came in approximately 6:30 am on 11/28/11 and was summoned to the C-Wing by LPN #7 because the resident had accused her of stealing her rings and she wanted her to talk to the resident about it and her behavior. She said she never mentioned she had assessed the resident's fingernails to be purplish/blue or that was the reason she wanted her to assess the resident. She said when she went in the room, she offered to give her pain medication and perform a routine blood sugar so as not to harshly approach the accusation issue. It was at this time she was shocked to see the resident's discolored fingers of the left hand. She stated she ask LPN #7 if she knew what the resident's fingers/hand were discolored and to go back to see if they were like that during her shift. She said, "(LPN #7's name) went back to check the resident, returned and said to me" 'No, this just happened! I never saw that', so she wrote the assessment for 6:45 am." When asked of the ADON how she would assess a [MEDICAL TREATMENT] resident, she could not identify what a bruit and thrill was and stated, "I just don't know which is which." She did not mention circulation checks, but stated she would check to make the dressing, if any, was intact and there was no evidence of bleeding. During the above same interview, the DON entered the room with education on fistula care and the management of Steal syndrome. She said she was in the process of developing an education in-service presentation on [MEDICAL TREATMENT] assessment and complications. She stated she verbally counseled two nurses; the 11/7 nurse LPN #7 and the oncoming shift 11/28/11 nurse LPN #3 because they did not send the resident immediately to the ER when the sudden change in condition occurred on 11/28/11 at 6:45 am. She stated she had no evidence of the verbal counseling of the aforementioned LPNs, but told them how and what to assess for when caring for a [MEDICAL TREATMENT] resident. When asked, in the presence of the ADM, what a bruit and thrill was, she stated; "I am not clinical on the floors and the ADON would know better than me. I guess I need some in-service education." The ADON immediately said, "I have already said I did not know." The DON stated she was not made aware of their assessment of a sudden change in condition until the 11:00 am meeting on 11/28/11. She stated she saw where LPN #3 had called the vascular surgeon's office at 9:20 am on 11/28/11 to move up the 10:00 am appointment. There was some confusion noted during the interview about whether the appointment was at 10:00 or 11:20 am. During the interview, the ADM and DON stated there was a problem with the facility's bus that delayed the resident leaving for the scheduled morning appointment with the vascular surgeon. They stated the resident was moved to another vehicle and left the facility around 10:30 am. The DON stated, "The [MEDICAL TREATMENT] center used the AV shunt for her last [MEDICAL TREATMENT] and the resident said so as noted in a written statement by LPN #7." This writer asked if she had spoken to the [MEDICAL TREATMENT] center to verify whether they used the AV shunt or if they had made an assessment of it; she responded, "No, I have not spoken to them, but I can." It was not ascertained by this writer or mentioned by any of the leadership, they were aware Resident #9 had a right CVC. On 12/8/11 at 9:00 am, an interview was conducted with the Administrator of the [MEDICAL TREATMENT] center. She stated the resident's newly AV shunt (inserted 11/18/11) was not "mature" enough to be used for [MEDICAL TREATMENT] treatments and they had not received a prescription/permission from the vascular surgeon to use it; the right CVC was used all the time. She reiterated firmly that the left AV fistula had never been used. She stated the resident had [MEDICAL TREATMENT] on Wednesday 11/23/11 instead of Thursday because of the Thanksgiving Holiday on 11/24/11. She stated on 11/26/11, they noted trace [MEDICAL CONDITION] of the left upper extremity the last time they saw her, they felt for a bruit and thrill and would have addressed any complaints, but she did not have any while she there on that day. During the above interview with the [MEDICAL TREATMENT] center's Administrator, review of their documentation indicated the resident was on [MEDICAL TREATMENT] 11/26/11 at 11:30 am for 210 minutes. She said their focus on the [MEDICAL TREATMENT] access was the Right CVC. She said they would have offered advice to the nursing facility at any time, if they would have called the center. Review of the [MEDICAL TREATMENT] center's documentation indicated the resident was on [MEDICAL TREATMENT] 11/26/11 at 11:30 am for 210 minutes. She stated on 11/22/11, they were made aware of a vascular surgeon's appointment, which she thought was on 11/23/11. The [MEDICAL TREATMENT] Administrator stated the nursing facility did not make them aware of the resident's ER visit on 11/24/11; they found out from the nephrologist (kidney specialist) the resident would not be dialyzing on 11/29/11 because she had surgery on 11/28/11. She stated she found out on 12/7/11; the resident had an amputation of her left arm. She said, "This is a first for me, I have never had this happen to someone's arm." On 12/7/11 at 11:10 pm, a telephone interview was conducted with LPN#7. She stated she was Resident #9's full time 11/7 charge nurse. She said on 11/27/11 starting at 11:00 pm and ending on 11/28/11 at 7:00 am, the resident. She stated the resident was pleasant and kind to her at the beginning of her shift, but around 1:00 pm, she accused her of taking rings off her fingers. She said, "She accused me of this and she never came into the building with any rings. So after that I decided not to touch her." When asked about the physician's orders [REDACTED].!" LPN#7 further stated, "I ask the ADON to come in and check on her behavior because she was accusing me of taking those rings. The ADON came back to me and asked if I had seen the purple nail beds on the left hand. I went back to look and told her that problem appeared suddenly so I documented it at 6:45 am." She could not explain why her initials appeared on the TAR for 2:00 am, 4:00 am and 6:00 am as signed off on an assessment that would have included checking for swelling, [MEDICAL CONDITION] and any other significant changes. She concluded by saying she did what she was supposed to do, she did not know about any problems she was having with her left arm/hand, although she was her assigned full time 11/7 nurse on 11/22nd, 23rd, 24th,26th and 27th. She stated she asked another 11/7 nurse (LPN #8) come in at around 1:00 pm to ask her about the stolen rings. LPN#7 stated she was not verbally counseled and was not aware there were any problems/issues with the care she provided Resident #9. An interview was conducted with LPN #8 on 11/7/11 at 11:40 pm. She stated LPN #7 asked her around 12:30 am on 11/28/11, to go in her room and check if the resident wanted her scheduled pain because she was not going in the room since she had accused her of stealing. LPN #8 stated she was not asked to conduct an assessment of the resident's arm throughout the night. LPN #3 was interviewed on 12/7/11 at 11:50 am. She stated she knew about Resident #9's complaints of numbness and tingling of the left arm on 11/22/11, and that she had gone to theER on [DATE] on her shift with the same complaint. She stated she was Resident #9's full time 7/3 charge nurse and had the resident for the 7/3 shift on the 23rd, 24th, 25th and 28th and with the exception of the 28th "everything was okay" as long as the resident was taking her "around the clock [MEDICATION NAME]". She stated on 11/28/11 she documented at 9:20 am, Resident #9 was continuing to have numbness to the left hand with no range of motion, blue/purple nail beds, but she had a bruit and thrill. She stated she called the vascular surgeon's off to see if the 11:20 am scheduled appointment could be moved up when she was told the appointment was at 10:00 am and the resident was sent out at that time. She stated she did not know the outcome of the resident's problems. She also stated she had not been verbally counseled for anything regarding the resident's care. A telephone interview was conducted with Resident #9's full time 3/11 pm charge nurse, LPN #6. She stated she was in charge of filling out the required daily skilled nursing assessments and the nurses were also required to chart by exception. She stated there was nothing out of the ordinary; her hands were pink and warm to the touch. She stated, "She was sent to hospital for something, I think blistering and swelling of the left arm. As long as she had [MEDICATION NAME] for left arm pain, she was ok. No one told me to check on anything else." According to review of the most recent skilled nursing assessments, LPN #6 was assigned to provide care on the 3/11 shift 24th, 25th, 26th and 27th. On each of these days LPN #6 documented no circulatory or skin problems, the resident received scheduled [MEDICATION NAME] for pain and the bruit and thrill was present. The C-Wing Unit Manager was interviewed on 12/7/11 at 11:00 am. She stated on 11/22/11 the restorative nursing assistant brought to her attention Resident #9 had some numbness and tingling from the wrist down on her left side. She stated she made a full assessment and determined the resident was unable to lift it far off the bed and there was some [MEDICAL CONDITION] noted, but the bruit and thrill was present. She stated a call was placed to the vascular center and orders were obtained to monitor the resident every 2 hours for any significant changes. An appointment was also made with the surgeon for 11/28/11. She said it was her expectation when close monitoring of an already established identified problem or change in condition; the assessment is made by the licensed nurse in charge, the assessment is documented every shift and as needed, as well as signed off on the TAR. She stated she heard the resident had to have her left arm amputated. On 12/15/11 at 12:00 pm, a telephone family interview was conducted the next of kin. He stated he insisted Resident #9 be seen in theER on [DATE] because of her complaints of left arm pain. He further said on Saturday and Sunday, he was at the nursing facility most of the day, noticed the darkness of her fingers on the left side and thought it was just because the [MEDICAL TREATMENT] was draining out her blood. He stated, "No one looked at her hand. It was a holiday weekend and I guess it was a skeleton crew, but they did not look at it, even when I kept asking about it and (Resident #9's name) kept telling them about the numbness and pain." He also stated the nursing staff consistently told him,"We give her the pain pills; she just likes to complain!" He further said,"If I knew then what I know now, maybe I could have done more to save her arm." Resident #9's legal guardian was interviewed on 12/19/11 at 11:30 am. She stated, "This wasn't justifiable and I was sorry the staff did not listen to her as time progressed. I have visited her recently and hope she will be able to adjust." The facility's policy and procedures entitled [MEDICAL TREATMENT]/[MEDICAL TREATMENT] care dated 10/11/11 included it was the policy of the facility to provide appropriate care and monitoring to [MEDICAL TREATMENT] for residents receiving [MEDICAL TREATMENT] services: 1. Correctly identify and document the type of [MEDICAL TREATMENT] access present by reviewing the MD note and place in the nurse's notes and care plan. 2. For AV Fistulas, check the site Bid (7-3, 3-11) for the presence of a bruit and thrill. Use a stethoscope to auscultate for a bruit and palpate for a thrill. Document assessment performed on MAR/TAR and any deviations from the norm in the nursing notes and notify MD. 3. Assess the site daily for S/S of infection (increased redness, warmth, swelling, pain, drainage) or bleeding. Notify the MD immediately. Nursing notes should reflect the assessment and follow-up nursing actions. 4. Notify the MD and [MEDICAL TREATMENT] center physician if at any time a thrill is not felt. Note: A thrill should resemble a "rush" or "flow" type feeling when the fistula site is palpated. 2. a. Resident #1, a [MEDICAL TREATMENT] resident, was observed on 12/7/11 at 11:30 am in bed. She had and right arm arterial venous (AV) fistula. The fingers on the right hand were very dark in color in comparison to the right hand. The resident was moving and using her right hand without any apparent difficulty. LPN #3 assigned to the resident was asked to conduct her normal assessment of the site and any other significant or pertinent assessments related to a [MEDICAL TREATMENT] resident. LPN #3 proceeded to the bedside with stethoscope in hand and stated she would check for a bruit and thrill at the right upper arm. The resident had two 2x2 gauzes on her upper arm approximately and inch apart above the elbow joint. The nurse was observed moving the stethoscopeto di

Based on observations, staff interview, document review, clinical record review and in the course of a complaint investigation, the facility staff failed to identity a process that improved the delivery of services and resident outcomes that resulted in administration and nursing system in nursing systems failures as identified by Immediate Jeopardy and constituted Substandard Quality of Care in which harm and quality deficiencies were identified during the survey. The Findings included: On [DATE] at 10:05 AM during a meeting with the Administrator, to review the Quality Assurance Program. The Administrator statedshe was made aware the survey team had identified significant issues with resident care and facilities practices resulting in system failures in administration, physician services and nursing services as identified by Immediate Jeopardy and constituted Substandard Quality of Care in which harm and quality deficiencies were identified as listed below: ? Resident #1, #9, and #10 did not receive care and services to prevent neglect in which harm was identified for Resident #9 and #10. ? Licensed nursing staff could not display the needed knowledge/competency, assessment and monitoring, as well as understand and perform Bruit and Thrill on [MEDICAL TREATMENT] residents #1, #2, #3, #4, #5 and #6. Resident #9 developed necrosis and gangrene resulting in an amputation of hand part of her forearm. Resident #9 developed darkened fingers and the nurse observed doing the check did not identify clinical indicator for a circulatory problem related to the shunt. The resident was later hospitalized with a clotted shunt. ? Resident #10 did not receive the correct ordered eye drop medication regime from the nursing staff. ? Resident #10 did not receive care and services to maintain hydration during a change in condition, developed dehydration and subsequently expired. ? Resident #10's physician and representative party (RP) was not notified of a change in condition that required physician intervention in which harm was identified. ? Certified Nursing Assistant (CNA's) did not receive the require 12 hours of continuing competency training per year. The Administrator stated these were the identified system failures that were discovered during the Immediate Jeopardy and Substandard Quality of Care status the facility was in during the immediate survey and she is totally responsible and upset, as well as disturbed that her administrative staff and, the facility's staff did not advise her of the problems. A review of the previous past three quarterly Quality Assurance Meeting Agenda only, with the Administrator evidenced continuing review of Pressure sores, Infections, Facility Incidents, Pharmacy Reports, Survey Reports, QA Audits, Resident Council Concerns, Family Grievances and Safety Issues. The Administrator stated the QA Committee had not identified a process that improved the delivery of services and resident outcomes with ongoing monitoring as indicated by the Immediate Jeopardy and Substandard Quality of Care issues. The Administrator stated all of the identified system failures would be addressed in the next Quality Assurance Quarterly meeting with monitoring.

Based on complaint investigations, observations, clinical record reviews, staff, resident and family interviews, and facility documentation, the facility staff failed to ensure 3 of 10 residents (Residents #9, #1 and #10) in the survey sample were free of neglect. 1. The facility staff neglected to provide Resident #9 with appropriate and consistent assessment and monitoring to prevent complications of a [MEDICAL TREATMENT] Arterial Venous (AV) Shunt, which resulted in a left surgical arm amputation. 2. The facility staff neglected to perform wound care to Resident #1's right necrotic foot. 3. The facility staff neglected to obtain treatment for [REDACTED].#10 expired. The findings included: 1. Resident #9 was admitted on [DATE] to C-Wing with [DIAGNOSES REDACTED]. ([MEDICAL TREATMENT] is blood pumped through a dialyzer to filter the blood through a surgically created artery to vein/AV connection called a fistula, usually through the right internal jugular vein if AV fistula has not been created or not ready for use, The Merck Manual 19th edition). The Admission-Readmission Nursing assessment dated [DATE] indicated there was port-a-catheter (referring to the CVC) in the right chest, 100% right eye [MEDICAL CONDITION], high blood pressure, chronic [MEDICAL CONDITION] and type II diabetes mellitus. An arterial venous (AV) shunt/fistula was inserted by the vascular surgeon on [DATE]. The resident had both accesses, but no orders to use the AV shunt for [MEDICAL TREATMENT]. Resident #9 was transferred to the local hospital from the vascular surgeon's office on [DATE] and did not return to the nursing facility. On the Minimum Data Set (MDS) assessment dated [DATE] Resident #9 scored 15 on the Brief Interview for Mental Status (BIMS), which indicated intact cognitive status. She was assessed with [REDACTED]. She was coded to have no behavioral symptoms. She was assessed to require extensive assistance from one staff for bed mobility, transfer, locomotion on the unit, dressing and toilet use. She was independent with set up only for eating and personal hygiene. She needed supervision with set up only for bathing. She had no impairment in upper or lower extremity. Mobility devices included a walker and wheelchair. She was coded occasionally incontinent of urine and always continent of bowel. Active [DIAGNOSES REDACTED]. She was coded for [MEDICAL TREATMENT]. Resident #9's current care plan dated [DATE] identified [MEDICAL CONDITION] with a port-a-cath in the "left" chest and [MEDICAL TREATMENT] three times per week on Tuesday, Thursday and Saturday at a local [MEDICAL TREATMENT] center. (The area was incorrectly identified. The port-a-cath was in the right chest) The care plan was updated on [DATE] to include placement of a fistula in the left arm. The goal was that the resident would continue to participate in [MEDICAL TREATMENT] without preventable complications and/or crisis. Some of the approaches the staff would use to accomplish this goal included check and record bruit (swishing sound heard with a stethoscope of blood flowing through an artery, (Mosby's Medical Dictionary, 6h edition) and thrill (a fine vibration felt over the flow of blood, such as through an AV fistula, Mosby's Medical Dictionary, 6th edition); immediately report any changes to the physician and [MEDICAL TREATMENT] center. Report any change in color or swelling to shunt or port-a-cath site. The care plan noted the resident complained of numbness in the left hand on [DATE] and special orders were written to monitor the site every 2 hours and treatment per physician's orders [REDACTED]. Physician orders [REDACTED].(,[DATE] and ,[DATE]); document adverse findings and follow-up in the nursing notes. These orders were not transcribed to the Treatment Administration Record (TAR), but there was a nurse's signature verifying transcription of the [MEDICAL TREATMENT] orders. Upon insertion of the AV fistula on [DATE], the post-op fistula care that was faxed to the nursing facility from the vascular specialist indicated monitoring to the area to include coolness, tingling, numbness of the fistula arm; if any redness, tenderness, excessive drainage or swelling appears along the length of the fistula report it to the vascular physician immediately. Report fever, chills or inability to fell thrill over the fistula. During an interview on [DATE] at 1:00 pm, the C-Wing Registered Nurse (RN) Unit Manager (UM) stated the orders to care for the [MEDICAL TREATMENT] site upon admission, on [DATE], should have been transcribed to the TAR, and would apply to the AV shunt in addition to the vascular surgeon's post operative instructions, which were not on the TAR. The nurse's noted dated [DATE] 11:00 am, indicated the restorative nurse aide called the C-Wing RN UM because Resident #9 complained of "not being able to feel good with her fingers from the wrist down on the left side." The notes referenced, upon the UM's assessment, the resident was unable to make a fist with the left hand and could only raise the left arm 3 inches off the bed. Arm was noted to have [MEDICAL CONDITION], no palpation of the thrill, but bruit was heard. Lower arm and fingers cool to touch. The Nurse Practitioner (NP) was noted to have instructed the nursing staff to monitor the resident and await a return call from the [MEDICAL TREATMENT] center. On [DATE] physician orders [REDACTED]. If swelling in left arm increases lightly wrap with ace bandage from elbow down to armpit. [MEDICATION NAME] (Narcotic pain reliever) ,[DATE] milligrams (mg) was increased from i (one) tab to ii (two) tabs by mouth every 4 hours. An appointment was scheduled for Monday [DATE] at 10:00 am with the vascular surgeon. The nurse's notes dated [DATE] indicated the resident had [MEDICAL TREATMENT] on the same date. There was no notation of any other adverse problems with the access sites (CVC or AV), nor a written assessment of left arm/hand or complaints from the resident. On [DATE], the nurse's notes indicated at 2:00 pm Resident #9 was sent via regular medical transport to the local Emergency Department (ED) for continued "numbness and unable to move left hand". On [DATE] timed for 9:00 pm, the nurse's notes indicated the resident returned to the facility with no new orders. [MEDICATION NAME] 5 milligrams (mg)/325 mg was administered for pain at 8:30 pm with no further complaints of pain. The Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. Nurse's notes for the same date timed at 9:30 pm indicated the resident returned from the emergency room with no new orders and the ER reported the resident would have another appointment set for left arm shunt replacement and the facility would be contacted in the next couple of days. On [DATE] all nurse's notes indicated no complaints of pain, discomfort, swelling or significant changes, but the MAR indicated [REDACTED]. Although the nurse's notes indicated otherwise, physician orders [REDACTED]. The MAR indicated [REDACTED]. On [DATE] at 5:00 pm, the nurse's notes indicated the resident returned from [MEDICAL TREATMENT]. Complaints of left arm pain continued and routine [MEDICATION NAME] was administered with no pain voiced by the resident at 6:00 pm. The nurse's notes on [DATE] indicated the resident received the scheduled [MEDICATION NAME] and that the left arm was checked every 2 hours absent of pain and swelling. The nurse's notes dated [DATE] at 12:45 am; only vital signs were recorded by LPN #7. At 1:00 am, LPN #7 documented the following narrative nurse note: "patient refused [MEDICATION NAME] after nurse called her name three times to awaken her and touched right hand, accused nurse of taking ring. Called nurse thief and liar using foul language. Patient then begin (sic) to accuse nurse of taking 2 rings off finger and attempting to replace them while asleep. Left arm warm to touch. Strong Bruit heard." The next nurse's note dated [DATE] was written by LPN #7 on 6:45 am: "pt. accepted pain med. Left arm accessed (sic). Nail beds noted purple. Patient unable to grip with hand. Bruit still heard upon auscultation. Skin warm to touch. Weak thrill felt. No c/o (complaints of) pain in area." Another entry directly written under the aforementioned note (illegible time) indicated "ADON aware of left arm accessment (sic). Reported to ,[DATE] shift." On [DATE] at 9:20 am LPN #3 noted the resident continued to have numbness of the left hand, nail beds bluish/purple in color, no range of motion (ROM). A call was placed to the vascular surgeon's office to see if appointment could be moved up from 11:20 am. The office informed the LPN, R#9's appointment was for a vascular study at 10:00 am. The LPN documented a bruit and thrill was present. On [DATE] at 1:00 pm, LPN#3 called the vascular surgeon's office and was informed Resident #9 was being admitted to the local hospital "something to do with fistula." The local hospital records indicated Resident #9 was admitted as an inpatient on [DATE] at 1:09 pm from the vascular surgeon's office. The vascular surgeon indicated in the History and Physical dated [DATE] at 2:13 pm he had been aware of the initial numbness and tingling, but was not informed of the progression of this to the current state and told the resident she required immediate intervention. According to an operative note dictated by the aforementioned vascular surgeon, on [DATE] at 5:59 pm, Resident #9 had procedures that included a left upper extremity arteriogram (an X-ray film of an artery, The Merck Manual, 19th edition) , ligation of the AV graft and fasciotomy of the left upper forearm. (Ligation - Tying off a blood vessel or duct with a suture or wire; 2. faciotomy- surgical incision into area of muscle, tendon, connective structures of the body Mosby's Medical Dictionary, 6th edition) Pre and postoperative [DIAGNOSES REDACTED]. Steal is a a clinical condition caused by arterial insufficiency and ischemia distal to a [MEDICAL TREATMENT] AV fistula or graft due to diversion of blood into the fistula or graft. Signs and symptoms of Steal include hand pain, numbness/tingling, pale cold hand, diminished or absent pulses, poor capillary refill and weakness (Fistula First. org, National Vascular Access Improvement Initiative). The aforementioned operative note also indicated the vascular surgeon had documented notes that the resident had motor and sensory function on [DATE], four days after placement of the AV graft, and some limited tingling and numbness in the hand, no palpable thrill in the graft, but an audible bruit. The surgeon noted a radial pulse was palpable according to the nursing notes he reviewed. He noted the resident was observed in theER on [DATE] because of some feeling of weakness. His notes indicated the ER physician concluded there was no gangrene, but the resident had limited motor function, the sensory function was intact, and the hand was viable and pink with some delayed sluggish capillary refill, but a radial artery signal was auscultated with Doppler (a hand held diagnostic tool to study blood flow in arteries and veins, Mosby's Medical Dictionary, 6th edition). The AV graft was noted to be open at the time. He noted subsequent to that, she was discharged back to the nursing facility where there were no calls made to update of any worsening changes in the resident's hand or forearm. The vascular surgeon further noted Resident #9 was seen in his office for a scheduled office visit on [DATE] with black fingers a frankly ischemic gangrenous hand with no motor or sensory function. The notes indicated the resident was told she had to be admitted to the hospital for the aforementioned operative procedures. The surgeon stated he took her to the operating room as soon as he could. Three procedures were performed: 1) [DATE] AV ligation and fasciotomy; 2) [DATE] amputation to mid forearm with washing out of the wound; and, 3) [DATE] further amputation to below the elbow joint. A hospital consultation from an orthopedic surgeon on [DATE] concluded the forearm appeared to be non-salvageable and upon discussions with the vascular surgeon, he recommended amputation at the level of viable musculature. It was noted this procedure may require a secondary return if the intraoperatively demarcation line of viability was not well defined. On [DATE] at 3:45 pm, and interview was conducted with Resident #9. She was observed in the local hospital in bed. Her left arm appeared to have been amputated to just below the elbow, dressed and wrapped in gauze. A significant amount of red blood was observed at the base of the stump onto a blue Chux (brand name) pad and left sleeve of hospital gown. As she spoke, she gestured with the left upper arm stump. She stated she had been telling the nurses at the nursing facility about her left hand pain, but mostly they gave her pain pills. She stated a few days after the shunt was placed in her arm, she complained of pain and tingling and only one nurse (gave the first name of C-Wing Unit Manager) actually checked her hand and arm (see above assessment [DATE]), but no one else did. She stated if she could have seen clearly (stated she was blind in the right eye) maybe she would have been able to tell the nurses what her hand looked like. She described the pain as a "constant bee sting". She said, "I don't understand how it got to the point, they had to cut my arm off. Oh God! Look at me. I went to the doctor and he was shocked at how my arm looked. He said he had to work on me straight away. I never thought this would happen, but I have to make adjustments." She further stated, "The night before I went to the doctors ([DATE]) I worse night ever and my arm felt like a lead pipe. The nurse did not pay any attention to what I was saying to her. She acted like she was mad at me. She ignored me!" She concluded by raising the left arm stump, "I want you to tell the nurse's my hand is hurting now." This writer informed the nurse of her complaints of pain. The nurse came into the room and reminded her it was phantom pain, but would give her some medication. On [DATE] at 4:15 pm, the vascular surgeon was interviewed at the bedside of Resident #9. He stated when he saw the resident during the schedule visit on Monday [DATE]; he was not prepared to see what he saw. He said the resident's fingers were completely necrotic and not viable and blisters on forearm and hand. He stated he called the nursing home and asked them why the condition of the resident's hand was not brought to my attention sooner; he could have tied it off. He said the facility told him they first saw the condition of the hand and fingers at around 6:00 am that morning ([DATE]). He further stated, "But even if I believed that they first saw her fingers in that condition and their story is correct; at 6:00 am why didn't they just send her to the ER by 911. The ED doctors and I would have seen her immediately! This is what I do for a living and based on my assessment of her hand, this could not have happened suddenly. By just doing good assessments of the residents, regardless of what the problem was, and close monitoring of residents on [MEDICAL TREATMENT], especially one with complaints; further studies could be done. At best, by the time a body part like the arm, hand and fingers start losing oxygen, the clock starts ticking and I probably have a 12 hour window to try and turn things around and restore adequate circulation, but this process began at least 48 hours prior my evaluation on her on [DATE]." During this interview, the vascular surgeon stated there were varying degrees of Steal syndrome and if he could get to a patient soon enough, he may be able to prevent further progression of the syndrome. He said Steal syndrome was characterized by the AV graft "stealing" or taking blood to the venous system, reversing the flow of blood absent sufficient circulation below the AV graft to the arm and hand. He said by the time the resident was seen, the Steal study proved to be futile because the extremity was dead. He stated, he tried to save the extremity, but to the best interest of the resident, to avoid other circulatory and infectious complications, and based on other professional consultation; amputation of the left forearm was inevitable. He stated most residents on [MEDICAL TREATMENT] have diabetes, [MEDICAL CONDITION] (sensation problems) and circulatory problems and are vulnerable to Steal syndrome and Resident #9 had all three. He said, "I have seen this from the community to the ED or my office, but never from a nursing home. All they had to do was monitor and make good assessments. I would make the diagnosis. I find this to be gross negligence on their part." He stated the staff needed further training on basic nursing assessments to include those residents on [MEDICAL TREATMENT] and if necessary, he would be glad to assist them. On [DATE] at approximately 1:15 pm, an interview was conducted Administrator (ADM), Director of Nursing (DON) and the Assistant Director of Nursing (ADON). The administrator stated, the investigation of the event was complete as of [DATE] and there was nothing different with the resident's left extremity until suddenly observed at 6:45 am on [DATE], when the nurse in charge of the resident saw Resident #9's left nail beds were purplish and she was unable to grip with her hand, but a bruit was heard and a thrill was present. The ADM stated the charge nurse then ask someone to come take a look at the hand, as well as the ADON. The ADM stated she and her staff fully read the chart and investigated the matter with the conclusion that everything that could have been done was done and the only critical issue was the resident was not sent out 911 on [DATE] at 6:45 am when it was first discovered her fingernails were discolored. She stated the two nurses involved were LPN #7 (off going ,[DATE] nurse) and LPN #3 ([DATE] oncoming ,[DATE] nurse) and the DON did a verbal counseling with them. During the above interview, in the presence of the ADM, the ADON was interviewed at 1:20 pm. The ADON stated she came in approximately 6:30 am on [DATE] and was summoned to the C-Wing by LPN #7 because the resident had accused her of stealing her rings and she wanted her to talk to the resident about it and her behavior. She said she never mentioned she had assessed the resident's fingernails to be purplish/blue or that was the reason she wanted her to assess the resident. She said when she went in the room, she offered to give her pain medication and perform a routine blood sugar so as not to harshly approach the accusation issue. It was at this time she was shocked to see the resident's discolored fingers of the left hand. She stated she ask LPN #7 if she knew what the resident's fingers/hand were discolored and to go back to see if they were like that during her shift. She said, "(LPN #7's name) went back to check the resident, returned and said to me" 'No, this just happened! I never saw that', so she wrote the assessment for 6:45 am." When asked how she would assess a [MEDICAL TREATMENT] resident, the ADON could not identify what a bruit and thrill was and stated, "I just don't know which is which." She did not mention circulation checks, but stated she would check to make the dressing, if any, was intact and there was no evidence of bleeding. During the above same interview, the DON entered the room with education on fistula care and the management of Steal syndrome. She said she was in the process of developing an education in-service presentation on [MEDICAL TREATMENT] assessment and complications. She stated she verbally counseled two nurses; the ,[DATE] nurse LPN #7 and the oncoming shift [DATE] nurse LPN #3 because they did not send the resident immediately to the ER when the sudden change in condition occurred on [DATE] at 6:45 am. She stated she had no evidence of the verbal counseling of the aforementioned LPNs, but told them how and what to assess for when caring for a [MEDICAL TREATMENT] resident. When asked, in the presence of the ADM, what a bruit and thrill was, she stated; "I am not clinical on the floors and the ADON would know better than me. I guess I need some in-service education." The ADON immediately said, "I have already said I did not know." The DON stated she was not made aware of their assessment of a sudden change in condition until the 11:00 am meeting on [DATE]. She stated she saw where LPN #3 had called the vascular surgeon's office at 9:20 am on [DATE] to move up the 10:00 am appointment. There was some confusion noted during the interview about whether the appointment was at 10:00 or 11:20 am. During the interview, the ADM and DON stated there was a problem with the facility's bus that delayed the resident leaving for the scheduled morning appointment with the vascular surgeon. They stated the resident was moved to another vehicle and left the facility around 10:30 am. The DON stated, "The [MEDICAL TREATMENT] center used the AV shunt for her last [MEDICAL TREATMENT] and the resident said so as noted in a written statement by LPN #7." This writer asked if she had spoken to the [MEDICAL TREATMENT] center to verify whether they used the AV shunt or if they had made an assessment of it; she responded, "No, I have not spoken to them, but I can." It was not ascertained by this writer or mentioned by any of the leadership, they were aware Resident #9 had a right CVC. On [DATE] at 9:00 am, an interview was conducted with the Administrator of the [MEDICAL TREATMENT] center. She stated the resident's newly AV shunt (inserted [DATE]) was not "mature" enough to be used for [MEDICAL TREATMENT] treatments and they had not received a prescription/permission from the vascular surgeon to use it; the right CVC was used all the time. She reiterated firmly that the left AV fistula had never been used. She stated the resident had [MEDICAL TREATMENT] on Wednesday [DATE] instead of Thursday because of the Thanksgiving Holiday on [DATE]. She stated on [DATE], they noted trace [MEDICAL CONDITION] of the left upper extremity the last time they saw her, they felt for a bruit and thrill and would have addressed any complaints, but she did not have any while she there on that day. During the above interview with the [MEDICAL TREATMENT] center's Administrator, review of their documentation indicated the resident was on [MEDICAL TREATMENT] [DATE] at 11:30 am for 210 minutes. She said their focus on the [MEDICAL TREATMENT] access was the Right CVC. She said they would have offered advice to the nursing facility at any time, if they would have called the center. Review of the [MEDICAL TREATMENT] center's documentation indicated the resident was on [MEDICAL TREATMENT] [DATE] at 11:30 am for 210 minutes. She stated on [DATE], they were made aware of a vascular surgeon's appointment, which she thought was on [DATE]. The [MEDICAL TREATMENT] Administrator stated the nursing facility did not make them aware of the resident's ER visit on [DATE]; they found out from the nephrologist (kidney specialist) the resident would not be dialyzing on [DATE] because she had surgery on [DATE]. She stated she found out on [DATE]; the resident had an amputation of her left arm. She said, "This is a first for me, I have never had this happen to someone's arm." On [DATE] at 11:10 pm, a telephone interview was conducted with LPN#7. She stated she was Resident #9's full time ,[DATE] charge nurse. She said on [DATE] starting at 11:00 pm and ending on [DATE] at 7:00 am, the resident. She stated the resident was pleasant and kind to her at the beginning of her shift, but around 1:00 pm, she accused her of taking rings off her fingers. She said, "She accused me of this and she never came into the building with any rings. So after that I decided not to touch her." When asked about the physician's orders [REDACTED].!" LPN#7 further stated, "I ask the ADON to come in and check on her behavior because she was accusing me of taking those rings. The ADON came back to me and asked if I had seen the purple nail beds on the left hand. I went back to look and told her that problem appeared suddenly so I documented it at 6:45 am." She could not explain why her initials appeared on the TAR for 2:00 am, 4:00 am and 6:00 am as signed off on an assessment that would have included checking for swelling, [MEDICAL CONDITION] and any other significant changes. She concluded by saying she did what she was supposed to do, she did not know about any problems she was having with her left arm/hand, although she was her assigned full time ,[DATE] nurse on ,[DATE]nd, 23rd, 24th,26th and 27th. She stated she asked another ,[DATE] nurse (LPN #8) come in at around 1:00 pm to ask her about the stolen rings. LPN#7 stated she was not verbally counseled and was not aware there were any problems/issues with the care she provided Resident #9. An interview was conducted with LPN #8 on [DATE] at 11:40 pm. She stated LPN #7 asked her around 12:30 am on [DATE], to go in her room and check if the resident wanted her scheduled pain because she was not going in the room since she had accused her of stealing. LPN #8 stated she was not asked to conduct an assessment of the resident's arm throughout the night. LPN #3 was interviewed on [DATE] at 11:50 am. She stated she knew about Resident #9's complaints of numbness and tingling of the left arm on [DATE], and that she had gone to theER on [DATE] on her shift with the same complaint. She stated she was Resident #9's full time ,[DATE] charge nurse and had the resident for the ,[DATE] shift on the 23rd, 24th, 25th and 28th and with the exception of the 28th "everything was okay" as long as the resident was taking her "around the clock [MEDICATION NAME]". She stated on [DATE] she documented at 9:20 am, Resident #9 was continuing to have numbness to the left hand with no range of motion, blue/purple nail beds, but she had a bruit and thrill. She stated she called the vascular surgeon's off to see if the 11:20 am scheduled appointment could be moved up when she was told the appointment was at 10:00 am and the resident was sent out at that time. She stated she did not know the outcome of the resident's problems. She also stated she had not been verbally counseled for anything regarding the resident's care. A telephone interview was conducted with Resident #9's full time ,[DATE] pm charge nurse, LPN #6. She stated she was in charge of filling out the required daily skilled nursing assessments and the nurses were also required to chart by exception. She stated there was nothing out of the ordinary; her hands were pink and warm to the touch. She stated, "She was sent to hospital for something, I think blistering and swelling of the left arm. As long as she had [MEDICATION NAME] for left arm pain, she was ok. No one told me to check on anything else." According to review of the most recent skilled nursing assessments, LPN #6 was assigned to provide care on the ,[DATE] shift 24th, 25th, 26th and 27th. On each of these days LPN #6 documented no circulatory or skin problems, the resident received scheduled [MEDICATION NAME] for pain and the bruit and thrill was present. The C-Wing Unit Manager was interviewed on [DATE] at 11:00 am. She stated on [DATE] the restorative nursing assistant brought to her attention Resident #9 had some numbness and tingling from the wrist down on her left side. She stated she made a full assessment and determined the resident was unable to lift it far off the bed and there was some [MEDICAL CONDITION] noted, but the bruit and thrill was present. She stated a call was placed to the vascular center and orders were obtained to monitor the resident every 2 hours for any significant changes. An appointment was also made with the surgeon for [DATE]. She said it was her expectation when close monitoring of an already established identified problem or change in condition; the assessment is made by the licensed nurse in charge, the assessment is documented every shift and as needed, as well as signed off on the TAR. She stated she heard the resident had to have her left arm amputated. On [DATE] at 12:00 pm, a telephone family interview was conducted the next of kin. He stated he insisted Resident #9 be seen in theER on [DATE] because of her complaints of left arm pain. He further said on Saturday and Sunday, he was at the nursing facility most of the day, noticed the darkness of her fingers on the left side and thought it was just because the [MEDICAL TREATMENT] was draining out her blood. He stated, "No one looked at her hand. It was a holiday weekend and I guess it was a skeleton crew, but they did not look at it, even when I kept asking about it and (Resident #9's name) kept telling them about the numbness and pain." He also stated the nursing staff consistently told him,"We give her the pain pills; she just likes to complain!" He further said,"If I knew then what I know now, maybe I could have done more to save her arm." Resident #9's legal guardian was interviewed on [DATE] at 11:30 am. She stated, "This wasn't justifiable and I was sorry the staff did not listen to her as time progressed. I have visited her recently and hope she will be able to adjust." The facility's policy and procedures entitled [MEDICAL TREATMENT]/[MEDICAL TREATMENT] care dated [DATE] included it was the policy of the facility to provide appropriate care and monitoring to [MEDICAL TREATMENT] for residents receiving [MEDICAL TREATMENT] services: 1. Correctly identify and document the type of [MEDICAL TREATMENT] access present by reviewing the MD note and place in the nurse's notes and care plan. 2. For AV Fistulas, check the site Bid (,[DATE], ,[DATE]) for the presence of a bruit and thrill. Use a stethoscope to auscultate for a bruit and palpate for a thrill. Document assessment performed on MAR/TAR and any deviations from the norm in the nursing notes and notify MD. 3. Assess the site daily for S/S of infection (increased redness, warmth, swelling, pain, drainage) or bleeding. Notify the MD immediately. Nursing notes should reflect the assessment and follow-up nursing actions. 4. Notify the MD and [MEDICAL TREATMENT] center physician if at any time a thrill is not felt. Note: A thrill should resemble a "rush" or "flow" type feeling when the fistula site is palpated. 2. During an observation of Resident #1 on [DATE] at 11:30 am, the toes on both feet were observed to be black, dried and shriveled. There were no dressings on the either foot. LPN #3 stated the feet had been like that and there were no procedures or treatments for them. Resident #1 was originally admitted to nursing home to C-Wing on [DATE] with [DIAGNOSES REDACTED]. She was readmitted on [DATE] with a [DIAGNOSES REDACTED]. The significant change in status Minimum Data Set (MDS) assessment dated [DATE] assessed Resident #1 as a 13 on the Brief Interview for Mental Status (BIMS), which indicated she was cognitively intact. She was not assessed with [REDACTED]. She was as

Based on staff interview, clinical record review, facility document review, and during the course of a complaint investigation the facility failed to repeatedly notify the physician and the representative party (RP) of an ongoing acute change in condition for 1 (Resident #10) of 10 residents in the survey sample. The nursing staff failed to notify the physician and the RP of the resident's ongoing bouts of emesis (vomiting) for 3 days ([DATE], [DATE] and [DATE]) that required physician intervention. The resident's condition declined resulting in a transfer to the emergency room where she expired. The findings include: Resident #10 was an [AGE] year old readmitted to the facility on [DATE] following a hospitalization . Current [DIAGNOSES REDACTED]. The current MDS (Minimum Data Set) a 14 day assessment with an ARD (assessment reference date) of [DATE] evidenced the resident scored a 6 of 15 on the brief mental status interview (BIMS) indicating the resident had severely impaired cognition. The resident's vision was severely impaired, (no vision or see's only light, colors or shapes; eyes do not appear to follow objects). Resident #10 required extensive assistance of 2 staff for bed mobility and transfers, and was completely dependent on staff for personal hygiene and bathing. The resident required extensive assistance of 1 staff for dressing and eating. Resident #10 was frequently incontinent of urine and always incontinent of bowel. The resident was not on a toileting program. Resident #10 was on a therapeutic mechanically altered diet. Section J 1400 prognosis indicated the resident did not have a condition or chronic disease that may result in a life expectancy of less than 6 months. Review of the facilities 24 hour report evidenced the resident had emesis x 1 on the evening of [DATE]. The nurses progress notes failed to document this event. There was no documentation in the nurses notes to provide a description of the amount or color of the emesis, assessment of the resident or notification of the physician or RP. Nurses notes dated [DATE] for 1:00 P.M., documented by the licensed practical nurse (LPN#1) evidenced the resident's vital signs were temperature (T) 99.2, blood pressure (B/P) ,[DATE], pulse (P)105 and respirations (R) 20. The resident had emesis x 1, and was asked if her "stomach was aching", she responded "No". There was no further assessment noted. The physician was not notified. At 6:25 P.M., the (evening shift nurse) documented the resident had emesis while trying to eat dinner. The resident's vital signs were T 98.6, P 81, R 18 and B/P ,[DATE]. The nurse did not notify the physician or RP of the emesis. Treatment was not obtained. No further assessments were noted. On [DATE] at 6:15 P.M., the evening nurse documented, "Staff member feeding resident. Resident started to vomit. Resident A+ O x 2 (alert and orientated), V/S (vital signs) WNL (within normal limits), (sign for no) other complaints. The physician and the RP were not notified. Treatment was not obtained. No further assessments were noted. On [DATE] at 9:20 A.M., LPN #1 documented the resident had "emesis x 1 today and the other day, spoke with speech (therapy) and I made a call out to (physician name) to get a order for a GI consult. VS T 96.2, P 88, R 24, B/P ,[DATE]". At 10:30 A.M., LPN #1 documented, "(name of physician) return the call and gave (sign for "no") new orders and stated not to give meds before meals. Will pass it on to on-coming nurse and RP was made aware". There was no evidence in the physician orders, or Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. On [DATE] at 8:00 A.M., the nurse documented the resident was having signs and symptoms of "moaning". The resident was administered an [MEDICATION NAME] ([MEDICATION NAME]). The resident had accepted all morning medications without difficulty, and would continue to monitor the resident. There was no assessment noted. At 9:00 A.M., this same nurse documented, "Med. effect (effective), resident resting quietly in bed both eyes closed, cont to monitor". There was no assessment noted. On [DATE] at 12:05 P.M., the LPN supervisor documented she was asked to assist to transfer the resident from the bed to the wheelchair to go to the dining room. Once the resident was placed in the wheelchair the resident leaned forward and started to vomit, the nurse described it as," A liquid tan in color with small particles, large amount noted coming for the nose and mouth". She assisted the resident back to bed. The primary nurse entered the room at this time, the resident was assessed and found to have crackles noted to the right lobe (lung), no signs of shortness of breath and the resident's pulse ox (oxygen) was 96% on room air. Pulse was 60, axillary T 97.5, the nurse was "unable to obtain BP at this time". At 12:10 P.M., the physician was paged. At 12:20 P.M., (the on-call physician) returned the phone call and orders were received for [MEDICATION NAME] (an antiemetic) 25 mg (milligram) suppository to be given now, change to a clear liquid diet tonight and resume regular diet in the morning and monitor for fever. At 12:25 P.M., the LPN supervisor called the RP to make her aware of the "current situation", and the physician orders. The RP "felt uneasy about keeping her here (Resident #10)". The LPN supervisor documented, "...informed the RP she had the right to send her (Resident #10) to the ER per her request and felt this maybe the best decision, RP requested her to be sent out to ER (emergency room )". At 12:35 P.M., the primary nurse documented the resident's B/P was ,[DATE] on the left arm, and ,[DATE] on the right arm. "Waiting transport". At 12:45 P.M., the primary nurse documented, "EMT (emergency medical team) in facility. Resident verbalized name to EMT's. A&O x 1. Transported to ER". The ER physician notes dated [DATE] indicated the resident was sent to the ER for declining mental status after several episodes of emesis. Under vomiting (severe) the ER physician documented, "This is a new problem. The problem has been resolved. There has been no fever. Mucous membranes are pale and dry. She appears to be writhing in pain and dehydrated. She appears unhealthy. She appears cachectic (emaciated). She appears toxic. She has a sickly appearance". Upon arrival to the ER at 1:14 P.M., the physician documented the resident's respiratory rate was 54. The resident was moaning and unable to answer questions. Per medics the resident was hypotensive on the scene. IV placement X 2 was attempted by ER RN (registered nurse) #1. At 1:39 P.M., the resident's blood pressure was ,[DATE], heart rate 101, respirations 50 and oxygen saturation 97%. Two more attempts for IV placement was performed by ER RN #2. At this time the ER physician attempted to place a IJ/EJ (internal /external jugular) line placement with 3 unsuccessful attempts. At 2:05 P.M., the family was counseled on a central line placement and requested time to decide. At 2:30 P.M., B/P was ,[DATE], heart rate 104, pulse 163, respirations 33, and oxygen saturation 63%. At approximately 2:45 P.M., a central line was successfully placed and a [MEDICATION NAME] of normal saline was immediately started. The resident was hypotensive at the start of the procedure, with noted decreased in respirations and decrease in heart rate. The resident's code status was confirmed by the family. Asystole was noted on the cardiac monitor, no pulses were noted, a Doppler study of the heart was obtained by the ER physician and the resident was pronounced at 3:02 P.M. The primary ER [DIAGNOSES REDACTED]. On [DATE] at 11:25 A.M., the LPN supervisor for [DATE] was interviewed. She stated she was not able to obtain the resident's blood pressure manually or via the vital sign machine. The primary care LPN obtained the resident's blood pressure of ,[DATE] and ,[DATE]. She stated she did not have this information when she called the physician. She told the physician she was not able to obtain a blood pressure. When asked why 911 was not called when the B/P was found to be low, she indicated she was already on the phone with the RP, gave the assessment and informed her the resident would be monitored. She informed the RP she had the right to send the resident to the ER and the decision was made to send the resident to the ER. This nurse stated the volume of the emesis was "a whole lot...you could fill half a (wash)basin, there was a lot on the floor". On [DATE] at 11:50 A.M., LPN #1 was interviewed. She stated when she called to notify the physician of the resident's emesis on [DATE] she had only notified him of the 2 emesis on her shift on [DATE] and [DATE]. She did not notify the physician the emesis started on [DATE], or of the emesis on the evening shifts of [DATE] and [DATE]. She also did not inform the physician of the resident's low grade temperature on [DATE]. On [DATE] at 10:05 A.M., the attending physician for Resident #10 was interviewed. He stated the facility had not notified him of the resident's multiple episodes of emesis between [DATE] and [DATE]. He stated he was notified of only 2 episodes of emesis (on [DATE] and [DATE]) and ordered the medications be given prior to meals. He stated if he had been notified of the multiple episodes of emesis from [DATE] through [DATE] he would have ordered an antiemetic, and ordered to push fluids. He indicated he was not aware the facility could administer IV fluids, as this also may have been an option for treatment. He indicated he was not aware of the resident's low blood pressure on [DATE] of ,[DATE] and ,[DATE] as he was not on call, and stated he would have ordered the resident to be sent to the emergency room via 911. On [DATE] at 10:38 A.M., the director of nurses (DON) was interviewed and the above findings were discussed. She stated she would have expected the nurses to have notified the physician of the nausea and emesis on [DATE], stating,"It wouldn't (emesis) have gone on that long without a resolution". She expected the nurses to have followed up with the physician. She would have expected the nurses to have completed an assessment to include a description of the emesis stating, "color can be significant". She also stated she would have expected nursing to have pushed fluids, and increased monitoring and assessment of the resident. Review of the facilities policy titled "Change of Condition" dated ,[DATE] reads the following: "It is the policy of this facility that changes in resident conditions are reported to the physician and responsible party promptly and such notifications will be noted in the medical record". Reportable changes include, but are not limited to: K. Nausea and vomiting. The nurse will assure the resident is assessed and monitored as indicated. Immediate Notification Required: 1. Immediate verbal notification of the physician will occur, if the resident, after assessment, is determined to be in need of immediate physician intervention, and/or change in resident status is noted. Always be prepared to discuss current assessment of the resident, treatments, labs, consults, and other pertinent data to the reason for physician notification. COMPLAINT DEFICIENCY

Based on staff interview, clinical record review, facility document review and during the course of a complaint investigation the facility failed to ensure 1 of 10 residents in the survey sample (Resident #10) was provided sufficient fluid to maintain hydration. The facility failed to provide care to reduce risk factors and ensure adequate fluid intake for Resident #10 to prevent dehydration based on increased needs during a change in condition. The findings include: Resident #10 was an [AGE] year old readmitted to the facility on [DATE] following a hospitalization . Current [DIAGNOSES REDACTED]. The current MDS (Minimum Data Set) a 14 day scheduled assessment with the assessment reference date of 11/15/11 evidenced the resident scored a 6 of 15 in the brief mental status interview (BIMS) indicating the resident had severely impaired cognition. The resident's vision was severely impaired, (no vision or see's only light, colors or shapes; eyes do not appear to follow objects). Resident #10 required extensive assistance of 2 staff for bed mobility and transfers, and was completely dependent on staff for personal hygiene and bathing. The resident required extensive assistance of 1 staff for dressing and eating. Resident #10 was on a therapeutic mechanically altered diet, with a current weight of 121 pounds. Section J 1400 prognosis indicated the resident did not have a condition or chronic disease that may result in a life expectancy of less than 6 months. Review of the care plan dated 11/04/11 indicating the resident was at risk for compromised nutritional and hydration status secondary to advanced disease process including cognitive impairment (Alzheimer's) and swallowing impairment. One of the goals set was the resident would not demonstrate avoidable symptoms of dehydration. The one intervention for hydration was to encourage extra fluids in hotter/humid temperatures, if not contraindicated. Hand written on the bottom of the page dated 11/18/11 was ,"Episodes of emesis-MD notified-do not give meds before meals". There were no other interventions/ approaches listed specifically to provide additional fluids or monitoring of the resident due to the emesis to maintain hydration. The ADL (activities of daily living ) care plan dated 10/11/11 identified the resident assistance needs fluctuated due to recent hospitalization , medical condition (UTI, [MEDICAL CONDITIONS], stroke, hypertension and [MEDICAL CONDITION]), ability to understand/follow directions and decreased vision. One of the approaches listed was to provide assistance with eating as needed and accepted with set up help, and encourage the resident to accept fluids and or/supplements and snacks between meals. Review of the facilities 24 hour report evidenced the resident had emesis x 1 on the evening of 11/15/11. The nurses progress notes failed to document this event. There was no documentation in the nurses notes to provide a description of the amount or color of the emesis or assessment of the resident. The physician and RP were not notified. There was no treatment order. The nurses notes dated 11/16/11 for 1:00 P.M. were reviewed. The (day shift nurse) licensed practical nurse (LPN#1) documented the resident's vital signs were temperature (T) 99.2, blood pressure (B/P) 181/99, pulse (P)105 and respirations (R) 20. The resident had emesis x 1, the resident was asked if her "stomach was aching", she responded "No". At 6:25 P.M., the (evening shift nurse) documented the resident had emesis while trying to eat dinner. The resident's vital signs were T 98.6, P 81, R 18 and B/P 142/73. For both of these bouts of emesis there was no documentation/description of the emesis i.e., amount/color, assessment of the resident or notification of the physician or RP. There was no treatment order. On 11/17/11 at 6:15 P.M., the evening nurse documented, "Staff member feeding resident. Resident started to vomit. Resident A+ O x 2 (alert and orientated), V/S (vital signs) WNL (within normal limits), (sign for no) other complaints. There was no documentation/description of the emesis, or assessment of the resident. The physician and RP were not notified. There was no treatment order. On 11/18/11 at 9:20 A.M., LPN #1 documented the resident had "emesis x 1 today and the other day, spoke with speech (therapy) and I made a call out to (physician name) to get a order for a GI consult. VS T 96.2, P 88, R 24, B/P 132/90". At 10:30 A.M., LPN #1 documented, "(name of physician) return the call and gave (No) new orders and stated not to give meds before meals. Will pass it on to on-coming nurse and RP was made aware". There was no evidence in the physician orders, or Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. On 11/19/11 at 8:00 A.M., the nurse documented the resident was having signs and symptoms of "moaning". The resident was administered an [MEDICATION NAME] ([MEDICATION NAME]). The resident had accepted all morning medications without difficulty, and would continue to monitor the resident. At 9:00 A.M., this same nurse documented, "Med. effect (effective), resident resting quietly in bed both eyes closed, cont to monitor". On 11/19/11 at 12:05 P.M., the LPN supervisor documented she was asked to assist to transfer the resident from the bed to the wheelchair to go to the dining room. Once the resident was placed in the wheelchair the resident leaned forward and started to vomit, the nurse described it as," A liquid tan in color with small particles, large amount noted coming for the nose and mouth". She assisted the resident back to bed. The primary nurse entered the room at this time, the resident was assessed and found to have crackles noted to the right lobe, no signs of shortness of breath and the resident's pulse ox (oxygen) was 96% on room air. Pulse was 60, axillary T was 97.5, the nurse was "unable to obtain BP at this time". At 12:10 P.M., the physician was paged. At 12:20 P.M., (the on-call physician) returned the phone call and orders were received for [MEDICATION NAME] (an antiemetic) 25 mg (milligram) suppository to be given now, change to a clear liquid diet tonight and resume regular diet in the morning, and monitor for fever. At 12:25 P.M., the LPN supervisor called the RP to make her aware of the "current situation", and the physician orders. The RP "felt uneasy about keeping her here (Resident #10)". The LPN supervisor documented, "...informed the RP she had the right to send her (Resident #10) to the ER per her request and felt this maybe the best decision, RP requested her to be sent out to ER (emergency room )". At 12:35 P.M., the primary nurse documented the resident's B/P was 64/40 on the left arm, and 70/40 on the right arm. "Waiting transport". At 12:45 P.M., the primary nurse documented, "EMT (emergency medical team) in facility. Resident verbalized name to EMT's. A&O x 1. Transported to ER". The ER physician notes dated 11/19/11 indicated the resident was sent to the ER for declining mental status after several episodes of emesis. Under vomiting (severe) the ER physician documented, "This is a new problem. The problem has been resolved. There has been no fever. Mucous membranes are pale and dry. She appears to be writhing in pain and dehydrated. She appears unhealthy. She appears cachectic (emaciated). She appears toxic. She has a sickly appearance". Upon arrival to the ER at 1:14 P.M., the physician documented the resident's respiratory rate was 54. The resident was moaning and unable to answer questions. Per medics the resident was hypotensive on the scene. IV placement X 2 was attempted by ER RN (registered nurse) #1. At 1:39 P.M., the resident's blood pressure was 98/57, heart rate 101, respirations 50 and oxygen saturation 97%. Two more attempts for IV placement was performed by ER RN #2. At this time the ER physician attempted to place a IJ/EJ (internal /external jugular) line placement with 3 unsuccessful attempts. At 2:05 P.M., the family was counseled on a central line placement and requested time to decide. At 2:30 P.M., B/P was 64/50, heart rate 104, pulse 163, respirations 33, and oxygen saturation 63%. At approximately 2:45 P.M., a central line was successfully placed and a [MEDICATION NAME] of normal saline was immediately started. The resident was hypotensive at the start of the procedure, with noted decrease in respirations and decrease in heart rate. The resident's code status was confirmed by the family. Asystole was noted on the cardiac monitor, no pulses were noted, a Doppler study of the heart was obtained by the ER physician and the resident was pronounced at 3:02 P.M. The primary ER final [DIAGNOSES REDACTED]. On 12/09/11 at 11:25 A.M., the LPN supervisor for 11/19/11 was interviewed. She stated she was not able to obtain the resident's blood pressure manually or via the vital sign machine. The primary care LPN obtained the resident's blood pressure of 64/40 and 70/40. She stated she did not have this information when she called the physician. She told the physician she was not able to obtain a blood pressure. When asked why 911 was not called when the B/P was found to be low, she indicated she was already on the phone with the RP, gave the assessment and informed her the resident would be monitored. She informed the RP she had the right to send the resident to the ER and the decision was made to send the resident to the ER. This nurse stated the volume of the emesis was "a whole lot...you could fill half a (wash) basin, there was a lot on the floor". On 12/09/11 at 11:50 A.M., LPN #1 was interviewed. She stated when she called to notify the physician of the resident's emesis on 11/18/11 she had only notified him of the 2 emesis on her shift on 11/16/11 and 11/18/11. She did not notify the physician the emesis started on 11/15/11, or of the emesis on the evening shifts of 11/16/11 and 11/17/11. She did not inform the physician of the resident's low grade temperature on 11/16/11. On 12/12/11 at 10:05 A.M., the attending physician for Resident #10 was interviewed. He stated the facility had not notified him of the resident's multiple episodes of emesis between 11/15/11 and 11/17/11. He stated he was notified of only 2 episodes of emesis (on 11/16/11 and 11/18/11) and ordered the medications be given prior to meals. He stated had he been notified of the multiple episodes of emesis from 11/15/11 through 11/17/11 he would have ordered an antiemetic, and ordered to push fluids. He indicated he was not aware the facility could administer IV fluids, as this also may have been an option for treatment. He indicated he was not aware of the resident's low blood pressure on 11/19/11 of 64/40 and 70/40 as he was not on call, and stated he would have ordered the resident to be sent to the emergency room via 911. On 12/12/11 at 12:10 P.M., the RN unit manager for "C" wing was interviewed. She stated she would have expected the nursing staff to have notified the physician, check the hydration status of the resident, assess the resident's mucous membranes, skin tugor. She also would have asked the physician for lab work or suggest IV fluids. She stated Resident #10 was dependent on staff for feeding and fluids. On 12/15/11 at 9:00 A.M., the certified nurse aide (CNA#2) providing direct care for Resident #10 was interviewed. She stated she recalled the resident having emesis twice for her. She stated on one occasion the resident "threw up quite a bit", she described it as "projectile". She stated she was instructed by LPN#1 to "just keep a close eye on her". When asked if she was directed to push fluids or provide any additional alternative fluids (such as popsicles or jello) she stated she did not recall. The ADL sheet indicated the resident "accepted" fluids on 11/15, 11/16, 11/17 and 11/18. When asked what this meant, she stated, "the resident made an attempt to accept fluids". There was no other documentation of the amount/ intake of fluids the resident was tolerating/accepting during this time frame. She stated the resident was a "total feeder...she could not see the meal trays unless it was directly in front of her". CNA #2 also indicated the resident was not able to administer herself her own water. The water pitcher was kept on the bedside table to the right of the resident. CNA#2 stated if the resident was not in bed she was placed in front of the nurses station during the day shift to provide constant supervision as the resident was a fall risk. Review of the registered dieticians nutritional assessment dated [DATE] indicated the resident's estimated daily fluid needs based on normal factors was 1680 cc's. There was no documentation in the clinical record to ensure the resident's estimated daily fluid needs were being met while the resident was having bouts of emesis. Review of the November 2011 MAR's (medication administration record), the CNA ADL Interim/Care Plan Summary dated 11/03/11, the nurses notes and the care plan failed to evidence any special needs were identified and additionally implemented based on the resident's change in condition to maintain hydration. On 12/12/11 at 10:38 A.M., the director of nurses (DON) was interviewed and the above findings were discussed. She stated she would have expected the nurses to have notified the physician of the nausea and emesis on 11/15/11, stating,"It wouldn't (emesis) have gone on that long without a resolution". She expected the nurses to have followed up with the physician. She would have expected the nurses to have completed an assessment to include a description of the emesis stating, "color can be significant". She also stated she would have expected nursing to have pushed fluids, and increased monitoring and assessments of the resident. COMPLAINT DEFICIENCY