Every finding on record at Marietta Heights Post Acute

Based on observation, interview and policy review, the facility failed to ensure water temperatures were below 120 degrees Fahrenheit (F). This had the potential to affect 13 residents (Residents #3, #7, #8, #12, #13, #22, #23, #25, #27, #28, #30, #31, and #37) the facility identified as being able to use the in-room sinks independently. The census was 32. Findings include: During a tour of the facility on 08/10/26, the water temperature was elevated in resident bathroom sinks. At 10:57 A.M., the water was 136 degrees F in Resident #5's room; 11:03 A.M., 136 degrees F in Resident #10's room; 11:04 A.M. 134 degrees F in Resident #32's room; 11:05 A.M. ,140 degrees F in Resident #9';s room; 11:06 A.M., 140 degrees F in Resident #27's room; 11:09 A.M., 140 degrees F in Resident #20's room; and at 11:12 A.M., 140 degrees F in Resident #7's room. During an interview on 08/10/26 at 11:16 A.M., Maintenance Director #172 stated he checked hot water temperatures weekly and had last tested the hot water in resident rooms on 08/05/26. He stated the hot water was usually around 115 degrees. There is one hot water tank for the 200 hall and one hot water tank for the 400 hall. Review of the water temperature check logs, including 08/05/26, revealed the water temperatures were below 120 degrees F. Maintenance Director #172 also checked the water temperatures on 08/10/26. At 11:18 A.M., the water was 140 degrees F in Resident #9's room; 11:19 A.M., 140 degrees F in Resident #27's room; 11:21 A.M., 138 degrees F in Resident #20's room; and at 11:22 A.M., 140 degrees F in Resident #7's room.= During an interview on 08/10/26 at 2:42 P.M., Maintenance Director #172 stated the facility had a contractor come in and the thermostat was stuck open on the 200 hall hot water tank and the element was stuck open on the 400 hall hot water tank. He stated the 400 hall hot water tank needed replaced. During an interview on 08/10/26 at 3:03 P.M., Resident #12 stated the water from the sink was a little hot but she turns the cold water on so it's not bad. Review of the facility policy titled Safety of Water Temperatures, revised December 2009, revealed water heaters that service resident rooms, bathrooms, common areas, and tub/shower areas shall be set to temperatures of no more than 120 degrees Fahrenheit. Maintenance staff shall conduct periodic tap water checks and record the water temperatures in a safety log.

Based on record review, interview, hospital record review, and policy review, the facility failed to ensure a resident's pain was controlled when the resident's pain medication was not available timely. This affected one (Resident #37) of one resident reviewed for pain management. Findings include:Record review revealed Resident #37 was admitted to the facility on [DATE] and re-admitted on [DATE] at 2:17 P.M. with diagnoses including chronic pain syndrome, end stage renal disease, polyneuropathy, spondylosis, and heart disease. Review of Resident #37's acute and chronic pain plan of care dated 05/11/25 and revised on 07/14/26 revealed to administer medication as ordered, notify physician if resident experiences unmanageable or intolerable pain, assess pain every shift as indicated, and resident sees pain management per her request. Review of Resident #37's discharge Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had pain in the last five days almost constantly. The pain affected her sleep, frequently interfered with day-to-day activity and her pain was nine on a one to ten scale, with ten being the worst pain. Review of Resident #37's hospital documentation dated 08/06/26 revealed that while the resident was in the hospital she was ordered Norco (an opioid medication) 7.5-325 milligram (mg) one tablet by mouth four times a day as needed for pain. The resident received a dose on 08/06/26 at 5:45 A.M. prior to her readmission to the nursing home. Review of Resident #37's discharge orders from the hospital dated 08/06/26 revealed the resident was ordered Norco 7.5/325 mg one tablet every four hours as needed for pain rated a five or above on the pain scale. In addition to the Norco, the resident was ordered Tylenol 325 milligrams for pain rated one to four on the pain scale. The resident had an order in place dated 08/06/26 for Lidocaine 4 percent patch, apply to affected area topically two times a day, for pain. The medication was to be administered at 7:30 AM and 7:30 PM. The resident was not administered the medication on 08/06/26 at 7:30 PM. The order was re-written on 08/07/26 to apply the Lidocaine patch to resident's lower back. Review of the resident pain assessment dated [DATE] revealed the resident [NAME] her pain a four. The pain was located in the back, feet, and hips and the resident described the pain as aching chronic and frequent. A pain rating of one was acceptable and repositioning and pain management relieved the pain. Review of Resident #37's medication administration record (MAR) dated August 2026 revealed no evidence the Norco 7.5/325 mg was administered on 08/06/26, 08/07/26, and 08/08/26. The resident received her first dose of Norco on 08/09/26 at 4:42 A.M., for a pain level of eight; two doses on 08/10/26 for pain level of four and eight respectively, and one dose on 08/11/26 for a pain level of six. Review of the narcotic control sheet revealed the Norco was not delivered to the facility until 08/08/26 and 60 pills were sent. The first dose of Norco was administered on 08/09/26 at 4:42 A.M. There was no documented time the Norco was delivered on 08/08/26. Review of Resident #37's progress notes dated 08/06/26 to 08/09/26 revealed no evidence the facility had contacted the hospital, pharmacy, or physician regarding the resident Norco not being available. During an interview on 08/10/26 at 4:57 P.M. and 08/12/26 at 2:00 P.M., Resident #37 stated she had returned to the facility on [DATE] after being in the hospital for three weeks. The resident reported she was ordered Norco for pain, and it took the facility two days to receive her pain medication. She stated her pain for those two days was off the chart without the Norco. When she had requested the Norco on 08/06/26, 08/07/26 and 08/08/26, staff told her it had not been delivered by the pharmacy and that was the only response they gave her. Resident #37 stated she was a retired nurse and believed it should have never taken two days to get her Norco. During an interview on 08/12/26 at 9:40 A.M., the Director of Nursing (DON) confirmed Resident #37 had returned from the hospital on [DATE] with an order for Norco, however the Norco was not received from the pharmacy until 08/08/26 and the resident was not administered the Norco until 08/09/26. During an interview on 08/12/26 at 10:00 A.M., Registered Nurse (RN) #168 stated Norco was available in the facility contingency medication box, and if the medication was not available the nurse should have called the hospital for the facility's provider and e-script and pulled the Norco from the contingency box. RN #168 stated there should not have been any reason for the delay in the administration of Resident #37's pain medication. Review of the policy titled Pain Assessment and Management, dated February 2001 revealed the purpose of this procedure is to help the staff identify pain in the resident, and to develop interventions that are consistent with the resident's goal and needs and that address the underlying causes of pain. The procedure identified staff were to review the medication administration record to determine how often the individual requests and receives pain medication, and to what extent the administered medication relieves the resident's pain.

Based on observation, record review, interview and review of Medscape website for medications, the facility failed to ensure a resident was free from unnecessary medication when the parameters for a hypotensive medication were not accurate. This resulted in a resident receiving the medication unnecessarily on multiple occasions. This affected one (Resident #4) of five residents reviewed for unnecessary medications. The facility census was 32. Findings include:Review of the medical record for revealed Resident #4 was readmitted on [DATE]. Diagnoses included type two diabetes mellitus with diabetic neuropathy, non-ST elevation myocardial infarction, permanent atrial fibrillation. Review of a care plan for Resident #4 revealed a focus of care for altered cardiovascular status related to a history of MI (myocardial infarction, or heart attack), hypertension, chronic systolic (congestive) heart failure, coronary artery disease after coronary artery bypass graft, atrial fibrillation, and hypotension, Revised on 11/26/25. Interventions included providing medications as ordered. The care plan further revealed an intervention for diuretic therapy related to his diagnoses of congestive heart failure and edema, revised on 11/26/25. Interventions included administering medication as ordered, asking the physician to review medication for possible dose reduction every three months, may cause dizziness, postural hypotension (a drop in blood pressure with change in body position), fatigue, and an increased risk for falls. Staff were to observe for possible side effects every shift. Review of the medical record for Resident #4 revealed an order dated 04/24/26 for the medication Midodrine (a prescription medication used to treat orthostatic hypotension, or low blood pressure when standing up). The order was for Midodrine 2.5 milligrams (mg) give one tablet by mouth three times a day. Hold if SBP (systolic blood pressure) is less than 110 millimeters of Mercury (mm/Hg) and notify the doctor or nurse practitioner. Review of progress notes for Resident #4, dated 04/29/26, revealed a note written by Physician #202 that the medications for the resident had been reviewed and reconciled. Review of progress notes for Resident #4, dated 05/05/26, revealed a note written by Nurse Practitioner (NP) #200 that the medications for the resident had been reviewed and reconciled. During an observation on n 08/11/26 at 12:50 P.M., Licensed Practical Nurse (LPN) #108 took Resident #4's blood pressure and it was 128/78 mm/Hg. At 12:55 P.M., LPN #108 prepared medications for Resident #4, including Midodrine 2.5 mg. At this time, LPN #108 confirmed the dose and also confirmed she was going to administer the medication to Resident #4. LPN #108 confirmed the medication was ordered to be held if the systolic blood pressure was less than 110. After reviewing the order, LPN #108 stated she did not believe the order was correct and had to call Nurse Practitioner (NP) #200 and clarify the order. After speaking with NP #200, it was determined the order written on 04/24/26 for Midodrine had incorrect parameters written, and the order should have read to hold the medication if the systolic blood pressure was greater than, not less than, 110 mm/Hg. During an interview on 08/11/26 at 3:50 P.M., NP #200 confirmed the Midodrine order for Resident #4 had the wrong parameters for administration. She confirmed the purpose of the Midodrine was to treat a low systolic blood pressure, therefore it would be held if the systolic blood pressure was higher, not lower. She believed the issue came from miscommunication between herself and the nurse taking the order. NP #200 confirmed she was the one who initially gave the parameters for the medication on 04/24/26 and it should have read hold if systolic blood pressure is greater than 110. This could have caused the resident to have a hypertensive episode by raising a blood pressure when it was already above 110. NP #200 confirmed Resident #4 had been receiving the Midodrine on multiple occasions unnecessarily when the resident's systemic blood pressure was above 110. Review of Medscape drug reference revealed Midodrine may slow heart rate. The risk of hypertension increases with use of other blood pressure medications and blood pressure should be monitored closely. Review of a facility policy titled Administering Medications dated 2001, revealed medications were to be administered in accordance with prescriber orders, including any required time frame. If a dosage was believed to be inappropriate or excessive for a resident, the person preparing or administering the medication would contact the prescriber, the resident's attending physician or the facility's medical director to discuss the concerns.

Based on observation, medical record review, infection control log review, review of local health department guidance, Center for Disease Control information review, review of text message communication, nursing staff schedule review, facility policy review and interview, the facility failed to develop and implement a comprehensive infection control program that included prevention, identification, investigation and reporting of communicable disease including Respiratory Syncytial Virus (RSV) infection. This resulted in Immediate Jeopardy and the likelihood of serious harm, complications and/or death for all 37 residents beginning on [DATE] when staff (Licensed Practical Nurse (LPN) #251) worked providing care to residents despite positive RSV test results and subsequently, a second staff (Certified Nursing Assistant (CNA) #237) was positive for RSV and worked (on [DATE]). Additionally, Actual Harm occurred on [DATE] when Resident #3 expired in the facility with RSV noted as a significant condition on the resident's death certificate. Despite known positive test results and symptoms, the facility Director of Nursing permitted staff to work with residents promoting resident exposure. The facility did not timely identify an RSV outbreak, investigate potential sources of the infection, implement timely and appropriate interventions to prevent the spread of RSV including isolation of symptomatic residents, prevent the co-horting of positive and negative residents, monitor residents for onset of symptoms or exacerbation of symptoms, timely report the outbreak to the local health department or ensure staff education to reduce the spread of infection to the highest extent possible. This affected six residents (#3, #20, #64, #66, #78, and #84) who contracted RSV while residing in the facility and had the potential to affect all 37 residents. On [DATE] at 1:13 P.M., the Administrator and Director of Nursing (DON) were notified Immediate Jeopardy began on [DATE] when the facility failed to ensure symptomatic and RSV positive staff, Licensed Practical Nurse (LPN) #251, was not permitted to work resulting in exposure to residents and other staff and failed to have a comprehensive and effective infection control program which resulted in the transmission of RSV among residents in the facility, across two units resulting in six residents (#3, #20, #64, #66, #78 and #84) contracting RSV; a 16.2% infection rate with no evidence the facility timely identified the outbreak or implemented appropriate and sustainable interventions to prevent the spread of the communicable disease. The Immediate Jeopardy was removed on [DATE] when the facility implemented the following corrective actions: On [DATE] following an internal review of the events described above and in conjunction with an ongoing survey, the facility initiated a comprehensive, multi-pronged response to address both the active outbreak and the underlying systemic gaps that contributed to it. The facility identified the potential trigger for the outbreak was staff attending work with symptoms and not reporting positive test results or being permitted to work despite positive test results and a physician slip to be off work. On [DATE] at 3:00 P.M. the Regional Director of Clinical Services (RDCS) RN #402 and Regional Assistant Director of Clinical Services RN #404 provided targeted re-education to the facility Clinical Managers. The training was regarding RSV-specific precautions and the critical importance of following current CDC guidance in the management of contagious respiratory illness in the skilled nursing facility setting. A total of five (5) clinical leadership staff (Infection Preventionist #256, RN #204, LPN Manager #266, Minimum Data Set (MDS)/RN #259, and the DON) received the training. All five individuals receiving the education were required to complete a post-test, with any missed questions resulting in individualized re-education and re-testing until a score of 100% was achieved. To ensure clinical leadership adherence to the corrective action plan going forward, the Regional Director of Clinical Services RN #402 would conduct direct oversight and accountability check-ins with the DON and clinical managers. Any future deviation from the corrective action plan, including permitting a staff member with a positive test result and a physician's written work restriction to work would result in progressive disciplinary action up to and including termination. This expectation was communicated directly to the DON and was documented in her personnel file On [DATE] at 4:00 P.M. the DON/Designee initiated a house-wide clinical assessment of all 37 current residents in the facility to identify any individuals with active signs or symptoms consistent with RSV or another communicable respiratory illness. Any symptomatic resident identified during this review was immediately prioritized for testing per physician order, placed on appropriate isolation precautions, and had their treating provider and responsible party notified without delay. No residents were identified on this date of being symptomatic for RSV. On [DATE] at approximately 4:30 P.M. the DON/designee also initiated direct outreach to all current 70 staff members to assess whether any employee was experiencing active signs or symptoms of RSV via telephone and in person interviews. Staff members reporting symptoms were directed to obtain RSV testing, to report their results to the facility prior to returning to work, and to remain on work restriction until their symptoms had fully resolved and they had been afebrile for a minimum of 24 hours without the use of any antipyretic (fever reducing) medication. Clearance to return was designated as a clinical leadership determination requiring confirmation from the DON or Infection Preventionist. The current staff were re-educated that any respiratory-related illness symptoms or positive RSV tests should be forwarded to the DON or the Infection Preventionist to enable the clinical managers listed above to communicate CDC guided work restrictions and return to work criteria. Subsequently, CNA #242 was identified with symptoms of communicable disease on [DATE]. The CNA was directed to get tested, and she was notified that she would be removed from the schedule until she had provided negative test results to the DON or the Infection Preventionist. CNA #242 reported proof of negative results on [DATE] at 12:20 P.M. to the DON. The facility implemented a plan for new hired staff to receive this education as part of their formal orientation process and they would be required to sign the acknowledgment prior to working any shift at the facility. On [DATE], the DON/Designee concurrently provided education to facility staff via written education regarding the obligation to report any signs or symptoms of communicable respiratory illness including RSV, COVID-19, and influenza directly to the Infection Preventionist or Director of Nursing before entering the building or beginning any shift. Staff were additionally educated on the facility's return-to-work standards, the requirement that confirmed communicable illness diagnoses be reported to clinical leadership regardless of where or when the positive result was obtained, and the fact that return-to-work decisions must always be made by the DON or Infection Preventionist and may never be delegated to scheduling or non-clinical personnel. All staff completing this education were also required to pass a post-test, with the same re-education and re-test requirement applied to any missed questions. Staff members must complete this written education prior to working their next scheduled shift. Two as needed (PRN) staff have not completed the education. These staff are Physical Therapist #261 and Occupational Therapist #215. On [DATE] active surveillance which included monitoring symptoms, proactively communicating with staff and residents for any symptoms, and testing as needed was initiated. Daily symptom monitoring for all residents including a respiratory assessment. Beginning [DATE] the DON/Designee initiated weekly audits of a minimum of five residents and five staff members per week for four consecutive weeks, and as needed thereafter, to ensure residents were free from unaddressed signs or symptoms of RSV or other communicable respiratory illness, and that staff members understood and were consistently adhering to the facility expectations regarding illness reporting and return-to-work requirements. It was the facility's expectation that staff members communicate any suspected illnesses directly with the DON or the Infection Preventionist immediately for further guidance. Any issues identified within the audits are to be forwarded to the QA Committee for immediate follow-up and review. On [DATE] at 11:29 A.M. the facility spoke with the medical director, Physician (MD) #406 related to the facility initial action plan related to the RSV outbreak and current Quality Assessment and Performance Improvement (QAPI) plan in place. MD #406 agreed and indicated he would like to further review in detail when he came to the facility on [DATE]. On [DATE], the facility's RSV policy was formally revised (Version 2.0) to include specific outbreak action steps, employee health pathways, and isolation guidance. This was completed by the Regional Director of Clinical Services RN #402 in coordination with CDC guidelines. During the review, it was determined that the existing facility policy related to RSV was not specific in relation to action planning, employee health, and specific pathways. On [DATE] at 12:30 P.M. MD #406 approved and signed the RSV Policy. Beginning [DATE], the Administrator/DON provided education to all agency account managers (Shiftkey/Clipboard) regarding the facility outbreak education related to RSV as well as the updated facility policy on RSV. They informed the agency account managers all agency staff scheduled to work at [NAME] Heights Post Acute must be re-educated on this information prior to the start of their scheduled shift, as well as any other future agency staff being informed of this updated policy/education prior to picking up any shift at [NAME] Heights Post Acute. Both agency companies have an electronic system in place that will require any potential agency staff members to complete the education that we have provided them with prior to approval for shifts at [NAME] Post Acute. Facility Scheduler #269 would be responsible for communication with the agency liaisons to ensure that this education was completed prior to their staff reporting to work at [NAME] Heights Post Acute. On [DATE] the Administrator and Director of Nursing initiated facility-wide education of all staff on the updated RSV Prevention and Outbreak Management policy (Version 2.0, [DATE]). The updated policy included new provisions for: signs and symptoms of RSV and resident risk factors to guide clinical monitoring, immediate isolation of residents upon symptom identification without waiting for confirmatory test results, active surveillance and daily symptom monitoring during an active outbreak (defined as daily rounding by the DON or Infection Preventionist) to assess all residents and staff for new signs or symptoms of communicable respiratory illness and continuing until the outbreak was formally declared resolved, staff illness reporting obligations, staff return-to-work criteria, and enforcement of physician-issued work restrictions. The updated policy was posted on the facility bulletin board. Staff were to read and sign an acknowledgment sheet confirming receipt and understanding of the updated policy and outbreak education. This would be completed by all staff no later than [DATE]. If this was not completed, the staff member would be removed from the schedule until completion. On [DATE] at 12:30 P.M. the facility held an in-person meeting with MD #406 to further discuss the facility's updated RSV policy as well as reviewing the facility-initiated RSV Outbreak plan. Attendees included the Administrator, DON, and Regional Director of Clinical Services RN #402. Physician #406 signed off and approved of the plan. The facility was now tracking staff symptoms and illness through daily symptom monitoring conducted by the DON or Infection Preventionist, including direct staff check-ins at the start of each shift and a review of any reported call-offs or illness notifications. This process was designed to identify trends, clusters, or emerging concerns among staff in a timely manner while maintaining compliance with applicable employee privacy standards. The facility identified that monitoring through a QAPI process for corrective actions would continue through end of the current quarter and then continue an as needed basis at scheduled QAPI meetings thereafter, based on identified trends or concerns.Although the Immediate Jeopardy was removed on [DATE], the deficiency remained at a Severity Level 2 (no actual harm with potential for more than minimal harm that is not Immediate Jeopardy) as the facility was in the process of implementing their corrective action plan and were monitoring to ensure on-going compliance. Findings include: 1.Review of the facility policy titled, Respiratory Syncytial Virus (RSV) Prevention, dated [DATE], revealed residents with risk factors for severe RSV infection were monitored for clinical signs and symptoms of the disease. The clinical staff was educated about the signs and symptoms of severe RSV disease including bronchiolitis, pneumonia, and worsening of serious conditions such as asthma, chronic obstructive pulmonary disease, or congestive heart failure. The clinical staff was educated about resident risk factors for developing severe RSV disease including lung disease, chronic cardiovascular diseases, diabetes mellitus, neurological conditions, kidney disorders, liver disorders, hematologic disorders, and immune compromise. Residents diagnosed with RSV were placed on contact precautions for the duration of their illness. The policy included the infection preventionist was responsible for surveillance and reporting of infectious disease. Review of the policy revealed it was not specific to action planning, employee health pathways, or outbreak action steps. Review of the facility [DATE] Infection Control Log revealed the facility identified staff and residents who had tested positive for RSV: On [DATE] Licensed Practical Nurse (LPN) #251 was positive. On [DATE] Certified Nursing Assistant (CNA) #237 was positive. On [DATE] Resident #66 was positive. On [DATE] Resident #64 was positive (lab test dated [DATE]). On [DATE] Resident #3 was positive (lab test dated [DATE]). On [DATE] Resident #84 was positive. On [DATE] Resident #20 was positive.And on [DATE] Resident #78 was positive (lab test date [DATE]). On [DATE] at 2:47 P.M. interview with Infection Preventionist (IP) #256 confirmed six residents (#3, #20, #64, #66, #78, and #84) and two staff members LPN #251 and CNA #237 had each tested positive for RSV as noted above. IP #256 revealed the first RSV positive staff was LPN #251, who tested positive for RSV on [DATE]. IP #256 stated this LPN did not report symptoms or a positive RSV test to management. The second RSV positive staff member, CNA #237, tested positive on [DATE], and the first resident, Resident #66, tested positive on [DATE]. During the interview, IP #256 stated she was following Centers for Disease Control and Prevention (CDC) guidelines for RSV prevention but revealed the facility only had one policy regarding the prevention of RSV. On [DATE] at 2:50 P.M. interview with the Director of Nursing (DON) revealed the facility did not have a comprehensive policy in place related to RSV to timely identify, monitor, and treat residents. During the interview the DON revealed surveillance had not been implemented for all residents including monitoring for fever, cough, congestion, or a decline in function, nor had the facility monitored high-risk residents closely to ensure they did not have complications associated with RSV.On [DATE] at 11:16 A.M. interview with IP #256 revealed she had not initiated contact tracing, did not have a line list (a fundamental epidemiological tool used to track individual cases during an outbreak), and did not timely identify an outbreak of RSV until [DATE] when three additional residents (who were exposed in the facility) tested positive (the facility already had two positive staff members and one resident at this time). IP #256 further revealed communal gatherings of dining and group activities did not cease until [DATE], nor was the local health department notified of the situation until [DATE]. On [DATE] at 12:37 P.M. interview with County Health Department RN #407 revealed she was notified on [DATE] by IP #256 of five residents and two staff members testing positive for RSV. RN #407 stated she would have expected to be notified within 24 hours of an identified outbreak (two or more cases) and she was not. RN #407 stated following notification she emailed RSV guidance to IP #257.Review of the information provided to the facility from the local health department (LHD) following their notification on [DATE] revealed it contained a Viral Respiratory Pathogen Toolkit for Nursing Homes/Long Term Care Facilities dated [DATE] which provided information and guidance related to preventing the spread of respiratory viruses in nursing homes. RSV was listed as a respiratory virus for the toolkit. The information revealed a comprehensive approach that included not only vaccination, but also testing, prompt treatment, and the prompt implementation of proven infection prevention and control measures was required. Taken together, these actions could protect residents and staff from respiratory illness. Further review when an infection due to a respiratory virus was suspected in a resident or health care personnel (HCP), it was important to take rapid action to prevent the spread to others in the facility. Nursing home residents, including older adults, those who were medically fragile, and those with neurological or neurocognitive conditions, may manifest atypical signs and symptoms of respiratory virus infection and may not have fever or respiratory symptoms. Less common symptoms can include new or worsening malaise, headache, new dizziness, nausea, vomiting, diarrhea, loss of taste or smell, or behavior changes. When an infection due to a respiratory virus was suspected in a resident or HCP, it was important to take rapid action to prevent the spread to others in the facility. On [DATE] at 1:20 P.M. interview with Regional Director of Clinical Services RN #402 confirmed the facility only had a general policy related to RSV/respiratory infection, not a comprehensive policy or policy specific to RSV prevention, monitoring or the procedure for how to address cases of RSV and prevent the spread of the disease. On [DATE] at 1:45 P.M. interview with the DON revealed she did not realize there was an RSV outbreak until [DATE] when multiple residents were symptomatic and tested positive for RSV. The DON confirmed the facility failed to screen CNA #237 following her RSV positive test result and ongoing symptoms before permitting her to return to work and potentially spreading the RSV virus to other staff and residents. The DON further confirmed the facility did not have an effective RSV outbreak management plan in place. On [DATE] at 1:50 P.M. interview with the Administrator confirmed the RSV outbreak was not timely identified and the facility failed to have a comprehensive RSV outbreak management plan in place to prevent the spread of RSV to residents. The Administrator also verified the outbreak root cause was traced back to LPN #251 and CNA #237 both working despite their positive RSV tests. On [DATE] at 12:37 P.M. a follow-up interview with (County Health Department) RN #407 revealed for Class B or C respiratory outbreaks (which do not have a specific definition), the health department considers two cases of the illness in the facility occurring within a seven-day period an outbreak. Outbreak reporting was to occur in one business day. On [DATE] at 11:23 A.M. interview with Nurse Practitioner (NP) #405 revealed she had not been involved in the development of a facility RSV policy and procedure following the identification of the current RSV outbreak and could not speak to any facility RSV policy. NP #405 revealed she did not recall initially being notified of RSV positive staff and stated she first became aware of the situation when Resident #66 tested positive for RSV following a hospitalization. On [DATE] at 10:15 A.M. interview with Medical Director/Physician #406 revealed he had not been directly involved with any RSV policy or procedure development and was only initially notified of resident cases. He stated he was unaware staff were the first to test positive. Review of the Centers for Disease Control guidance for RSV isolation in long-term care facilities (LTCFs), per the Viral Respiratory Pathogens Toolkit for Nursing Homes, focus on prompt identification, using Transmission-Based Precautions (isolation) for symptomatic residents, and implementing source control (masking) to prevent spread. Symptomatic residents should be isolated, and in the event of an outbreak, facilities should implement enhanced measures such as co-horting residents and staff. When an infection due to a respiratory virus is suspected in a resident or health care personnel (HCP), it is important to take rapid action to prevent the spread to others in the facility.Nursing home residents, including older adults, those who are medically fragile, and those with neurological or neurocognitive conditions, may manifest atypical signs and symptoms of respiratory virus infection and may not have fever or respiratory symptoms. Less common symptoms can include new or worsening malaise, headache, new dizziness, nausea, vomiting, diarrhea, loss of taste or smell, or behavior changes. When an infection due to a respiratory virus is suspected in a resident or HCP, it is important to take rapid action to prevent the spread to others in the facility. While decisions about testing and treatment, prophylaxis, and the recommended duration of isolation vary depending on the pathogen, IPC strategies, such as placement of the resident in a single-person room, use of a facemask for source control, and physical distancing, are the same regardless of the pathogen. Information from the CDC (dated [DATE]) also noted RSV could also cause severe disease and hospitalization in adults. RSV could sometimes also lead to exacerbation of serious conditions such as asthma, chronic obstructive pulmonary disease (COPD) and heart failure. The following conditions increase the risk of severe RSV- chronic cardiovascular disease (e.g., heart failure, coronary artery disease, or congenital heart disease [excluding isolated hypertension]), chronic lung or respiratory disease (e.g., chronic obstructive pulmonary disease, emphysema, asthma, interstitial lung disease, or cystic fibrosis), end-stage renal disease or dependence on hemodialysis or other renal replacement therapy, diabetes mellitus complicated by chronic kidney disease, neuropathy, retinopathy, or other end-organ damage, or requiring treatment with insulin or sodium-glucose cotransporter-2 (SGLT2) inhibitor, neurologic or neuromuscular conditions causing impaired airway clearance or respiratory muscle weakness (e.g., poststroke dysphagia, amyotrophic lateral sclerosis, or muscular dystrophy [excluding history of stroke without impaired airway clearance]), chronic liver disease (e.g., cirrhosis), chronic hematologic conditions (e.g., sickle cell disease or thalassemia), severe obesity (body mass index ≥40 kg/m2), moderate or severe immune compromise and residence in a nursing home. 2. The following State agency investigation related to staff testing positive for RSV revealed: a. On [DATE] at 10:48 A.M. interview with LPN #251 revealed she had been sick for a couple of days and she stated while working a shift on [DATE] (shift started on [DATE]) she developed symptoms of a severe cough, fever, sore throat and increased fatigue. LPN #251 stated she left work early, relieved by the DON and later tested positive for RSV (at an offsite provider). LPN #251 stated she returned to work on [DATE] as her symptoms had improved, but she continued to have a sore throat and congestion. LPN #251 revealed she did not report her ongoing symptoms or RSV positive test result to facility management because she didn't think she needed to. LPN #251 stated the DON did not inquire about her symptoms upon her return to work. The LPN stated she was assigned to work on 400 hall. On [DATE] at 11:20 A.M. interview with the DON revealed LPN #251 did not report that she had tested positive for RSV. LPN #251's mother (Resident #99) had informed the DON of her daughter testing positive for RSV. The DON stated she was unsure of the date when she learned of LPN #251's positive RSV test. The DON confirmed she did not exclude her from working or inquire about symptoms because LPN #251 had returned to work by the time she had found out about her diagnosis. Review of the nursing schedule revealed LPN #251 primarily worked on Hall 400 and was scheduled to work on [DATE], [DATE], [DATE], [DATE], and [DATE] which included shifts after testing positive for RSV and per LPN #251, still having symptoms. b. Review of a text message dated [DATE] at 8:56 A.M. sent from CNA #237 to Staffing Coordinator #269 revealed CNA #237 stated that she had RSV and the doctor had written her off work for Monday [DATE] and Tuesday [DATE]. CNA #237 stated she had worked the last three nights with it and asked if it would be ok for her to work on Monday and Tuesday but wanted to let Staffing Coordinator #269 know that she was contagious. Review of a text message dated [DATE] at 10:05 A.M. sent from Staffing Coordinator #269 to CNA #237 revealed Staffing Coordinator #269 stated ok, I asked the DON what she wants to do. Review of a text message dated [DATE] at 1:06 P.M. sent from Staffing Coordinator #269 to CNA #237 revealed Staffing Coordinator #269 stated CNA #237 was good to work your shifts if you're fever free. Review of the text message dated [DATE] at 1:06 P.M. sent from CNA #237 to Staffing Coordinator #269 revealed CNA #237 stated sounds great, thank you! On [DATE] at 4:33 P.M. interview with CNA #237 revealed LPN #251 had been working and was really sick with a cough and congestion. On [DATE], CNA #237 said she began coughing and thought it was a common cold. CNA #237 revealed she went to her doctor after work and tested positive for RSV. CNA #237 stated she texted the scheduler on [DATE] and informed her of testing positive for RSV and of her physician slip indicating that she should be off work through Tuesday, [DATE]. CNA #237 stated Staffing Coordinator #269 told her that she had spoken with the DON and as long as she was not fevered for 24 hours, she could return to work. CNA #237 revealed she returned to work on [DATE] with continued sneezing and coughing despite having direction from her physician to be off work.On [DATE] at 11:39 A.M. interview with Staffing Coordinator #269 revealed CNA #237 had texted her on [DATE] and informed her of having an RSV positive test result and asked if she could return to work on Monday, [DATE]. Staffing Coordinator #269 stated she informed CNA #237 that she could return to work if she did not have symptoms and wore a mask. Staffing Coordinator #269 revealed she was unsure of an exact policy for staff reporting off work with RSV or symptoms of RSV, stating, we haven't had any additional RSV positive staff, so I'm not sure of our policy, Review of the CNA [DATE] schedule revealed CNA #237 was not scheduled [DATE] or [DATE] but did work as scheduled on [DATE] and [DATE]. Information provided from the Administrator during the survey revealed the CNA worked on the 400 hall. 3. The following State agency investigation related to residents testing positive for RSV after exposure from facility staff revealed: a. Medical record review revealed Resident #66 was admitted to the facility on [DATE] with diagnoses including diabetes mellitus, chronic obstructive pulmonary disease, chronic respiratory failure with hypoxia, chronic kidney disease, congestive heart failure, and anxiety disorder. Resident #66 resided in the 400 hall (the work location of LPN #251 and CNA #237). Review of a nursing progress note dated [DATE] at 9:17 P.M. revealed Resident #66 had a temperature of 100.2, nasal congestion, moist cough, shortness of breath, and crackles auscultated in her lungs. The physician was notified with orders for a chest x-ray and COVID test. Review of the medical record revealed no documentation that droplet or contact precautions or isolation were initiated as a precaution even though there were recent RSV cases with staff. Review of a nursing note dated [DATE] at 2:08 P.M. revealed chest x-ray results indicated left, lower lob pneumonia with pleural effusion with borderline cardiomegaly. Levaquin (antibiotic) 500 milligrams (mg) started daily for seven days. Nurse practitioner in to see resident with order given for 4PLEX RSV (nasal swab test for RSV). Review of the 4PLEX RSV laboratory test dated [DATE] revealed a positive result. Review of a nursing progress note dated [DATE] at 7:31 P.M. revealed droplet precautions were in place. Review of a physician order dated [DATE] at 12:03 P.M. revealed the order for droplet and contact precautions for RSV. Further review of the medical record revealed the order for isolation was not placed until [DATE]; however, the progress notes indicated the resident was placed in isolation to prevent the spread of illness. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment, dated [DATE], revealed Resident #66 had intact cognition and required staff assistance with activities of daily living (ADLs). Observation on [DATE] at 9:10 A.M. of Resident #66 revealed she resided on the 400 Hall. Droplet and contact isolation precautions were in place at the time of this observation. b. Medical record review revealed Resident #64 was admitted to the facility on [DATE] with diagnoses including emphysema, asthma, schizophrenia, and hypertension. The resident resided on the 200 hall. Review of a nursing progress note dated [DATE] at 5:40 P.M. revealed the resident had a non-productive cough with wheezing bilaterally. Mucinex (thins mucus) 600 mg twice daily, chest x-ray, and 4PLEX RSV test were ordered. Review of the medical record revealed no evidence or documentation of the resident being placed on isolation precautions or of being separated from his roommate, Resident #92, while the test was pending. Review of Resident #64's 4PLEX RSV laboratory test dated [DATE] revealed a positive result. Review of a nursing progress note dated [DATE] at 5:40 P.M. revealed the 4PLEX RSV test result was positive. The resident's roommate Resident #92 was not tested until [DATE] (result negative). On [DATE], Resident #92 was relocated to a room on 400 hall. Review of the quarterly MDS 3.0 assessment, dated [DATE], revealed the Resident #64 had moderately impaired cognition and required staff assistance with activities of daily living.Observation on [DATE] at 9:15 A.M. of Resident #64 revealed he resided on the 200 Hall. Droplet and contact isolation precautions were in place at the time of this observation. c. Medical record review revealed Resident #3 was admitted to

Based on observation and interview, the facility failed to protect the privacy of personal records of all residents by storing medical records in an unlocked, open resident room in the facility which could be accessed at all times. This had the potential to affect all residents. The facility census was 37.Findings include: On 04/27/26 at 9:44 A.M., an observation of room [ROOM NUMBER] revealed two hospital beds and a table in the middle. Each surface was covered with resident records. The door was open and unlocked. This was confirmed by the administrator during interview on 04/27/26 at 10:22 A.M. On 04/27/26 at 10:18 A.M., an interview with Licensed Practical Nurse (LPN) #256 revealed the 100 hall was formerly the memory care unit. Since the unit had been closed, the doors to the unit were never locked. This was confirmed by the administrator during interview on 04/27/26 at 10:34 A.M. On 04/27/26 at 10:20 A.M., an observation of room [ROOM NUMBER] revealed a room with the door wide open. There was a box on the floor with an open binder containing medical records including covid vaccination information lying on top of the box. This was confirmed by the administrator during interview on 04/27/26 at 10:34 A.M. On 04/27/26 at 10:34 A.M., an interview with the Administrator revealed his expectation for medical records was they be stored in a room not easily accessible by residents. He reported the facility had a room in the 400-hall dedicated to medical records and the medical records were managed by Medical Records (MR) #230. The administrator further confirmed room [ROOM NUMBER] and 112 both contained resident medical records. Both rooms had the doors to entry unlocked and open. Records in room [ROOM NUMBER] contained records for an active resident of the facility. He indicated the facility just did not have enough storage space. He would make sure something was done with these records as soon as possible. On 04/27/26 at 11:41 A.M., an interview with Medical Records Director (MRD) #230. When something needed to be uploaded to the electronic medical record, it would be placed in his box by nursing, then scanned into the resident file. The facility kept Do Not Resuscitate Forms, informed consent, or things we may need to access with a power outage in a paper file once scanned. Paper files were kept in the Medical Records office. To his knowledge, there were no other medical records kept anywhere else in the facility. He knew through the company they were required to keep any records for seven years. Anything beyond seven years, he was advised he could shred the files. He knew medical records needed to be stored behind a locked door. Review of an undated facility policy titled Location and Storage of Medical Records version 2.0 revealed the facility would protect and safeguard all medical records. All medical records for current residents were kept electronically. Any records which were not electronic would be filed in the Medical Records Department. All medical records were maintained by the Medical Records Director/Assistant. When a resident was discharged , all paper medical records for the resident would be uploaded to the Electronic Health Record (EHR) within 30 days of discharge from the facility. Medical Records older than 36 months would be kept according to the Medical Record Retention policy. Medical records were to be stored in a locked room and protected from fire, water damage, insects, and theft. This deficiency represents non-compliance investigated under Complaint Number 2968896.

Based on record review, review of a Self-Reported Incident, policy review and interview, the facility failed to treat residents with dignity and respect. This affected one resident (Resident #2) of three residents reviewed for dignity. The facility census was 37.Findings include: Review of the medical record for Resident #2 revealed an admission date of 06/26/25. Diagnoses included end stage renal disease, cognitive communication deficit, atherosclerotic heart disease, paroxysmal atrial fibrillation, type two diabetes with diabetic polyneuropathy, peripheral vascular disease, non-pressure chronic ulcer of the left foot, chronic non-pressure ulcer of the right foot and other encephalopathy. Review of a care plan for Resident #2, dated 03/26/26, revealed a focus of care for cognitive impairment related to cognitive communication deficit. Interventions included anticipating needs and meeting them promptly.Review of Self Reported Incident (SRI) Tracking Number 273294, dated 04/14/26, revealed the facility investigated an incident of staff abuse of a resident. Resident #2 reported to the Administrator on 04/14/26 that Dietary Aide (DA) #207 had thrown a pan at her over the weekend. The report indicated a thorough investigation had occurred as well as education, and the allegation was unsubstantiated. On 04/29/26 at 11:30 A.M., an interview with Dietary Manager #222 revealed she had reviewed the incident of reported abuse of Resident #2. She reported Resident #2 was non-compliant and on a renal diet. DA #207 just tells it like it is to Resident #2. If that was what her diet ticket said, that was what she got, and we weren't making no exceptions for her. The dietary manager thought the resident was vindictive and said whatever she had to in order to get DA #207 in trouble. She reported DA #207 had a brisk mouth but didn't do anything wrong.On 04/29/26 at 11:35 A.M., an interview with DA #224 revealed she did not think a pan or anything else had actually been thrown at the resident, however DA #207 had thrown a package of rolls at her and Resident #2 witnessed this and made the allegation.DA #224 stated she was afraid to work with DA #207 and refused to work with her any longer. She reported DA #207 had been suspended for a couple days while the facility investigated the alleged incident, but she was allowed to come back to work. She stated DA #207 was rude to Resident #2 all of the time, but also felt she was rude to everyone. DA #224 was legally blind, and DA #207 would slam things down on the counter and yell things at her like can't you read what that says? and this would embarrass her.On 04/29/26 at 11:59 A.M., an interview with Resident #2 revealed she had gone to the kitchen to check the menu for the evening. The old lady (referencing DA #207) in the kitchen was rude and said, what do you want now? when Resident #2 went to the kitchen. The next thing she knew, the woman threw a pan at her. She reported she told the woman she was a danger to every resident in the facility acting like that. She had not been interviewed by anyone from the facility since reporting the situation to the administrator. The resident stated the DA went on a family leave for a few days and everything was smooth and peaceful. Resident #2 reported she felt afraid of DA #207 because DA #207 did not treat her respectfully On 04/30/26 at 2:00 P.M., an interview with the Administrator revealed he had not personally investigated an incident of abuse reported as SRI #273294 on 04/14/26 but DA #207 was a really sweet lady. He did think it was more of a Human Resources issue with DA #207, and she was allowed to return to work with no interventions, no disciplinary action, and no further investigation, which the Administrator felt he needed to do, but I just have not had the time.Review of a facility policy titled Dignity, dated 2001, revealed each resident would be cared for in a manner that promoted and enhanced their sense of well-being, level of satisfaction with life, and feelings of self-worth and self-esteem. The policy indicated residents would be treated with dignity and respect at all times. Residents would be able to exercise their rights without interference, coercion, discrimination or reprisal from any person or entity associated with the facility. Staff would always speak respectfully to residents, including addressing the resident by his or her name of choice and not labeling or referring to the resident by his room number, diagnosis or care needs. Staff were expected to treat cognitively impaired residents with dignity and sensitivity including addressing the underlying motives or root causes for behavior and not challenging or contradicting the resident's beliefs or statements.This deficiency represents non-compliance investigated under Complaint Number 2968896.

Based on record review, review of a self-reported incident and interview, the facility failed to thoroughly investigation an allegation of staff to resident abuse. This affected one resident (#2) of three residents reviewed for abuse. The facility census was 37. Findings include:Review of the medical record for Resident #2 revealed an admission date of 06/26/25. Diagnoses included end stage renal disease, cognitive communication deficit, atherosclerotic heart disease, paroxysmal atrial fibrillation, type two diabetes with diabetic polyneuropathy, peripheral vascular disease, non-pressure chronic ulcer of the left foot, chronic non-pressure ulcer of the right foot and other encephalopathy. Review of a care plan for Resident #2, dated 03/26/26, revealed a focus of care for cognitive impairment related to cognitive communication deficit. Interventions included anticipating needs and meeting them promptly.Review of Self Reported Incident (SRI) Tracking Number 273294, dated 04/14/26, revealed the facility investigated an incident of staff abuse of a resident. Resident #2 reported to the Administrator on 04/14/26 that Dietary Aide (DA) #207 had thrown a pan at her over the weekend. The report indicated a thorough investigation had occurred as well as education, and the allegation was unsubstantiated. On 04/29/26 at 11:30 A.M., an interview with Dietary Manager #222 revealed she had reviewed the incident of reported abuse of Resident #2. She reported Resident #2 was non-compliant and on a renal diet. DA #207 just tells it like it is to Resident #2. If that was what her diet ticket said, that was what she got, and we weren't making no exceptions for her. The dietary manager thought the resident was vindictive and said whatever she had to in order to get DA #207 in trouble. She reported DA #207 had a brisk mouth but didn't do anything wrong.On 04/29/26 at 11:35 A.M., an interview with DA #224 revealed she did not think a pan or anything else had actually been thrown at the resident, however DA #207 had thrown a package of rolls at her and Resident #2 witnessed this and made the allegation. DA #224 stated she was afraid to work with DA #207 and refused to work with her any longer. She reported DA #207 had been suspended for a couple days while the facility investigated the alleged incident, but she was allowed to come back to work. She stated DA #207 was rude to Resident #2 all of the time, but also felt she was rude to everyone. DA #224 was legally blind, and DA #207 would slam things down on the counter and yell things at her like can't you read what that says? and this would embarrass her.On 04/29/26 at 11:59 A.M., an interview with Resident #2 revealed she had gone to the kitchen to check the menu for the evening. The old lady (referencing DA #207) in the kitchen was rude and said, what do you want now? when Resident #2 went to the kitchen. The next thing she knew, the woman threw a pan at her. She reported she told the woman she was a danger to every resident in the facility acting like that. She had not been interviewed by anyone from the facility since reporting the situation to the administrator. The resident stated the DA went on a family leave for a few days and everything was smooth and peaceful. Resident #2 reported she felt afraid of DA #207 because DA #207 did not treat her respectfully.On 04/30/26 at 2:00 P.M., an interview with the Administrator revealed he had not personally investigated an incident of abuse reported in SRI #273294 on 04/14/26. He had Dietary Manager (DM) #222 review the incident and do interviews with staff. He confirmed no interviews or witness statements were included with the investigation of the self-reported incident and he thought the DM still had them. Further, he indicated he did not believe all staff who were present when the incident occurred had been interviewed. The Administrator stated he felt he had the statements for the alleged incident investigation but after searching, he verified he was unable to locate statements for the investigation. Review of a facility policy titled Abuse, Neglect, Exploitation or Misappropriation-Reporting and Investing dated 2001 revealed all reports of resident abuse, neglect, exploitation, or theft/misappropriation of resident property are reported to local, state and federal agencies and thoroughly investigated by facility management. Findings of all investigations are documented and reported. All allegations are thoroughly investigated and initiated by the administrator. The investigation may be assigned to an individual trained in reviewing, investigating and reporting such allegations.This deficiency is an incidental finding discovered during the complaint investigation.

Based on record review, interview, and policy review, the facility failed to ensure a fall intervention was implemented immediately after a fall. This affected one resident (Resident #78) of three residents reviewed for accidents. The facility census was 37. Findings include:Review of the medical record revealed Resident #78 was admitted to the facility on [DATE] with diagnoses including diabetes mellitus, dementia, morbid obesity, coronary artery heart disease, and chronic obstructive sleep apnea.Review of the Care Plan revised on 04/20/26 revealed Resident #78 was at risk for falls with interventions including to encourage the resident to ask for assistance with all transfers, to wear non-skid footwear, and to use his walker for ambulation. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment, dated 04/24/26, revealed Resident #78 had intact cognition and required staff assistance with activities of daily living.Review of a nursing progress note dated 04/25/26 at 5:37 A.M. revealed Resident #78 was found sitting on the floor in his room by a certified nursing assistant (CNA). The CNA notified the nurse who assessed Resident #78 and performed neurological checks. The medical provider was notified and with orders to continue to monitor. Further review of the nursing progress note revealed no documentation or evidence of an immediate fall intervention implemented following the fall.Review of the fall investigation dated 04/25/26 revealed no documentation or evidence of an immediate fall intervention implemented following the fall. Further review of care plan revealed no new fall interventions following the most recent fall on 04/25/26.Review of the Interdisciplinary Team (IDT) progress noted dated 04/30/26 at 4:22 P.M. revealed the IDT met to review Resident #78's incident. Resident attempted to stand beside bed to use urinal. While attempting to stand, resident's foot slipped, which ultimately resulted in a fall. New intervention for grip strips to left side of bed to prevent further occurrences.Interview on 05/06/26 at 3:49 P.M. with Director of Nursing confirmed a new fall intervention was not implemented timely following Resident #78's fall on 04/25/26. The DON further confirmed that a new fall intervention was not implemented until the IDT met on 04/30/26 and implemented the new intervention for grip strips to the left side of the bed to prevent further occurrences. Review of the facility's policy titled, Managing Falls and Fall Risk, undated, revealed staff will identify appropriate interventions to reduce the risk of falls. If a systematic evaluation Add a residence of a resident's fall risk identifies several possible interventions, the staff may choose to prioritize interventions. If falling recurs despite initial interventions, staff will implement additional interventions or different interventions or indicate why the current approach remains relevant. In conjunction with the attending physician, staff will identify and implement relevant interventions to try to minimize serious consequences of falling.This deficiency represents noncompliance identified under Complaint Number 2970501.

Based on record review, policy review, Employee Counseling Form review and interview, the facility failed to maintain complete and accurate medical records. This affected two (Resident #84 and Resident #78) of three residents reviewed for accurate medical records. The facility census was 37.Findings include: 1.Review of the medical record revealed Resident #78 was admitted to the facility on [DATE] with diagnoses including diabetes mellitus, dementia, morbid obesity, coronary artery heart disease, and chronic obstructive sleep apnea.Review of the quarterly Minimum Data Set (MDS) 3.0 assessment, dated 04/24/26, revealed Resident #78 had intact cognition and required staff assistance with activities of daily living.Review of Resident #78's 4PLEX RSV laboratory test dated 04/24/26 revealed a positive result. Review of the Infection Control Log, dated April 2026, revealed Resident #78 tested positive for RSV on 04/27/26.Interview on 04/30/26 at 3:27 P.M. with Infection Preventionist (IP) #256 stated that she became aware of Resident #78's RSV positive test result on 04/27/26 when she reviewed labs on Monday and realized LPN #213 misread Resident #78's RSV lab result dated 04/24/26 as negative. IP #256 confirmed she did not revise the infection control log with Resident #78's correct RSV positive test date. Interview on 04/30/26 at 3:37 P.M. with LPN #213 revealed she incorrectly read Resident #78's RSV lab test result as negative and charted this incorrectly. LPN #213 stated she had no idea that Resident #78 was RSV positive until 04/27/26 when she was notified by IP #256.Interview on 05/06/26 at 3:50 P.M. with the Director of Nursing confirmed the Infection Control Log was inaccurate and did not reflect Resident #78's correct RSV positive lab result. 2. Medical record review revealed Resident #84 was admitted to the facility on [DATE] with diagnoses including chronic respiratory failure, pulmonary embolism, atrial fibrillation, congestive heart failure (CHF), chronic kidney disease, diabetes mellitus, cognitive communication disorder, and anxiety disorder. Review of Resident #84's Care Plan, initiated on 03/30/26, revealed the resident has altered cardiovascular status related to CHF with interventions including assessing for shortness of breath and cyanosis every shift, monitor/document/report to physician changes in lung sounds on auscultation, edema, and changes in weight.Review of the admission Minimum Data Set (MDS) 3.0 assessment, dated 04/09/26, revealed Resident #84 had moderately impaired cognition and required staff assistance with activities of daily living.Review of a physician order dated 04/21/26 revealed the order to obtain a daily weight due to congestive heart failure (CHF): notify physician of weight gain or loss of 3 pounds (lbs.) in one day or 5 lbs. in one week.Review of the 4PLEX RSV laboratory test dated 04/22/26 revealed a positive result.Review of Resident #84's Weight Summary revealed a weight of 112.0 on 04/24/26, no recorded weight on 04/25/26, and a weight of 117.4 on 04/26/26. Review of the medical record revealed no evidence of physician notification following the 5.4 lb. weight gain on 04/26/26.Review of a nursing progress note dated 04/25/26 at 6:23 A.M. revealed the resident refused to be weighed for CHF monitoring. Review of the medical record revealed no evidence of physician notification of Resident #84's weight refusal. Review of a nursing progress note dated 04/25/26 at 7:05 P.M. revealed the resident refused to be weighed for CHF monitoring. Review of the medical record revealed no evidence of physician notification of Resident #84's weight refusal. During first review of the nursing progress notes, there was no evidence of physician notification of Resident #84's refusal to be weighed on 04/25/26. Subsequent review revealed a late entry nursing progress note created on 04/29/26 at 12:38 P.M. (authored by the DON) with the effective date of 04/27/26 at 12:37 P.M. and a follow-up to the nursing progress note dated 04/25/26 at 7:05 P.M (authored by LPN #902). The newly created note revealed the Medical Doctor and Resident Representative were notified of refusals.Interview on 04/29/26 at 4:24 P.M. with LPN #902 revealed she did not recall notifying the physician or the family representative of Resident #84's refusal to be weighed on 04/25/26. LPN #902 stated she always documented notifications in her nursing notes. LPN #902 confirmed that she had not been contacted by the DON to verify if the physician had been notified.Interview on 04/29/26 at 2:00 P.M. with the DON confirmed the physician was not notified of Resident #84's refusal to be weighed as ordered and was not notified of the resident's weight gain of 5.4 lbs. from 04/24/26 through 04/26/26. The DON confirmed that she entered the late entry progress note on 04/29/26 at 12:38 P.M. as a follow-up to the nursing progress note dated 04/25/26 at 7:05 P.M authored by LPN #902 because she mistakenly thought the on-call physician had been notified. The DON confirmed that she had no evidence of the physician notification prior to charting incorrect information in Resident #84's nursing progress note on 04/29/26 at 12:38 P.M.Interview with the Administrator on 04/29/26 at 4:57 P.M. with Administrator stated after reviewing emails to the on-call service for the date of 04/25/26, it was determined there was no communication between LPN #902 and the on-call physician service related to Resident #84's refusal of a weight or any other refusals as stated by the DON. The Administrator further stated the DON was counseled regarding inaccurately recording information in Resident #84's medical record. Review of the Employee Counseling Form, dated 04/29/26, provided by the Administrator, revealed the DON received a verbal warning related to adding a late entry nursing progress note without confirming such notification with the staff member on duty at the time that the notification occurred and for not ensuring the medical record was complete and reflective of the care provided. The corrective action plan revealed the DON would be audited on the importance of validating that items are 100% complete in the medical record before adding any additions.Review of the facility's policy titled, Change in a Resident's Condition or Status, undated revealed our facility promptly notifies the resident, his or her physician, and the resent representative of changes in the resident's condition and/or status. The nurse will notify the resident's attending physician when there has been a significant change in the resident's physical /emotional/mental condition, or specific instruction to notify the physician or changes in the resident's condition. This deficiency represents noncompliance investigated under Complaint Number 2970501.

Based on observation and interview, the facility failed to post, in a place readily accessible to residents and family members and legal representatives of residents, the results of the most recent survey of the facility, which included any surveys, certifications, and complaint investigations made during the three preceding years, and any plan of correction in effect with respect to the facility, available for any individual to review upon request. This affected all residents of the facility. The facility census was 37.Findings include:On 04/27/26 at 10:30 A.M., an observation of the facility survey book, located in the main lobby on a table top, did not contain the survey results (2567) from the 03/09/26 survey or the plan of correction for the survey. On 04/27/26 at 10:34 A.M., an interview with the Administrator verified he had not placed the 2567 (the survey results and/or the plan of correction) into the facility survey book from the most recent survey dated 03/09/26. This deficiency represents non-compliance investigated under Complaint Number 2968896.

Based on record review, review of the facility's water management program, observation, interview, and policy review the facility failed to ensure enhanced barrier precautions were implemented per orders/care plan for three residents (Resident #11, #22 and #28) and the water management program was implemented per the facility's protocol. This affected three residents (Resident #11, #33 and #28) of three residents observed for enhanced barrier precautions but had the potential to affect all 38 residents residing in the facility related to the water management program. Findings include: 1. Medical record review revealed Resident #11 was admitted to the facility on [DATE] with diagnoses including end stage renal disease, paraplegia, neoplasm of colon, need for assistance with personal care, and neuromuscular dysfunction of bladder. Review of Resident #11's current orders dated 02/2026 revealed catheter care every shift, change indwelling urinary catheter (facility identified as foley) every month and as needed, monitor two lumen catheters in left chest every shift, and enhanced barrier precautions (EBP) (staff to utilize gowns and gloves for high-contacted resident care activity due to placement of an indwelling medical device). Observation on 02/23/26 at 8:30 A.M., revealed Resident #11 had an EBP sign on the door frame. There was no evidence of a personal protective equipment (PPE) cart outside the room for staff to don PPE prior to entering the resident's room. Observation on 02/23/26 at 8:33 A.M., revealed Certified Nursing Aide (CNA) #568 exited Resident #11's room with a plastic bag of linens. There was no evidence of a PPE cart in the room or outside the room. The CNA confirmed she had just performed urinary catheter care for Resident #11. The surveyor asked the CNA about PPE and if it was worn while the CNA provided care to the resident. The CNA verified she had only worn gloves while providing catheter care to the resident but she should have also worn a gown since the resident was on EBP. 2. Medical record review revealed Resident #38 was admitted to the facility on [DATE] with diagnoses including neuromuscular dysfunction of bladder, need for assistance with personal care, urinary device, personal history of methicillin resistant staphylococcus aureus infection (MRSA) and urine retention. Review of Resident #38's orders revealed indwelling urinary catheter care every shift, change urinary catheter per facility's policy, EBP (use gown and gloves for high-contact resident care, including dressing, bathing, showering, transfers, hygiene care, changing lines, changing briefs, assisting with toileting, dressing changes, and care of any device (trach, central line, tube feeding, catheter) for reducing the chance of spreading infections, treatments to open areas on the left buttocks and right medial thigh. Observation on 02/23/26 at 8:33 A.M., during the initial tour revealed Resident #38 had a sign outside her room for EBP, however there was no PPE cart observed outside the room or in the room. During the observation CNA #551 entered Resident #38's room without applying PPE and provided direct care to Resident #38 and exited the room. Licensed Practical Nurse (LPN) #528 confirmed CNA #551 should have worn PPE when providing direct care to Resident #38 because she had a urinary catheter and open wounds. LPN #528 provided education to CNA #551. Interview on 02/23/26 at 9:15 A.M., with CNA #551 confirmed she had provided direct care to Resident #38 without wearing PPE because she didn't see the sign on the door frame that indicated the resident was on EBP. 3. During the initial tour on 02/23/26 at 8:33 A.M., with LPN #532, who was also the Infection Preventionist (IP) revealed Resident #22 had a sign outside their rooms for EBP, however no PPE cart was observed outside or inside the resident's room. LPN #523 reported Resident #22 was on EBP for wounds. Interview on 02/23/26 at 2:58 P.M., with LPN #532 confirmed CNA #568 should have worn gloves and gown during catheter care and CNA #551 should have worn PPE when providing direct care to Resident #38 because she had a urinary catheter and wounds. Review of the facility policy titled Enhanced Barrier Precautions (EBP) dated 2001 revealed EBP are utilized to reduce the transmission of multi-drug-resistant organisms (MDRO's) to residents. EBP are used as an infection prevention and control intervention to reduce the transmission of multi-drug-resistant organisms (MDROs) to residents. EBP's employ targeted gown and glove use in addition to standard precautions during high contact resident care activities when contact precautions do not otherwise apply. Gloves and gowns are applied prior to performing the high contact resident care activity (as opposed to before entering the room). PPE is changed before caring for another resident. Examples of high-contact resident care activities required the use of gowns and gloves for EBP's including dressing, bathing/showering. transferring, provide hygiene, changing lines, changing briefs or assisting with toileting, device are used (urinary catheter) and wound care (any skin opening requiring a dressing. EBP's are indicted for resident infected or colonized with Centers for Disease Control (CDC) targeted or epidemiologically important MDRO. Signs are posted in the door or wall outside the resident's room indicating the type of precautions and PPE required. PPE is available outside of the residents' rooms. Resident families and visitors are notified of the implementation of EBP thought out the facility. 4. Review of the facility Water Management Plan revealed that areas of the facility subject to Legionella were: ice machines, dead legs, less frequently used areas, water heaters, respiratory therapy equipment, HVAC-PTAC units, and faucet aerators and shower heads. (The facility currently did not have residents residing in resident rooms on two of four hallways of the facility- roomm). Review of the control measures for the Water Management Plan revealed control measures included: less frequently used areas including soiled utility rooms, medication rooms, shower rooms, and empty resident rooms. The plan stated that a weekly task would include going to all these less frequently used areas and run both hot and cold water for three minutes. Review of weekly check sheets from 02/04/26 through 02/25/26, titled water management program assessment and monitoring weekly check, revealed the sheets only included resident room numbers (all resident rooms) with a check mark. The weekly check sheets did not indicate what was being done at the time of the checks and did not include other less frequently used areas identified (soiled utility rooms, medications rooms, shower rooms). Interview with Maintenance Director #524 on 03/03/26 at 8:45 A.M. confirmed the weekly check sheets only included resident room numbers and a check mark. He confirmed the check sheet did not specify what was being checked at the time of the weekly checks. He stated this was the form used to run both hot and cold water for three minutes in the less frequently used areas. He confirmed the areas identified by the facility as less frequently used (soiled utility rooms, medications rooms, and shower rooms) were not included on the weekly check sheet. In addition, review of a form titled weekly checks for hot/cold water temperatures in shower rooms, bio room, soiled linen, and empty rooms for 01/07/26 through 02/28/26 revealed that it had check marks only. No temperatures were documented. Interview with Maintenance Director #524 on 03/03/26 at 8:45 A.M. confirmed he monitored hot water temperatures but did not document what the temperatures were or should be. He also stated he felt he needed further education about the facility's water management plan.

Based on observation, record review, facility policy review and interview, the facility failed to implement a comprehensive, individualized and effective behavioral health plan to address Resident #22's mental health needs related to depression. This affected one resident (Resident #22) of three residents reviewed for behavioral/emotional needs.Actual psychosocial harm occurred beginning on 10/31/25 when Resident #22 was assessed to have a deterioration in mental health with increase in depression symptoms with request to speak to a therapist. The facility failed to obtain the requested services for the resident. The resident's mental health continued to decline. Interview on 02/23/26 with Resident #22 revealed he had still not been provided the necessary mental health therapy services; he had completely isolated himself to his room, isolated from his family, which was his support system and was not routinely bathing due to his worsening depression.Findings included: Record review revealed Resident #22 was admitted to the facility on [DATE] with diagnosis including anxiety, need for assistance with personal care, insomnia, and depression. Review of the resident's hospital Discharge summary, dated [DATE] and authored by Medical Doctor (MD) #900, revealed Resident #22 did have some mention of depression due to his current situation, and he was seen in consultation by neuropsychology with impression and recommendation as follows: patient describes longstanding history of recurrent depression which has been only recently addressed. He also reports increased anxiety. The resident had a longstanding history of post-traumatic stress disorder (PTSD) which has also never been formally treated or addressed. He is currently being treated from a psychopharmacological standpoint with bupropion (anti-depressant) 300 milligram (mg) daily, Zoloft (anti-depressant) 100 mg daily and trazadone (anti-depressant) 100 mg nightly. The hospital discharge summary included the MD strongly recommended outpatient follow-up with psychiatry for ongoing monitoring and management of psychiatric condition. The resident would also benefit from outpatient counseling and stated he had initiated the process prior to hospitalization. MD #900 recommended case management to work with him to confirm he does in fact have outpatient follow-up for mental health service. Outpatient mental health services would be helpful in both managing the resident's depression and anxiety as well as monitoring sobriety. Continued review of the hospital discharge summary revealed the resident was independent for oral hygiene and upper body dressing, required (staff) set-up assistance with bathing himself and toilet transfer. Resident #22 required (staff) partial/moderate assistance to brush hair, shower, and transfer, substantial to maximum (staff) assistance with lower body dressing and was dependent on staff for toileting hygiene. In terms of his cognition and communication, the resident was independent for all tested tasks. The resident was stable to discharge. Review of Resident #22's admission social service assessment authored by Social Service Designee (SSD) #502 dated 12/12/24 revealed the resident had a drug history and previous psychological or psychiatric intervention. The resident reported he was in a psychiatric hospital in 9th grade but couldn't remember the name. The resident reported he struggled with depression. The resident reported he had experienced or witnessed a traumatic event in his life. Please note, per the assessment, the event was described as childhood trauma. The assessment asked if the care plan reflected the resident's needs and wishes related to trauma. The assessment was marked no. Additionally, the assessment indicated the resident had no cognitive impairment and planned to discharge back to the community Review of Resident #22's plan of care for the use of psychotropic medications (antidepressants and hypnotics) related to depression, anxiety, and insomnia dated 12/19/24 and revised 09/10/25 revealed to monitor and document and report to MD signs and symptoms of depression unaltered by antidepressants medication: sad, irritable, anger, never satisfied, crying, shame, worthlessness, guilt, suicidal ideations, mood, agitation, disruptive sleep, fatigue, lethargy, does not enjoy usual activities, changes in weight/appetite, and unrealistic fears Review of Resident #22's psychosocial-behavior plan of care, dated 03/05/25 and revised on 10/15/25, revealed the resident had anxiety, depression, and insomnia. The resident frequently refused care such as bathing and weights. Interventions included to have activities assess for diversional activities, monitor behaviors, document and record behavioral episodes, encourage resident to verbalize feelings, maintain a calm, slow, understandable approach, and staff to encourage resident to bathe on scheduled shower days. Please note, there was no evidence of coping skills or interventions to be used, specific to the resident, as identified in consultative behavioral health visits. Review of Resident #22's activities plan of care dated 03/21/25 revealed the resident was at risk for social isolation due to depression, prefers to stay in room, and social withdraw. Interventions included to educate on the importance of social interactions, encouraging and assist in engagement in activities, encourage verbalize/communicate feelings, maintain daily activity routine, provide activity materials, introduce to peers who share similar interest, and reassure resident their safety and your respect for their wishes. Review of a consulting behavioral health note, from former Licensed Social Worker #577, dated 08/01/25, revealed the resident was seen for anxiety, depression, mental health history, and substance use/recovery support. The resident was alert and oriented times four and open and cooperative. The resident was seen today for continuation of therapeutic support and pet therapy services. The resident reported he was experiencing fluctuation in mood, describing himself as feeling up and down. He acknowledged emotional difficulty with today being this providers final session, stating he was trying his best not to freak out. Despite this, the resident expressed he felt he was continuing to make progress and takes steps forward. Continued review of the consulting behavioral health note revealed Resident #22 continued to pursue a power chair to enhance his independence and remained engaged in facility life, including attending daily lunches in the dining room and participating in activities when able. The resident's awareness of depressive symptoms, acknowledging a lack of motivation, but stated he was making efforts to leave his room [ROOM NUMBER]-2 times per day, even if only briefly. The resident's thought process was logical, organized, and future oriented. Interventions included therapeutic support and reassurance, development and monitoring of behavioral health plans, and pet therapy. Review of a progress note from previous Consulting Psychiatric Medical Doctor (MD) #888 dated 09/05/25 revealed the resident had put on weight and was no longer able to effectively bathe himself and was resistant to getting bathed now. Today remains unkempt and malodorous. The note revealed the resident would like to see a therapist. He was seeing someone from ViaQuest, but MD #888 did not believe they were therapists. The note revealed the resident slept adequately, attended some activities, was out of his room some and had no side effects to medications. The note included the resident felt he was on a reasonable regimen. He talks to his family on the phone. Continued review of the consulting behavioral note revealed Resident #22 had affective disorder and anxiety. The resident's symptoms were worsened by social stressors and improved with stability. The resident had a history of depression going back to his teens. The resident was homeless; due to the house he inherited was sold for back taxes while he was in the hospital and he couldn't do anything about it. He had an [AGE] year-old son. His father committed suicide when he was young. The resident had difficulty sleeping, little interest, depressed or hopeless, and crying spells. As a teenager, he wrote a letter to his mom considering suicidal ideations, but no attempts. He formally drank seven days a week and used drugs since he was teen but quit over a year ago. This childhood was chaotic. The resident exam indicated the resident's abnormals included obese, disheveled, malodorous, abnormal gait, fair judgement concerning everyday activities/social situations, and fair insight concerning psychiatric condition. The plan for generalized anxiety was to continue Effexor (anti-depressant) at current dose, insomnia was fair and to continue on Belsomra (sedative/hypnotic) 20 mg at bedtime and Trazadone (anti-depressant) 100 mg at bedtime, and for the recurrent major depressive disorder continue Effexor 150 mg daily. The plan noted the resident was a candidate for therapy. Record review revealed there was no documented evidence the resident was referred to see a therapist/therapy or that individualized and effective interventions were in place related to the resident's depression. However, the facility developed a plan of care, dated 09/10/25 (revised 01/06/26) which indicated the resident was resistive to care related to depression, anxiety, and pain. He refused bathing, weights, and leg wraps. The intervention included allow the resident to make decisions about treatment regimen, to provide sense of control. Educate resident/family/caregivers on the possible outcomes of not complying with treatment or care. Encourage as much participation/interaction by the resident as possible during care activities. Give clear explanation of all care activities prior to and as they occur during each contact. If possible, negotiate a time for activities of daily living so that the resident participates in the decision-making process. Return at the agreed upon time. Praise the resident when behavior is appropriate. Provide resident with opportunities for choices during care provision. Record review revealed no evidence the facility associated his resistance to care with an increase in his depression. Review of Resident #22's quarterly Minimum Date Set (MDS) assessment dated [DATE] revealed the resident's cognition was intact. The assessment noted the resident had little interest or pleasure 7-11 days, feeling down, depressed, or hopeless, 12-14 days, feeling tired or having little energy 7-11 days, feeling bad about yourself or that you are a failure or have let yourself or your family down 2-6 days, and had thoughts that he would be better off dead, or of hurting self in some way 2-6 days[KA1.1][AE1.2][SP1.3][KA1.4][AE1.5]. The resident had no behavior. Diagnoses included debility, malnutrition, anxiety, depression, asthma, respiratory failure and medication included anti-depressants, hypnotics, and opioids. The previous MDS, dated [DATE] revealed the resident had no mood or behaviors. Following the completion of this MDS, no changes were noted to be made to the resident's plan of care to address the identified mood changes[KA2.1][AE2.2]. Review of a ViaQuest Therapeutic Behavior Service (TBS) note authored by TBS #575 (TBS provided assistance with coping skills but was not a licensed therapist or permitted to provide therapy services) dated 09/17/25 revealed resident's care plan objectives were to improve depression by engaging and increase social activities outside of the home evidenced by participating in two activities per week and learning and implementing one coping skill per week. Review of the care plan revealed no revision to include the interventions discussed with the TBS during sessions such as coping skills and breathing techniques, activity engagement. And no revisions to include the information from the MDS such as letting your family down, feeling better off dead, etc. Review of Resident #22's quarterly MDS assessment dated [DATE] revealed the resident cognition was intact. The assessment revealed the resident had little interest or pleasure 12-14 days, feeling down, depressed, or hopeless, 12-14 days, trouble falling or staying asleep or sleeping too much 12-14 days, feeling tired or having little energy 12-14 days, feeling bad about yourself or that you are a failure or have let yourself or your family down 12-14 days, trouble with concentration 12-14 days, moving or speaking so slowly that other people have noticed 12-14 days. His behaviors included rejection of care 1 to 3 days. Diagnoses include debility, malnutrition, anxiety, depression, asthma, respiratory failure and the medication section was skipped. Review of a behavior progress note, dated 10/31/25 from previous MD #888 (not contained as part of the resident's medical record) revealed the resident was difficult to motivate things. Says he needs a therapist to help him. Needs medication changes. He had fallen this morning and was not bathing. He devalues all suggestions. MD #888's plan included treatment for the anxiety to encourage bathing, dressing, and activities, which he devalues each. The plan was to increase Effexor gently to 187/5 mg daily. The resident spent much of the day in bed and was not willing to increase hypnotics further. The note included for recurrent major depressive disorder, look for solutions as far as a therapist or medication. Adjust Effexor to 187.5 mg daily. Record review revealed there was no documented evidence the resident was referred to a therapist. Review of ViaQuest Therapeutic Behavior Service (TBS) note, authored by TBS #575 dated 11/14/25, revealed the resident reported he had been to the dining room recently to eat but had not been to a group activity recently. Resident #22 stated my anxiety had been creeping in and I don't know why. Resident #22 talked about his door being shut while he was sleeping and when he woke up, he panicked. The resident reported when he was a kid his mom used to lock him in a closet while her boyfriend beat her and that door being shut brought those memories back. The resident was asked to practice Star (a calming technique designed to help manage stress and anxiety. It involves visualizing a star shape while coordinating breathing patterns to promote relaxation) breathing in session as we discussed times that he could have used it. Review of Resident #22's TBS note, authored by TBS #575 dated 12/09/25, revealed the resident was self-isolating in room and (had a) decrease in hygiene. The resident self-reported that he had not been to an activity in a while Resident stated I don't really know why other than nothing looks like it is worth the effort it takes to get down there. Resident was asked when the last time he had been to the shower room and had an odor detected and he did not want to leave his room. The resident reported he could not state the last time he went to the shower room. The TBS talked about the importance of good hygiene. The resident engaged about his star breathing coping skill and how using it can help reduce symptoms. There were no social service notes in the medical record regarding the resident's mental or psychosocial status or evidence of facility interventions to assist the resident in managing his depression from 11/14/25 through 12/10/25. Review of Resident #22's TBS note, authored by TBS #575 dated 12/11/25, revealed the resident was self-isolated and lacked hygiene. The resident self-reported that he still had not been to any activities. The resident had not been to the shower room as well. This was more than several weeks for not leaving his room. The note included we talked about consistently using star breathing and box breathing throughout the day to help reduce depression. This would help reduce symptoms and help resident stop self-isolating. Resident engaged in practicing his star breathing and box breathing (a simple, four step stress-reduction technique used to calm the nervous system, improve focus, and manage anxiety). Review of Resident #22's annual MDS assessment dated [DATE] revealed the resident cognition was intact. The resident had little interest or pleasure 12-14 days, feeling down, depressed, or hopeless, 12-14 days, trouble falling or staying asleep or sleeping too much 2-6 days, feeling tired or having little energy 12-14 days, feeling bad about yourself or that you are a failure or have let yourself or your family down 12-14 days, trouble concentration 7-11 days, moving or speaking so slowly that other people have noticed 2-6 days. Social isolation often. His behaviors included rejection of care 1 to 3 days. Activity preference clothes to wear somewhat important, personal belongings very important, choose between a tub bath, shower, bed bath, sponge bath very important, snacks very important, bedtime very important, family and friend involvement not important at all, phone in private not very important. It was very important to listen to music. It is somewhat important to keep up with new, and do things with groups of people, and do favorite activities. It was very important to get fresh air. Diagnoses include debility, malnutrition, anxiety, depression, asthma, respiratory failure and medication included anti-depressants, hypnotics, diuretics, and opioids. Review of Resident #22's annual social history and discharge planning assessment, dated 12/11/25 and authored by Social Service Designee #502, revealed the resident had a previous pill addiction. The resident reported he felt social isolation often. The resident had a history of not taking showers. The resident was not currently taking psychotropic medications (please note, the resident was receiving psychotropic medications). The note also indicated the resident had no significant life events/trauma history (Please note, the resident had previously discussed his childhood and issues with PTSD). The resident planned to become a long-term resident. The resident's quality of life objectives included engaging in hobbies, socializing, and staying active. Review of ViaQuest Nurse Practitioner (NP) note, dated 12/17/25, revealed Resident #22 was friendly and cooperative. He endorses (his) depression was 10 out of 20 which he reports as occurring comes and goes and anxiety as all of the time but varies in severity. He reports difficulty with both falling asleep and staying asleep and appetite was good. The resident reported he was compliant with medication and was requesting to talk with a psychiatrist. Talked with the resident about services of NP, nursing and therapeutic behavioral service (TBS). No changes made on this day. Discussed options of Genesight testing (a test that analyzes how your genes may affect medication outcomes) due to maximum medication dosages. The resident stated he would like to think about it. Record review revealed no documented evidence the resident was referred to a psychiatrist for follow up mental health services per his request. Review of Resident #22's psychosocial plan of care, dated 12/17/25 revealed the resident had little interest or pleasure in doing things. Interventions included assisting with conflict resolution as needed, listening alternatively, provide emotional support. There were no resident specific interventions as discussed through his consulting behavioral health sessions. Review of a facility concern form dated 01/08/26, and authored by the Administrator, revealed Resident #22 reported, while he was willing to meet with the counseling provider currently assigned (ViaQuest TBS), he didn't feel the sessions were helpful or effective for him. He stated the new services did not offer the same level of support or connection he experienced previously. The resident expressed he missed his former provider and feels that the therapeutic relationship he had with former Licensed Social Worker #577 (previously employed by MD #888 and not an employee of the facility) was more beneficial. He was clear that, moving forward, he would prefer to meet only with former Licensed Social Worker #577, if possible. His concerns and preferences were acknowledged, and the resident was encouraged to continue communicating his needs so appropriate follow-up can occur. A facility corrective action included that Resident follow-up reflected after discussing his preferences for returning to his former counselor, the Administrator had contacted former Licensed Social Worker (LSW) #577 to determine whether she could resume services. LSW #577 explained she was no longer affiliated with the agency our facility currently contracts with and was now employed by a different provider. She stated she would only be able to see the resident again if our facility entered a formal contract with her new agency (employer). The plan included because we (the facility) maintain an active contract (ViaQuest) with her previous employer arranging for her to see the resident independently would constitute a breach in that agreement and was therefore not permissible. (Please note, LSW #577 was not employed with ViaQuest prior to leaving, she was employed by MD #888) The Administrator returned to the resident to update him on these limitations. He acknowledged the information and stated that, at this time, he doesn't wish to see any counselor other than LSW #577. He did not identify interest in meeting with an alternative provider but was respective to being informed of other options in the future. Review of ViaQuest Nursing Note dated 01/08/26 revealed the resident endorsed depression was related to his situation and history growing up. The resident reported he gets depressed most days and his anxiety was related to missing his family, his personal situation, and his upbringing. The resident requested a therapist. This note revealed the nurse updated the nurse practitioner (NP) as directed. The resident was educated on GeneSight testing and agreed to have testing done. Record review revealed no evidence the resident was referred to a therapist as requested at this time. Review of a TBS note, authored by TBS #575 and dated 02/17/26, revealed the resident was lying in bed and seemed to be less talkative than normal. Review of a TBS note, authored by TBS #575 and dated 02/19/26, revealed the resident had poor personal hygiene, malodor and was unkempt. The resident had not showered in over a month and had noticeable odor. The resident had also been self-isolating and overeating. The resident reported he was not showered and stated that his knees are sore from a recent fall. The resident did engage in conversation about self-isolating and how he needed to go to activities as in the past it had improved his overall mood. We talked about getting showered and cleaned up to also help improve overall mood. The resident was receptive to getting a shower when talking about the next time his young son comes to visit him he would be clean and smell good. Review of Resident #22 current plan of care, as of 03/03/26 revealed no evidence the resident had a plan of care for PTSD or any potential PTSD triggers throughout his comprehensive care plan such as leaving the resident's door open. Review of Resident #22 behavior monitoring the treatment administration record (TAR) dated 09/2025 to 02/2026 revealed staff documentation as follows: On 09/02/25 the resident had anxious, restless, and withdraw/depression, September 7th restless, afraid, withdraw/depressed, and mood change; 09/08/25 mood change and withdraw/depressed; 09/09/25 afraid; 09/13/25 withdraw/depressed and afraid; 09/14/25 agitated, withdraw/depression and afraid; 09/16/25 agitated withdraw/depressed, and afraid, and September 30th withdraw/depression, anxious, and mood change. There was no documentation for rejection of care. Please note, the behavior monitoring was not specific to targeted behaviors. Staff did not document the resident had any behaviors on the TAR for October 2025, November 2025, or December 2025. On 01/15/26, the resident had agitation; 01/20/26 the resident was anxious. On 02/13/26, the resident was withdrawn/depression and 02/20/26 withdrawn/depression, other, and anxious. Observation on 02/23/26 at 2:27 P.M. revealed Resident #22 had a sign taped to his door that indicated leaving the resident's door open. Multiple observations during the onsite survey revealed the sign remained on the resident's door. Interview on 02/23/26 at 2:37 P.M. with Resident #22 revealed a concern the facility was not addressing his depression and anxiety and he needed to see a therapist. Resident #22 reported he had told the new Administrator several times he needed to see a therapist; however, nothing ever got done. The resident shared when he was first admitted he was seen by former consulting Licensed Social Worker #577, (this LSW previously saw the resident in the facility as she worked for MD #888 but left the practice of MD #888 and went on to another employer. The facility terminated their contract with MD #888 and started using services from ViaQuest). The facility recently hired a new company; however, the staff were not therapists and were just teaching him breathing techniques that didn't help him. The resident reported that some days he felt like he was going to have a breakdown. Observation of the resident at the time of the interview revealed the resident was unkempt and had malodorous odor. On 02/24/26 at 10:56 A.M., Resident #22 was observed sitting in his room with the television on. The resident reported after the conversation he had with the surveyor on 02/23/26, the facility social worker (Social Service Designee #502) had visited him and asked him what his issues were. The resident reported he told SSD #502 the same issue that had been going on and had been reported to the Administrator (in January 2026), he wanted to see a therapist. The SSD did schedule an appointment for him see a therapist in the community. The resident reported his depression, and anxiety had been so bad lately that he had not been sleeping well and his anxiety medication was not helping. Observation on 02/24/26 at 12:40 P.M., revealed Resident #22 was sitting on the edge of the bed asleep. Interview on 02/24/26 at 12:46 P.M. with SSD #502 confirmed he followed up with Resident #22 on 02/23/26 after the resident spoke with the State surveyor. The SSD revealed he had made an appointment with a therapist in the community and revealed he was unaware Resident #22 had voiced mental health concerns to the Administrator in January 2026 as the Administrator was responsible to address concerns and the concern log. Interview on 02/25/26 at 7:06 A.M., with Resident #22 revealed he had spoken with the Administrator several times, but the last time was in January 2026 regarding his desire to see a therapist. However, the resident stated he had given up asking because nothing was done about his concern. The resident shared SSD #502 visited him shortly after he talked with the surveyor about his concern with mental health services and now he finally had an appointment to see a therapist. The resident stated he had started asking to see a therapist a few weeks after the former licensed social worker had left around September 2025; however, he didn't feel the Administrator addressed his concerns and would say I will follow up but never did. The resident reported his depression was worse and he had isolated himself to his room more, which was an indication his depression was worse. The resident reported his Effexor (anti-depressant) was increased a few months ago, but he stated he didn't notice a difference. The resident reported he had been staying in his room and didn't care if he got up or socialized and he had also stopped communicating with friends (mother of his son)/family and had pulled the curtain shut in his room, which was another indication his depression and anxiety were worsening. Interview on 02/25/26 at 8:03 A.M., with the Administrator revealed he had talked to Resident #22 three times; however, he only filed one complaint form (January 2026). The Administrator reported the resident wanted to see the previous contracted Licensed Social Worker #577; however, she was employed for another company now and there would be a conflict of interest so she couldn't provide services to Resident #22. Interview on 02/25/26 at 9:11 A.M., with the previous contracted LSW #577 revealed she did not speak to the Administrator in January or anytime regarding providing services to the facility or Resident #22. The LSW reported she had spoken to Resident #22, in detail, to explain she was going to a new company and would no longer be providing services to him and the resident voiced understanding. The LSW reported that if the resident needed services, the facility could reach out to her, and they could discuss potential options suitable to meet the resident's psychosocial and behavioral health needs. Interview on 02/25/26 at 10:11 A.M. with the Administrator and review of the concern form, completed in January 2026, revealed he may have talked to someone else where LSW #577 worked and not her directly about resuming services with Resident #22. Additionally, the facility stopped using the behavioral health services of MD #888 and started using ViaQuest for behavioral health services beginning 12/06/25. The Administrator stated he was unaware the resident wanted to see a therapist until the SSD followed up with the resident on 02/23/26, after the resident expressed his concerns to the State surveyor. A follow-up interview with the Administrator on 02/25/26 at 3:18 P.M. revealed he was incorrect regarding the employer for LSW #577. The Administrator verified LSW #577 was employed by MD #888 and never for ViaQuest as stated on the concern form. Interview on 02/25/26 at 1:56 P.M. with ViaQuest TBS #575 revealed she was not a therapist or counselor, and her role was to help residents identify triggers and develop coping skills to minimize symptoms but not healing past traumas. TBS reported the mental health services were newer and she was not sure what the mental services included, and she did not have access to the ViaQuest NP notes. The TBS confirmed LSW #577 did not work for ViaQuest. TBS #575 revealed each time she saw Resident #22 she had to tell him she was not a therapist. TBS #575 indicated the resident had a current behavior of overeating. She stated sometimes she talked to staff regarding the resident's coping skills but not always. Resident #22's goals this week were going to activities and getting a shower. The TBS revealed the facility didn't get a copy of her notes (from her visits) and she would have to call her office to get permission to have the records released. (The records were subsequently released and included as noted above in the survey findings). Interview on 02/26/26 at 6:35 A.M., with Licensed Practical Nurse (LPN) #501 and LPN #5

Based on observation, interview, record review and policy review the facility failed to complete a comprehensive assessment for a resident who had an identified weight gain and diagnosis of congestive heart failure and failed to notify staff of a physician ordered fluid restriction. This affected one resident (Resident #31) of four residents reviewed for nutrition. The facility census was 38.Findings include: Review of Resident #31's medical record revealed an admission date of 08/09/24 and diagnoses including atrial fibrillation, dementia, chronic obstructive pulmonary disease, chronic respiratory failure, persistent mood disorder, hypertension, and cardiomegaly.Review of Resident #31's care plan revealed the resident being at risk for decreased cardiac output and abnormal lab values related to atrial fibrillation, hyperlipidemia, hypertension, use of anticoagulant medication, cardiomegaly, CHF(Congestive heart failure) Date Initiated: 08/19/2024 Revision on: 12/02/2025. The care plan goal was for the resident to have no s/s of decreased cardiac status as evidenced by no shortness of breath, no complaints of chest pain, vital signs with in normal limits, and no increased edema. Date Initiated: 08/19/2024 Revision on: 09/10/2025 Target Date: 02/16/2026. Care plan interventions include: Elevate head of bed as tolerated, date Initiated: 08/19/2024, Elevate legs as tolerated, date Initiated: 08/19/2024, Encourage to follow up with cardiologist with any changes in condition, date Initiated: 08/19/2024, Give medications per physician order, date Initiated: 08/19/2024, Monitor extremities for s/s compromised circulation: discoloration, coolness to touch, decreased/absent pulses, pain with elevation, pallor, edema, muscle wasting, thick/mycotic toenails, date Initiated: 08/19/2024, Monitor for adverse affects of anticoagulant meds: abnormal bleeding, blood in stool, urine, emesis, mucous & gums; c/o abdominal pain, back pain, severe headaches; check skin for bruises, cuts, scratches, date Initiated: 08/19/2024, Monitor for indicators of hypotension, including: dizziness or light-headedness, fainting/syncope, lack of concentration, blurred vision, nausea, cold clammy pale skin, rapid shallow breathing, fatigue, depression, thirst, date Initiated: 08/19/2024 and weigh per doctor's order, date Initiated: 08/19/2024. Review of Resident #31's quarterly Minimum Data Set (MDS) dated [DATE] revealed a brief interview for mental status score of 05 indicating the resident had severe cognitive impairment. Further review of the MDS revealed Resident #31 used a wheel chair for mobility, required substantial/maximal assistance with showering/bathing and bed mobility, was dependent on staff for toileting hygiene and for transfers, and was always incontinent of bladder and frequently incontinent of bowel. Review of Resident #31's physician's orders revealed an order dated 02/14/26 for weights one time a day for congestive heart failure (CHF), notify Medical Doctor (MD) of (a) three pound (weight) gain/loss in 24 hours. The resident was not on a diuretic medication at this time for CHF.Review of Resident #31's medication and treatment administration records for February 2026 revealed Resident #31 weighed 216.8 pounds on 02/21/26, on 02/22/26 weighed 214 pounds, on 02/23/26 weighed 220.2 pounds. Review of Resident #31's progress notes revealed a note dated 2/23/2026 at 6:39 A.M. written by Registered Nurse (RN) #549 that read Med One notified of 6.2 (pound) lb weight gain in 24 hours No N.O.at this time. (There was no documentation of the resident's condition or an assessment of the resident's condition at the time of the weight assessment/report of the resident's weight gain to the on call provider.Review of Resident #31's progress notes revealed a note dated 02/24/26 at 12:00 A.M. by Certified Nurse Practitioner (CNP) #890 indicating CNP #890 discussed a plan with the resident family and staff to promote elevation of the residents legs due to peripheral edema. CNP #890 noted the resident had a six pound weight gain on 02/23/26. An observation on 02/24/2026 at 2:32 P.M. revealed Resident #31 to be resting in, bed sitting upright at a 90 degree angle with his bilateral hands and lower forearms observed to be very swollen. An observation on 02/25/2026 at 7:53 A.M. revealed Resident #31 to be up in his wheelchair moving about the facility with his bilateral hands and lower forearms observed to remain very puffy and swollen. An observation on 02/25/26 at 4:20 P.M. revealed Resident #31's bilateral hands and lower forearms to remain swollen.Review of Resident #31's physician's orders revealed an order dated 02/26/26 with a start date of 02/26/26 to encourage (the) resident to elevate (his) legs as he allows every shift, to wear knee high ted hose every shift, a start date of 03/02/26 for weekly weights one time a day every Monday for CHF, notify (Medical Doctor) MD of (a) five pound (weight) gain/loss in 24 hours. Further review of Resident #31's physician's orders revealed an order dated 02/27/26 with a start date of 03/02/26 for Lasix oral tablet 20 milligrams (mg) give 10 mg by mouth one time a day every Monday, Wednesday and Friday for weight gain.Additional review of Resident #31's physician's orders revealed an order dated 02/26/26 with a start date of 02/26/26 for a 2,000 milliliter (ml) fluid restriction and to serve 1,440 ml for dietary per day. Dietary amount per meal: Breakfast 480 ml, lunch 480 ml, and dinner 480 ml. Review of Resident #31's progress notes revealed a note dated 02/26/26 at 12:00 A.M. written by Physician #889 indicating the resident was seen for weight gain with his most recent weight being 217.6 pounds. Further review revealed Physician #889 indicated the resident had been noted to have increased edema, was medically stable and had a past history of atrial fibrillation but no mention of was made of congestive heart failure in the available documentation. In an interview on 02/26/2026 at 10:00 A.M. the Director of Nursing (DON) revealed that for a resident on daily weights with a weight gain greater than the order parameters she would expect the nurse to reweigh the resident to ensure the weight was correct, to notify the resident's medical provider. The DON stated that she would expect a registered nurse caring for a resident with a weight gain greater than the order parameters to have done a respiratory assessment on the resident and to have assessed the resident for edema or an increase in edema. The DON revealed that she would have expected the nursing staff to have reapproached a resident, who was on daily weights with a recent gain, throughout the day to try to get a weight.Review of Resident #31's progress notes revealed a note dated 2/26/2026 at 2:36 P.M. written by RN #545 that indicated Dr. saw resident today. New orders (were given) for Fluid Restrictions 2000 ml /24hr. [NAME] Hose knee highs and Elevate legs as resident allows. Resident and daughter in law notified.An observation on 03/03/2026 at 8:15 A.M. revealed Resident #31 eating breakfast in his room. On Resident #31's breakfast tray there was an empty 240 ml container of milk, an empty 120 ml container of juice and a water glass with 360 ml of ice water. Resident #31's meal ticket was present on the tray and did not indicate the resident was on a fluid restriction.In an interview on 03/03/26 at 8:20 A.M. Certified Nursing Assistant (CNA) #561 verified Resident #31's breakfast tray contained an empty 240 ml container of milk, an empty 120 ml container of juice and a water glass with 360 ml of ice water and that Resident #31's meal ticket is used by nursing and dietary to ensure the resident gets the correct diet type, texture and amounts of food and fluids was present on the tray and did not indicate the resident was on a fluid restriction. CNA #561 stated she was not aware Resident #31 was on a fluid restriction.Review of the policy titled Encouraging and Restricting Fluids revised 10/2010 revealed the resident water pitcher and/or water cup should be removed from the room and the specific instructions for the fluid restriction would be followed.

Based on observation, record review, interview, review of manufacturer guidelines, and facility policy review, the facility failed to ensure kitchen staff (Cooks #531 and #541) were competent with job responsibilities. This had the potential to affect all the residents in the facility. The facility census was 38. Findings include: 1.Observation of the kitchen 02/23/26 at 8:08 A.M. with [NAME] #541 and [NAME] #531 revealed the dishwasher temperatures were only being recorded in the morning and the evening. There were no temperatures recorded for the lunch dishes. Cooks #541 and #531 reported they only took temperatures twice a day, and not when they washed dishes for each meal. They reported they were recording the dishwasher temperatures on a Parts Per Million (PPM) Sanitation log, and not on a dishwasher log. The temperatures for the whole month were recorded as 160 degrees Fahrenheit (F) for the wash cycle, and 190 degrees F for the rinse cycle without variation. Every day, the same wash cycle and rinse cycle temperatures were recorded for morning and evening. Observation on 02/23/26 at 8:38 A.M. of the dishwashing cycle revealed the dish wash cycle temperature was 145 degrees F for the wash cycle and 189 degrees F for the rinse cycle. The Surveyor stated out loud that the wash cycle temperature was 145 degrees F. [NAME] #531 pulled the dishes through the dishwasher to make room for the next rack. [NAME] #541 asked the dishwasher (Cook #531) to reset the booster. [NAME] #531 did not know how to reset the booster so [NAME] #541 told him to drain the tank, hit the red button, and flip the switch. After the booster was reset at 8:44 A.M., the dishwasher wash cycle temperature was 164 degrees F and the dishwasher did not click onto the rinse cycle. [NAME] #531 was not paying any attention to what the temperature readings were and he pushed the dishes out of the dishwasher and was going to push another rack through when the Surveyor intervened and informed [NAME] #531 that the dishwasher had not clicked onto the rinse cycle. [NAME] #541 told him to put the dishes back in and rewash them. When [NAME] #531 put them back in, the wash cycle temped at 155 degrees F and the rinse cycle tempted at 164 degrees F. At 8:47 A.M., the dishwasher cycle ran again, and it washed at 154 degrees F and rinsed at 179 degrees F. At 8:50 A.M. the dishwasher washed at 155 degrees F and rinsed at 181 degrees F, at which time it reached the manufacturer recommendation of 150 degrees wash and 180 degrees rinse 2. Observation of the lunch meal tray line 02/24/26 at 10:56 A.M. revealed the meal was store-bought pasta salad, turkey and cheese croissants, green beans or mixed vegetables, and cake. Milk was listed as an available beverage. [NAME] #541 obtained a temperature of 202.8 degrees Fahrenheit for the mixed vegetables, 205.7 degrees for the pureed green beans, and 197 degrees for the regular green beans. There were no observations of the cook obtaining temperatures of the milk, pasta salad, or logging the temperatures.Review of the ingredients in the Italian pasta salad from the food supplier included the pasta salad contained mayonnaise and eggs. The facility served the Italian pasta salad to residents as planned. There was not a temperature recorded for the pasta salad prior to serving to residents.Observation 02/24/26 at 11:12 A.M. of the binder that contained the meal temperature logs included the lunch meal was recorded at 180 degrees Fahrenheit for both the vegetable and vegetable puree. The milk temperature was recorded at 33 degrees. The temperatures obtained at the start of the tray line were not recorded in the binder.Interview 02/24/26 at 11:12 A.M. with [NAME] #541 included when asked why the food temperatures the surveyor observed for the lunch meal were not written on the lunch log, he stated it only needs to reach 165 degrees. 3. Review of the personnel records for [NAME] #531 revealed a 07/21/25 date of hire. Review of the personnel record for [NAME] #541 revealed a hire date of 01/13/26. Review of the personnel records revealed there was no evidence of on-the-job training. There was no evidence that the staff was taught to run the dishwasher, reset the booster, log tray line meal temperatures, and all other job responsibilities.Interview 02/26/26 at 12:12 P.M. with Human Resource #554 verified the facility did not have any documentation of on-the-job training having been completed to verify dietary staff were taught to run the dishwasher, reset the booster, log accurate temperatures for meal service tray line, and dishwashing tasks.Review of the policy Food Preparation and Service revised November 2022 included when verifying food temperatures staff use a thermometer which is both clean and sanitized and calibrated to ensure accuracy. All food service equipment and utensils will be sanitized according to current guidelines and manufacture recommendations. Proper hot and cold temperatures are maintained during food distribution and service. Foods that are held in the temperature danger zone are discarded after four hours. The temperatures of food held in steam tables are monitored throughout the meal service by food and nutrition services staff.Review of the [NAME] AM Select Dishwasher instruction manual included operating temperatures for all models listed 150 degrees F as the minimum effective temperature for the wash cycle and 180 degrees minimum effective temperature for the rinse cycle.

Based on observation, record review, review of manufacturer guidelines, review of invoices, and interview, the facility failed to store and serve food under sanitary conditions. This had the potential to affect all residents residing in the facility. The facility census was 38. Findings include: 1.Observation of the kitchen 02/23/26 at 8:08 A.M. with [NAME] #541 and [NAME] #531 revealed the following:Observation of the walk-in freezer revealed the rib shaped pork patties, breakfast omelets, and precooked hamburger patties were left open which exposed the food to the freezer air.The walk-in refrigerator temperature log was over 41 degrees Fahrenheit since 02/04/26 and been taken out of use.The kitchen did not have a working oven. In the dry storage area, there was [NAME] pasta opened on 01/19/26 which noted it was to be disposed of on 02/19/26. There was three [NAME] pastas that were opened and undated. There was an elbow macaroni opened, not sealed, and without an open date. There was [NAME] long pasta not dated, and [NAME] long pasta not sealed nor dated. There was an additional classic [NAME] pasta opened on 12/21/25 without a disposal or discard date listed. The temporary portable refrigerator that was outside, to replace the walk-in refrigerator, had a thermometer in it that was reading 42 degrees Fahrenheit (F). The mercury thermometer the facility was using was loose in its case with one side broken off its support and moving around.Observation of the dishwasher temperature log revealed the dishwash temperatures were taken in the morning and in the evening. There were no temperatures written for the lunch dishes. They only took them twice a day not when they washed dishes for each meal. They were being recorded on a Parts Per Million Sanitation log not a dishwasher log. The temperatures for the whole month were recorded as 160 degrees F for the wash cycle, and 190 degrees F for the rinse cycle without variation. Every day, the same wash cycle and rinse cycle temperatures were recorded for morning and evening. Observation on 02/23/26 at 8:38 A.M. of the dishwashing cycle revealed the dish wash cycle temperature was 145 degrees F for the wash cycle and 189 degrees F for the rinse cycle. The Surveyor stated out loud that the wash cycle temperature was 145 degrees F. [NAME] #531 pulled the dishes through the dishwasher to make room for the next rack. [NAME] #541 asked the dishwasher (Cook #531) to reset the booster. [NAME] #531 did not know how to reset the booster so [NAME] #541 told him to drain the tank, hit the red button, and flip the switch. After the booster was reset at 8:44 A.M., the dishwasher wash cycle temperature was 164 degrees F and the dishwasher did not click onto the rinse cycle. [NAME] #531 was not paying any attention to what the temperature readings were and he pushed the dishes out of the dishwasher and was going to push another rack through when the Surveyor intervened and informed [NAME] #531 that the dishwasher had not clicked onto the rinse cycle. [NAME] #541 told him to put the dishes back in and rewash them. When [NAME] #531 put them back in, the wash cycle temped at 155 degrees F and the rinse cycle tempted at 164 degrees F. At 8:47 A.M., the dishwasher cycle ran again, and it washed at 154 degrees F and rinsed at 179 degrees F. At 8:50 A.M. the dishwasher washed at 155 degrees F and rinsed at 181 degrees F, at which time it reached the manufacturer recommendation of 150 degrees wash and 180 degrees rinse.Interview 09/23/26 at 8:50 A.M. with [NAME] #541 verified the freezer had food items open to the freezer air, items in the dry storage were opened and not sealed and/or dated, the dishwasher log had the exact same wash and rinse temperatures taken for the entire month, no dishwasher temperatures were recorded for the lunch meal in February 2026, and the dishwasher temperatures were not reaching the sanitary levels upon observation.2. Observation 09/23/26 at 9:01 A.M. of the kitchenette with Activity Director #527 revealed that they did not take any refrigerator temperatures on 02/22/26 or the evening of 02/21/26. The freezer temperature was not being recorded at all. The refrigerator contained an undated turkey and cheese sandwich with the initials SC. There was also a piece of coconut cream pie sent by the kitchen which was undated.Interview 09/23/26 at 9:06 A.M. with Activity Director #527 verified the undated food items and missed refrigerator temperatures.3. Observation of the lunch meal tray line 02/24/26 at 10:56 A.M. revealed the meal was store-bought pasta salad, turkey and cheese croissants, green beans or mixed vegetables, and cake. Milk was listed as an available beverage. [NAME] #541 obtained a temperature of 202.8 degrees Fahrenheit for the mixed vegetables, 205.7 degrees for the pureed green beans, and 197 degrees for the regular green beans. There were no observations of the cook obtaining temperatures of the milk, pasta salad, or logging the temperatures.Observation 02/24/26 at 11:12 A.M. of the binder that contained the meal temperature logs included the lunch meal was recorded at 180 degrees Fahrenheit for both the vegetable and vegetable puree. The milk temperature was recorded at 33 degrees. The temperatures were not consistent with the temperatures observed during tray line temperatures. In addition, food temperatures were not being recorded consistently.Review of the February 2026 food temperature logs revealed for 02/01/26 only a supper meal was recorded. There was no temperature logs recorded for 02/02/26, 02/03/26, 02/04/26, or 02/05/26. On 02/07/26, there was only a supper temperature recorded. There were no food temperature logs for 02/08/26, 02/09/26, 02/10/26, or 02/11/26. The 02/12/26 food temperature log contained breakfast and lunch meal temperatures and no temperatures recorded for the supper meal. The food temperatures for breakfast were all recorded as 180 degrees F for the hot cereal, pancakes, French toast, and pureed bread and 33 degrees F for the milk and juice. For lunch, the entree, substitute, and the entree ground/pureed were recorded at 180 degrees F and the milk at 33 degrees F. There were no supper temperatures recorded. There were no food temperature logs for 02/13/26, 02/14/26, 02/15/26, 02/16/26, 02/17/26, 02/18/26, or 02/19/26. On 02/20/26, there were no breakfast or lunch temperatures recorded, only supper. On 02/21/26, there was breakfast and lunch temperatures recorded and no supper. The breakfast and lunch temperatures were all recorded at 180 degrees F including the breakfast eggs and hot cereal and the lunch entree, substitute, the entree ground/pureed, and the starch substitute. The pureed starch, the vegetable substitute, and the pureed vegetable were all recorded at 180 degrees F. The milk was recorded at 33 for breakfast and lunch and the juice was recorded at 33 degrees for breakfast. On 02/23/26, the same pattern was observed with all the breakfast and lunch hot foods having 180 degree F temperatures recorded and the milk, juice, and dessert recorded at 33 degrees F.Interview 02/24/26 at 11:12 A.M. with [NAME] #541 included when asked why the food temperatures the surveyor observed for the lunch meal were not written on the lunch log he said it only needs to reach 165 degrees. Review of the ingredients in the Italian pasta salad from the food supplier included the pasta salad contained mayonnaise and eggs. The facility served the Italian pasta salad to residents as planned. There was not a temperature recorded for the pasta salad prior to serving to residents on 02/24/26.Review of the facility policy Food Receiving and Storage dated 2001 included all food stored in the refrigerator or freezer are covered, labeled, and dated with the use by date. Dry goods are handled and stored in a manner that maintains the integrity of the packaging until they are ready to use. Those foods and snacks kept on nursing units, including all foods belonging to residents, are labeled with the resident's name, the item, and the use by date. All food items to be kept at or below 41 degrees Fahrenheit are placed in the refrigerator located at the nurse station and labeled with the use by date.Review of the policy Food Preparation and Service revised November 2022 included when verifying food temperatures staff use a thermometer which is both clean and sanitized and calibrated to ensure accuracy. All food service equipment and utensils will be sanitized according to current guidelines and manufacture recommendations. Proper hot and cold temperatures are maintained during food distribution and service. Foods that are held in the temperature danger zone are discarded after four hours. The temperatures of food held in steam tables are monitored throughout the meal service by food and nutrition services staff.Review of the [NAME] AM Select Dishwasher instruction manual included operating temperatures for all models listed 150 degrees F as the minimum effective temperature for the wash cycle and 180 degrees minimum effective temperature for the rinse cycle.4. Observation of the kitchen 02/23/26 at 8:08 A.M. with [NAME] #541 and [NAME] #531 revealed the walk-in refrigerator temperature log was over 41 degrees F since 02/04/26 and been taken out of use.The walk-in refrigerator was recorded at 50 degrees for the evening temperature on the 02/04/26 temperature log. To the right of the 50-degree F temperature, a temperature of 48 degrees F was written with the additional notation came to service. The facility obtained a portable refrigerator on 02/09/26 that was outside. The portable refrigerator was hooked up on 02/10/26. The temperature log for the portable refrigerator started on the morning of 02/11/26 with a reading of 36 degrees F. On 02/12/26, the evening temperature was recorded at 50 degrees F.Interview on 02/25/26 at 4:05 P.M. with Dietary Manager #538 revealed she would have taken the A.M. temperature on 02/12/26 of 37 degrees F around 5:00 A.M. when she arrived for work and the 50-degree F temperature around 4:00 P.M. before tray line. Written on the line next to 50 degrees F was less than two hours. When asked how she knew the refrigerator was not keeping temperature for less than two hours the Dietary Manager #538 stated a regional employee was doing a mock survey and found it warm. They moved everything into the reach in refrigerator. Dietary Manager #538 said she tested the milk and it was 39 degrees F, but she did not document that anywhere. A service technician came that day and had it up and running. It was later determined the regional employee was at the facility on 02/11/25 (not 02/12/25), the refrigerator was found warm around 2:30 P.M., and the refrigerator was not emptied when it was found to be 50 degrees F.Interview on 02/25/26 at 4:52 P.M. with the Administrator revealed he was not in the facility on 02/12/26 when it was discovered that the portable refrigerator was not keeping temperature. He said he was notified. On 02/13/25 at 5:10 P.M., the Administrator received a picture of four cases of drinks that were being thrown away.Interview on 02/26/26 at 9:58 A.M. with Maintenance Director #524 revealed on 02/12/26 at 2:36 P.M., Dietary Manager #538 texted him that the rental refrigerator unit was not cooling. At 2:38 P.M., he called the company he rented the portable refrigerator from, and they came out and serviced the unit. The condenser was not kicking on. It had something to do with the fan not working. He normally leaves at 3:00 P.M., but he waited to go home till they fixed the unit. They were finished fixing it by 5:00 P.M. Interview on 02/26/26 at 2:12 P.M. with [NAME] #516 revealed on 02/12/26 he clocked in and got ready. There was food in the rental refrigerator unit outside on 02/12/26. The built-in thermometer on the outside of the refrigerator read 50 degrees F. When he walked in, it was ridiculously warm. He grabbed the potato salad, it was 42 degrees F. He removed a pasteurized juice that was 50.2 degrees F, the milk was 50.4 degrees F, and the margarine was 50 degrees F. The rental refrigerator was fixed that afternoon. No one tested the milk to see what the temperature was when the repair was complete. Dietary Manager #538 left the milk in the rental unit and said maintenance would take care of it and left. [NAME] #516 reported they had never heard what to do for milk or juice for supper. The dietary staff decided to text Dietary Manager #538 and she did not reply to [NAME] #531. Dietary Aide #523 told him that Dietary Manager #538 responded to him and said she would relay the information about throwing out the milk. When [NAME] #516 arrived for work on 02/13/26, he walked out when he found out from Dietary Aide/Cook #531 and [NAME] #541 that they served the milk from the rental refrigerator for breakfast and lunch. He said he should have taken it upon himself to throw out the milk that was 50.4 degrees on 02/12/26 when he found the rental refrigerator was not cooling. [NAME] #516 reported Dietary Manager #538 said she thought the milk was fine. She spoke to the other staff and told them it would be ok. He looked for the Administrator and Human Resource. He found the Director of Nursing who called the Administrator and told him what he did to prevent the drinks that were in the rental refrigerator from being served and he had not done enough when he found out the drinks were served for breakfast and lunch. He indicated when he left on 02/12/26 there was not enough milk and juice in the reach-in refrigerator for breakfast.Interview on 03/02/26 at 10:37 A.M with Office Manager #583 revealed they received the call at 2:38 P.M. of their rental refrigerator not reaching temperature. There was a technician onsite who left and would have been at the facility by about 3:15 P.M. They diagnosed the problem and took about 15 minutes to fix. It was a total of about an hour they were here total. They would have finished by about 4:15 P.M.Interview on 03/02/26 at 12:51 P.M. with Technician #590 revealed the rental refrigerator was 50.4 degrees F when he arrived at the facility. It took about an hour to diagnose, fix, and ensure the temperature dropped to normal range. It was 37 degrees F when he left. There was a coil that was bad. He relayed he had to remove shelves from the portable refrigerator to fix the rental. He moved crates of single serve milk and juice to another shelf. He said they were in the rental while he was repairing the refrigerator. Interview on 03/02/26 at 1:30 P.M. with Maintenance #524 verified he was not asked to throw away any items from the rental refrigerator. Interview on 03/04/26 at 8:23 A.M. with Dietary Aide #523 revealed the milk for supper on 02/12/26 would have been in the reach-in refrigerator when the rental refrigerator broke. He did not carry any milk inside from the portable refrigerator after they discovered it was hot. Interview on 03/02/26 at 8:57 A.M. with [NAME] #541 said he only knew the walk-in refrigerator was down. When he worked on 02/13/26, he did not know the rental refrigerator broke the day prior. He does not recall any conversation related to the warm milk or juice being thrown out. He recalls throwing out some wilted lettuce. He did not know where the milk came from that he served 02/13/26.Interview on 03/02/26 at 9:14 A.M. with Dietary Manager #538 revealed she spoke to maintenance staff, and he said the refrigerator was warm for less than two hours and that is why she wrote that on the log. Interview 03/03/26 at 11:28 A.M. with United Dairy Delivery #588 revealed he usually delivers milk twice a week, usually on Tuesdays and Fridays. He did not make any additional deliveries due to the facility having to throw products out. He was never told they had to replace milk or juice due to needing to throw it away.Review of delivery records revealed on 02/13/26, United Dairy delivered at 12:06 P.M. 200 chocolate milk cartons, a container of cottage cheese, 500 2% milk cartons, and 225 cartons of orange juice. Interview 03/03/26 at 1:49 P.M. with the Administrator revealed he received a photo at 5:10 P.M. on 02/13/26 that the milk delivery came and she was throwing away 4 cases of milk and juice. Verified they were thrown away after the breakfast, lunch and supper meals were served. No staff acknowledged getting rid of the milk and juice that remained in the rental refrigerator until 5:10 P.M. the next day. This deficiency represents noncompliance investigated under Complaint Number 2788578.

Based on observation, record review, review of Quality Assurance and Performance Improvement program (QAPI) meeting minutes, and interview, the facility failed to maintain an ongoing, comprehensive, and effective Quality Assurance and Performance Improvement Program to address concerns with facility practices and operations, to ensure corrective action plans from prior survey activity addressed quality concerns, systemic gaps and outcomes and corrective interventions were evaluated for effectiveness to meet the total care needs of the residents in the facility. This affected all 37 residents residing in the facility.Findings include: Review of the facility Quality Assurance and Performance Improvement program (QAPI) Meeting Sign-In Sheet, dated 02/19/26, revealed topics addressed at the meeting included findings from an internal mock survey, ensuring interventions were in place and the plan to introduce a new hall. The QAPI Action Plan included following the committee's review of February's findings, a comprehensive set of corrective and preventive action items were initiated to strengthen system reliability, reinforce staff accountability, and ensure readiness for the upcoming state survey consistent with the approach used in the October QAPI cycle where the facility initiated a comprehensive set of action items to address each citation and ensure that the corrective measures were implemented promptly, consistently, and in alignment with regulatory expectations. The February action plan focused on improving communication pathways, standardizing processes, and validating that corrective actions were fully integrated into daily operations.Further review of QAPI Minutes provided revealed no evidence the facility held a QAPI meeting after the bi-annual survey on 03/09/26 and prior to the alleged allegation of compliance date of 04/21/26 to ensure compliance was achieved with the deficiencies issued as a result of the bi-annual survey including the infection control practices/concerns and quality of care concerns.a. Review of the facility's Plan of Correction for the citation at Data tag F880 (from the Special Focus Facility Bi-annual survey dated 03/09/26) revealed beginning March 16, 2026, the Infection Control Nurse/Designee initiated random enhanced barrier precaution (EBP) audits on a minimum of five residents with EBP or isolation orders weekly for four weeks and as needed thereafter. Any issues identified in the audit process would be forwarded to the QA committee for immediate follow-up. The results of the audits would be reviewed during the QA meetings to determine if current action plan was effective or if additional interventions would need to be added.During the post-survey revisit completed on 05/15/26, Data Tag F880 was cited at a Severity Level 4 (Immediate Jeopardy) and scoped at an L which indicated the deficiency was widespread, potentially affecting all residents in the facility. The facility lacked a comprehensive infection control program to prevent the spread of RSV. The facility encountered an RSV outbreak with an infection rate of 16.2% and the death of one resident, Resident #3. Prior to the survey, the facility failed to implement comprehensive and sustainable interventions and failed to ensure staff were educated related to the communicable disease to prevent the outbreak within the facility.On 04/29/26 at 11:16 A.M. interview with Infection Preventionist (IP) #256 revealed she had not initiated contact tracing, did not have a line list (a fundamental epidemiological tool used to track individual cases during an outbreak), and did not timely identify an outbreak of RSV until 04/22/26 when three additional residents tested positive (the facility already had two positive staff members and one resident at this time). IP #256 further revealed communal gatherings of dining and group activities did not cease until 04/22/26, nor was the local health department notified of the situation until 04/22/26. On 04/29/26 at 12:37 P.M. interview with County Health Department Registered Nurse (RN) #407 revealed she was notified on 04/22/26 by IP #256 of five residents and two staff members testing positive for RSV. RN #407 stated she would have expected to be notified within 24 hours of an identified outbreak (two or more cases) and she was not. RN #407 stated following notification she emailed RSV guidance to IP #257.On 04/29/26 at 1:20 P.M. interview with Regional Director of Clinical Services RN #402 confirmed the facility only had a general policy related to RSV/respiratory infection, not a comprehensive policy or policy specific to RSV prevention, monitoring or the procedure for how to address cases of RSV and prevent the spread of the disease.On 04/29/26 at 1:45 P.M. interview with the DON revealed she did not realize there was an RSV outbreak until 04/22/26 when multiple residents were symptomatic and tested positive for RSV. The DON confirmed the facility failed to screen CNA #237 following her RSV positive test result and ongoing symptoms before permitting her to return to work and potentially spreading the RSV virus to other staff and residents. The DON further confirmed the facility did not have an effective RSV outbreak management plan in place.On 04/29/26 at 1:50 P.M. interview with the Administrator confirmed the RSV outbreak was not timely identified and the facility failed to have a comprehensive RSV outbreak management plan in place. The Administrator also verified the outbreak root cause was traced back to LPN #251 and CNA #237 both working despite their positive RSV test.On 05/05/25 at 11:23 A.M. interview with Nurse Practitioner (NP) #405 revealed she had not been involved in the development of an RSV policy and procedure following the identification of the current RSV outbreak and could not speak to any facility RSV policy. NP #405 revealed she did not recall initially being notified of RSV positive staff and stated she first became aware of the situation when Resident #66 tested positive for RSV following a hospitalization.On 05/06/26 at 10:15 A.M. interview with Medical Director/Physician #406 revealed he had not been directly involved with any RSV policy or procedure development and was only initially notified of resident cases. He stated he was unaware staff were the first to test positive. (See Findings at F880)b.Review of the facility's Plan of Correction for the citation at Data Tag F684 (from the Special Focus Facility Bi-annual survey dated 03/09/26) revealed beginning 03/16/26, the DON/Designee initiated random audits on a minimum of five residents with physician-ordered dietary or fluid restrictions weekly for four weeks and as needed thereafter. Audits included review of the signed communication forms to verify all applicable disciplines had acknowledged receipt of active orders; comparison of dietary records, nursing documentation, and the care plan to verify consistent implementation of ordered restrictions across all departments and shifts; and direct observation of meal service for affected residents to verify that fluid allotments are being implemented as ordered. Any issues identified within the audits would be forwarded to the Quality Assurance (QA) committee for immediate follow-up. The results of the audits would be reviewed during the QA meetings to determine if current action plan was effective or if additional interventions will need to be added.During the post-survey revisit completed on 05/15/26, Data Tag F684 was cited at a Severity Level 3 Actual Harm, with a scope and severity of G which indicated the deficiency was isolated but affected two residents, Resident #2 and #84. The facility failed to timely and appropriately identify a change in condition resulting in two emergent transfers and subsequent hospital admissions for the residents affected. (See Findings at F684). During the onsite survey, interview with the Administrator confirmed the most recent QAPI meeting was held as a quarterly meeting in February 2026. The Administrator confirmed the ongoing non-compliance identified for the facility and number of identified quality of care concerns. The Administrator revealed since Medical Director #406 began his new role in February 2026, the facility had not held a QAPI meeting and acknowledged the deficiencies at F684 and F880 were recites to the prior survey.The facility's QAPI policy was requested from the Administrator and Director of Nursing (DON) during the survey but was not provided.

Based on observation, invoices, and interviews, the facility failed to ensure all electrical equipment was maintained in safe operating condition. This had the potential to affect all residents residing in the facility. The facility census was 38. Findings include: 1.Observation of the kitchen 02/23/26 at 8:08 A.M. with [NAME] #541 and [NAME] #531 revealed the walk-in refrigerator temperature log was over 41 degrees Fahrenheit (F) since 02/04/26 and had been taken out of use.The walk-in refrigerator was recorded at 50 degrees for the evening temperature on the 02/04/26 temperature log. To the right of the 50 degree F temperature, a temperature of 48 degrees was written and came to service was written. The temperature reading had been 40 degrees F recorded as the morning temperature on 02/02/26, 02/03/26 and 02/04/26. Interview on 02/25/26 at 4:13 P.M. with Dietary Manager #538 revealed she deleted her text and she cannot remember who texted her about the refrigerator being over temperature. She said she was told the temperature was in the 50's. She said she texted back and said get everything out of the cooler and put things in the reach-in refrigerator. She did not instruct the staff to take the temperature of any of the foods. They did not throw anything away. She said someone came to service the refrigerator but she had no paperwork and did not know who the person was. On 02/05/26, an evening temperature of 56 degrees F was recorded. On 02/06/26, an evening temperature of 54 degrees was recorded. There were no temperatures recorded for 02/07/26 or 02/08/26. On 02/09/26 the morning temperature was recorded at 58 degrees F. Interview on 02/26/26 at 2:11 P.M. with [NAME] #516 who was present on 02/04/26 revealed he opened the door to the refrigerator and the temperature was nicer in the walk-in than outside. He thought that was not a good sign. He texted Dietary Manager #538 and told her the temperature was in the 50's in the walk-in refrigerator. Items that would spoil were put in the reach in refrigerator. He had a conversation with the Dietary Manager #538 that the walk-in refrigerator was 40 degrees F three mornings in a row. Interview on 02/26/26 at 3:07 P.M. with the Administrator revealed he received a text at 9:45 A.M. on 02/08/26 about the walk-in refrigerator being 55 degrees F. He did not see the text on that Sunday morning and did not respond. He stated it was the first time he was informed that the walk-in refrigerator was not cooling. He did not know the temperature was 50 degrees F on 02/04/26 and he did not call a serviceman out on 02/04/26. He included he had no paperwork from any service repairman for 02/04/26. He verified there was a four-day delay in his notification of the walk-in refrigerator being broken. He verified reaching out to obtain a rental and repair the walk-in refrigerator was delayed five days.Interview on 02/26/26 at 3:22 P.M. with Maintenance #524 revealed he received a text at 7:30 P.M. on 02/08/26 that the walk-in refrigerator temperature was high. He stated it was the first time he was informed that the walk-in refrigerator was not cooling. He had no knowledge of the walk-in refrigerator not cooling on 02/04/26. He said if he knew the walk in was not cooling, he would have rented a rental unit sooner than 02/09/26. He verified there was a five-day delay in reaching out to get a rental unit and repair the walk-in refrigerator.2. Observation of the kitchen on 02/23/26 at 8:08 A.M. with [NAME] #541 and [NAME] #531 revealed the kitchen did not have a working oven. Both ovens became nonfunctioning between 01/30/26 and 02/05/26. The heating element of the oven on the right was welded to the bottom of the oven for approximately three weeks to one month related to a power surge.Interview 02/26/26 at 8:32 A.M. with Maintenance #524 revealed the oven that caught fire inside had welded the heating element to the bottom of the oven panel and was bought new in June 2025. The oven on the left was bought new in March of 2025. The oven bought in March 2025 had problems since it was bought and had not been working on-and-off since October 2025. He stated it was a lemon and the company did not want to stand behind the warranty, blaming the facility on not running the correct wattage of electricity to the oven. A new heating element was ordered for the oven. Interview 02/26/26 at 8:32 A.M. with the Administrator revealed on 03/06/26, the facility bought an oven with a new stove. On 06/09/25, a new stove with grill was bought. The Administrator stated there was too much power going from the breaker to the ovens and it damaged them. He had an invoice dated 01/30/26 indicating both ovens were down and had been repaired. The invoice indicated the repairman had returned on 02/02/26 for electrical panel troubleshooting. On 02/10/26 the Administrator received a quote for a single deck convection oven with a removable door. 02/17/26, a heating element for the oven was ordered. The new oven was ordered and due for delivery around 03/16/26. This deficiency represents noncompliance investigated under Complaint Number 2788578.

Based on review of resident council minutes, review of concern forms, review of the facility's assessment and interview, the facility failed to maintain sufficient staffing to timely meet the total care needs of all residents. This affected ten residents (#1, #2, #4, #11, #14, #15, #22, #27, #28, and #47) of 38 residents residing in the facility. Review of Resident Council minutes dated 09/15/25 to 02/18/26 revealed old business resolved was resident had voiced concerns about how long it takes aides to find help using the Hoyer (mechanical lift). New concerns residents voiced included concerns about staff call offs and not having enough staff members available. An action plan was to provide education about call offs and scheduling. Additional staff provided to help residents' needs. During the meeting held on 11/17/25 and 12/15/25 resident's voiced concerns about food being served late. During the 12/15/25 meeting, residents present indicated food being served late was still going. The plan was to have mangers help pass trays, minimize residents down to two hallways, and interview with residents individually. Due to the relocation of residents to two facility hallways, during the meeting held on 01/20/26 concerns with food being served late was noted to be resolved. Review of facility concerns forms dated 09/16/25 to 02/23/26 and residents and family interview revealed the following staffing concerns: a. On 10/29/25 Resident #11 felt her call light was not answered timely. The recommended corrective action was to educate staff via [NAME] on the importance of responding to call lights as soon as possible or at least ensuring that staff members acknowledged a resident does have their light on and they would be assisted shortly. b. On 11/07/25 Resident #47 had concerns about call light response time. The recommended corrective action was education to be given to all nursing staff via [NAME] regarding the importance of responding to call lights promptly. c. On 12/08/25 Resident #4 had concerns with the call light response time. Residents were interviewed and the facility identified two residents to have problems. As a result, the facility recommended corrective action included educating staff on the importance of call light response time. d. On 12/10/25 Resident #11 voiced a concern about call light response time. Residents were interviewed and the majority of residents did not have any issues, however on the 200 hall there were two residents who had problems. As a result, the facility recommended corrective action included educating staff on the importance of call light response time. e. On 01/19/26 Resident #1 revealed difficulty locating a specific night-shift aide for approximately three hours. The facility determined the staff member was not assigned to the resident's unit. However, there was no evidence the facility resolved whether the resident's care needs were addressed based on a result of the concern and/or that staff was available to meet his needs during this timeframe. f. Interview with Resident #15's husband on 02/23/26 at 2:12 P.M. revealed that a few weeks ago, one staff person assisted the resident to the bathroom when there should have been two staff assisting with the use of a lift. He stated the resident fell in the bathroom with resulting bruising to her waist area. The husband attributed the incident to a lack of staff. During the interview, Resident #15's husband revealed staff were slow to answer the call light when his wife needed to use the bathroom. g. Interview on 02/23/26 at 10:24 A.M., with Resident #2 revealed there wasn't adequate staff on night shift. The resident reported there was only on certified aide for 19 residents and call lights were not answered timely. The waiting time for call lights can take up to an hour and one night she fell asleep after waiting over an hour. h. Interview on 02/23/26 at 1:59 P.M., with Resident #4 revealed staffing concerns indicating she had to wait 1.5 hours for ice water. The resident stated staff would answer the call light and say they would be back and they don't return timely. i. Interview on 02/25/26 at 11:10 A.M., with the Ombudsman revealed there was current concerns from residents regarding staffing shortage. j. Interview on 02/23/26 at 2:28 P.M., with Resident #14 revealed the facility needed more staff. The staff were too busy to help, and he had to wait for help to get off the floor after sustaining a fall. k. Interview on 02/24/26 at 2:30 P.M., with Resident #1, #27, and #28 during a resident council meeting with the surveyor revealed the facility staffing concerns including the facility did not have adequate staffing on night shift. The residents reported they had to wait 30 minutes or longer for staff to answer the call lights. The residents voiced concerns that staff walk by the call lights or say they would be back and don't return. Resident #1 reported he needed a Hoyer lift to transfer and had to wait a long time for staff to get help to transfer him. Follow up interview on 02/25/26 at 9:40 A.M., with Resident #1 revealed the facility tells him when he reports staffing concerns they have more staff, but he states he doesn't see it. The resident reported that the staff on night shift were young and they stood around and goof off. The resident stated he had to wait to get out of bed because there wasn't enough staff available to operate the Hoyer lift to help him out of bed timely. Follow-up interview on 02/25/26 at 10:58 A.M., with Resident #27 revealed he had concerns with a lack of staff on night shift. The resident voiced concerns he had to wait a long time for staff to answer his call light timely. l. An interview during the survey with Anonymous Staff Member (ASM) #200 revealed concerns staff were not educated on staffing procedures. ASM #201 and #202 voiced concerns there were frequently not enough staff during the night shift. They indicated the facility scheduled three certified nursing assistants (CNA); however, there were usually only two who actually worked. The ASMs revealed there were several residents who required Hoyer lifts for transfers and there were several residents who required weights and showers on night shift which required additional staff to assist/help on the floor while the staff completed these tasks. In addition, the ASMs revealed several residents were night owls and didn't sleep on night shift and they requested food and snacks to be prepared which took extra time. The ASMs indicated staffing concerns/issues had been reported to management who were on call but very seldom did they come in to cover call offs. m. Review of self-reported incident (SRI) #270847 and investigation dated 02/12/26 revealed Resident #22 reported a concern regarding the care he received from Certified Nursing Assistant (CNA) #550. The resident stated his legs became numb after he had been seated on the toilet waiting for assistance from staff. The resident indicated he was not upset about the wait itself but felt that when the CNA entered the room, she displayed an unpleasant demeanor. The staff were educated on abuse prevention, appropriate resident interactions, and mandatory reporting requirements. Further review of the no evidence the resident concern regarding the wait time was investigated. The surveyor requested information; however, it was never provided.Interview on 02/25/26 at 7:06 A.M., with Resident #22 revealed he had activated his call light and had waited over 30 minutes in the bathroom, and his legs went numb, so he started yelling for help. The resident reported this was not the first time he had to wait over 30 minutes for staff to respond to his call light. The resident reported when the staff doesn't respond timely, he starts yelling until staff come.Interview on 02/25/26 at 7:23 A.M., with Certified Nursing Aide (CNA) #550 confirmed she was the CNA assigned to Resident #22 on 02/11/26. The CNA confirmed the resident had waited at least 20 minutes for help due to the other CNA assigned to the hall was on break and she was providing care to another resident. The housekeeper came and told the resident need assistance, but she could not leave the resident whom she was providing care to. The CNA confirmed she in the at least 20 minutes providing care to the other resident then she went to assist Resident #22. Interview on 02/25/26 at 11:10 A.M., with the Director of Nursing revealed she was aware there were concerns with staff on night shift and she had planned on making some night shift observations; however, that had not been completed as of this time. Review of the facility assessment dated [DATE] revealed there were 15-20 residents who required one to two staff assist and 15-20 residents who were dependent on staff. The direct care staff schedule included two licensed nurses on day and night shift, four CNAs on dayshift and three CNAs on night shift. As the census or centers needs change, to include resident acuity, staffing levels were adjusted accordingly. The assessment indicated residents and their family's input would be taken into consideration when making these decisions.Interview on 03/04/26 at 9:15 A.M. with Staffing Coordinator #503 revealed she scheduled staff based on the census and tried to have two nurses and four CNAs on day shift and two nurses and three CNAs on night shift. If there was a call off, she stated she looked for coverage but felt with the current facility census they would be ok with only three CNAs on day shift and two CNAs on night shift.

Based on resident/representative interview, staff interview, policy review, record review, and review of binding arbitration agreements, the facility failed to ensure binding arbitration agreements were explained to residents/representatives in a manner that they understood and included an explanation that they were giving up the right to litigation in a court proceeding and could withdraw/terminate the agreement within 30 days after signing. This affected five residents (#2, #7, #10, #17, and #19) of six residents reviewed for arbitration agreements. The facility census was 38.Findings Include:The facility Administrator identified, with a list, that all 38 residents in the facility had signed a binding arbitration agreement. 1. Review of the record for Resident #7 revealed a readmission date of 11/25/25. A Minimum Data Set (MDS) assessment on 12/19/25 indicated a Brief Interview for Mental Status (BIMS) score of 15 indicating intact cognition. Review of a Binding Arbitration Agreement revealed it indicated Resident #7 had electronically signed (no actual signature) the agreement on 09/25/25. The staff member signing the agreement for the facility was Admissions Director #562. Interview with Resident #7 on 02/25/26 at 2:25 P.M. revealed he did not remember signing an arbitration agreement on 09/25/25. He stated he did not remember signing anything electronically and did not remember anything being explained to him as limiting his right to litigation in a court proceeding. 2. Review of the record for Resident #2 revealed an admission date of 04/28/25. A Minimum Data Set (MDS) assessment on 12/31/25 indicated a BIMS score of 13 indicating intact cognition. Review of a Binding Arbitration Agreement revealed it indicated Resident #2 had electronically signed (no actual signature) the agreement on 09/25/25. The staff member signing the agreement for the facility was Admissions Director #562. Interview with Resident #2 on 02/25/26 at 4:00 P.M. revealed she did not remember signing an arbitration agreement on 09/25/25. She stated she did not remember anything being explained to her as limiting her right to litigation in a court proceeding. 3. Review of the record for Resident #19 revealed an admission date of 02/10/26. A Minimum Data Set (MDS) assessment dated [DATE] revealed a BIMS test indicated a score of 12 indicating moderately impaired cognition. Review of a Binding Arbitration Agreement revealed it indicated Resident #19 had electronically signed (no actual signature) the agreement on 02/12/26. The staff member signing the agreement for the facility was Admissions Director #562. Interview with Resident #19 on 02/26/26 at 11:40 A.M. revealed he did not remember signing an arbitration agreement on 02/12/26. He stated he did not remember anything being explained to him as limiting his right to litigation in a court proceeding. He stated it would take two lawyers and a little kid to understand those kind of papers. 4. Review of the record for Resident #17 revealed an admission date of 02/09/26. Review of a Binding Arbitration Agreement revealed it indicated Resident #17's sister had electronically signed (no actual signature) the agreement on 02/12/26. The staff member signing the agreement for the facility was Admissions Director #562. Interview with Resident #17's sister on 03/02/26 at 9:49 A.M. revealed she had not been to the facility to sign any papers. She stated she might have talked to someone on the phone about admission papers but did not remember a binding arbitration agreement being discussed. She stated she was sick when the admission papers were discussed and she has been very overwhelmed by the whole admission process. She stated she would not have signed it, if it had been explained to her as limiting their right to litigation in a court proceeding. She was not aware that she had 30 days to withdraw or terminate agreement. She stated she would like to terminate the agreement. 5. Review of the record for Resident #10 revealed an admission date of 10/17/25. Review of a Binding Arbitration Agreement revealed it indicated Resident #10's daughter had electronically signed (no actual signature) the agreement on 10/21/25. The staff member signing the agreement for the facility was Admissions Director #562. Interview with Resident #10's daughter on 03/02/26 at 10:05 A.M. revealed she lived out of state and had not been to the facility to sign any papers. She stated she had not had any conversations with anyone regarding admission paperwork. She stated there were some papers mailed through the mail to her and she was told it was required to sign. She stated she would not have signed the Binding Arbitration Agreement if it had been explained to her as limiting their right to litigation in a court proceeding. Interview with Admissions Director #562 on 02/26/26 at 8:20 A.M. revealed the Binding Arbitration Agreement is part of the facility admission packet. She stated that any resident with a BIMS score above 12 could sign the arbitration agreement. Otherwise, she talked to the family/representative about the arbitration agreement. She stated that she had been doing this since approximately December 2024. She stated that she used a laptop with the arbitration agreement already prepopulated in. She stated rarely did she have anyone decline to sign it. She stated that it required pushing a button on the laptop to electronically sign the arbitration agreement. When asked how she explained the arbitration agreement to residents/representatives, she stated that she explained that if their insurance did not pay, this kept it out of the court system. She stated she explained that you sit down to discuss the bill. She stated she explained that if their stay was not covered, this gave you the right, outside of court, to discuss without having to go to court and they are responsible for the bill if they didn't. She stated that was the [NAME] of what is said. She further stated that it was all about the bill/money. She stated she did not know if residents/responsible parties were able to withdraw or terminate the agreement within any certain time frame. She stated she did not know anything about who would be used as an arbitrator if one were to be used. Interview with Regional [NAME] President #579 on 02/26/26 at 9:30 A.M. revealed binding arbitration agreements were not to be a condition of admission. He confirmed residents/representatives should be able to withdraw/terminate an arbitration agreement within 30 days of signing. He confirmed that if an arbitration agreement was signed, the resident/representative would not be able to pursue litigation through the courts for issues such as injuries, wrongful death, property damage (as listed in the arbitration agreement). He confirmed the agreement should be explained well enough that they understand they can't pursue court litigation for the above items listed in the arbitration agreement. He stated education would be provided to the staff about having the arbitration agreements signed. Review of the facility policy dated November 2023 titled Binding Arbitration Agreements revealed residents (or their representatives) have the right to make informed decisions about important aspects of their health, welfare, and safety. Binding arbitration agreements are voluntary for the residents. Residents are not compelled, pressured, or coerced to enter into a binding arbitration agreement. The terms and conditions of a binding arbitration agreement are explained to the resident (or representative) in a way that ensures his or her understanding of the agreement, including that the resident may be giving up his or her right to have a dispute decided in a court proceeding (litigation). Residents are provided 30 days after signing to fully review and rescind any agreement not understood at the time of admission. Any facility personnel who are responsible for explaining the terms and conditions of binding arbitration agreements to the residents (or representatives) are trained in the specifics of this policy and in the requirements.

Based on observation, policy review, and interview, the facility failed to ensure a resident was provided a dignified dining experience. This affected one resident (#6) of five residents observed for dining. The facility census was 38.Findings include: Review of Resident #6's medical record revealed a 01/28/25 admission with diagnoses including atrial fibrillation, hypertension, vascular dementia with behavioral disturbance, hypothyroidism, anemia, Vitamin D deficiency, vascular dementia, mood disturbance, depression, history of falling, insomnia, dysphagia, abnormalities of gait and mobility, long term use of anticoagulants, hypokalemia, muscle weakness and cognitive communication deficit. Review of the resident's Activity of Daily Living/Mobility plan of care included the resident required assistance related to weakness, and impaired mobility. Interventions included the resident will have needs anticipated and met by staff. Eating: Up to supervision/verbal cues with assist of one for task initiation and follow through initiated: 02/03/25 revision on: 12/17/25. Review of the 02/18/26 Quarterly Minimum Data Set Assessment (MDS) revealed the resident was severely impaired for daily decision making, had no dental issues, two falls since last assessment, adequate vision with no glasses, needed partial moderate assist with oral hygiene, supervision or touching assistance for eating. Observation on 02/23/26 at 11:50 A.M. of the lunch meal revealed Certified Nurse Aide (CNA) #551 revealed she stood over the resident's bedside and fed her the lunch meal. CNA #551 fed the resident her meal standing over the resident instead of sitting at her level. The resident was fed pureed fruit cocktail, chicken tortilla soup, broccoli and a ham sandwich. The resident was holding her coffee cup drinking from her cup of coffee independently. At the time of this observation, an attempt to interview the resident was unsuccessful as the resident was unable to answer questions appropriately. Interview on 02/23/26 at 12:34 P.M. with CNA #551 revealed the resident had been needing more help. CNA #155 verified she stood and fed the resident instead of sitting next to the resident and this was a dignity issue. Review of the facility policy, Assisting the Impaired Resident With in Room Meals, (revised September of 2013) included if you were going to be seated during the feeding position a chair where it will be convenient for you and the resident. The policy did not address standing while feeding a resident.

Based on closed record review, review of fall investigations, review of Quality Assurance (QA) documentation, Mayo Clinic Diabetic Ketoacidosis information review, review of hospital notes, and interviews, the facility failed to comprehensively assess and timely identify an acute change in Resident #22's condition resulting in hospitalization and failed to ensure effective and necessary care and treatment was provided to manage the resident's diabetes mellitus. This affected one resident (#22) of four residents reviewed for change in condition. The facility census was 53. Actual harm occurred beginning on 11/02/25 when Resident #22 was noted at multiple times on this date to have a blood sugar that read hi (a hi reading is reached when the blood sugar result is too high for the glucometer to read, often greater than 600 milligrams per deciliter (mg/dL)) on the glucometer without effective and/or adequate monitoring and treatment. On 11/03/25 Resident #22 did not receive her diabetic medication (blood sugar lowering medications), insulin glargine (a long acting human insulin use to manage blood glucose levels in individuals with type 1 and type 2 diabetes) or Novolog insulin (a rapid acting insulin used to manage blood sugar levels in individuals with type 1 and type 2 diabetes) at (if needed based on blood sugar results) at 9:00 A.M. as scheduled. Resident #22 was later found (on this date) in her room unresponsive on the floor with a hi blood sugar glucometer reading. Resident #22 was transferred to the hospital and admitted to the intensive care unit (ICU) for treatment of diabetic ketoacidosis (a life-threatening medical emergency that occurs when the body, lacking sufficient insulin, breaks down fat for energy, creating high levels of ketones that make the blood acidic) and sepsis (a life-threatening medical emergency where the body's response to an infection triggers a chain reaction that causes tissue damage and organ dysfunction). Findings include:Review of Resident #22's closed medical record revealed Resident #22 was admitted to the facility on [DATE] with diagnoses including type I diabetes with diabetic neuropathy, muscle weakness, and difficulty in walking. Review of a care plan dated 09/10/25 revealed Resident #22 required hyperglycemic medication related to diabetes. Goals included Resident #22 would exhibit a therapeutic effect related to the use of medication, would not have signs or symptoms of hyperglycemia, and would not have side effects related to the medication. Interventions included to administer medications per orders, vital signs as indicated, pharmacy review as indicated, finger sticks as ordered and report abnormal findings to physician, labs as orders and report abnormal results to physician, observe for signs and symptoms of hyperglycemia (flushed skin, dry skin, drowsiness, nausea, vomiting, abdominal pain, increased respiration) and report to physician, observe for signs and symptoms of hypoglycemia (dizziness, lethargy, diaphoresis, headache, irritability, confusion, restlessness, shallow respirations) and notify physician, observe for symptoms of lactic acidosis and immediately report to physician (feeling tired or weak, muscle pain, trouble breathing, abdominal pain, feeling cold, cold or blue hands and feet, dizziness or light headedness, slow or irregular heartbeat, persistent nausea and/or vomiting, shortness of breath and an enlarged or tender liver or weight loss). Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #22 had mildly impaired cognition, refused care one to three days, and required (staff) supervision or touching assistance for transfers and bed mobility. Review of an order dated 09/18/25 revealed Resident #22 had an order to receive insulin glargine subcutaneous solution pen-injector 100 units/milliliters (ml) 15 units subcutaneously one time a day at 9:00 A.M. for diabetes. Review of an order dated 10/21/25 revealed Resident #22 was to receive Novolog injection solution 100 unit/ml as per sliding scale (depending on fingerstick blood sugar results) four times a day with blood sugar checks scheduled to be obtained at 9:00 A.M., 12:00 P.M., 5:00 P.M., and 9:00 P.M. If the resident's blood sugar was 150-200 (mg/dL) give 4 units, if 201-250 give 6 units, if 251-300 give 10 units, if 301-350 give 15 units, if 351-400 give 18 units, if 401-450 give 22 units subcutaneously four times a day for diabetes with instructions to call physician if blood sugar was greater than 450 or less than 75. Review of a progress note dated 10/21/25 by Certified Nurse Practitioner (CNP) #515 revealed Resident #22 had been having intermittent hypoglycemia despite an elevated glycated hemoglobin (A1c), but was not experiencing hyperglycemia with blood sugar ranging from 350-528. The progress note revealed hyperglycemia was improved with additional Novolog. Review of a nursing note dated 11/02/25 at 1:57 P.M. authored by Registered Nurse (RN) #156 revealed Resident #22's blood sugar showed hi on two devices. The on-call company (of medical providers) was called, and orders were received to give 26 units of Novolog and call back in two hours. The 26 units of Novolog insulin was documented as given. Review of a nursing note dated 11/02/25 at 3:14 P.M. authored by RN #156 revealed Resident #22's blood sugar was 477 (hyperglycemic), the on-call physician was called again and per their request 26 units (of Novolog insulin) was given with instructions to call back in two hours. Review of a nursing note dated 11/02/25 at 4:10 P.M. authored by RN #156 revealed Resident #22 had a fall in the morning while attempting to stand up to get a cup for ice. Resident #22 stated she stood up, then slid to the floor but did not hit her head. Resident #22 had a skin tear on her right elbow which was cleaned with wound cleanser and covered with a bordered gauze. (Note- this is a late entry note for a fall that had occurred 11/02/25 earlier in the day in the dining room). Record review and review of a facility fall investigation revealed no evidence a root cause analysis was completed or evidence the facility considered the resident's fall to be associated with her elevated blood sugar levels that had been identified on this date. Review of a nursing note dated 11/02/25 at 4:52 P.M. authored by RN #156 revealed Resident #22's blood sugar showed hi on two devices. The on-call company (of medical providers) was called, and orders were received to give 26 units of Novolog insulin and call back in two hours. The 26 units of Novolog insulin were documented as given. Review of a nursing note dated 11/02/25 at 4:57 P.M. authored by RN #156 revealed Resident #22's blood sugar was 477 mg/dL, the on-call physician was called again and per their request 26 units were given with instructions to call back in two hours. Review of a nursing note dated 11/02/25 at 6:08 P.M. authored by RN #156 revealed Resident #22's blood sugar was 347 mg/dL. The note included information was passed to the night shift nurse. Review of the MAR for this date, revealed when the resident's blood sugar was 347 mg/dL, the resident should have received 15 units of Novolog insulin. However, there was no evidence the resident received the 15 units of Novolog insulin at this time. The MAR identified a 9 which indicates to look at the nursing note; however the corresponding nursing note did not provide evidence the Novolog insulin was administered and/or a reason why it was not. Record review revealed no evidence the resident ' s blood sugar was re-checked or monitored between 11/02/25 at 9:33 P.M. and 11/03/25 at 11:50 A.M. Review of the Medication Administration Record (MAR) dated 11/03/25 revealed no documented evidence Resident #22 received her 9:00 A.M. physician ordered glargine insulin or blood sugar check for the possible administration of Novolog insulin per sliding scale coverage. Review of the medication administration record (MAR) dated 11/03/25 at 4:30 A.M. revealed Resident #22 received Med Pass (dietary supplement) and consumed 100%. Review of task documentation for 11/03/25 at 8:20 A.M. by Certified Nurse Aide (CNA) #175 revealed Resident #22 ate 26-50% of her breakfast on this date. Review of a nursing note dated 11/03/25 at 12:34 P.M. authored by LPN #183 revealed she had gone to check Resident #22's blood sugar but was unable to find her in her room, Resident #22's wheelchair was in her room, LPN #183 asked an aide if they knew where Resident #22 was, but they did not know. Additional people were asked where Resident #22 was, but they did not know. Shower rooms, bathrooms and other public areas were searched. An aide found Resident #22 in her room on the floor between her bed and window laying on the left side of her face. Resident #22 was lying in her own vomit. The aide assisted Resident #22 back into bed. LPN #183 checked Resident #22's blood sugar which read hi and the nurse practitioner was notified and stated to complete a full skin sweep and to get vitals. At this time the resident's blood pressure was documented to be low at 88/40 manually and the resident's pulse was 121 beats per minute (bpm). Resident #22's oxygen saturation would not read but after applying two liters of oxygen it read 83%. Skin check revealed left side of resident's face was puffy. Nurse practitioner was notified and gave orders to send Resident #22 to the hospital. Resident #22's son was notified. There was no additional information in the nursing progress note as to when the resident had last been seen prior to this time. A corresponding fall investigation dated 11/03/25 at 11:50 A.M. and authored by LPN #183 revealed at approximately 11:50 A.M. nursing staff went to Resident #22's room to perform routine blood glucose monitoring in preparation for the lunch meal. When arriving to the room, staff noted Resident #22 was not in her bed or wheelchair as expected. The nurse immediately began to look for the resident and asked several staff members if they had seen Resident #22 or knew her whereabouts. Staff did not know, and the Administrator reported to Resident #22's room to check and found her lying on her left side on the floor between her bed and the window, an area which was not visible from the doorway or hallway. Resident #22 was found with emesis present on the floor near her face though the emesis was not obstructing her airway; the resident was assessed to be breathing without difficulty. Staff immediately ensured Resident #22's safety and initiated assessments. When LPN #183 returned to the room moments later, staff had already assisted the resident back into her bed with appropriate assistance. Resident #22 was alert and responsive, able to communicate, and stated she was not sure what she was trying to do when she ended up on the floor. The investigation revealed Resident #22's level of consciousness was deviated from her normal baseline. Vitals signs were obtained and revealed significant abnormalities from the resident's baseline. Blood pressure was 88/40 (mg/Hg- normal reading 120/80) which was significantly lower than baseline, heartrate was elevated to 121 bpm, and notably Resident #22's pulse was irregular which represented a new finding that had not been previously documented. Respiratory rate was 16 breaths per minute, temperature was 98 (degree Fahrenheit), and oxygen saturation was critically low at 83% on 2 liters per minute (lpm) of supplemental oxygen in place at the time she was found on the floor, likely falling off when the fall occurred. Blood glucose was obtained and read hi indicating hyperglycemia. The investigation revealed given the abnormal vital signs, the new irregular heart rhythm, the severe hyperglycemia, and the resident's complex medical history including type I diabetes mellitus, the licensed medical provider was immediately notified and ordered Resident #22 to be sent to the emergency department. The investigation included the resident had multiple risk factors including type I diabetes with history of unstable blood glucose levels, gastrointestinal symptoms including nausea and vomiting in the days preceding the fall, and the resident's unwitnessed activity without seeking staff assistance via call light. Review of a nursing note dated 11/03/25 at 12:26 P.M. authored by LPN #139 revealed Resident #22 was transferred to the emergency department (ED). Review of a hospital note dated 11/03/25 at 12:44 P.M. revealed Resident #22 presented to the ED due to altered mental status and a fall at her nursing facility. Resident #22 was not oriented to time, place, or person and stated she had pain throughout her body. Report was Resident #22 was missing for two hours in the facility and was found beside her bed. The emergency medical services (EMS) staff reported Resident #22's blood sugar was greater than their detectable range on the way to the ED. At 12:51 P.M., Resident #22's vital signs included temperature of 98.2 F, heartrate of 114 bpm, respirations of 28, blood pressure 86/71 (hypotensive), and oxygen level of 91. Resident #22 had an elevated white blood cell count at 17.7, a low but stable hemoglobin at 10.8, venous blood gases (VBG) were acidotic at 7.26 and her glucose was over 1000. Resident #22's chemistry panel showed a low sodium of 125, potassium of 5.8, creatinine elevated to 1.55, glucose was 1039, lactic acid was 4.5, and beta hydroxybutyrate of 6.07 which confirmed a diagnosis of diabetic ketoacidosis (DKA). Resident #22 was placed on DKA protocol, she received one liter of fluid prior to the right femoral CVC being placed and would not receive a second liter because she met the criteria for severe sepsis and already received 2000 ml at this time. Resident #22 was empirically treated with cefepime (antibiotic) and vancomycin (antibiotic) for severe sepsis/septic shock. Resident #22 needed to be admitted to the ICU. Admitting diagnoses included DKA, high anion gap metabolic acidosis, an acute urinary tract infection, a non-ST elevated myocardial infarction (NSTEMI) with troponin levels up to 2630, and sepsis. Review of a nursing note dated 11/03/25 at 9:57 P.M. authored by LPN #136 revealed she called the hospital for an update on Resident #22 who was admitted to the intensive care unit (ICU) for diabetic ketoacidosis and low blood pressure. The Director of Nursing (DON) was notified. The resident did not return to the facility following hospitalization. Review of an undated statement from Medical Director (MD) #129 revealed DKA is a progressive condition that typically develops over several hours to days and results from a combination of factors including inadequate insulin, increased insulin resistance, decreased oral intake, gastrointestinal illness, and other physiological stressors.Interview on 11/12/25 at 2:17 P.M. with Resident #22's family revealed Resident #22's blood sugar had been above 1000 and her blood pressure had bottomed out on 11/03/25 which was what led to hospitalization. The family member revealed when they were informed of Resident #22's fall, they were told staff would monitor her, but they requested resident be sent out to the emergency room instead. The family member stated Resident #22's son had been at the facility (on 11/03/25) at about 9:00 A.M. and they received a call at about 11:40 A.M. asking if they were aware of where Resident #22 was. Resident's family stated they were frustrated because she (Resident #22) needed assistance to get out of bed and staff just walked right by without checking the floor to see if she fell. Resident #22's family revealed on 11/02/25, Resident #22 had been nauseous with vomiting which was reported to a nurse (unspecified what nurse) and again on 11/03/25 the nurse (unspecified what nurse) was told the resident was sick at about 9:30 A.M. when her son left. Interview on 11/12/25 at 2:40 P.M. with LPN #183 revealed on 11/03/25, a nurse had called off leaving two nurses for three hallways. LPN #183 stated she was on the 200 hall and LPN #174 had the 300 hall, while the 400 hall (Resident #22 resided on the 400 hall) did not have a nurse. LPN #183 stated a nightshift nurse, LPN #151, was supposed to stay and pass morning medications for the 400 hall until the facility was able to find coverage for a dayshift nurse. LPN #183 stated she wasn't sure if LPN #151 passed any medication and if so, it was only a couple. LPN #183 stated another nurse was coming to the facility at noon at cover the 400 hall. LPN #183 stated she had heard during her shift Resident #22 was not feeling well but could not recall where she heard the information. LPN #174 finished her halls medication pass first and moved on to the 400 hall for medications and had asked an aide, Certified Nurse Aide (CNA) #175, to start checking resident vital signs. LPN #183 stated she finished her medication pass on 200 hall and sometime after 11:00 A.M., she went to tell LPN #174 a resident on the 300 hall was requesting her. At approximately 11:30 A.M., LPN #183 stated she went to check Resident #22's blood sugar before the lunch meal but she was not able to locate the resident in her room. Resident #22's wheelchair was in her room, but she was not in bed, in the bathroom, or the common areas. LPN #183 stated she had entered the room to about the center of the room but was not able to see the floor next to the window from that standpoint. LPN #183 stated someone else went to Resident #22's room and found her on the floor next to the window, in her vomit. LPN #183 stated she asked CNA #175 when vitals for Resident #22 were checked and CNA #175 stated she went to the resident's room at about 10:00 A.M. but she was unable to find her. LPN #183 stated Resident #22's son had been in to visit and left at about 9:30 A.M., and multiple nurse managers were out of the facility for personal reasons so there was not much help. LPN #183 stated once she arrived back to Resident #22's room to check on her, the aide had already put her in bed, she had vomit on her, her face was puffy, and she didn't look good. LPN #183 stated she checked Resident #22's vitals, which were awful, her blood sugar read hi which means greater than 600, her pulse was 121 beats per minute, oxygen would not read, and blood pressure was 88/40. LPN #183 stated there were no visible injuries to Resident #22, but she had troubles with her blood sugars for a while due to being a type I brittle diabetic. Interview on 11/17/25 at 2:10 P.M. with Regional Director of Clinical Services (RDCS) #188 confirmed on 11/03/25 Resident #22 did not receive her scheduled dose of 15 units of insulin glargine or the Novolog per sliding scale (ordered with blood sugar checks) within the appropriate timeframe scheduled for the medications due to LPN #151 leaving prior to medication administration without informing nursing management so they could replace her on the hall. RDCS #188 believed Resident #22 was last checked on at about 9:30 A.M., after her son left and had been seen in bed while staff were walking down the hall afterwards, but they were not able to hammer down a time when she came out of bed. RDCS #188 revealed an aide was supposed to check vitals but when she was not able to locate resident, did not report her missing from her room but indicated the aide did continue to look for the resident on her own. RDCS #188 confirmed Resident #22 had experienced harm as a result of this incident due to having high blood sugar and not receiving blood glucose monitoring or scheduled doses of insulin as ordered on 11/03/25, leading to subsequent hospitalization and treatment for DKA and sepsis. Interview on 12/04/25 at 7:18 A.M. with LPN #151 revealed she worked the night shift of 11/02/25 and did not identify any concerns with Resident #22. LPN #151 stated she later found out Resident #22 had been vomiting and nauseous on 11/02/25 during the previous shift but stated that had not been reported to her during shift change report. LPN #151 stated she did stay over the morning of 11/03/25 to wait for someone to count the cart with her but was not on the floor or caring for residents when Resident #22 had a visitor, had vomited, or had fallen out of bed. Interview on 12/04/25 at 8:00 A.M. with RN #156 revealed on 11/02/25, she worked Resident #22's hallway which was not typically where she works. RN #156 stated in the morning when checked Resident #22's blood sugar was in the 300s but in the afternoon, the glucometer read hi. RN #156 stated she was unsure of what hi meant so she asked another nurse who told her to call the doctor. RN #156 was not able to recall the amount of insulin the on-call provider ordered, but stated she administered it and called back in two hours per their instructions. When she re-checked Resident #22's blood sugar, it was still hi so the on-call provider told her to administer another dose of insulin and check again in two hours. RN #156 stated she followed instructions and when she last checked her blood sugar, it was fine and she passed it on to nightshift. RN #156 stated Resident #22 had been shaky during observations but stated she was ok and that happened often. RN #156 stated she was unsure of Resident #22's baseline but was concerned her sugars had been running above 400 all day. RN #156 stated when she would call the provider, she would mention she previously called and was given the same instructions and asked if they wanted her to proceed with the same order again, and they responded yes. RN #156 stated she was concerned there was not much intervention for the Resident #22. RN #156 stated Resident #22 was a brittle diabetic. RN #156 could not recall a fall, nausea, or vomiting during her shift. During the interview, when asked about the nursing progress note entries dated 11/02/25 at 3:14 P.M. and 4:57 P.M. (which were identical in content but at different times), RN #156 stated she did enter the documentation for Resident #22's blood sugars as duplicates but indicated she only had blood sugar concerns twice during her shift. RN #156 stated she was concerned because Resident #22 had a fall the following morning and was admitted to the ICU and was still there last week. Interview on 12/04/25 at 11:01 A.M. with the Director of Nursing (DON) revealed she was not present on 11/03/25 when Resident #22 missed scheduled insulin and was found to be in DKA. The DON stated Resident #22 was a type I diabetic and had a history of high and low blood sugars, saw an endocrinologist, and had had multiple medication adjustments made. The DON also indicated Resident #22 was non-compliant with her prescribed diet. The DON also revealed Resident #22 had previously been seen / treated in the emergency room for weakness and altered mental status in relation to her blood sugars. During the interview, the DON confirmed Resident #22's blood sugar being hi for two days beginning on 11/02/25 and continuing to 11/03/25 was a change in her baseline condition as well as the resident having confusion and nausea/vomiting. The DON stated since she personally knew the resident's history, she would have checked the resident's blood sugars more frequently throughout the night. The DON also indicated she had a history of working in critical care and as an RN had more critical care knowledge than an LPN might. Interview on 12/04/25 at 11:53 A.M. with CNA #194 revealed she was assigned to Resident #22's unit on 11/03/25. CNA #194 stated Resident #22's son had visited the morning of 11/03/25 and reported to the nurse, LPN #151, that the resident had been complaining of an upset stomach but LPN #151 threw a fit and was angry because she was not supposed to be at the facility since her shift was finished. CNA #194 stated she checked on Resident #22 and checked her vitals and her temperature was 99.8 which was reported to LPN #151 who didn't address concerns. CNA #194 stated she then went to LPN #174 and informed her of the situation and LPN #174 checked on Resident #22. CNA #194 stated she was giving showers, so CNA #175 was rounding for her and supposed to check resident vital signs. However, CNA #175 could not find Resident #22 and did not inform anyone until the nurse went to check blood sugars. CNA #194 stated after about two and a half hours of CNA #175 not locating Resident #22, she went to her room and saw her on the floor, her face was swollen and discolored, her oxygen tubing was tight on her face and around her neck. CNA #194 stated she picked Resident #22 up on instinct and began to clean her. She had yelled for a nurse and the Administrator entered the room and observed the situation. CNA #194 stated she instructed CNA #175 to get washcloths so a bed bath could be complete, and LPN #183 entered the room and appeared to be panicked. CNA #194 stated she could not recall additional details other than giving a bed bath, talking to the resident, and the ambulance coming. CNA #194 stated Resident #22 was out of it while they were talking. CNA #194 stated a couple weeks leading up to 11/03/25, Resident #22 was vomiting a lot and her sugar kept dropping, even as low as 32. Interview on 12/04/25 at 12:01 P.M. with Resident #22's son revealed he was visiting the facility on 11/03/25 and left at approximately 9:30 A.M. The son revealed he reported he told the nurse at the nurses' station Resident #22 had an upset stomach. He could not recall which nurse he spoke to or what she looked like. Information included on the Mayo Clinic website revealed signs and symptoms of DKA include being very thirsty, urinating often, feeling a need to throw up and throwing up, having belly pain, being weak or tired, being short of breath, having fruity-scented breath, and being confused. It's important to get care right away and if not treated, DKA can lead to death. Review of a policy titled Change in Condition dated 2001 revealed a significant change in condition is a major decline or improvement in resident status that will not normally resolve itself, impacts more than one area of resident health status, requires interdisciplinary review, and is ultimately based on the judgement of clinical staff and the guidelines outlined in the resident assessment instrument. This deficiency represents non-compliance investigated under Complaint Number 2664625.This deficiency is evidence of continued non-compliance from the survey completed 09/15/25.

Based on observation, interview, record review, and policy review the facility failed to ensure that residents received treatment and care in accordance with professional standards of practice when the facility failed to timely ensure outside facility appointments were maintained. This affected one resident (#3) of 15 residents reviewed. The census was 48.Findings include:Record review revealed Resident #3 was admitted to the facility on [DATE] with diagnoses including polyneuropathy, end stage renal disease, atrial fibrillation, cardiomyopathy, thoracic aortic aneurysm, aphasia, type 2 diabetes, hypertension, gout, chronic pain syndrome, and acute kidney injury.Review of Resident #3's quarterly minimum data set (MDS) completed on 08/04/25 revealed a brief interview for mental status score (BIMS) of 13. Section M for skin conditions revealed Resident #3 had diabetic foot ulcers with application of dressing to feet.Review of Resident #3's record revealed an order dated 08/28/25 to cleanse diabetic ulcer to left foot with in house wound cleanser and pat dry, apply medi- honey and cover with foam every day shift every other day and as needed for wound care. Review of Resident #3's record revealed an order dated 07/08/25 to apply Opti foam dressing to right foot for protection three times weekly everyday shift Tuesday, Thursday, and Saturday and as needed for wound care.Review of Resident #3's record revealed an admission comprehensive skin assessment completed 04/29/25 with a right plantar wound 0.1 centimeter (cm) in depth, 2.5 cm in width, and 2.0 cm in length.Review of Resident #3's record revealed an admission comprehensive skin assessment completed 04/29/25 with a left plantar wound 8.5 cm in length, 9.5cm in width, and 0.1 cm in depth.Review of Resident #3's record revealed a skin and wound evaluation completed 08/07/25 revealed the resident has a diabetic right medical foot wound present on admission, 0.1cm squared in area, 0.5 cm in length, and 0.2cm in width. The wound is 0.1cm in depth.Review of Resident #3's weekly comprehensive skin evaluation completed 08/21/25 revealed Resident #3 has one or more newly identified or existing wounds or skin integrity concerns. Site is a left heel pressure.Review of Resident #3's record revealed a skin and wound evaluation completed 09/03/25 for left plantar foot diabetic wound, present on admission. Measurements are 2.3cm squared in area, 2.1 cm in length, 1.5 cm in width, and 0.1 cm in depth.Review of Resident #3's progress notes revealed a note dated 08/23/25 at 4:41 P.M. revealed Resident #3 had a wound center appointment for 08/26/25.Record review revealed a progress note dated 08/26/25 at 7:26 A.M. stating Resident #3 was in the hospital. Review of progress notes revealed Resident #3 was in the hospital from [DATE] through 08/27/25.Review of Resident #3 progress notes revealed no documentation of attempts to reschedule wound care appointments for Resident #3.Review of Resident #3 discharge record for the hospital on [DATE] revealed no evidence or documentation of a wound care appointment being scheduled due to missing their appointment on 08/26/25.Review of Resident #3 active, completed, and discontinued orders revealed no active ordered appointment for wound care center follow up after 08/19/25Record review revealed no documentation of any follow up with wound care center for Resident #3.Record review of Resident #3 wound care clinical document last visit with wound care was on 08/19/25 with a recommended follow up appointment within one week.Interview on 09/04/25 at 3:12 P.M. with Receptionist #1002 of Resident #3 wound care center revealed Resident #3 was not at their appointment on 08/26/25 due to being in the hospital. Receptionist #1002 confirmed no appointment has been rescheduled at this time for Resident #3.Interview on 09/04/25 at 4:00 P.M. with Assistant Clinical Regional Director #167 stated Resident #3's wound care appointment that was canceled on 08/26/25 was rescheduled by the hospital while she was inpatient there. Assistant Clinical Regional Director #167 confirmed there was no documentation of this or evidence an appointment was scheduled.

Based on observation, review of the facility assessment, review of facility marketing material, medical record review, policy reviews, review of staffing schedules August 2024 through October 2024, and interviews, the facility failed to develop and implement comprehensive and individualized treatment and services to ensure residents, who displayed behaviors and/or were diagnosed with dementia received the appropriate treatment and services to attain or maintain their highest practicable physical, mental and psychosocial well-being. The facility's failure to provide adequate and needed services to residents, admitted to the facility secured memory care unit, resulted in Immediate Jeopardy and included an incident of actual physical and psychosocial harm to Resident #48 that occurred on 09/29/24 at approximately 10:00 P.M. when staff failed to provide adequate supervision/intervention to prevent the resident from being assaulted by Resident #46. The facility's failure to provide adequate and needed services to residents placed all seven residents (#33, #36, #46, #47, #48, #51, and #259) at risk for additional harm, serious injury and death when the facility failed to ensure staff working the secured memory care unit received specialized training for providing care to residents with diagnosis of dementia, the facility failed to provide identified services including medical treatment, specialized care services and social activities to all residents and the facility failed to ensure adequate staffing levels were maintained to provide necessary resident supervision. This affected seven residents (#33, #36, #46, #47, #48, #51, and #259 of seven residents who resided on the facility secured memory care unit. On 10/03/24 at 4:27 P.M., the facility Administrator, Director of Nursing, and Clinical Service Manager (CSM) #357 were notified Immediate Jeopardy began on 09/29/24 when Resident #46 was having aggressive behaviors towards other residents on the memory care unit without evidence of effective and necessary staff intervention. Resident #46's behaviors escalated, and the resident began punching Resident #48 with a closed fist to her head. At the time of the incident, there was one staff member, State tested Nursing Assistant (STNA) #345 on the unit. STNA #345 left the residents/area to find additional staff to assist with the situation. Following the incident, Resident #48 was observed seated in the dining room, leaning forward in her chair with her hands covering her head and sobbing. The Immediate Jeopardy continued due to the facility's failure to provide activities, supervision, and competent staff to address the total care and behavioral health care needs for all seven residents admitted to the facility secured memory care unit. The Immediate Jeopardy was removed on 10/04/24 when the facility implemented the following corrective actions: On 09/29/24 at approximately 10:20 P.M. Resident #46 and Resident #48 were both transported to the hospital for evaluation. On 09/30/24 at 2:04 A.M. Resident #48 returned to the facility from the hospital. The Psychiatric Nurse Practitioner (NP) saw Resident #48 in the facility on 09/30/24. On 09/30/24 at 7:45 A.M. head-to-toe assessments were completed for the four non-interviewable residents residing on the Memory Care Unit by the Director of Nursing. Assessments included pain assessment, psychosocial assessments and skin inspections. Five (5) family members were interviewed by phone to identify any care concerns. Two residents were interviewed. On 09/30/24 at 9:00 A.M. Resident #46 returned to the facility from the hospital. On 09/30/24 at 12:00 P.M. Resident #46 was placed on one-to-one supervision with a plan for the one-to-one to continue until the resident was discharged . On 10/02/24 at 7:00 A.M. State tested Nursing Assistant (STNA) staffing was increased to two staff members at all times during the 7:00 A.M. to 7:00 P.M. and 7:00 P.M. to 7:00 A.M shifts for the secured Memory Care Unit. The increase in staffing was to provide activities for the memory care unit and to provide daily care and supervision/safety for the seven residents on the secured memory care unit. The facility plan indicated as the unit census increased (capacity 17) resident needs for care, activities and supervision would be assessed to determine if an increase in staff was needed. On 10/02/24 at 10:50 A.M. Resident #48 was assessed for psychosocial needs and injury by the Licensed Practical Nurse (LPN) and Corporate Licensed Social Worker. Resident #48 would continue monitoring as needed by the Psychiatric NP and nurses for changes in psychosocial status. On 10/02/24 at 12:15 P.M Resident #46 was discharged from the facility to an Inpatient Behavioral Health facility for evaluation, medication review and potential adjustments. On 10/03/24 (no time identified) A root cause analysis of the resident-to-resident altercation on 09/29/24 was completed by the Clinical Service Manager. The facility root cause analysis identified staff were not properly trained in dementia care and there was a lack of activities for residents on the Memory Care Unit. On 10/03/24 at 4:30 P.M an Ad Hoc Policy review was held with the Administrator, Director of Nursing, Regional Clinical Services Manager, Medical Director, Diet Tech, Medical Records/Accounts Payable, Director of Rehab, Staff Development Coordinator, Unit Manager, Business Office Manager, Maintenance Director, Central Supply/Scheduler, and Activity Coordinator to review facility policies for the Memory Care Unit, Staffing and Dementia care training, activities on the Memory care unit, interventions for residents with outburst/behaviors, and the Abuse policy on how to respond to residents with behaviors. The facility identified policies were appropriate but were not implemented daily for the Memory Care unit. On 10/03/24 at 5:00 P.M. the Regional Clinical Services Manager educated the Administrator, Director of Nursing, Unit Manager, and Staff Development coordinator, regarding policies and procedures for the Memory Care Unit, Staffing and Dementia care training, activities on the Memory care unit, immediate interventions for residents with outburst/behaviors and the Abuse policy including how to respond to redirect residents with behaviors. On 10/03/24 at 5:30 P.M. the Corporate Licensed Social Worker (LSC) reviewed the care plans for all residents on the secured Memory Care Unit to ensure appropriate interventions for behaviors, supervision and activities were in place. On 10/03/24 at 11:00 P.M. staff education was provided for 23 STNAs, two (2) activities staff, nine (9) therapy staff, 11 LPNs, five (5) RNs, six (6) Dietary staff, six (6) Housekeeping staff on the facility Memory Care Unit policies and procedures, Staffing and Dementia care training, activities and immediate interventions for residents with outburst/behaviors by the Staff Development Coordinator. The facility provided a plan for training to continue on hire, annually and as updates to Memory Care training were available and as necessary to maintain the highest level of care, supervision, quality of life and activities for Memory Care residents. Training would be completed by 10/04/24 at 11:00 P.M. Beginning on 10/04/24 (no time identified) resident referrals for placement on the Memory Care Unit would be screened by the DON and Social Services to determine if residents were appropriate for the unit by reviewing the history of the resident including resident testing that had occurred before acceptance to the Memory Care Unit. Beginning on 10/04/24 (no time identified) the facility implemented a plan for the LNHA/Designee to audit staffing on the Memory Care Unit to ensure two staff members were always present on the Memory Care Unit. Audits would be completed five days a week for four weeks. Beginning on 10/04/24 (no time identified) the facility implemented a plan for the DON/ Designee to audit resident care plans for appropriate interventions for resident behaviors and for the Memory Care Unit supervision. Audits would be completed on three residents three times a week for four weeks. Beginning on 10/04/24 (no time identified) the facility implemented a plan for the LNHA/Designee to audit activities on the Memory Care Unit to ensure activities on the Memory Care Unit based on the Alzheimer's Association recommendations and were being completed. An activity calendar would be hung in the resident lobby on the Memory Care Unit and would be overseen by the Activity director, three times a week for four weeks (beginning on 10/04/24) and (activity) calendar was specialized for the Memory Care Unit, three times a week for four weeks. Beginning on 10/10/24 (no time identified) the facility identified a Quality Assessment and Performance Improvement meeting would be completed every week with the Medical Director to review audits and any additional changes for QAPI plan/modifications or further education for four weeks then monthly for two. Although the Immediate Jeopardy was removed on 10/04/24, the facility remained out of compliance at Severity Level 2 (no actual harm with potential for more than minimal harm that is not Immediate Jeopardy) as the facility was in the process of implementing their corrective action plan and monitoring to ensure on-going compliance. Findings Include: On 09/30/24 at 9:11 A.M. observation during an initial tour of the facility revealed a secured memory care unit with seven residents, Resident #33, #36, #46, #47, #48, #51, and #259 who resided on the unit. At the time of the observation there was one staff member, STNA #343 observed working on the unit. Review of the facility staffing schedules from August, September and October 2024 for the Memory Care unit revealed only one STNA was scheduled to be on the unit at all times with the memory care residents from 08/01/24 through 10/02/24. Interview on 10/02/24 at 9:07 A.M. with STNA #305 revealed she did not receive any type of memory care training and had been employed by the facility for a couple months. STNA #305 stated she was thrown back on the (memory care) unit. Interview on 10/02/24 at 9:14 A.M. with STNA #338 revealed she did not receive any training to work on the memory care unit nor did she receive any dementia care training upon hire to the facility. When asked if she felt comfortable working with aggressive residents, STNA #338 stated, I guess. Interview on 10/02/24 at 9:52 A.M. with Licensed Practical Nurse (LPN) #325 revealed there was only ever one staff member on the unit prior to the one to one being initiated for Resident #46 following an incident on 09/29/24. LPN #325 stated she had not received any training to work the memory care unit. LPN #325 stated in addition, she did not receive a full three-day orientation on hire. During the interview, LPN #325 stated she had never witnessed any organized activities on the unit. Interview on 10/02/24 at 10:19 A.M. with Activities Assistant (AA) #344 revealed the aides who worked on the memory care unit were the staff who were responsible to provide activities to the residents. AA #344 said the staff were provided items needed to complete the activities, and sometimes the residents got to attend activities off the memory care unit such as church, prayer group, or musical guests. AA #344 stated she documented their activities once she was made aware they participated. Interview on 10/02/24 at 11:16 A.M. with Resident #46's family (FM #203) revealed the facility does not provide activities on the memory care unit so she took it upon herself to purchase Bingo and additional games to do activities with the residents because there was only one aide on the unit, and the aide can't provide care and activities to the residents. Interview on 10/02/24 at 12:12 P.M. with Certified Nurse Practitioner (CNP) #361 revealed she was unaware of a (staff) training program for the memory care unit. CNP #361 stated she had concerns about the facility only having one staff member on the unit because even if there were only seven residents currently on the unit, if there was an emergency or someone was having behaviors, other residents may be left alone while staff were addressing the resident in need of care, or if they were providing showers to residents, the other residents would be unsupervised. CNP #361 stated in case of an emergency, one staff member should stay with the affected resident, and another should go for help. Observation on 10/02/24 at 2:33 P.M. revealed the memory care activity for this time was Sounds of Serenity. During observation, there were no staff in the dining area to provide the activity. There was a country western on the television, two residents were sleeping, and two were talking. There were no Sounds of Serenity at this time. Observation on 10/02/24 at 2:41 P.M. revealed AA #344 entered the unit, took the memory care activity calendar and then left the unit. The 2:30 P.M. activity was still not started. Interview on 10/02/24 at 2:58 P.M. with STNA #338 revealed she did not know she was responsible for providing activities while working on the memory care unit. STNA #338 stated she had not ever been told she was supposed to provide activities, but if she had to do activities, help residents with behaviors, help take residents to the bathroom, or help during an emergency by herself, her job would not be possible to complete. STNA #338 stated it was too much work for one person to complete and stated, what if someone falls or I get beat up? STNA #338 confirmed Sounds of Serenity did not happen, and stated none of the scheduled activities for 10/01/24 or 10/02/24 were completed for the residents. Interview on 10/02/24 at 3:09 P.M. with STNA #332 revealed she did not receive any type of training to work the memory care unit and there was no formal memory care program. STNA #332 stated she used her own work experience and knowledge to complete activities with the residents. STNA #332 stated there was only ever one aide working at a time on the unit for a 12-hour shift and felt it was unsafe because if something happened, she would not be able to contact the nurse for help. STNA #332 stated when she had an incident happen on the unit a while back, she had to leave the resident and run to the door of the memory care unit to call for help and felt she was potentially delaying care or leaving other residents unsupervised when she had to care for just one individual's needs. During an interview on 10/02/24 at 3:35 P.M. with the DON, the concerns related to the lack of resident supervision and activities on the memory care unit were shared. The DON indicated she was only allowed to staff the unit with what corporate told her she should staff. The DON also stated she had concerns with the supervision levels on the unit. During the interview, the DON revealed the secured memory care unit had first opened in February 2024. The unit had a total capacity for 17 residents. Interview on 10/02/24 at 3:58 P.M. with STNA #345 revealed she did not have any type of dementia care training specific to the memory care unit. Interview on 10/02/24 at 4:14 P.M. with LPN #323 revealed she did not receive any type of memory care training while working at the facility. LPN #323 stated she did not believe having only one staff member on the memory care unit was sufficient. Interview on 10/02/24 at 5:36 P.M. with the DON revealed she was unable to provide documented evidence any type of memory care training or specialized training was completed for the staff who worked on the memory care unit. Interview on 10/08/24 at 12:57 P.M. with Medical Director (MD) #367 revealed he was not sure of the facility policies regarding staffing the memory care unit. MD #367 said there should always be someone on the unit to supervise the residents. MD #367 was not sure about what type of education he would expect for staff working the memory care unit. Review of pamphlet titled Legacy [NAME] Skilled Nursing & Rehabilitation: Cognitive Spa Memory Care Program dated 2023 revealed a secured memory care unit was provided at the facility and memory care was provided by specially trained professionals dedicated to the unique and ever-changing needs of those living with Alzheimer's and related dementia. The unit utilized a Secure Care System which allowed individuals a safe, secure and homelike environment. The memory care program was to provide compassionate staff specially trained using HealthCare Interactive's CARES training (innovative set of training products for online training and qualifies individuals for Alzheimer's Association essentiALZ certification), daily social activities that use visual aids and functional routines to promote independence and well-being personalized to residents, a safe and secure cheerful homelike setting, and additional services including hospice, palliative care, and respite care if needed. Review of a pamphlet titled Legacy [NAME] Skilled Nursing & Rehabilitation: Services Guide dated 2024 revealed the facility's memory care unit had care provided by specially trained professionals dedicated to the unique and ever-changing needs of those living with Alzheimer's and related dementia. Utilizing a SecureCare system allows each individual a safe, secure and homelike environment. The secured dementia unit provides patients with daily social activities and routines, an enclosed courtyard, CARES trained staff, psychological services, and other care services including hospice, palliative care and respite care if needed. Review of a policy titled Memory Care Unit dated 11/30/23 revealed memory care would be offered to residents with a diagnosis of dementia and a Global Deterioration Scale Stage 4-6 who would benefit from a secured, person-centered care setting with activity-based programming. If a resident was identified as a potential candidate for the memory care unit, an assessment would be completed and the physician would be notified and if he agreed, an order would be obtained. If family or guardian agree, the resident would be admitted to the memory care unit and quarterly assessments would be completed. Review of the facility assessment dated [DATE] revealed no evidence of the facility having a secured memory care unit, services provided on said unit, or staffing plan for a memory care unit. The following incident and care for Resident #48 and Resident #46 were investigated during the annual survey with concerns identified related to the lack of comprehensive and individualized dementia care/services to meet both residents total care needs and to provide supervision to prevent the assault of Resident #48: a. Record review revealed Resident #48 was admitted to the facility on [DATE] with diagnoses including Alzheimer's disease, anxiety disorder, unspecified psychosis, and disorientation. The resident was admitted to the facility secured Memory Care unit. Review of an assessment titled Memory Care Unit Criteria dated 06/18/24 revealed Resident #48 had a diagnosis of Alzheimer's and inappropriate behaviors including wandering, exit seeking, and she was easily redirected. The assessment revealed Resident #48 would benefit from a structured environment with specialized activities and was appropriate for memory care unit. Record review revealed there was no physician order for placement on the facility secured memory care unit. Review of a care plan dated 06/25/24 and revised on 09/11/24 revealed Resident #48 required a special memory care unit related to a diagnosis of dementia with behaviors and at risk of elopement and cognitive loss with poor safety awareness. Goals included participation in activities, socializing with others appropriately, and her quality of life being maintained at an optimal level while on the special memory care unit. Interventions included assessing Resident #48 for appropriate placement on the unit upon admission, quarterly, and as needed (06/25/24); engage resident in simple, structured activities that avoid overly demanding tasks (06/25/24); escort off unit for walks in or outside facility if appropriate for a change of scenery (06/25/24); introduce to peers on the unit with similar interests and cohesive temperament to assist in establishing common bonds (06/25/24); provided one to one intervention as needed (06/25/24); and provide diversional activities for resident (06/25/24). Review of a quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #48 had severe cognitive impairment, disorganized thinking, mild depression, no behaviors, and required supervision for activities of daily living. Review of a nursing note dated 09/29/24 at 10:13 P.M. by Licensed Practical Nurse (LPN) #323 revealed Resident #48 was sitting in the dining room when another resident came up behind her and began hitting her with fists on both sides of her head several times. Resident #48 was shaken up and crying, no injuries were noted, neurological checks were within normal limits, and the nurse practitioner was called and gave orders to send to the emergency department (ED) to be evaluated. Resident #48's family was notified of the incident. Review of a Certified Nurse Practitioner (CNP) #360 note dated 09/29/24 at 10:15 P.M. revealed Resident #48 was hit hard on both sides of her head by another resident. No immediate injuries were noted but Resident #48 was sent to the hospital for evaluation and treatment. Review of a nursing note dated 09/29/24 at 10:20 P.M. by LPN #323 revealed an (emergency) squad was at the facility to transport Resident #48 to the ED, report was called, and the DON was notified of the incident. Review of a nursing note dated 09/30/24 at 2:04 A.M. by LPN #323 revealed Resident #48 returned to the facility from the ED. She was alert, denied pain, neuro checks were resumed, and family was updated. Review of a nursing note dated 09/30/24 at 9:50 A.M. by Registered Nurse (RN) #359 revealed Resident #48 had been sent to the ED, no injuries were noted, and psychosocial effects (of the assault by Resident #46) were to be followed up by social services. b. Record review revealed Resident #46 was admitted to the facility on [DATE] (admitted from the hospital where he received treatment and services on the psychiatric unit) with diagnoses including schizoaffective disorder bipolar type, Alzheimer's disease, intermittent explosive disorder, other conduct disorder, and type A behavior pattern. The resident was admitted to the facility and then moved to the secured Memory Care unit on the same day of admission; however, record review revealed no Memory Care Unit assessment was completed for the resident. Review of a hospital note dated 07/22/24 (prior to admission) revealed Resident #46 was admitted to the hospital for intermittent explosive disorder from a long-term care nursing facility, where he was noncompliant with medications, had auditory and visual hallucinations, was aggressive, going after female staff, and urinating everywhere. Resident #46 was admitted to the hospital to adjust medications at the psych unit. Review of a hospital note dated 07/23/24 (prior to admission) revealed Exelon (cognition enhancing medication used in the treatment of Alzheimer's related dementia) and Namenda (central nervous system medication used in the treatment of dementia and Alzheimer's disease) were implemented to attempt to impact positively on activity of daily living (ADL) maintenance, behaviors, and cognition. Medications would be tapered upwards as needed and tolerated. Medications would be utilized to decrease impulsivity and aggression to return to the least restrictive environment. Review of a hospital note dated 07/24/24 revealed Resident #46's Namenda was increased. Review of a hospital note dated 07/25/24 revealed Resident #46 had a paradoxical effect to Ativan (benzodiazepine used in the treatment of anxiety) and to make sure he does not take Ativan. Medications were adjusted. Review of a hospital note dated 07/26/24 revealed Resident #46 was exit-seeking, fighting and hitting another patient, and had taken a napkin and tried to feed it to another patient. A dose of Geodon (anti-psychotic medication used in the treatment of mental and mood disorders) was administered and was ineffective. He did eventually calm down and slept approximately six hours. Medication adjustment was made to discontinue Risperdal and start Seroquel (anti-psychotic medication) due to the completion of GeneSight testing (a test to see how a patient's genes may affect their response to certain medications). A hospital note dated 07/27/24 revealed Resident #46 had behaviors of trying to shove a paper towel down another resident's throat, he also tried to climb in bed with a female patient but did not exhibit sexual behaviors. Resident #46 was given a dose of Ultram (narcotic medication used to treat pain), which was effective, and he slept six hours. Review of a hospital note dated 07/28/24 revealed Resident #46 was pacing the halls, exit seeking and attempting to go into other resident rooms. When attempting to redirect, Resident #46 because agitated and aggressive, attempted to hit one of the nurses, and Vistaril (antihistamine used in the treatment of anxiety) 50 mg was ordered. Resident #46 was mumbling and yelling at staff, he did have a urinary tract infection and was waiting for culture and sensitivity reports. Resident #46 slept approximately nine hours after having medication. Review of discharge orders dated 08/06/24 from the hospital included orders for Seroquel 50 mg by mouth three times daily, Namenda 10 mg by mouth twice daily, Exelon patch 13.3 mg every morning, and Ultram 50 mg by mouth twice daily. Review of Resident #46's facility medical record revealed a physician order for Seroquel 50 milligrams (mg) one tablet by mouth three times a day for schizophrenia (08/06/24); memantine (Namenda) oral tablet 10 mg one tablet by mouth two times a day for dementia (08/06/24); and rivastigmine (Exelon) transdermal patch 24-hour 13.3 mg/24 hours apply one patch transdermal one time a day for dementia (08/07/24). There was no evidence the order for Ultram 50 mg by mouth was carried over from the hospital discharge orders to the resident's facility orders. Review of a nursing note dated 08/06/24 at 4:41 P.M. by LPN #331 revealed Resident #46 was admitted to the facility from the hospital and had behaviors while being taken for his weight. The note did not specify what type of behaviors. Review of a provider note dated 08/07/24 at 1:00 A.M. by Medical Director (MD) #367 revealed Resident #46 admitted to the facility after being admitted to the hospital for inpatient psychiatric services related to aggression, visual hallucinations, and behaviors. At a previous facility, Resident #46 was non-compliant with medications. Resident #46 did have exit seeking behaviors during inpatient stay, so he was admitted to the secured dementia unit and had a wanderguard in place. Staff were to monitor for behaviors. Review of a care plan dated 08/07/24 and revised on 09/11/24 revealed Resident #46 required the special memory care unit related to a diagnosis of dementia with behaviors and at risk of elopement and cognitive loss with poor safety awareness. His goal was to maintain current level of cognitive function through the review date. Interventions included do not rush or show annoyance/impatience (08/07/24); encourage family involvement (08/07/24); encourage resident to make routine, daily decisions and coach through process if decisions are not forthcoming (08/07/24); engage resident in simple, structured activities that avoid overly demanding tasks (08/07/24); keep resident's routine consistent and try to provide consistent caregivers as much as possible in order to decrease confusion (08/07/24); limit choices, use cueing, task segmentation, written lists, instructions that will maximize involvement in daily decision making and activity (08/07/24); and monitor, document, and report to the doctor any changes in cognitive function, specifically changes in decision making ability, memory, recall and general awareness, difficulty in expressing self, difficulty understanding others, level of consciousness and mental status (08/07/24). Review of a care plan dated 08/07/24 and revised on 09/11/24 revealed Resident #46 was at risk for changes in mood related to disease process, new admission, stating he was fidgeting or restless, having trouble falling and staying asleep, having little pleasure in doing activities, schizophrenia, and trouble concentrating on things. Goals included having mood improved evidenced by happier, calmer appearance, no signs or symptoms of depression, anxiety, or sadness through next review. Interventions included administer medications as ordered, monitor for side effects and effectiveness (08/07/24); allow time and encourage to express feelings (08/07/24); arrange for clergy or spiritual leader of choice to visit as requested (08/07/24); assist in developing a program of activities that is meaningful and of interest and encourage and provide opportunities for exercise and physical activity (08/07/24); assist to identify strengths, positive coping skills and reinforce them (08/07/24); behavioral health consult as needed (08/07/24); encourage activities of choice, give reminders and escort as needed (08/07/24); encourage, assist, and support to maintain as much independence and control as possible to ask for help and express feelings (08/07/24); monitor and record mood to determine if problems seem to be related to external causes such as medications, treatments, or concern of diagnoses (08/07/24); and monitor, record and report to physician as needed risk for harm to self, suicidal plan, past attempt at suicide, risky actions, intentionally harmed or tried to harm self, refusing to eat or drink, refusing medications or therapy, sense of hopelessness or helplessness, impaired judgement or safety awareness (08/07/24). Review of a care plan dated 08/07/24 revealed resident #46 was at risk for behavior symptoms related to mental illness, schizophrenia, and explosive disorder. Goals included maintaining involvement with ADL performance and social activities, accepting care and medications as prescribed, and reducing risk of behavioral symptoms. Interventions included administer medications as ordered, monitor and document side effects and effectiveness (08/07/24); analysis of key times, places, circumstances, triggers and what de-escalates behavior and document (08/07/24); assess for causes of behavior and alter environment as needed (08/07/24); assess resident's coping skills and support system (08/07/24); escort to a private area if unable to divert resident's attention (08/07/24); provide diversional activities as appropriate (08/07/24); provide positive feedback for good behavior, emphasize the positive aspects of compliance (08/07/24); and refer to psych as needed (08/07/24). Review of a nursing note dated 08/10/24 at 6:30 A.M. by LPN #312 revealed Resident #46 wandered during the night without direction or purpose, required much redirection and attempted to wander into other resident rooms. Resident #46 had also taken off his brief and was rinsing it in the sink, plugged up the sink and water overran onto the bathroom and bedroom floor and was playing in the water, swishing it around. Review of an admission MDS completed on 08/13/24 revealed Resident #46 had severely impaired cognition, inattention, disorganized thinking, had moderate depression, wandered one to three days, and required supervision for transfers and walking. Review of a care plan dated 08/16/24 revealed Resident #46 required use of psychotropic medications with potential for adverse reactions related to behaviors associated with dementia. The goal was to perform to highest level of ADLs, have regular elimination pattern, and communicate appropriately with others. Interventions included administer medic [TRUNCATED]

Based on record review, facility policy review and interviews, the facility failed to develop and implement an effective pain management program to adequately manage pain for Resident #7 and Resident #156. This affected two residents (#7 and #156) of four residents reviewed for pain management. The facility census was 61. Actual harm occurred beginning on 09/27/24 when Resident #156, with diagnoses of pyogenic and rheumatoid arthritis, myalgia, and chronic back syndrome, did not received ordered pain medication (Methadone) following admission, resulting in unrelieved (per Minimum Data Set (MDS) assessment almost constant pain that affected his sleep, interfered with therapy and affected his day-to-day activities) pain. The resident vocalized the increased unrelieved pain and was subsequently transferred to the hospital for evaluation and admitted with a diagnosis of intractable back pain, requiring hospital treatment. Actual harm occurred on 09/21/24 when Resident #7, with diagnoses of history of traumatic fractures and rheumatoid arthritis, was prescribed Oxycodone (narcotic pain medication) five times a day and the facility failed to ensure the resident received the medication resulting in missed doses of medication. The resident had unrelieved pain with symptoms of withdrawal as evidenced by the resident sustaining irritability, crying/tearfulness, sweating, stomach cramps, and feeling weird. Findings included: 1. Review of the medical record revealed Resident #156 was admitted to the facility on [DATE]. Diagnoses included kidney disease, diabetes, pyogenic arthritis, diabetic foot ulcer, endocarditis congestive heart failure, rheumatoid arthritis of the right shoulder, sepsis, myalgia, and chronic pain syndrome. Review of the baseline care plan dated 09/27/24 revealed Resident #156 had a potential for pain related to a condition or disease process. Interventions were to observe for signs and symptoms of pain, determine the pain intensity with the FACES pain scale, and medicate per physician's order. Review of the restorative note dated 09/27/24 at 7:53 P.M. revealed Resident #156 was totally dependent of two staff for bed mobility, required no assistive devices for bed mobility, he was unable to balance himself for sitting, he was able to turn from his right to the left side while in bed with two staff assist, he was able to turn from the left to the right side while in bed with two staff assist, he was unable to move from lying to sitting in bed, unable to lift his legs off the bed, unable to bend his knees, unable to dangle his feet, and unable to pull self-up in bed. He was alert and oriented to person , place and time. The resident complained of pain with bed mobility. The note revealed the resident was not appropriate for a (restorative) program at this time. Review of the physician's orders dated 09/27/24 revealed Resident #156 had an order for acetaminophen 325 mg every four hours as needed for pain. Review of the physician's orders dated 09/28/24 revealed Resident #156 had orders for Oxycodone (pain medication) five milligrams (mg) every six hours as needed, Baclofen (muscle relaxant) 10 mg once daily for muscle spasms, and Methadone (pain medication) five mg give 7.5 mg three times daily for pain. Review of a narrative nurse's note dated 09/28/24 at 5:23 P.M. revealed Nurse Practitioner (NP) #502 ordered to hold the resident's Methadone 7.5 milligrams (mg) until the physician reviewed. Resident notified. Review of the On-Call NP Note dated 09/28/24 at 6:08 P.M. revealed the Director of Nursing (DON) called to clarify that Resident #156 was on Methadone 7.5 mg three times daily prior to hospitalization and he had received the medication from the pain clinic. The DON explained the resident was currently prescribed Lyrica 75 mg twice daily, Oxycodone 5 mg three times daily and Methadone 7.5 mg three times daily. The NP (#502) discussed with the DON about changing the Oxycodone 5 mg from routine to as needed every six hours and Methadone 7.5 mg three times daily in order to prevent over medication. The DON was agreeable to the medication recommendations. Review of the physician's orders dated 09/29/24 revealed Resident #156 had orders for Lyrica (pain medication) 75 mg twice daily and pain scale per [NAME] FACES scale every shift. Review of the Med Pass Note dated 09/29/24 at 2:31 A.M. revealed the Methadone for Resident #156 was not administered and was to be delivered by the pharmacy. Review of the Med Pass Note dated 09/29/24 at 8:08 A.M. revealed the Methadone for Resident #156 was not administered due to waiting delivery from the pharmacy. Review of the Med Pass Note dated 09/29/24 at 1:20 P.M. revealed the Methadone for Resident #156 was not administered due to on order. Review of the Med Pass Note dated 09/29/24 at 2:27 P.M. revealed Lyrica 75 mg was not administered due to on order. Review of the Med Pass Note dated 09/29/24 at 11:00 P.M. revealed the Methadone was not administered due to not being available from the pharmacy. The pharmacy was called regarding the Methadone not being delivered and they stated they do not have it in stock and were looking into getting some from another company to send. They stated they do not have a time or know when they would have it available. Review of the Five-Day Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #156 had intact cognition and was dependent on staff for self-care. The assessment revealed the resident received a scheduled and as needed pain medication. His pain frequency was almost constant. The pain affected his sleep, interfered with therapy and affected his day-to-day activities almost constant. His pain was rated a numeric 10 on a scale of one to 10 with 10 being the worst pain. Review of the Skilled Nurse's Note dated 09/30/24 at 3:12 A.M. revealed the pain level for Resident #156 was five to six out of 10. He stated he hurts even more and all over. Review of the Med Pass Note dated 09/30/24 at 9:03 A.M. revealed the Methadone was not administered due to they were waiting on delivery from the pharmacy. Review of the September 2024 Medication Administration Record revealed Resident #156 was administered the following: Oxycodone five milligrams on 09/28/24 at 1:40 A.M. with no pain level documented. Tylenol 325 milligrams on 09/28/24 at 11:34 A.M. for pain level six out of 10. Tylenol 325 milligrams on 09/29/24 at 8:08 A.M. for a pain level of four out of ten. Oxycodone five milligrams on 09/29/24 at 11:51 A.M. for a pain level of seven out of ten. Lyrica 75 milligrams on 09/29/24 in the evening, no time documented. Oxycodone five milligrams on 09/29/24 at 9:00 P.M. for a pain level of seven out of ten. Oxycodone 5 milligrams on 09/30/24 at 9:00 A.M. for a pain level of five out of ten. Lyrica 75 milligrams on 09/30/24 in the morning, no time documented. Oxycodone 5 milligrams on 09/30/24 at 5:32 P.M. for a pain level of five out of ten and it was documented to be not effective. Methadone 7.5 milligrams on 09/30/24 in the evening, no time or pain level documented. Tylenol 325 milligrams on 09/30/24 at 8:02 P.M. for a pain level of five out of ten and it was documented as being not effective. Lyrica 75 milligrams on 09/30/24 in the evening, no time documented. On 09/30/24 at 2:07 P.M. an interview with Resident #156 revealed his pain was not controlled and he was not receiving his pain medication as ordered. He indicated his pain was in his lumbar back area. Review of the pharmacy delivery slip dated 09/30/24 revealed Resident #156 received 30 tablets of Methadone 5 milligrams. They were delivered and signed in (by facility staff) at 9:08 P.M. Review of the Narrative Nurse's Note dated 10/01/24 at 11:48 A.M. revealed the family requested Resident #156 be sent to the emergency room (ER) for evaluation of uncontrolled pain. Review of the Narrative Nurse's Note dated 10/01/24 at 11:50 A.M. revealed Resident #156 was on scheduled Lyrica and Methadone, which was given as scheduled, he had as needed Tylenol and Oxycodone available as requested at the time of his discharge to the hospital. The note indicated the resident had not requested any as needed medications or notified the nurse that he was in need of them. The family was stating they wanted the resident sent out for ER evaluation at this time. The family was asking if the resident was on Methadone and the nurse explained he had an order for scheduled Methadone. Review of the Narrative Nurse's Note dated 10/01/24 at 4:15 P.M. revealed the nurse spoke to the ER about the resident's status and he was being admitted with intractable back pain. On 10/03/24 at 11:45 A.M. an interview with the DON revealed Resident #156 was on palliative care at the hospital, however he was not on palliative care at the facility and she did not know why. She stated he came to the facility on Lyrica, Oxycodone three times a day routine and and Methadone three times a day routine. She stated she attempted to talk NP #502 out of making the Oxycodone three times daily as needed but NP #502 was concerned about him being on Oxycodone and Methadone at the same time even though he had been on it prior to going to the hospital and was ordered from the hospital to the facility. She stated they could not get the Methadone from their pharmacy so they were trying to get a local pharmacy to send it. She verified the resident had his routine Oxycodone discontinued and changed to as needed. However, he was not receiving his Methadone as ordered for pain due to not being able to obtain it from the pharmacy then he went out to the hospital for severe pain in his back on 10/01/24. She verified there was no documentation or evidence the NP or physician were notified the facility was not able to obtain the Methadone from the pharmacy and Resident #156 had not been receiving it as ordered. On 10/03/24 at 2:14 P.M. an interview with State tested Nursing Assistant #347 revealed the first time she worked with Resident #156 was on 09/30/24. She stated the resident told her he had trouble rolling to his right side due to his shoulder pain. She stated he had told her several times he was in pain and she told the nurse working. She stated she could hear the resident moaning in the hallway from his room a few times when she would walk past his room. Review of the facility policy titled, Pain Assessment and Management, dated 11/30/23 revealed the purpose of the policy was to help the staff identify pain in the resident and to develop interventions that are consistent with the resident's goals and needs and that address the underlying causes of pain. Attempts to reach NP #502 during the survey were unsuccessful as the NP did not return the surveyors calls with three attempts made to reach the NP. 47985 2. Record review revealed Resident #7 was admitted to the facility on [DATE] with diagnoses including personal history of traumatic fractures, muscle weakness, and rheumatoid arthritis. Review of a care plan dated 01/30/24 revealed Resident #7 was at risk for pain/discomfort related to rheumatoid arthritis, spondylosis, and shoulder pain. The goal was for Resident #7 to verbalize relief of pain or ability to cope with incompletely relieved pain as evidence by no interruption in normal activities due to pain and no discomfort related to side effects of analgesia through the review date. Interventions included acknowledge presence of pain and discomfort and listen to resident's concerns (01/30/24), assess for pain (01/30/24), encourage non-medicinal interventions to control pain and decrease use of analgesic therapy including repositioning, stretching, exercise, and relaxation techniques to assist with pain control (01/30/24), and report to nurse any change in usual activity attendance patterns or refusal to attend activities related to signs or symptoms or complaints of pain or discomfort (01/30/24). Review of a quarterly MDS assessment completed on 07/05/24 revealed Resident #7's cognition remained intact, had no behaviors, she received a scheduled pain medication regimen, had pain in the last five days frequently which occasionally made it hard to sleep at night and limited day-to-day activities. Review of a quarterly pain assessment completed on 08/27/24 revealed Resident #7 had pain in the last five days frequently, which occasionally interfered with sleeping and day-to-day activities. Resident #7 rated her pain at a seven out of ten. Assessment stated, patient takes scheduled pain medication and is effective most days. Review of a medication administration record (MAR) for September 2024 revealed Resident #7 had a pain level of eight on 09/20/24 at 9:00 P.M. and medication was administered. On 09/21/24, Resident #7 did not receive her 1:00 A.M., 9:00 A.M., or 1:00 P.M. doses of Oxycodone. Her pain was not assessed during those timeframes. Review of a nurse practitioner (NP) note dated 09/20/24 at 11:23 P.M. by NP #502 revealed Oxycodone dose was not available in pyxis (facility back up medication storage) and the correct dose would be available in the morning. The NP gave an order to hold Oxycodone until the correct dose arrived to the facility. Review of a nursing note dated 09/20/24 at 11:31 P.M. by Licensed Practical Nurse (LPN) #312 revealed at 11:11 P.M. NP #502 was made aware Oxycodone for Resident #7 would not be delivered until the early morning and resident would miss one dose. Review of a nursing note dated 09/21/24 at 7:10 A.M. authored by LPN #312 revealed the LPN called the pharmacy and spoke with staff because she had spoken with a representative of the pharmacy last night who had promised the Oxycodone would be sent so it was received in time for the morning dose and it was not. LPN #312 instructed the pharmacy to drop ship this medication this morning, and the pharmacy staff stated they would email the pharmacist to see what she could do to help. There were no additional nursing notes regarding Resident #7's pain medication being delivered, Resident #7's status or pain being assessed, or any new orders being obtained. Review of physician orders revealed Resident #7 had an order in place dated 10/03/24 for Oxycodone oral tablet 10 milligrams (mg) give 10 mg orally five times a day for pain. Interview on 10/07/24 at 4:19 P.M. with Resident #7 revealed her pain medications ran out approximately two weeks ago and she missed five doses. Resident #7 stated she began to have withdrawals. Resident #7 was informed she was not able to receive medication out of the pyxis because it contained an incorrect dose (5 mg). Resident #7 stated she began to feel funny, was irritable and yelled at the nurse, was crying and hurting so bad, was sweating and her stomach was cramping and feeling weird. Resident #7 stated she was told the medication would arrive at midnight, then 2:30 A.M., then 10:30 A.M. (the next day) but it still did not come. Resident #7 stated the medication she missed was Oxycodone and stated the nurse (Registered Nurse (RN) #339) told her she was having withdrawals. Resident #7 stated she was asked not to tell the survey team this information. Resident #7 stated the pharmacy was in Kentucky. Interview on 10/08/24 at 12:52 P.M. with LPN #352 revealed she was working the day Resident #7 missed several doses of her medication, but she was not her assigned nurse. LPN #352 stated there was a pyxis/medication bank available and the doctor could be called to get new orders as needed. LPN #352 stated signs of withdrawal included shakiness, sweating, and irritability. Interview on 10/08/24 at 12:57 P.M. with Medical Director (MD) #367 revealed he could not recall if he was notified of Resident #7 running out of Oxycodone and missing several doses. He stated it would have been appropriate for the staff to call him to receive a new order and script for a one-time dose, or limited time dose, of whatever dosage was available of Oxycodone in the pyxis. Interview on 10/08/24 at 1:28 P.M. with the DON confirmed Resident #7's MAR for September (2024) showed at least three missed doses of Oxycodone, with no evidence pain assessments were completed. The DON stated the nurse could have gotten a separate script to use the available dosage in the pyxis until the resident's medication arrived. Interview on 10/08/24 at 1:42 P.M. with LPN #312 revealed the dose available in the Pyxis for the Oxycodone was 5 mg. When she had called the CNP, the medication had not yet been ordered, so LPN #312 ordered the medicine, received the order to hold the medication until the morning dose arrived from the pharmacy, and then the medication did not arrive. LPN #312 stated she called before she left her shift to inquire why the medication hadn't arrived yet and to make sure they drop shipped the medication. LPN #312 stated she worked night shift, so she was not present to see how Resident #7 was doing after missing doses of Oxycodone. LPN #312 stated by the time she worked again, Resident #7 was her normal self, and she did not receive anything in report regarding concerns of Resident #7. LPN #312 stated if she knew the medication would not arrive timely from the pharmacy, she would have requested an order to hold the current dose Resident #7 was prescribed and get a new order for Oxycodone 5 mg two tablets by mouth five times a day until her regular dose came in. Interview on 10/08/24 at 2:56 P.M. with the DON revealed if a resident was sweating, irritable, and feeling weird after being prescribed Oxycodone five times a day for an extended period of time, it was likely she was withdrawing. The DON stated Resident #7 had mentioned the incident to her but only said she received her medication, so the DON stated she believed it was taken care of. Interview on 10/08/24 at 3:19 P.M. with RN #339 revealed she was not the nurse who worked on Resident #7's hall but she was working on 09/21/24 and remembered Resident #7 approaching her and telling her she had been without her pain medication; she was in pain and was tired of this happening. RN #339 stated Resident #7's face looked like she could have been in some pain. Resident #7 stated she was starting to sweat. It could have been anxiety, but it could have been withdrawal as often as she takes Oxycodone and as long as she's been taking it. RN #339 stated to her knowledge, there were 5 mg Oxycodone available in the Pyxis, but she stated she was unaware what Resident #7's assigned nurse had tried to do that day. She was able to recall it was LPN #325. Attempts to reach LPN #325 for interview during the survey were unsuccessful.

Based on observation, record review, review of facility billing/financial information, review of the facility assessment, review of the Administrator and Director of Nursing Job Description, and interviews, the facility failed to be administered in a manner that enabled it to use its resources effectively and efficiently to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident resulting in Immediate Jeopardy and actual harm or the potential for serious harm, injury and/or death to all facility residents. The facility administration failed to take appropriate action resulting in substandard quality of care deficiencies identified under Freedom from Abuse, Neglect, and Exploitation and Quality of Care. The facility administration failed to take appropriate action resulting in Immediate Jeopardy when Resident #80's blood pressure was not adequately monitored to prevent incidents of hypotension (low blood pressure) and failed to notify the physician of the resident's hypotension resulting in a delay in care and treatment. Resident #80 subsequently passed away. The facility administration failed to take appropriate action resulting in substandard quality of care when the facility neglected to operate in a manner to ensure all bills were being paid in a timely manner to prevent potential interruption in service. The facility administration failed to ensure residents were provided appropriate and timely care related to pressure ulcers, safe and comprehensive discharge, monitoring of medical conditions and change in condition, continence, pain management, monitoring of medication usage resulting in unnecessary medication administration, comprehensive pharmacy support, and personal care/hygiene. The facility's inaction caused and/or had the potential to cause serious harm, injury or death to all residents. The facility census was 65. On [DATE] at 1:38 P.M. Licensed Nursing Home Administrator (LNHA) #200, Director of Nursing (DON) #147, [NAME] President of Clinical Services #103, Assistant Administrator #137, and Regional Clinical Service Manager (RCSM) #102 were notified Immediate Jeopardy began on [DATE] when the facility failed to maintain effective administrative services to meet the total care needs of all residents. The Immediate Jeopardy was removed on [DATE] when the facility implemented the following corrective actions: On [DATE] at 8:00 A.M., Physician #206 assumed role of facility Medical Director, with initiation of [NAME] Services for Nurse Practitioner oversight. Contact information of both parties posted throughout facility. Letters to be either hand delivered or mailed certified to all current residents and/or responsible parties of the update in medical director. On [DATE] (no time identified), an Ad Hoc Policy Review was held with the Administrator #200, Assistant Administrator #137, Director of Nursing #147, Regional Clinical Services Manager #102, [NAME] President of Nursing Operations #103, Chief Nursing Officer #207, Medical Director #206, Social Service Designee #159, Activities Director #167, Diet Tech #160, Medical Records/Accounts Payable #157, RN/MDS #161, Director of Rehab #168, RN/ADON #128, RN Staff Development Coordinator/Infection Control #164, Admission Staff #144 , Business Office Manager #142, Maintenance Director #141, Central Supply/Scheduler #140, and NP #205 to review facility polices for Abuse, Mistreatment, Neglect, Exploitation and Misappropriation of Resident Property; Resident Rights; Staffing and Scheduling Policies: Change in Resident Condition; Medication Administration; Pressure Ulcer Prevention; Incontinence Management; Pain Management; Discharge Planning; Infection Control; and QAPI. Medication Administration Policy was updated to reflect following physician's orders for blood pressure and pulse monitoring with parameters per orders from the physician/physician extender. Change in Resident Condition policy was updated to specifically address acute changes in condition including abnormal vital signs. Parameters were provided by the facility Nurse Practitioner #204 for administration of cardiac medications as follows: Ace Inhibitors- hold if SBP<90 and notify MD/NP, angiotensin 2 Receptor Blockers (ARBs)- hold of SBP<90 and notify MD/NP, Beta Blockers- hold if HR<60 and notify MD/NP, Calcium Channel Blockers- hold if HR<60 and/or SBP<90 and notify MD/NP, and Vasodilators- hold if SBP<90 and notify MD/NP. Staffing and Scheduling Policies were updated to reflect staffing would be based off resident needs, acuity, and State staffing requirements. The staffing pattern was updated to reflect a full time 3p-11p State tested Nursing Assistant (STNA) and an additional 20 hours for an Infection Control Nurse. These policies were incorporated into the Facility Assessment. On [DATE] (no time identified)-, the Regional Clinical Services Managers educated the Administrator #200, Assistant Administrator #137, Director of Nursing #147, RN ADON #128, and RN SDC/IC #164 regarding updated policies and procedures for Abuse, Mistreatment, Neglect, Exploitation and Misappropriation of Resident Property; Resident Rights; Staffing and Scheduling Policies; Change in Resident Condition; Medication Administration; Pressure Ulcer Prevention; Incontinence Management; Pain Management; Discharge Planning; Infection Control; and QAPI. On [DATE] (no time identified)-, the Administrator #200 and Director of Nursing #147 educated Administrative Staff, including Social Services Designee #159, Admissions Director #167, Business Office Manager #142, RN/MDS #161, Diet Tech #160, Maintenance Director #141, Activities Director #167, Central Supply/Scheduler #140, Medical Records #157, and Director of Rehab #168 regarding updated policies and procedures for Abuse, Mistreatment, Neglect, Exploitation and Misappropriation of Resident Property; Resident Rights; Staffing and Scheduling Policies: Change in Resident Condition; Medication Administration; Pressure Ulcer Prevention; Incontinence Management; Pain Management; Discharge Planning; Infection Control; and QAPI. On [DATE] (no time identified)-, all facility staff were educated on updated policies and procedures for Abuse, Mistreatment, Neglect, Exploitation and Misappropriation of Resident Property; Resident Rights; Staffing and Scheduling Policies: Change in Resident Condition; Medication Administration; Pressure Ulcer Prevention; Incontinence Management; Pain Management; Discharge Planning; Infection Control; and QAPI. Education completed included 16 nurses, 28 nurses' aides, 1 activity staff, 5 environmental services staff, 6 dietary staff, and 6 administrative staff. 1 employee who was on vacation would be educated prior to returning to work. All other staff were educated. Education was completed by RN/ADON #128, SDC/IP #164, Diet Tech #160, Maintenance Director #141, and Activities Director #167. Department heads completed education of policies to their respective department staff. On [DATE] (no time identified), an Ad Hoc Resident Council meeting was held with Activities Director #167 and Administrator #200 to review the updated policies and procedures for Abuse, Mistreatment, Neglect, Exploitation and Misappropriation of Resident Property; Resident Rights; Staffing and Scheduling Policies: Change in Resident Condition; Medication Administration; Pressure Ulcer Prevention; Incontinence Management; Pain Management; Discharge Planning; Infection Control; and QAPI. Residents in attendance were Residents #25, #60, #59, #62, #61, and #47. There were no concerns verbalized during the resident council meeting regarding policies shared and information reviewed, and residents were appreciative of the information. On [DATE] (no time identified)- complete head to toe assessments on all current residents were completed by Licensed Nurses RN #131, RN #152, and LPN #129. Assessments included vital signs, pain assessment and skin inspections and there was no deviation from the resident's baseline and no unidentified skin impairments. On [DATE] (no time identified)-, Guardian Angels consisting of administrative staff conducted rounds for all interviewable residents to discuss any care concerns. Guardian Angels is a customer service program at the facility where the IDT meets with each resident ,d+[DATE] days a week to discuss and resolve any needs or concerns, they may have. If a concern arises during this interaction, then the facility would follow its policy for concerns. Concerns are recorded on a log and are investigated and resolved within five working days. Findings of the concern logs were reviewed with QAPI for potential quality improvement areas. Four (4) residents verbalized concerns which were reviewed and resolved on [DATE] by the Administrator #200. On [DATE] (no time identified)-RN/ADON #128 and RN SDC/IC #164 reviewed all non-interviewable residents to ensure they remain at their psychosocial baseline with no evidence of inadequate care being provided. On [DATE] (no time identified)-, RN/MDS #161 completed bowel and bladder screens on all current residents to ensure appropriate toileting interventions were implemented per the residents' level of need. The facility would be completing a staffing meeting five days a week and forecast the weekend shifts to ensure that the resident needs and acuity were being reviewed with the resident census. The staffing pattern was updated to reflect a full time 3p-11p STNA and an additional 20 hours for an Infection Control Nurse. On [DATE] (no time identified)- SSD #159 reviewed all current residents to ensure that an appropriate plan for discharge was in place. There were no changes to the discharge plan of care for any resident assessed. Thirteen (13) vendors who were due bills per their contracts were issued a payment between [DATE] and [DATE] following terms of condition. Twenty-five (25) vendors who were due bills per their contracts were issued payments on [DATE] following terms of condition. The facility determined all vendors who provide good and services with Legacy [NAME] were in good standing as of [DATE]. Beginning on [DATE] (no time specified)- ongoing auditing would be implemented and completed by the Director of Nursing #147 and/or Designee to be completed five days a week for four weeks. Auditing to include ensuring residents with wounds have appropriate treatments, interventions, and documentation in place; that residents feel their care needs are being met; that appropriate level of toileting assist was being completed per the residents' assessed needs; medications were available for administration and administered per physician's order; pain was assessed and medications were available and administered; and that residents had appropriate discharge plans implemented upon admission as indicated. Audit information would be reviewed with weekly QAPI meeting. Any negative findings will initiate changes to the improvement plan. Although the Immediate Jeopardy was removed on [DATE], the facility remained out of compliance at Severity Level 2 (no actual harm with potential for more than minimal harm that is not Immediate Jeopardy) as the facility is still in the process of implementing their corrective actions and monitoring to ensure on-going compliance. Findings Include: Upon entrance to the facility on [DATE], Assistant Administrator #137 introduced herself to the survey team as the Acting Administrator; however, after additional information was gathered it was determined Assistant Administrator #137 was not a licensed administrator in the State of Ohio and Administrator #101 was actually the administrator of record for the facility at the time of the survey team's entrance. The survey team requested additional information from the facility regarding the administration and leadership changes of the facility. On [DATE] at 1:22 P.M. and [DATE] at 12:09 P.M., interview with Medical Director/Physician #105 revealed she was resigning due to the lack of administration and corporate involvement at the facility and lack of staff competency to perform job duties to ensure resident safety. Physician #105 reported she had brought concerns to the facility's attention for the last six months and the concerns still had not been addressed. Per Physician #105, in [DATE] the Administrator and DON were fired, however this did not resolve the issues occurring at the facility. Physician #105 reported the issues were worse now than they were. Physician #105 reported she started attending the morning meeting at the facility to make sure resident care issues were followed up on and not falling through the cracks. Physician #105 reported she felt her licenses were in jeopardy as well as the licenses of others who worked at the facility. Review of an email from Administrator #200 dated [DATE] at 12:00 P.M. revealed there had been five changes in Administrator at the facility since [DATE]: [DATE] to [DATE] Administrator #300 [DATE] to [DATE] Administrator #301 [DATE] to [DATE] Administrator #302 [DATE] to [DATE] Administrator #101 [DATE] to present Administrator #200. The email further revealed there had been five changes in Director of Nursing since [DATE]: [DATE] to [DATE] Director of Nursing #303 [DATE] to [DATE] Director of Nursing #304 [DATE] to [DATE] Director of Nursing #305 [DATE] to [DATE] Director of Nursing #306 [DATE] to present Director of Nursing #147. Interview on [DATE] at 8:01 A.M. with the DON and Assistant Administrator #137 revealed the DON started in February 2024 and the Assistant Administrator started in mid-March (2024). Assistant Administrator #137 was licensed (as an Administrator) in [NAME] Virginia, but not Ohio at this time. Per the DON and Assistant Administrator #137, the previous Administrator (#101) was a traveling Administrator, and he didn't keep track of concerns or outcomes in the facility. The DON reported corporate had little involvement except the corporate nurse who would come weekly and review records for missing information. The DON and Assistant Administrator #137 reported the root cause of many of the concerns the surveyors were finding was there were so many changes in leadership (Administration/DON) in the last 13 months. During the survey, the following care concerns were identified by the survey team. The facility's inaction caused serious harm including death and had the likelihood of causing serious harm or injury to all residents: 1. The facility failed to ensure Resident #80's blood pressure was adequately monitored to prevent incidents of hypotension (low blood pressure) and failed to notify the physician of the resident's hypotension resulting in a delay in care and treatment. This resulted in Immediate Jeopardy with serious life threatening harm on [DATE] when the resident, who had a history of hypotension, had a blood pressure of ,d+[DATE] which was not reported to the physician, physician ordered blood pressure and pulse monitoring was not completed, a beta blocker medication (works to lower blood pressure) was administered with a resulting blood pressure of ,d+[DATE] which was not reported to the physician and no treatment was provided. The resident was found two hours later without a pulse or respiration and was declared deceased . In addition, concerns that were actual harm that did not rise to the level of Immediate Jeopardy occurred due to the facility failure to notify Resident #34's physician of low blood pressure and staff administered hypertensive and diuretic medication that resulted in a significant drop in the resident's already low blood pressure that required hospitalization of the resident for treatment. Actual harm occurred when the facility failed to follow Resident #53's physician orders for weight monitoring and the resident sustained a significant weight gain with staff failure to notify the physician with the change in condition resulting in a delay in care and treatment until the resident attended a medical appointment with the pulmonologist resulting in a direct admission to the hospital for three days for treatment of congestive heart failure. 2. The facility neglected to operate in a manner to ensure all bills were being paid in a timely manner to prevent potential interruption in services as evidenced by the facility owing 38 vendors outstanding fees for services and supplies that were rendered. 3. The facility failed to develop and implement a comprehensive and individualized pressure ulcer prevention program to ensure timely, accurate and thorough pressure ulcer assessments were completed and to ensure adequate interventions and treatment was in place to promote healing and prevent new ulcers from developing. Actual Harm occurred on [DATE] when Resident #29, who exhibited severe cognitive impairment, had current pressure ulcers present and required substantial/maximal assistance for bed mobility and total dependence for toileting was assessed to have new in-house developed pressure ulcers. The resident was assessed to have an unstageable (Full-thickness skin and tissue loss in which the extent of tissue damage within the ulcer cannot be confirmed because the wound bed is obscured by slough or eschar) pressure ulcer to the left buttock and a Stage II (Partial-thickness loss of skin with exposed dermis, presenting as a shallow open ulcer. The wound bed is viable, pink or red, moist, and may also present as an intact or open/ruptured blister) pressure ulcer to the right buttock. The facility failed to identify the left buttock ulcer until it was unstageable. The new pressure ulcer development occurred due to the lack of adequate interventions including turning and repositioning. Actual Harm occurred on [DATE] when Resident #30, who exhibited severe cognitive impairment, had current pressure ulcers present and required moderate assistance with toileting and bed mobility was assessed to have two new in-house acquired pressure ulcers. An unstageable pressure ulcer to the right lower leg and a Stage II pressure ulcer to the right heel. The facility failed to identify the right lower leg pressure ulcer until it was unstageable. The new pressure ulcer development occurred due to the lack of adequate interventions including turning and repositioning and off-loading of the resident's heels. Actual Harm occurred on [DATE] when Resident #41, who required staff assistance for turning and repositioning was assessed to have a deterioration in status of a coccyx pressure ulcer with an increase in the presence of slough tissue. In addition, on [DATE] the resident was assessed to develop a new in-house acquired Stage II pressure ulcer to the right heel. The resident complained of increased pain to the right heel and voiced concerns staff failed to provide turning and repositioning interventions to prevent the development and/or deterioration. In addition, the new pressure ulcer to the right heel developed due to a lack of adequate interventions including off-loading of the resident's heels. 4. The facility failed to ensure services and assistance to maintain bladder continence for Resident #25 and failed to ensure Resident #29 received appropriate treatment and services to treat urinary tract infections Actual Harm occurred on [DATE] when Resident #25, who had been always continent of bladder as assessed to be frequently incontinent of bladder. The resident reported the increased incontinence was a result of having to wait on staff to assist him to use the urinal resulting in accidents/incidents of urinary incontinence. Actual Harm occurred on [DATE] to Resident #29 when she required re-hospitalization and admission for seven days for treatment of sepsis and bacteremia secondary to UTI requiring intravenous antibiotic administration and infectious diseases consult due to the facility's failure to administer intravenous antibiotics as ordered and obtain urine samples for analysis including culture and sensitivity. The facility continuously failed to follow physician orders related to the infectious disease consult as the consult was never completed even after Resident #29's physician continued to order the infectious disease consult on orders dated [DATE], [DATE], and [DATE]. 5. The facility failed to implement an effective and timely pain management program. Actual harm occurred when Resident #67 who was admitted for orthopedic aftercare, experienced pain rated a 10 out of 10 (on a ,d+[DATE] pain scale with 10 being the most severe) to the right hip. Staff failed to notify the provider the ordered narcotic analgesic pain medication, Oxycodone was not available, resulting in the resident continuing to experience pain as evidenced by the resident's crying and moaning in pain requiring the resident being transferred to the emergency room for uncontrolled pain where the resident was treated with intravenous administration of narcotic pain medication. Actual harm occurred when Resident #44, admitted to the facility without a comprehensive pain assessment being completed and an ordered neuropathic pain medication was ordered and not administered for two days resulting in the resident's experiencing continuous pain the resident rated as 12 out 10 (,d+[DATE] pain scale) and delayed treatment with an ordered pain medication. 6. The facility failed to ensure residents drug regimen was free from unnecessary medication. The facility failed to receive order clarification of anticoagulation medication therapy for Resident #16 resulting in a resident receiving an unnecessary anticoagulation medication for ten days. Actual harm occurred for Resident #16 when the resident's medical providers wrote the first order to call the resident's cardiologist to clarify the Heparin (anticoagulant medication) order. The resident continued to receive Heparin three times a day for ten days following the resident's medical provider orders written repeatedly on [DATE], [DATE] and [DATE] to clarify orders due to the resident's hemoglobin continued to drop down to 7.8 g/dL (normal range 13.3 -17.7 g/dL) and the ordered diagnostic test for occult blood was delayed in completion. The facility failed to complete adequate blood sugar monitoring for Resident #44 to ensure the correct amount of insulin was administered. 7. The facility failed to provide Resident #67 a safe discharge and failed to provide the resident or resident representative with required documentation upon discharge resulting in actual harm. Resident #67 was admitted with primary diagnosis of post-surgical hip repair and was immediately discharged by the facility, without a safe place to be discharged to, after being observed in the facility parking lot on one occasion smoking and taking sips of alcohol. Following the resident's discharge, she did not have a safe place to go, 911 was called and the resident was transported to the emergency room where she was subsequently admitted to the hospital as the resident was assessed/deemed unsafe to return home and the facility refused to re-admit the resident. 8. The facility failed to provide pharmaceutical services to meet the needs of each resident resulting in residents not receiving physician ordered medications in a timely manner. This affected 11 residents, Resident #4, #9, #15, #16, #24, #25, #26 #35, #41, #44, and #60. 9. The facility failed to ensure residents who were unable to carry out activities of daily living received the necessary services to maintain good grooming and personal hygiene in the areas of bathing and incontinence care. This affected five residents, Resident #13, #41, #50, #54, and #79. 10. The facility failed to have sufficient nursing staff to meet the comprehensive and complex needs of all residents in areas including bathing, incontinence care, toileting, interventions to prevent pressure ulcers such as turning/repositioning, answering call lights, dining service, and medication administration. Interview with Medical Director/Physician #105 on [DATE] at 1:22 P.M. confirmed the facility was short staffed. Residents were not receiving shower per preference, call lights were not answered timely, staff weren't checking on residents frequently, nursing not addressing new orders timely, assessments were not completed timely, medications weren't administered per orders or timely, and residents had odors and were unkempt. Physician #105 reported she had resigned because she had voiced concerns to the administration since October/[DATE] and her concerns still have not been resolved. Interview with Nursing Assistant #117 on [DATE] at 11:00 P.M. revealed there were not enough staff to be able to complete scheduled showers or answer call lights timely. He/she stated there was usually only one aide per hallway so if you were in with a resident completing a bed bath, there might be four call lights going off. He/she stated it might be 30 minutes before he/she could answer them because of being on the hall by him/herself. He/she stated that if a resident required a two-person assistance, you had to go find someone to help and wait until that staff person was not busy because they were on a hall by themselves. He/she stated staff on the 7:00 P.M. to 7:00 A.M. shift don't have a chance to start scheduled showers until 11:00 P.M. to 12:00 A.M. and residents don't like it. Interview with Nursing Assistant #118 on [DATE] at 11:15 P.M. revealed there were not enough staff and showers were hit and miss for residents. He/she stated there was usually only one aide per hallway and that was not enough. He/she stated staff were not able to check and change residents who were incontinent every two hours or turn and reposition residents every two hours. He/she stated residents sometimes had to wait a long time in the bathroom for assistance. He/she stated he/she felt residents were neglected due to not enough staff to provide the care needed. Interview with Licensed Practical Nurse #154 on [DATE] at 11:20 P.M. revealed she did not feel there was s enough staff to meet resident needs. She stated she felt rushed and did not take any breaks or lunch. She stated residents had to wait longer for call lights to be answered and to go to the bathroom with only one aide per hallway (four aides total at night). She stated sometimes she can't get the medications administered timely if she has to help the aide. Interview with Licensed Practical Nurse #153 on [DATE] at 11:25 P.M. revealed there were not enough staff to be able to complete scheduled showers. She said sometimes they were done in the middle of the night. She stated she was new at the facility and had trouble getting the medications administered within the scheduled time frame of 7:00 P.M. to 11:00 P.M. She stated she had to do things the aides were too busy to do. She stated she does not take any breaks and feels defeated when she leaves the facility. Interview with Nursing Assistant #127 on [DATE] at 11:55 P.M. revealed there were not enough staff to meet the needs of the residents including showers. He/she stated staff can't answer call lights timely or give the care the residents need. He/she stated some residents require the assistance of two staff and there was no one to help her/him. He/she stated staff have to go look for another staff to assist them and that takes time. He/she stated residents have to wait too long if he/she was in another room with another resident providing care. He/she stated staff can't give showers to residents who require a Hoyer lift with only one staff person on each hall. He/she confirmed staff were not able to check and change residents who were incontinent every two hours. He/she stated he/she was not able to get residents up in the morning that want to get up because there is not enough staff. He/she stated there was usually one aide per hallway (four total) or sometimes less. He/she stated he/she had worked with only two aides for the whole building. Interview with Nursing Assistant #149 on [DATE] at 12:00 A.M. revealed there was usually one aide per hallway (four total). He/she stated he/she had worked when there were only two aides for the whole building. He/she stated there were not enough staff to meet residents' needs. He/she stated he/she had been told not to do showers because of not enough staff. Interview with Nursing Assistant #201 on [DATE] at 12:15 A.M. revealed there were not enough staff to being able to complete resident showers as scheduled. He/she stated there were anywhere from ,d+[DATE] aides working at night for the whole building. He/she stated there had been a lot of change in routine due to the changes in administration. He/she stated there was a lack of communication in the facility. He/she stated staff have to give showers at times when residents don't want them, but the residents know if they don't take them at that time, then they won't get a shower. Interview with Nursing Assistant #122 on [DATE] at 3:05 P.M. revealed the facility was very short staffed. He/she stated most days there was only one aide per hallway (7:00 A.M. to 7:00 P.M.). He/she stated the aide would have to leave their hall to go assist another staff who needed help with a resident who required two-person assistance. He/she stated call lights were then not answered timely. He/she stated it was just survival there in getting things done that need to be done. He/she confirmed showers were not completed as scheduled. He/she stated the dining room was often closed for most meals due to not having enough staff to supervise residents in the dining room and on the hallways. Interview with Licensed Practical Nurse #150 on [DATE] at 8:40 A.M. revealed she was new to the facility. She stated there were not enough staff to be able to meet residents' needs. She stated aides were not able to get showers done. She confirmed residents were not able to go to the dining room at times. Interview with Scheduler #140 on [DATE] at 10:15 A.M. revealed she was instructed to follow an equation to determine how many nursing assistants and nurses to schedule each day. She stated the census was multiplied by 1.10 for nurses and 1.62 for nursing assistants. She stated she had expressed to the Director of Nursing and Administrator there were not enough staff to meet resident needs but was instructed to continue to follow the equation. Interview with Director of Nursing (DON) #147 on [DATE] at 10:30 A.M. confirmed an equation was used to determine staffing levels. She confirmed she felt there was not enough staff to meet residents' needs and stated she had discussed it with the previous Administrator, but stated she was told they still must follow the staffing equation. Interview with the current Administrator/Regional Director of Operations #200 on [DATE] at 11:20 A.M. revealed there was a formula (equation) for how many staff were allowed based on a budget goal. She stated she was not aware of the need for additional staff. Interview on [DATE] at 12:43 PM with Assistant Administrator #137 and Director of Nursing (DON) #147 confirmed that multiple changes in Administrator and Director of Nursing in the past year and the lack of leadership was the root cause of the concerns noted at the time of this survey. Interview with Resident #44 on [DATE] at 1:06 P.M. revealed the facility didn't have enough staff to care for the residents. Most of the staff don't wear name badges and when you ask for assistance, they say we can't help you or we need to find someone else to help because they all have back problems and can't do anything by themselves. It takes up to an hour or longer for staff to answer call lights. The staff have attitudes, and you can tell they don't want to be there. There was usually one aide for 40 residents. Staff verbally tell him they are short staff. Interview with Resident #25 on [DATE] at 10:33 A.M. revealed there was not enough staff, and the aides were too busy. The resident stated this had been brought up [TRUNCATED]

Based on medical record review, staff, certified nurse practitioner and physician interviews, hospital record review, review of literature from Centers for Disease Control (CDC), National Health Institute, and American Heart Association, and facility policy review, the facility failed to ensure Resident #80's blood pressure was adequately monitored to prevent incidents of hypotension (low blood pressure) and failed to notify the physician of the resident's hypotension resulting in a delay in care and treatment. This resulted in Immediate Jeopardy with serious life threatening harm beginning on [DATE] when Resident #80, who had a history of hypotension, had a blood pressure of ,d+[DATE] which was not reported to the physician, physician ordered blood pressure and pulse monitoring was not completed, a beta blocker medication (works to lower blood pressure) was administered with a resulting blood pressure of ,d+[DATE] on [DATE] which was not reported to the physician and no treatment was provided. Resident #80 was found two hours later, on [DATE] at 12:50 A.M. without a pulse or respiration and was declared deceased . Actual Harm (that was not Immediate Jeopardy) occurred on [DATE] when Resident #34, with a diagnosis of heart failure, had a hypotension blood pressure reading that staff failed to notify the resident's physician of and staff administered hypertensive and diuretic medication that resulted in a significant drop in the resident's already low blood pressure that required hospitalization for three days due to hypotension with dizziness and fatigue symptoms where treatment included intravenous fluids and vasopressor medication (used to treat severe low blood pressure). Actual Harm (that was not Immediate Jeopardy) occurred on [DATE] to Resident #53, with a diagnosis of congestive heart failure, when staff failed to follow physician orders for weight monitoring; the resident sustained a significant weight gain and staff failed to notify the physician with the change in condition resulting in a delay in care and treatment until the resident attended a medical appointment with the pulmonologist resulting in a direct admission to the hospital for three days for treatment of congestive heart failure requiring intravenous diuretic administration and strict fluid restriction. In addition, concerns identified which did not rise to Immediate Jeopardy or harm that was not Immediate Jeopardy occurred due to the facility's failure to complete timely and comprehensive assessment and monitoring including neurological assessment for a resident with an unwitnessed fall, failure to complete ordered consults in the areas of surgery, gynecology, and hematology for a resident with low hemoglobin with evidence of continued bleeding, and failure to complete dressing changes and monitoring of the condition of stasis ulcers. This affected five residents (#5, #31, #34, #53, #78 and #80) of 36 residents reviewed for quality of care and treatment. The facility census was 65. On [DATE] at 1:38 P.M. Licensed Nursing Home Administrator (LNHA) #200, Director of Nursing (DON) #147, [NAME] President of Clinical Services #103, Assistant Administrator #137, and Regional Clinical Service Manager (RCSM) #102 were notified Immediate Jeopardy began on [DATE] for Resident #80, with a history of low blood pressure (hypotension), when staff failed to monitor the resident's blood pressure including completion of physician ordered blood pressure checks, failed to notify the physician of hypotension thereby delaying care and treatment, and staff continued administration of a blood pressure lowering medication resulting in Resident #80 being found without pulse or respirations and declared deceased . The Immediate Jeopardy was removed on [DATE] when the facility implemented the following corrective actions: On [DATE] at 8:00 A.M. current Medical Director, Physician #5, was notified of early release from contract effective [DATE]. All current resident families notified of Medical Director Transition via phone and in person, along with notification to cognitively intact residents. On [DATE] at 8:00 A.M., Physician #206 assumed role of facility Medical Director, with initiation of [NAME] Services for Nurse Practitioner oversight. Contact information of both parties posted throughout facility. Letters to be either hand delivered or mailed certified to all current residents and/or responsible parties of the update in medical director. On [DATE] (no time identified), an Ad Hoc Policy Review was held with the Administrator #200, Assistant Administrator #137 Director of Nursing #147, Regional Clinical Services Manager #102 , [NAME] President of Nursing Operations #103, Chief Nursing Officer #207, Medical Director/Physician #206, Social Service Designee (SSD) #159, Activities Director #167, Diet Tech #160, Medical Records/Accounts Payable #157, RN/MDS #161, Director of Rehab #168, RN/ADON #128, RN Staff Development Coordinator/Infection Control #164, Admission Staff #144 , Business Office Manager #142, Maintenance Director #141, Central Supply/Scheduler #140, and NP #205 to review facility polices for Change in Resident Condition and Medication Administration, with regards to following physician's orders for blood pressure and pulse monitoring with parameters per orders from the physician/physician extender. Change in Resident Condition policy was updated to specifically address acute changes in condition including abnormal vital signs. Parameters were provided by the facility Nurse Practitioner #204 for administration of cardiac medications as follows: Ace Inhibitors- hold if SBP<90 and notify MD/NP, angiotensin 2 Receptor Blockers (ARBs)- hold of SBP<90 and notify MD/NP, Beta Blockers- hold if HR<60 and notify MD/NP, Calcium Channel Blockers- hold if HR<60 and/or SBP<90 and notify MD/NP, and Vasodilators- hold if SBP<90 and notify MD/NP. On [DATE] (no time identified), the Regional Clinical Services Managers educated the Administrator #200, Assistant Administrator #137, Director of Nursing #147, RN ADON #128, and RN SDC/IC #164 regarding updated policies and procedures for Change in Resident Condition including addressing acute changes in condition with abnormal vital signs and Medication Administration, with regards to following physician's orders for blood pressure and pulse monitoring with parameters per orders from the physician/physician extender. Parameters were provided by the facility Nurse Practitioner #204 for administration of cardiac medications as follows: Ace Inhibitors- hold if SBP<90 and notify MD/NP, angiotensin 2 Receptor Blockers (ARBs)- hold of SBP<90 and notify MD/NP, Beta Blockers- hold if HR<60 and notify MD/NP, Calcium Channel Blockers- hold if HR<60 and/or SBP<90 and notify MD/NP, and Vasodilators- hold if SBP<90 and notify MD/NP. On [DATE] (no time identified), the Administrator #200 and Director of Nursing #147 educated Administrative Staff, including Social Services Designee #159, Admissions Director #144, Business Office Manager #142, RN/MDS #161, Diet Tech #160, Maintenance Director #141, Activities Director #167, Central Supply/Scheduler #140, Medical Records #157, and Director of Rehab #168 regarding updated policies and procedures for reporting a Change in Resident Condition including addressing acute changes in condition with abnormal vital signs and Medication Administration, with regards to following physician's orders for blood pressure and pulse monitoring with parameters per orders from the physician/physician extender. Parameters were provided by the facility Nurse Practitioner#204 for administration of cardiac medications as follows: Ace Inhibitors- hold if SBP<90 and notify MD/NP, angiotensin 2 Receptor Blockers (ARBs)- hold of SBP<90 and notify MD/NP, Beta Blockers- hold if HR<60 and notify MD/NP, Calcium Channel Blockers- hold if HR<60 and/or SBP<90 and notify MD/NP, and Vasodilators- hold if SBP<90 and notify MD/NP. On [DATE], all facility staff educated on updated policies and procedures for reporting Change in Resident Condition including addressing acute changes in condition with abnormal vital signs and Medication Administration, with regards to following physician's orders, for blood pressure and pulse monitoring with parameters per orders from the physician/physician extender. Parameters were provided by the facility Nurse Practitioner #204 for administration of cardiac medications as follows: Ace Inhibitors- hold if SBP<90 and notify MD/NP, angiotensin 2 Receptor Blockers (ARBs)- hold of SBP<90 and notify MD/NP, Beta Blockers- hold if HR<60 and notify MD/NP, Calcium Channel Blockers- hold if HR<60 and/or SBP<90 and notify MD/NP, and Vasodilators- hold if SBP<90 and notify MD/NP. Education completed included 16 nurses, 28 nurses' aides, 1 activity staff, 5 environmental services staff, 6 dietary staff, and 6 administrative staff. A medication administration competency will be completed by each licensed nurse prior to their next scheduled shift. Medication Administration competency includes, but is not limited to, five rights of medication administration with all routes, medication storage, receiving medication, and documentation. Competency includes assessment of pulse and/or BP checked and charted when indicated- held, if appropriate. One employee is on vacation and will be educated prior to returning to work. All other staff were educated. Education was completed by RN/ADON #128, SDC/IP #164, Diet Tech #160, Maintenance Director #141, and Activities Director #167. Department heads completed education of policies to their respective department staff. Medication Competencies are being completed by DON #, RN/ADON #128, and RN SDC/IC #164. On [DATE] (no time identified), an Ad Hoc Resident Council meeting was held with the Activities Director #167 and Administrator #200 to review the updated policies and procedures for Change in Resident Condition and Medication Administration, with regards to following physician's orders. Residents in attendance were Residents #25, #60, #59, #62, #61, and #47. There were no concerns verbalized during the resident council meeting regarding policies shared and information reviewed and residents were appreciative of the information. On [DATE] (no time identified) head to toe assessments were completed on all current residents by Licensed Nurses RN #131, RN #152, and LPN #129. Assessments included vital signs, pain assessment and skin inspections and there was no deviation from the resident's baseline and no unidentified skin impairments. On [DATE] (no time identified), Clinical Service Manager RN #102 completed audits on all resident medications to ensure that medications are available and administered per physician's orders. On [DATE] (no time identified), Clinical Services Manager # 102 and DON #147 audited the telephone orders of all current residents to ensure there were no missed orders requiring processing and implementation. There were no unprocessed orders. On [DATE] (no time identified), all current residents on cardiac medication had orders updated to reflect cardiac medication monitoring parameters by RN VPCS #103 per verbal order from NP #204. Beginning on [DATE] ongoing auditing will be implemented and completed by the Director of Nursing #147 and/or Designee 5 days a week for 4 weeks. Director of Nursing/Designee to complete telephone order audit of all residents to ensure no orders are missed. Additional auditing to include ensuring vital signs are monitored per physicians orders and any deviation from the residents baseline are reported to the physician/physician extender as a change in condition as indicated. All elements of the IJ removal plan were implemented and completed by [DATE]. Although the Immediate Jeopardy was removed on [DATE], the facility remained out of compliance at Severity Level 2 (no actual harm with potential for more than minimal harm that is not Immediate Jeopardy) as the facility is still in the process of implementing their corrective actions and monitoring to ensure on-going compliance. Findings include: 1. Review of the closed medical record for Resident #80 revealed an admitted [DATE] with diagnoses including diabetes mellitus, acute kidney failure, acute respiratory failure, pulmonary embolism, and cellulitis. The resident expired at the facility on [DATE]. Review of an acute care hospital discharge summary dated [DATE] revealed the resident had been admitted to the hospital on [DATE]. She presented to the emergency department with complaints of generalized weakness and a fall on [DATE]. During her stay she had low blood pressure which improved with intravenous fluids and holding of all antihypertensive therapy. Hospital records identified Resident #80's blood pressure was then stable and on discharge she would no longer be on Amlodipine (a calcium channel blocker used to treat high blood pressure) or Lisinopril (an ACE inhibitor used to treat high blood pressure). Hospital records identified Resident #80 would resume Atenolol (a beta blocker used to treat high blood pressure) on discharge from the hospital. Resident #80's blood pressures at the hospital on the day of discharge ([DATE]) were noted to be: [DATE] at 3:35 A.M. ,d+[DATE]; [DATE] at 7:31 A.M. ,d+[DATE]; and [DATE] at 10:42 A.M. ,d+[DATE]. Review of the Center for Disease Control (CDC) literature revealed a normal blood pressure is noted to be below ,d+[DATE] mmHg. Review of the National Institute of Health (NIH) literature revealed a low blood pressure is a blood pressure lower than ,d+[DATE] mmHg. Review of an admission nursing assessment completed by Registered Nurse (RN)/Assistant Director of Nursing (ADON) #128 on [DATE] revealed Resident #80 was admitted to the facility at 5:05 P.M. A baseline care plan on admission stated the primary medical reason for admission was diabetes and atrial fibrillation. The goal was to manage or improve medical status. Interventions included vital signs every shift for three days and monitor tolerance to medications. The admission nursing assessment included a blood pressure of ,d+[DATE] at 8:03 P.M. There was no evidence the physician was notified of the blood pressure of ,d+[DATE]. The resident had a physician's order on admission on [DATE] for Atenolol 50 milligrams two times daily for hypertension (high blood pressure) which was scheduled to be given in the morning and evening. Review of a progress note on [DATE] by Certified Nurse Practitioner (CNP) #104 revealed Resident #80 had hypotension during her hospitalization and was not able to be on beta-blockers and all blood pressure medications were stopped. Resident #80 was alert and oriented. Blood pressure was ,d+[DATE] on last check. We will check blood pressure and heart rate every shift (facility has two shifts: 7:00 A.M. to 7:00 P.M. and 7:00 P.M. to 7:00 A.M.) and then do orthostatic lying, sitting, and standing blood pressure and heart rate every morning for five days and notify providers if systolic drops more than 10 mmHg (orthostatic blood pressures check for drops in blood pressure when going from lying or sitting to standing). Review of Resident #80's physician's orders revealed a paper written order on [DATE] to check blood pressure and heart rate every shift and do orthostatic blood pressure and heart rate lying, sitting, and standing every morning for five days. The physician order identified staff were to notify the CNP if Resident #80's systolic blood pressure went down by 10 mmHg or more. However, review of physician's orders in the electronic medical record revealed the orders to monitor blood pressure were not entered until [DATE] (one full day after the orders were given) and were scheduled to start on [DATE] (two full days after the orders were given). The orders were listed on the treatment administration record (TAR) for [DATE]. Review of the TAR for [DATE] revealed no documentation of the physician ordered blood pressure monitoring being completed at all. Review of Resident #80's medical record including nursing progress notes, skilled nursing assessments, and vital sign documentation revealed the only blood pressures obtained were: [DATE] at 8:03 P.M. ,d+[DATE]; [DATE] at 3:30 P.M. ,d+[DATE]; and [DATE] at 12:38 A.M. ,d+[DATE] (prior to [DATE] at 10:45 P.M.). Review of the medication administration record (MAR) and medication administration audit report revealed Registered Nurse (RN) #131 had given Resident #80 Atenolol 50 milligrams on [DATE] at 7:49 P.M. There was no evidence the resident's blood pressure had been checked prior to giving the medication since [DATE] at 12:38 A.M. (approximately 19 hours prior). Review of the nursing progress notes on [DATE] at 10:45 P.M. revealed a blood pressure of ,d+[DATE] mmHg was documented in the nurse's progress notes by RN#131. The note indicated the blood pressure was below the resident's baseline and the resident was sleeping during the shift. There was no evidence the physician was notified of the low blood pressure of ,d+[DATE] or that any type of treatment was provided. The next nursing progress note for Resident #80 by RN #131 on [DATE] at 12:50 A.M. (approximately two hours after the blood pressure of ,d+[DATE]) revealed the nursing assistant came to the nurse and stated she did not think the resident was breathing. RN #131 went to the resident's room and listened to her heart. No respirations or heartbeat was noted. Cardiopulmonary resuscitation (CPR) was initiated and 911 was called. The responders took over CPR when they arrived, but CPR was stopped at 1:15 A.M. upon orders from the hospital emergency physician. Resident #80 expired at that time at the facility. Interview with RN #131 on [DATE] at 5:18 P.M. revealed she did not really remember Resident #80. She confirmed that she had given the resident her medication on the evening before the resident died . RN #131 stated she did not really know a lot about Resident #80. RN #131 stated blood pressure should be checked prior to giving a blood pressure medication. She stated she could not recall if Resident #80's blood pressure of ,d+[DATE] mm/Hg that was documented on [DATE] at 10:45 P.M. had been obtained prior to giving the blood pressure medication that evening or after. RN #131 stated she did not remember if the physician was notified of Resident #80's low blood pressure or not. She stated it would usually be documented in the nursing progress notes if the physician was notified. She confirmed Resident #80 expired at the facility on [DATE] as per her progress note. Interview with the Director of Nursing (DON) #147 on [DATE] at 7:20 A.M. confirmed there was no evidence the physician was notified of Resident #80's blood pressure of ,d+[DATE] on [DATE]. She stated the facility did not have a policy on when to notify physicians regarding blood pressure levels. She stated some residents had a physician's order with parameters of when to notify the physician. She confirmed Resident #80 did not have any physician ordered parameters of when to notify related to blood pressure. She stated she would have notified the physician of Resident #80's blood pressure being ,d+[DATE]. She further stated she would have re-checked the resident's blood pressure in 15 minutes to see if it was still low. She confirmed there was no evidence the resident's blood pressure was re-checked again until [DATE] at 3:30 P.M. (approximately 19 hours later) when it was ,d+[DATE] (documented under vital signs in electronic medical record). The DON confirmed a resident's blood pressure should be checked prior to administering a blood pressure medication and the medication should be held if the blood pressure is too low. She confirmed there was no evidence Resident #80's blood pressure was checked prior to giving the medication on [DATE] at 7:49 P.M. She stated the blood pressure of ,d+[DATE] mm/Hg documented on [DATE] at 10:45 P.M. may not have been obtained at the time it was documented (could have been earlier). Interview with CNP #104 on [DATE] at 8:20 A.M. confirmed neither she nor the physician was notified of Resident #80's low blood pressure of ,d+[DATE] mm/Hg on [DATE]. CNP #104 stated a blood pressure that low could be life threatening without treatment. CNP #104 stated if she had been notified of Resident #80's low blood pressure, she would have either ordered intravenous fluids to be given or if the resident was symptomatic, she would have sent the resident to the emergency room . She stated the Atenolol blood pressure medication would start taking effect within 30 minutes to one hour after given. She confirmed the low blood pressures Resident #80 had should have been rechecked within an hour and the physician should have been notified. She stated the nurses at the facility never re-check low or high blood pressure unless she tells them to. Interview with Medical Director #105 on [DATE] at 12:09 P.M. revealed she had resigned her position at the facility due to staff competency related to issues such as putting physician orders in timely, medication errors, lack of administrative staff, etc. She stated the issues had been going on for six months and, although brought to the attention of the facility, still had not been addressed. Review of facility policies revealed the facility did not have a policy that specified what constituted an abnormal blood pressure or when to notify the physician of abnormal blood pressures. Review of the facility policy titled Change in a Resident's Condition, dated [DATE] revealed the facility shall notify the resident, his or her attending physician, and representative (sponsor) of changes in the resident's medical/mental condition. The procedure stated the nurse supervisor/charge nurse will notify the resident's attending physician or on-call physician when there has been a change in resident condition. Except in medical emergencies, notifications will be made timely of a change occurring in the resident's medical/mental condition or status. The nurse supervisor/charge nurse will record in the resident's medical record information relative to changes in the resident's medical/mental condition or status. The policy did not include any information to describe what met the definition of a change in the resident's condition. 2. Record review revealed Resident #34 was admitted to the facility on [DATE] with diagnoses including congestive heart failure, nonrheumatic aortic stenosis, presence of prosthetic heart valve, presence of cardiac pacemaker, history of transient ischemic attack, hypertensive heart disease with heart failure, sick sinus syndrome, and anxiety. Review of Resident #34's diuretic therapy plan of care related to heart failure dated [DATE] revealed they may cause dizziness, fatigue, postural hypotension, and an increased risk for falls. Observe for possible side effects every shift. Review of Resident #34's at risk for decreased cardiac output related to heart failure plan of care dated [DATE] revealed to monitor vital signs per physician order. Review of a nursing progress note dated [DATE] at 1:23 A.M. revealed the resident's blood pressure was ,d+[DATE] mm/Hg on [DATE] at 9:34 P.M. and his pulse was 64. Review of Resident #34's physician orders and medication administration record (MAR) for [DATE] revealed the resident was ordered Amlodipine (calcium channel blocker) 5 milligrams (mg) daily for hypertension in the morning, Lasix (diuretic) 40 mg daily for edema in the morning, Lisinopril (ACE inhibitor) 40 mg daily for hypertension in the morning, Buspirone (anxiolytic) 5 mg in the morning, afternoon, and evening for hypertension, Spironolactone (diuretic) 100 mg daily in the morning for hypertension, Metoprolol (beta blocker) 100 mg in the morning and 100 mg in the evening for hypertension. Staff were to check the resident's blood pressure prior to administering the Metoprolol. Record review of the MAR dated [DATE] revealed Resident #34's blood pressure was ,d+[DATE] mm/Hg for the morning dose of Metoprolol (time not specified). The medication Metoprolol was administered at this time by Licensed Practical Nurse (LPN) #130. The resident did not have blood pressure or pulse parameters for the administration of the Metoprolol. The resident had also received Oxycodone (narcotic) 5 mg at 5:38 A.M. and Tylenol (analgesic) 325 mg at 8:06 A.M. for pain (these medications can enhance the effects of hypertension medications). Review of the MAR dated [DATE] revealed a secondary blood pressure reading of ,d+[DATE] mm/Hg and pulse of 73 (time not specified). The MAR identified the resident had a onetime order to send Resident #34 to the emergency room for low blood pressure on [DATE]. Review of a nursing progress note dated [DATE] from 9:31 A.M. to 9:52 A.M., revealed Resident #34 was transferred to the hospital due to an emergency in which the resident's urgent medical needs necessitated an immediate transfer. The reason for the transfer was abnormal vital signs and the resident had complaints of weakness and was hypotensive (,d+[DATE] and ,d+[DATE]) and had already received his morning medications. The Nurse Practitioner (CNP) #104 was notified and orders given to send the resident to the emergency room (ER) for evaluation. Review of a nursing progress note dated [DATE] at 4:36 P.M., revealed Resident #34 was admitted to the hospital for treatment of a diagnosis of septic shock. Interview on [DATE] at 8:46 A.M., with CNP #104 and Physician #105 revealed CNP #104 was in the building doing visits (on [DATE]) when the nurse approached her and reported Resident #34's blood pressure was low and she had already administered all his morning medications including blood pressure and diuretic medications. The CNP #104 and Physician #105 confirmed the nurse should have held the resident's blood pressure and diuretic medication for a blood pressure of ,d+[DATE] and notified either CNP #104 or Physician #105. CNP #104 reported she had to send the resident to the ER due to within an hour after receiving all his medication his blood pressure had dropped to ,d+[DATE] and she knew his blood pressure was going to continue to drop even more with all the medications he had received. Resident #34 would need close monitoring and treatment the facility could not offer due to his medical history and the potential for fluid overload if she had ordered the administration of intravenous fluids at the facility. CNP #104 and Physician #105 confirmed Resident #34's hospitalization could have been prevented if staff would have notified them of the blood pressure of ,d+[DATE] prior to administering all his medication. Interview on [DATE] at 9:40 A.M., with Registered Nurse (RN) #128 revealed if a resident's blood pressure was ,d+[DATE], she would have held his blood pressure and diuretic medication and notified the physician. Interview on [DATE] at 10:48 A.M., with Clinical Service Manager (CSM) #102 revealed the facility did not have a policy on blood pressure monitoring, however the nurse should have used nursing judgement and held the resident's medication (blood pressure medications and diuretics) and contacted the physician when the resident's blood pressure was ,d+[DATE]. Review of the American Heart Association article dated [DATE] revealed a reading of less than ,d+[DATE] millimeter of mercury (mm Hg) is considered hypotension. Hypotension is the term for blood pressure that is too low. A number of drugs can cause low blood pressure, including diuretics and other drugs that treat hypertension; heart medications such as beta blockers; drugs for Parkinson's disease; tricyclic antidepressants; erectile dysfunction drugs, particularly in combination with nitroglycerine; narcotics; and alcohol. Other prescription and over-the-counter drugs may cause low blood pressure when taken in combination with high blood pressure medications. Among the heart conditions that can lead to low blood pressure are an abnormally low heart rate (bradycardia), problems with heart valves, heart attack and heart failure. In addition, review of Resident #34's physician order dated [DATE] revealed an order for daily weights for congestive heart failure. Review of Resident #34's weights dated [DATE] to [DATE] revealed no evidence the residents' weights were obtained on [DATE], [DATE], [DATE], and [DATE]. Interview on [DATE] at 3:17 P.M. with the Director of Nursing (DON) confirmed Resident #34's had orders for daily weights and there was no evidence the weights were obtained on [DATE], [DATE], [DATE], and [DATE]. 3. Record review revealed Resident #53 was admitted to the facility on [DATE] with diagnoses including myocardial infarction, syncope and collapse, hypertensive emergency, congestive heart failure, hypovolemia, acute kidney failure, hyponatremia, dehydration, and edema. Review of Resident #53's at risk for decreased cardiac output plan of care dated [DATE] revealed to monitor vital signs per physician order. a. Review of Resident #53's hospital discharge orders dated [DATE] and [DATE] revealed since the resident has heart failure, weights should be completed daily and notify the doctor of a weight gain of three pounds in one day or five pounds in a week. Review of Resident #53's physician orders dated [DATE], [DATE], [DATE], revealed to weigh resident every Monday, Wednesday, and Friday for congestive heart failure. Review of Resident #53's weights revealed on [DATE] the resident weighed 230 pounds and [DATE] the resident weighed 233.6 pounds, (which was a 3.6-pound weight gain), there was no evidence of physician notification. On [DATE] the resident weighed 235.8 pounds and on [DATE] he weighed 244.6 and a reweigh of 247.6 pounds, which was a 11.8-pound weight gain, there was no evidence of physician notification. Review of Resident #53's nursing progress note dated [DATE] revealed the resident had left the facility to attend a medical appointment with the pulmonologist. The nursing progress note revealed the pulmonology department called and reported the resident was sent to the ER by the physician due to a 13-pound weight gain. Review of Resident #53's nursing progress note dated [DATE] revealed the resident was admitted to the hospital for treatment of congestive heart failure. Review of Resident #53's re-admission history and physical dated [DATE] revealed the resident was a [AGE] year-old male who was found to have a 13-pound weight gain when he went out to an appointment. Ultimately, he was sent to the ER at that point. The resident was given intravenous Lasix (diuretic) 40 mg twice daily, put on strict fluid restrictions, and was stabilized. The resident reported he was down about 10 pounds and the edema in his legs was improving. He will be weighed daily and staff to notify if there was a three-pound weight gain with fasting weights in the morning prior to eating or drinking. b. Review of Resident #53's physician's order dated [DATE] revealed the order was changed to weight daily in the morning prior to eating breakfast and to void prior to weighing and to notify the provider if there was a three-pound weight gain in one day or five-pound weight gain in seven days or less. Review of Resident #53's cardiology orders dated [DATE] revealed to take Torsemide (diuretic) 20 mg every morning, if there was a three-pound weight gain in 24 hours take an extra dose of Torsemide. Review of Resident #53's daily weights dated [DATE] revealed the resident's weight was 237.2 pounds and on [DATE] the resident's weight was 243 pounds, which indicated a 5.8-pound weight gain. There was no evidence of physician notification and no evidence the resident was administered an extra dose of Torsemide as ordered. Review of Resident #53's orders and MAR dated ,d+[DATE] revealed on [DATE] no evidence the extra dose of Torsemide was administered per order if there was a three-pound weight gain in 24 hours. Review of Resident #53's progress no [TRUNCATED]

Based on record review, interview, and policy review the facility failed to implement an effective and timely pain management program. This affected two residents (#44 and #67) of four reviewed for pain. Actual Harm occurred on 03/12/24 at 2:30 P.M. when Resident #67, who was admitted for orthopedic aftercare, experienced pain rated a 10 out of 10 (on a 1-10 pain scale with 10 being the most severe) to the right hip. Staff failed to notify the provider the ordered narcotic analgesic pain medication, Oxycodone was not available, resulting in the resident continuing to experience pain as evidenced by the resident's crying and moaning in pain requiring the resident being transferred to the emergency room for uncontrolled pain where the resident was treated with intravenous administration of narcotic pain medication. Actual Harm occurred on 03/15/24 when Resident #44 was admitted to the facility without a comprehensive pain assessment being completed, an ordered neuropathic pain medication was ordered and not administered for two days resulting in the resident's experiencing continuous pain the resident rated as 12 out 10 (1-10 pain scale) and delayed treatment with an ordered pain medication. Findings include: 1. Closed record review revealed Resident #67 was admitted to the facility on [DATE] with diagnoses including aftercare for orthopedic surgery, displaced condyle fracture of lower end of right femur, intervertebral disc degeneration, osteoarthritis, and replacement of right hip and knee joint. Review of Resident #67's admission orders dated 03/12/24 revealed Oxycodone 10-325 mg one tablet every four hours as needed for pain. Review of Resident #67's baseline pain care plan dated 03/12/24 revealed to administer pain medication as ordered. Review of Resident #67's nursing note dated 03/12/24 at 2:30 P.M., revealed the resident arrived via stretcher from the hospital. The resident was alert and oriented times four. The resident had a port to the upper right chest. The resident had a surgical incision to the left hip extending down to the left posterior knee. The resident reported the right posterior foot was slightly bruised due to a break of metatarsal. The resident acknowledged he was in severe pain 10/10. The facility was awaiting pharmacy to deliver medications. Review of Resident #67's nursing note dated 03/13/24 at 4:43 A.M. revealed the resident was screaming out profanities in room about not being able to get pain medication all day. The writer let the resident know that staff were sending the resident out and apologized profusely for not being able to get her pain medication. The writer reported she had tried multiple times to get pain medication from the pharmacy. Around 4:00 A.M. the pharmacy called back and said they had not received the narcotic scripts. The writer searched the nurse's station and couldn't find any admission paperwork for the resident, therefore couldn't find the narcotic scripts. The resident requested to be sent to the emergency room (ER) since the facility couldn't medicate for pain. The Certified Nurse Practitioner (CNP) #104 was notified and agreed to send the resident to the ER. On 03/13/24 at 4:46 A.M. Resident #67 was transferred to the ER for uncontrolled pain. Review of Resident #67's emergency room notes dated 03/13/24 revealed the resident was seen for pain management. The resident was noted to be crying and moaning in pain. The pain was described as an aching pain in the post-surgical femur area. The resident rated the pain 10 out of 10. The resident was administered intravenous Hydromorphine 1 milligram (mg) at 6:08 A.M., 7:18 A.M., and 8:46 A.M. as well as Zofran 4 mg at 6:10 A.M., 9:26 A.M., and 12:42 P.M., for nausea. Review of Resident #67's nursing note dated 03/13/24 at 5:10 P.M. revealed the resident returned to the facility and was in an unpleasant mood and irritable. The resident stated her entire body was tingling like pins and needles and she was nauseated. The resident began vomiting bile; however, the facility was not able to administer Zofran due to the resident receiving a sublingual dose of Zofran during transport at 4:10 P.M. The staff provided non-pharmacological measures to alleviate vomiting. Review of physician note dated 03/14/24 revealed Resident #67 had fallen and sustained a right femur fracture and was transferred to the facility after having surgery for after care. She had also fractured her left fifth metatarsal and had T1 and T11 compression fractures. The resident had gone out of the hospital yesterday for uncontrolled pain, nausea, and vomiting. The resident had chronic pain and was managed by another provider and had been on Oxycodone 10 mg every four hours as needed for quite some time. Interview on 03/26/24 at 1:22 P.M., with the Medical Director, Physician #105 revealed the resident was not administered pain medication timely resulting in the resident returning to the emergency room for pain management after admission to the facility. Interview on 04/08/24 at 10:00 A.M., with Physician #105 revealed she had faxed scripts directly to the pharmacy shortly after the resident was admitted for her pain medication. The facility then called CNP #104 early in the morning the next day and requested for the resident to be transferred to the ER for uncontrolled pain. The nurses should have been able to get the pain medication out of the facility emergency supply and staff did not call to report any concerns that pain medication was not available. Interview on 04/08/24 at 10:22 A.M., with Registered Nurse (RN)/ Assistant Director of Nursing (ADON) #128 revealed there should never be a delay in getting pain medication since the providers can fax or e-script prescriptions directly to the pharmacy from home and there was medication in the emergency supply including Oxycodone. ADON #128 confirmed Resident #67 had to been sent to the emergency room for uncontrolled pain due to the facility did not administer pain medication timely. 2. Record review revealed Resident #44 was admitted to the facility on [DATE] with diagnoses including type II diabetes mellitus, heart disease, malignant neoplasm of part of the lung, acquired absence of the lung, age-related physical disability, and neuropathy. Review of Resident #44's admission assessment dated [DATE] indicated the resident had no pain as evidenced by facial expression. The remaining parts of the assessment were left blank including if the resident had pain in the last five days, frequency of pain, what causes your pain, what alleviates the pain, and does the pain affect activities of daily living. Review of Resident #44's Brief Interview for Mental Status (BIMS) assessment dated [DATE] revealed the resident BIMS was 15 out of 15 (cognition intact). Review of orders dated 03/13/24 revealed order for a referral to a neurologist for neuropathy. Review of Resident #44's occupational therapy notes dated 03/15/24 revealed the resident reported increased exertion and chronic pain. Further review of therapy notes revealed on 03/18/24 the resident declined to do any more therapy due to pain all over though refused anything for pain management including over the counter medications. Review of Resident #44's pain plan of care dated 03/24/24 revealed the resident was at risk for pain/discomfort related to depression, age-related debility. Intervention included to acknowledge the presence of pain and discomfort. Listen to residents' concerns, administer pain medication per physician orders. Observe and report changes to the physician. Assess pain using the Wong-Baker faces pain scale. Offer change in position. Report changes to the nurse. Review of Resident #44 paper orders dated 03/25/24 revealed Gabapentin (anti-convulsant, nerve pain medication) 100 mg three times daily for neuropathy. The order was signed off on 03/26/24 at 12:45 A.M. There was no evidence the resident or family were notified of the new order. Review of Resident #44 electronic orders dated March 2024 revealed no evidence of an order for Gabapentin, however nursing entered an order for Gabadone (dietary management for sleep disorders) on 03/26/24. Gabadone and Gabapentin are not the same medication. Interview on 03/26/24 at 1:06 P.M. with Resident #44 and his wife revealed CNP #104 would not order the resident's Gabapentin for neuropathy pain because it was considered a narcotic. The resident reported his pain level was high at the time of the interview but wouldn't give a number (on a 1-10 pain scale). The resident's wife reported the resident could not take pain medication because it affected his cognition, however staff are telling them that Gabapentin was a narcotic. Interview on 03/26/24 at 1:22 P.M., with Physician #105 revealed she had spoken to CNP #104, and she reported she had written orders yesterday for the resident's Gabapentin per the resident request. Interview on 03/26/24 at 3:39 P.M. with CNP #104 revealed she was in the facility on 03/25/24 until 2:30 P.M. and wrote a prescription for the Gabapentin due to the facility's pharmacy was Kentucky and requires a written prescription for the Gabapentin due to in Kentucky it is considered a narcotic but not in Ohio. CNP #104 confirmed she did not order Gabadone. Interview on 03/26/24 at 4:08 P.M. with the Director of Nursing (DON) confirmed the order for Gabapentin was entered incorrectly by the nursing staff, however the resident did not receive the Gabadone due to it not being available. Interview on 03/27/24 at 4:14 P.M., with Resident #44 revealed he just finally received the first dose of Gabapentin, and his neuropathy pain was rated a 12 out 10 (1-10 pain scale). Interview on 03/27/24 from 4:18 P.M. to 4:35 P.M., with Licensed Practical Nurse (LPN) #129 and Registered Nurse (RN) #126 confirmed the resident just received his first dose of Gabapentin around 2:00 P.M., and it was originally ordered on 03/25/24. RN# 126 reported she had used a different resident's (#42) Gabapentin to give Resident #44 due to his had not arrived at this time. LPN #129 confirmed there was Gabapentin in the emergency box the RN could have utilized. LPN #129 reported she called the pharmacy, and they had the signed scripts for the Gabapentin since 03/25/24 and was not sure why the Gabapentin was not sent, and they would send it out with tonight's delivery. Interview on 03/28/24 at 8:36 A.M., with RN #128 (ADON) revealed on 03/17/24 the resident had pain 9 out of 10, however there was no evidence the provider was notified The RN reported the resident didn't have a pain assessment completed after the admission assessment, which indicated the resident had no pain as evidence of facial expressions. Review of the facility policy and procedure titled Pain Assessment and Management, dated 11/30/23 revealed pain management was defined as the process of alleviating the resident's pain to a level that was acceptable to the resident and is based on his or her clinical condition and established treatment goals. Review the medication administration records to determine how often the individual requests and receives pain medication, and to what extent the administered medication relieves the resident's pain. This deficiency represents non-compliance investigated under Master Complaint Number OH00152295 and Complaint Number OH00151794.

Based on record review and interview the facility failed to ensure a resident's drug regimen was free from unnecessary medication when the facility failed to receive ordered clarification of anticoagulation medication therapy resulting in a resident receiving an unnecessary anticoagulation medication for ten days, and failed to complete adequate blood sugar monitoring to ensure the correct amount of insulin was administered for a resident. This affected two residents (#16, #44) of 36 residents reviewed for quality of care. Actual Harm occurred on 03/21/24 to Resident #16 when Certified Nurse Practitioner (CNP) #104 and Medical Director/Physician #105 wrote the first order to call Resident #16's cardiologist to clarify the Heparin (anticoagulant medication) order. Resident #16 continued to receive Heparin three times a day for ten days following Physician #105's orders written repeatedly on 03/22/24, 03/25/24 and 04/01/24 to clarify orders due to the resident's hemoglobin continued to drop down to 7.8 g/dL (normal range 13.3 -17.7 g/dL) and the ordered diagnostic test for occult blood was delayed in completion. Findings include: 1. Record review revealed Resident #16 was admitted to the facility on [DATE] with diagnoses including dissection of unspecified site of aorta, hypertensive emergency, substance abuse, cerebral infarction due to embolism, acute kidney failure with tubular necrosis, and presence of coronary angioplasty implant and graft. Further review of Resident #16's orders dated 03/20/24 revealed the resident was receiving Aspirin (blood thinning medication) 81 mg daily for prevention, Brilinta (anti platelet medication) 90 milligrams (mg) twice daily, and Heparin (anticoagulant medication) 5000 units every eight hours for blood clot prevention. There was no documented evidence of an order to interchange Brilinta with Plavix. Review of Resident #16's orders dated 03/21/24 to 04/01/124 revealed orders were written by Certified Nurse Practitioner (CNP) #104 and/or the Medical Director/Physician #105 on 03/21/24, 03/22/24, 03/25/24 to follow up with cardiologist regarding how long and why the resident needed to be on Heparin along with Brilinta (antiplatelet medication) (Brilinta was later interchanged to Plavix, also an antiplatelet medication) and Aspirin (anticoagulant medication and nonsteroidal anti-inflammatory medication). On 04/01/24 the order written by NP#104 indicated the Heparin needed clarified today due to having significantly worsening anemia. Also, an order was re-written on 04/01/24 by NP #104 that indicated the hemoccult need done as soon as possible for anemia and there was a note in parentheses that indicated the order was originally written on 03/29/24. Further review of the orders revealed NP#104's order for Hemoccult stool times two for anemia was actually written on 03/28/24. Review of Resident #16's laboratory results revealed the resident's Hemoglobin on 03/22/24 was 9.1 g/dL (13.3-17.7), 03/25/24 8.5 g/dL, 03/27/24 8.4 g/dL, 04/01/24 8.1 g/dL and 04/02/24 7.8 g/dL. Review of Resident #16's nurses note dated 04/01/24 revealed the writer spoke to the cardiologist to clarify the Heparin orders. The cardiologist reported the Heparin was just a therapeutic dose and new orders were received to discontinue the Heparin. Interview on 04/02/24 at 8:46 A.M. with Certified Nurse Practitioner (CNP) #104 revealed the resident was admitted on the 20th or 21st with orders for Brilinta, Aspirin, and Heparin. Physician #105 wrote orders to call cardiologist for clarification on Heparin and she re-wrote the order once or twice and it was still not clarified as of 04/01/24. Yesterday (4/01/24) she had the Assistant Director of Nursing (ADON) #128 call to get clarification on the Heparin due to the resident's Hemoglobin having dropped from 11 to 8 g/dL. The cardiologist reported the resident didn't need the Heparin. CNP #104 reported she was upset the resident was on Heparin for 10 days and the resident could have possibly bled out with the combination of all three drugs (Heparin, Plavix, and Aspirin) and staff never clarified the order. CNP #104 reported pharmacy had interchanged the Plavix for the Brilinta, which she had verbally told staff she didn't want it interchanged. Interview on 04/02/24 at 2:39 P.M. with Clinical Service Manager (CSM) #102 confirmed there was no documented evidence the cardiologist was contacted to clarify heparin order per the physician's order written on 03/21/24, 03/22/24, and 03/25/24. CSM #102 confirmed there was no evidence the hemoccult cards were collected per orders written on 03/28/24. CSM #102 confirmed a progress note written on 03/29/24 indicated the resident had a bowel movement, however there was no evidence the hemoccult sample was collected. Interview on 04/03/24 at 7:36 A.M. with Resident #16 and CSM #102 revealed the resident reported staff just told him the day before yesterday about needing a stool sample, however they just brought him the supplies yesterday afternoon to collect the stool and he had already had a bowel movement earlier that day. The resident denied active rectal bleeding or any abnormal bleeding/bruising. Review of Resident #16's progress note dated 04/08/24 revealed the resident's hemoccult card was positive. The provider ordered a gastrointestinal (GI) consultation. (Resident #16's medical record did not contain the exact date when the hemoccult test was completed). 2. Record review revealed Resident #44 was admitted to the facility on [DATE] with diagnoses including type II diabetes mellitus, heart disease, malignant neoplasm of part of the lung, acquired absence of the lung, age-related physical disability, and neuropathy. Review of Resident #44's hyper/hypoglycemia plan of care dated 03/24/24 revealed to give medication as ordered and monitor lab values per physician order. Review of Resident #44's admission orders dated 03/11/24 revealed Humalog insulin inject as per sliding scale: if 200-249 = 2 units, 250-299 = 4 units, 300-349 = 6 units, 350-399 = 8 units, and 400 and above give 10 units and call the provider. Administer subcutaneously before meals and at bedtime for diabetes. Keep refrigerated before opening. Review of Resident #44's Medication Administration Records (MAR) dated March 2024 revealed on 03/18/24 the 11:30 A.M., blood sugar was taken at 2:39 P.M. and 4 units of insulin was administered and the 4:30 P.M. blood sugar was taken at 5:18 P.M. and Resident #44 received 4 units of insulin. On 03/21/24 the 11:30 A.M., blood sugar was taken at 1:21 P.M. and administered 2 units of insulin, the 4:30 P.M. blood sugar was taken at 6:16 P.M. and the resident was administered 2 units of insulin. On 03/22/24 the 4:30 P.M. blood sugar was taken at 6:14 P.M., and the resident was administered 2 units of insulin. Interview on 03/28/24 at 8:15 A.M., with Resident #44's wife revealed she had concerns the nurses were checking Resident #44's blood sugar after he had eaten his meals which required him to have insulin administered based on the results after he had eaten. Resident #44's wife reported the resident was receiving insulin unnecessary due to his blood sugar being high after he has eaten, and the staff should have checked his blood sugar before his meals. Interview on 03/28/24 at 2:13 P.M., with Registered Nurse (RN) #128 revealed Resident #44 meals are delivered at 7:45 A.M., 11:45 A.M., and 4:45 P.M. Interview on 04/01/24 at 7:58 A.M. and 8:53 A.M. with the Director of Nursing (DON) confirmed per the MAR Resident #44's blood sugar check was obtained after the resident ate a meal and insulin was administered after meals on 03/18/24, 03/21/24, and 03/22/24. The DON confirmed the blood sugars and insulin should have been administered prior to meals per the physician orders. The DON reported the facility didn't have a policy or procedure for obtaining blood sugar and the nurse should follow the doctors' orders. Interview on 04/01/24 at 8:21 A.M. with Certified Nurse Practitioner (CNP) #104 confirmed the resident's blood sugar and insulin should be taken prior to meals so it can be accurately regulated. CNP #104 reported if the resident's blood sugars were taken after meals the blood sugars would be elevated requiring additional insulin which would also affect Resident #44's treatment plan. This deficiency represents non-compliance investigated under Master Complaint Number OH00152295 and Complaint Number OH00151794.

Based on record review, interview, and policy review, the facility failed to provide Resident #67 a safe discharge and failed to provide the resident or resident representative with required documentation upon discharge. This affected one resident (#67) of one resident reviewed for discharge. The facility census was 65 residents. Actual Harm occurred on 03/16/24 (four days after admission), when Resident #67, who was admitted with primary diagnosis of post-surgical hip repair, was immediately discharged without a safe place to be discharged to, after being observed in the facility parking lot on one occasion smoking and taking sips of alcohol. Following the resident's discharge, she did not have a safe place to go, the resident was transported to the emergency room by a friend where she was subsequently admitted to the hospital as the resident was assessed/deemed unsafe to return home and the facility refused to re-admit the resident. Findings include: Record review revealed Resident #67 was admitted to the facility on [DATE] and was discharged on [DATE]. The resident's diagnoses included orthopedic aftercare, fracture of lower end of right femur, presence of right artificial joint, asthma, pneumonia, acute kidney failure, bronchitis, dorsalis, heart disease, hypertension, gastro-esophageal reflux disease, hernia, osteoarthritis, history of falling, difficulty walking, and need for assistance with personal care. Review of Resident #67's admission progress note dated 03/12/24 revealed the resident arrived at the facility via stretcher from the hospital. The resident was in a pleasant mood, alert, and oriented times four. Resident #67 had a port to the right upper chest with a single lumen. The resident had a surgical incision to the hip extending down to the posterior knee. The resident was in severe pain, rated a 10 on a scale of one to 10 with 10 being the most severe pain. The facility was awaiting pharmacy to deliver medications. Review of Resident #67's progress notes dated 03/13/24 revealed the resident was sent to the emergency room (ER) with uncontrolled pain at 4:46 A.M., due to the facility being unable to administer the resident ordered pain medication due to the pharmacy not delivering the medication. The resident returned from theER on [DATE] at 5:10 P.M. via stretcher. The resident was in an unpleasant mood, irate, and irritable. The resident began vomiting and non-pharmacological interventions were attempted to alleviate the vomiting. Review of Resident #67's progress note dated 03/16/24 (Saturday) at 5:54 P.M. revealed the resident was discharged from the facility after being seen earlier smoking marijuana and drinking alcohol. The resident reported she had a medical marijuana card, and it helped her calm down. The resident reported she only had a few sips of alcohol and she had hit a couple joints. The Director of Nursing (DON) contacted the Administrator to determine what the proper channel would be. The facility Medical Director/Physician #105 was notified, and all agreed that she would be immediately discharged . The resident was given all medication including narcotics. The writer went over the discharge with her and told the resident if she had any issue to call 911 or to be taken to the nearest ER. Discharge papers were sent with the resident's friend who was taking her home. The resident was sent home in a wheelchair to make sure the resident could get around safely. The police escorted the resident out. The resident did become loud with staff saying she wanted to know how and why she was being discharged and the police told her to come with them as they could not change the decision. The resident was discharged for violating facility policy. Further review of the electronic and paper medical record revealed no evidence of discharge paperwork. Review of Resident #67's hospital emergency department note dated 03/16/24 at 7:30 P.M. revealed the resident was a [AGE] year-old female who presented to the ER for evaluation of back pain and bilateral leg pain. She recently had orthopedic surgery for right femur fracture and was sent to a local skilled facility for aftercare. Today there was an incident at the facility, and she was forcibly removed. Afterwards she did not know where to go so a family member picked her up and dropped her off at the ER. She has chronic back pain and pain from surgery on her right leg. She was not able to go home because she could not care for herself. Due to the resident walking on her leg and worsening pain will obtain an x-ray of right leg. The resident would also need to be placed (for continued medical/nursing care). Review of the hospital record revealed the x-ray showed a periprosthetic fracture of the distal femur on the right which appears slightly more displaced compared to the previous x-ray. The physician called a specialist to discuss, and he stated since the fracture had already been internally fixated that there would be no interventions indicated. The writer called for admission, and the resident was accepted for placement for pain control. Review of Resident #67's hospital note date 03/16/24 revealed the resident had a right distal femur fracture repair approximately one week ago. The resident also noted she had fractured her left fifth metatarsal. She was forcibly removed from the facility by staff and law enforcement after she was found drinking alcohol (ethanol level was undetectable). The resident admitted she had a couple sips. The resident reported she was unable to return home because she was not able to care for herself nor complete her activities of daily living as she could not bear weight on either leg. Review of the hospital record revealed a call was placed to this skilled nursing home and the facility reported they would not be willing to take the resident back due to the resident threatening staff and overall behavioral issues. Case management attempted to be contacted but were not available to assist with further placement at this time. Review of hospital orthopedic note dated 03/17/24 revealed the resident had uncontrolled pain after surgery to right femur and a fractured left fifth metatarsal fracture. Order for non-weight bearing to right lower extremity and weight bearing as tolerated to left lower extremity in boot. During the onsite investigation, it was determined the resident was currently residing in her home (after receiving hospital treatment). The resident was discharged home from the hospital on 03/22/24. Interview on 03/26/24 at 1:22 P.M. and 04/08/24 at 10:00 A.M. with the Medical Director/Physician #105 confirmed Resident #67 was improperly discharged when she was found outside smoking and drinking wine. Physician #105 reported the facility had called after the decision was made discharge the resident on 03/16/24. It was her understanding they were sending the resident to the ER. Physician #105 reported she had spoken to the facility Monday (03/18/24) morning regarding her concerns with the discharge not being appropriate. Physician #105 was not aware of any concerns that would have warranted an immediate discharge such as the resident being of harm to herself or others. Interview on 04/08/24 at 10:22 A.M., with Registered Nurse (RN)/ Assistant Director of Nursing (ADON) #128 reported when a resident was discharged there was a form under the assessment tab that would be completed and a copy would be signed and given to the resident upon discharge, however there was no discharge assessment started or completed for Resident #67. The RN/ADON #128 looked through the paper medical record as well with the surveyor and was not able to locate any discharge paperwork. Interview on 04/08/24 at 11:08 A.M. and 12:05 P.M. with Clinical Service Manager (CSM) #102 reported Resident #67 was issued an immediate discharge notice for violating the facility's smoking policy. CSM #102 confirmed the facility was not able to locate any evidence of discharge paperwork for Resident #67. CSM #102 confirmed the discharge paperwork should have been documented under the assessment tab in the electronic medical record and there was no evidence it was completed. CSM #102 reported she was not able to locate any documented evidence of discharge paperwork in the resident's paper chart either. Interview on 04/08/24 at 11:32 A.M. with Assistant Administrator (AA) #137 confirmed the facility was a smoking facility. The residents had designated times and smoking areas for use. Interview on 04/08/24 at 11:58 A.M. with Resident #67 revealed she was told she was discharged from the facility for drinking alcohol, and she was only given a bag of pills upon discharge. She was not given instructions on how to take the medication, no wound supplies or instruction, and no home health services or equipment were arranged. The resident reported she had only taken a few sips of her friend's wine cooler. The resident reported she had nowhere to go upon discharge (from the facility on 03/16/24) because she could not get into her house. The resident reported she ended up going to the ER because she was non-weight bearing and had no place to go. The resident reported she was not safe to return home because she could not care for herself. At the time of the interview, the reisdent was still upset about the discharge and continued to feel that she could not provide care for herself, she still did not have supportive services arranged including equipment. Review of the facility policy and procedure titled Resident Transfer and discharge date d 06/08/22 revealed it was the facility policy to permit each resident to remain in the facility and not to transfer or discharge a resident, unless the transfer or discharge meets the criteria identified in this policy. A facility-initiated transfer or discharge was one in which the resident objects to, did not originate through a resident's verbal or written request, and/or is not in alignment with the resident's stated goals for care and preferences. If a facility-initiated discharge was determined the interdisciplinary team (IDT) would determine whether one of the following conditions exist: The resident improved and no longer needs services, the facility cannot meet the resident's needs, the resident or other individuals would be endangered, or the resident failed to pay for their stay. Continued review of the policy revealed once the IDT determine a discharge was appropriate, the following would be documented in the record. The reason for discharge. If a resident's need could not be met, the documentation would include what specific needs that could not be met. If the reason for the discharge was because the resident no longer needs nursing home services or because the facility can no longer [NAME] the resident's needs, the required documentation supporting those reasons must be completed by the resident's physician. If the reason for the discharge was because the health or safety of the resident or individuals in the facility was endangered, the documentation supporting those reasons must be completed by any physician. Appropriate discharge planning, including any resident and/or family education and referrals. Once a determination was made the resident discharge was appropriate, a written discharge notice would be issued to the resident and a copy to the office of general counsel, the department of health, and the long-term care ombudsman. The notice must include the reason of discharge, the proposed date of discharge (not the date must be 30 days from the sate the notice was issued), a statement that the resident would not be discharged before the date specified in the notice, the proposed location of discharge (which must meet the resident safety needs), the statement that the resident has the right to appeal, the name, address ,and telephone number of the state long term care ombudsman. The written notice must be provided to the resident at least 30 days in advance of the proposed discharge, unless any of the following applies: resident health has improved sufficiently, the resident has resided in the facility for less than thirty days, and emergency exist where the safety of individuals in the facility was endangered or the health of the individual in the facility would otherwise be endangered or the resident has urgent medical needs that require a more immediate or discharge. If a resident was to be discharged for any of the above reasons notice should be provided as many days in advance of the proposed transfer or discharge as was practicable. The IDT would provide the resident with appropriate preparation prior to discharge to ensure a safe and orderly discharge in accordance with the facility discharge planning policy. If a resident request an appeal of the discharge, the facility will not discharge the resident while the appeal was pending, unless the failure to discharge the resident would endanger the health and safety of the resident or other residents in the facility. Review of the facility policy and procedure titled Resident Smoking, (dated 06/08/22) revealed the admission coordinator or designee will inform the resident in writing, at the time of admission, regarding the facility smoking policy and resident responsibility. If a resident was unable to adhere to the facility smoking policy, facility Administration may determine this ground for immediate discharge if it impedes the safety of this and/or other residents. This deficiency represents non-compliance investigated under Master Complaint Number OH00152295.

Based on observations, record review, policy review and interview the facility failed to develop and implement a comprehensive and individualized pressure ulcer prevention program to ensure timely, accurate and thorough pressure ulcer assessments were completed and to ensure adequate interventions and treatment was in place to promote healing and prevent new ulcers from developing. This affected three residents (#29, #30, and #41) of three residents reviewed for pressure ulcers. The facility census was 65. Actual Harm occurred on 04/03/24 when Resident #29, who exhibited severe cognitive impairment, had current pressure ulcers present and required substantial/maximal assistance for bed mobility and total dependence for toileting was assessed to have new in-house developed pressure ulcers. The resident was assessed to have an unstageable (Full-thickness skin and tissue loss in which the extent of tissue damage within the ulcer cannot be confirmed because the wound bed is obscured by slough or eschar) pressure ulcer to the left buttock and a Stage II (Partial-thickness loss of skin with exposed dermis, presenting as a shallow open ulcer. The wound bed is viable, pink or red, moist, and may also present as an intact or open/ruptured blister) pressure ulcer to the right buttock. The facility failed to identify the left buttock ulcer until it was unstageable. The new pressure ulcer development occurred due to the lack of adequate interventions including turning and repositioning. Actual Harm occurred on 09/20/23 when Resident #30, who exhibited severe cognitive impairment, had current pressure ulcers present and required moderate assistance with toileting and bed mobility was assessed to have two new in-house acquired pressure ulcers. An unstageable pressure ulcer to the right lower leg and a Stage II pressure ulcer to the right heel. The facility failed to identify the right lower leg pressure ulcer until it was unstageable. The new pressure ulcer development occurred due to the lack of adequate interventions including turning and repositioning and off-loading of the resident's heels. Actual Harm occurred on 02/28/24 when Resident #41, who required staff assistance for turning and repositioning was assessed to have a deterioration in status of a coccyx pressure ulcer with an increase in the presence of slough tissue. In addition, on 03/18/24 the resident was assessed to develop a new in-house acquired Stage II pressure ulcer to the right heel. The resident complained of increased pain to the right heel and voiced concerns staff failed to provide turning and repositioning interventions as needed to prevent the development and/or deterioration. In addition, the new pressure ulcer to the right heel developed due to a lack of adequate interventions including off-loading of the resident's heels. Findings include: Review of facility documentation revealed the facility identified six residents as having pressure ulcers (including Residents #29, #30, and #41). None of the pressure ulcers were identified as facility acquired. Review of a wound log provided by the facility identified Residents #29 and #30 had been identified to have a decline in the status of their ulcers. At the time of the survey, there were 21 residents on the 200 hall, 17 residents on the 300 hall (where Resident #29, #30, and #41 resided), and 21 residents on the 400 hall. The facility identified 24 residents as being dependent for bathing, dressing, and transferring. The facility identified 31 residents as requiring 1-2 staff assistance for bathing, dressing, and transferring. Interviews with direct care staff revealed a lack of staffing contributed to the development and deterioration of the pressure ulcers for these residents: Interview with Nursing Assistants #117, #118, #122, and #127, on 03/28/24 between 11:00 P.M. and 11:55 P.M. and 04/01/24 at 3:05 P.M. revealed there was one nursing assistant per hallway on the 7:00 P.M. to 7:00 A.M. shift. and residents were neglected as staff were not able to provide the care needed, including turning and repositioning residents and providing incontinence care every two hours as required. Staff stated it was just survival there in getting things done that need to be done. During the interview, the STNA revealed Resident #29 would lay on her sides and would wear heel protector boots when they were applied by staff. 1. Review of the medical record for Resident #29 revealed an admitted [DATE] and diagnoses including diabetes and acute kidney failure. Review of an admission nursing assessment dated [DATE] revealed the resident had a Stage II (partial-thickness loss of skin with exposed dermis, presenting as a shallow open ulcer) pressure ulcer on the coccyx, a Stage I (intact skin with a localized area of non-blanchable erythema (redness) , described as a diabetic ulcer to the right heel, and an unstageable diabetic ulcer on the left heel. Record review revealed there were no descriptions or measurements of the areas completed at this time. Physician's orders were obtained on 11/17/23 to offload heels in bed as tolerated and turn and reposition as tolerated and as needed. Review of a Minimum Data Set (MDS) assessment completed 11/21/23 revealed the resident had a Brief Interview for Mental Status (BIMS) score of 12 (moderate cognitive impairment). The assessment revealed Resident #29 required substantial/maximal assistance with rolling left to right and was dependent for dressing, bathing, and toileting. The assessment noted the resident had two unstageable pressure ulcers. Review of weekly wound notes by the wound nurse practitioner revealed on 11/22/23 the resident was noted with moisture associated skin damage (MASD) of the sacrum measuring 3.5 cm by 4.5 cm by 0.1 cm deep. The left heel was noted to be an unstageable pressure ulcer measuring 4.5 cm by 4.3 cm. with 100% necrosis. The right heel was noted to be an unstageable pressure ulcer measuring 2 cm by 2.5 cm with 100% necrosis. The note stated to turn and reposition the resident every two hours. Review of weekly wound notes by the wound nurse practitioner on 11/29/23 revealed the ulcer measurements remained the same. Recommendations included to keep heels off the bed, heel protector boots, turn and reposition every two hours. Review of the plan of care dated 12/01/23 revealed the resident was noted with an activities of daily living/mobility deficit. Interventions included transfer with two assists, provide total assistance with bed mobility, mechanical lift with two assist, and total dependence with toileting. On 12/04/23 potential for alteration in skin integrity related to immobility and history of skin breakdown was added. Interventions included treatments as ordered, encourage to offload heels as tolerated, turn and reposition as needed, and use pillows/pads to support/position as appropriate. (The use of Prevalon boots was not part of the plan of care until 03/31/24). The resident was hospitalized from 12/04/23 to 12/10/23. Upon return on 12/10/23, Resident #29 was noted to have an unstageable pressure ulcer on the coccyx measuring 2.0 cm by 1.5 cm, an unstageable pressure ulcer on the right heel measuring 2.5 cm by 2.5 cm, a Stage II pressure ulcer on the sacrum measuring 2 cm by 0.5 cm by 0.1 cm, a Stage II pressure ulcer on the right buttock measuring 1.5 cm by 1 cm by 0.1 cm deep, and an unstageable pressure ulcer on the left upper spine measuring 0.5 cm by 1.5 cm. (The left heel was not mentioned). Review of wound care notes by the Wound Nurse Practitioner dated 12/20/23 revealed Resident #29 was noted to have an unstageable pressure ulcer of the left heel measuring 4.5 cm by 4.3 cm with 100% necrotic tissue; an unstageable pressure ulcer of the right heel measuring 2 cm by 2.5 cm with 100% necrotic tissue; a MASD wound of the sacrum measuring 6.5 cm by 2.5 cm by 0.1 cm deep; no other areas were noted. The wound status was noted to be declined. The note stated to keep heels off bed, heel protector boots, turn and reposition every two hours. The resident was seen at an outside wound clinic on 12/21/23 and was noted to have pressure ulcers on the coccyx (3 cm by 0.8 cm by 0.2 cm); right gluteus (1 cm by 0.5 cm by 0.1 cm); left heel (5 cm by 5 cm by 0.1 cm) and right heel (2 cm by 2 cm by 0.1 cm). Recommendations included Prevalon boots while in bed or float heels on pillows and turn from left to right every two hours and as needed. The resident was hospitalized from 12/27/23 until 01/08/24. Upon return, Wound Care notes from the wound nurse practitioner on 01/10/24 revealed the resident had the following pressure ulcers: left heel unstageable measuring 4.7 cm by 4 cm with 100% necrosis; right buttock Stage III (Full-thickness loss of skin, in which subcutaneous fat may be visible in the ulcer and granulation tissue and epibole (rolled wound edges) are often present) measuring 1.7 cm by 1 cm by 0.1 cm deep; sacrum Stage III measuring 4.7 cm by 0.6 cm by 0.3 cm deep. Again, recommendations were made for keeping heels off bed, heel protector boots, and turn and reposition every two hours. The resident was hospitalized from 01/14/24 to 01/20/24. On 01/24/24 the resident had physician's orders for turn and reposition as tolerated and off load heels in bed. Weekly wound notes dated 01/24/24 revealed the resident had the following pressure ulcers: Coccyx Stage III measuring 8.2 cm by 5.0 cm by 0.4 cm deep; right gluteus Stage II measuring 4.5 cm by 2.0 cm by 0.1 cm deep; left heel Stage III measuring 5.0 cm by 4.5 cm by 0.1 cm deep; right heel Stage III measuring 1.0 cm by 1.0 cm by 0.1 cm deep. On 02/01/24 the outside wound clinic recommended Prevalon boots in bed or float heels on pillows and turn every two hours. Interview with Clinical Services Manager #102 on 04/03/24 at 10:00 A.M. confirmed as of this date, Resident #29 did not have a physician's order for Prevalon boots. She stated the Prevalon boots had been added to the care plan on 03/31/24, even though they were recommended by the wound clinic initially on 12/21/23. A physician progress note on 03/05/24 revealed Resident #29 had unstageable pressure ulcers on her heels that were causing her a lot of pain. An MDS assessment completed 03/18/24 documented the resident had a BIMS score of 6 (severe cognitive impairment) and was dependent on staff for rolling left to right, toileting, dressing, and transfers. Observations on 03/26/24 at 1:35 P.M. and 3:45 P.M. revealed Resident #29 was in bed on her back with the head of the bed elevated. The resident did have heel boots on both feet at those times. Observations on 03/27/24 at 9:38 A.M., 11:17 A.M., and 1:54 P.M. revealed Resident #29 was in bed on her back with slippers on (no heel protector boots) and her heels were resting on a pillow. On 03/27/24 wound notes by the wound nurse practitioner revealed the resident had an unstageable pressure ulcer on the left heel measuring 4.2 cm by 4.5 cm by 0.2 cm with 75% necrotic tissue and 25% slough, an unstageable pressure ulcer on the right heel measuring 2 cm by 2.6 cm by 0.1 cm deep with 90% slough and 10% granulation, and a Stage III pressure ulcer on the sacrum measuring 8.8 cm by 2.2 cm by 0.3 cm deep with 75% slough and 25% granulation. Recommendations included keeping heels off bed, heel protector boots, and turn and reposition every two hours. Observations on 03/28/24 at 8:41 A.M. and 10:38 A.M. revealed the resident was in bed on her back with her heels resting on a pillow (no heel protector boots on). At 10:38 A.M. the resident had a flat pillow under her right side, but it did not tilt her enough to relieve pressure from her buttocks. At 12:11 P.M. the resident was in bed on her back with the staff feeding lunch. Interview with Certified Nurse Practitioner (CNP) #104 on 04/01/24 at 8:15 A.M. revealed Resident #29 should have Prevalon boots on and she should be turned so that the pressure was off her buttocks. Review of the March 2024 treatment administration record for Resident #29 revealed off loading heels in bed (ordered 01/24/24) was not documented as completed on 03/07/24, 03/12/24, 03/13/24, and 03/14/24. Turning and repositioning as tolerated and as needed (ordered 01/24/24) was not documented as completed on 03/07/24, 03/12/24, 03/13/24, and 03/14/24. Application of heel boots was not listed on the March 2024 treatment administration record. Interview with Nursing Assistant #122 on 04/01/24 at 3:05 P.M. Resident #29 would lay on her sides and would wear heel protector boots when they were applied by staff. Interview with Clinical Services Manager #102 on 04/03/24 at 10:00 A.M. confirmed the resident's pressure areas were not measured until 11/22/23 and should have been measured upon admission. She confirmed the resident's right heel was noted as a Stage I upon admission and on 11/22/23 was noted with necrosis which appeared to be a decline in the ulcer. Observation of the treatments for Resident #29 on 04/03/24 at 11:20 A.M. revealed the resident was in bed on her back. The resident had heel protector boots on but not Prevalon boots (have a cut out area near the heel to avoid any pressure at all on the heels). The resident was observed to have a 3.5 cm by 5.5 cm by 0.2 cm deep area on the left heel with 75% brown necrotic tissue covering the wound and 25% granulation. She had a 3.5 cm by 4 cm by 0.1 cm deep area on the right heel that was 75% slough and 25% granulation tissue. She had a 4 cm l by 1 cm open area on the coccyx that had 90% slough and 10% granulation described as unstageable. She also had two new areas on the buttocks: left upper buttock 2.5 cm by 4 cm unstageable with white slough and right upper buttock 0.5 cm by 0.5 cm by 0.1 cm Stage II open area. Interview with Assistant Director of Nursing #128 on 04/03/24 at 11:20 A.M. confirmed at the time of the observation, Resident #29 had developed two new pressure ulcers on her buttocks since the week prior which included an unstageable ulcer to the left upper buttock and a Stage II pressure ulcer to the right buttock. 2. Review of the medical record for Resident #30 revealed an admitted [DATE] with diagnoses including diabetes and adult failure to thrive. The resident also had diagnoses of Stage IV (full-thickness skin and tissue loss with exposed or directly palpable fascia, muscle, tendon, ligament, cartilage or bone in the ulcer. Slough and/or eschar may be visible on some parts of the wound bed. Epibole (rolled edges), undermining and/or tunneling often occur. Depth varies by anatomical location) pressure ulcer with osteomyelitis of the vertebrae, sacral, and sacrococcygeal areas and a deep tissue injury on the left heel present upon admission. The resident received Hospice services. On 07/11/23 the resident was noted to have an unstageable pressure ulcer to the coccyx measuring 14.5 cm by 6.3 cm by 2.4 cm deep with undermining, 50% slough 10% eschar. The resident had an unstageable pressure ulcer to the left hip measuring 7 cm by 6.5 cm by 3 cm deep with undermining with 50% slough/eschar. The resident had an unstageable pressure ulcer to the left heel measuring 4 cm by 6 cm by 0.1 cm deep with 25% eschar. Review of the plan of care dated 07/11/23 revealed the resident had an activities of daily living deficit. Staff were to provide extensive assistance with bed mobility. The care plan also noted the resident had alteration in skin integrity due to pressure ulcers and treatments were to be provided as ordered. Review of wound care notes by the Wound Nurse Practitioner revealed on 09/20/23 the resident continued with the Stage IV pressure ulcer on the coccyx (12 cm by 9 cm by 2 cm deep), Stage III pressure ulcer on the left heel (1.5 cm by 4 cm) and left posterior thigh (4.5 cm by 3.2 cm by 1.8 cm). The resident was now noted to have a new in-house developed pressure ulcer on the right heel, a Stage II pressure ulcer measuring 6 cm by 10 cm described as a blister that drained) and an in-house developed unstageable pressure ulcer on the right lateral lower leg measuring 9.5 cm by 1.5 cm. The wound care notes did not indicate how the areas developed. On 10/09/23 (following the development of the new in-house acquired pressure ulcers on 09/20/23) the plan of care revealed the resident had potential for altered skin integrity related to a history of skin breakdown, impaired mobility, and diabetes. Interventions included to encourage to off load heels as tolerated and encourage to turn and reposition as needed. The resident was hospitalized from 10/05/23 to 10/09/23. Upon return, on 10/11/23 the resident was noted to have unstageable pressure ulcer to the coccyx (12 cm by 8.5 cm by 1.2 cm deep), an unstageable pressure ulcer to the left hip (4 cm by 1.8 cm by 1.8 cm deep), a right lower leg pressure ulcer (9 cm by 1.5 cm), a left heel pressure ulcer (3.5 cm by 4 cm) and a right heel pressure ulcer (4 cm by 5 cm). On 10/09/23 the resident had physician's orders to off load heels in bed as tolerated, turn and reposition as tolerated and as needed, and Prevalon boots to be worn to bilateral feet at all times as tolerated. (There was nothing documented in the record to indicate the resident refused care). Review of a quarterly MDS assessment dated [DATE] revealed the resident had a BIMS score of 7 (severe cognitive impairment). The assessment revealed Resident #30 required moderate assistance with toileting and rolling in bed. The resident was dependent on staff for transfers. Observations on 03/26/24 at 1:33 P.M. revealed Resident #30 was in bed on her back (no pillows on either side). Her left heel was resting on a pillow and her right heel was resting on the mattress. She did not have Prevalon boots on. On 03/26/24 at 3:44 P.M. the resident remained in bed on her back. (The surveyor was unable to determine if boots were on as the resident was resting). Observations on 03/27/24 at 7:52 A.M., 9:35 A.M., and 11:15 A.M. revealed Resident #30 was in bed on her back. At 1:53 P.M. the resident was up in a wheelchair while the air mattress on her bed was changed. At 2:45 P.M. the resident was back in bed on her back. Observations on 03/28/24 at 8:36 A.M., 10:39 A.M., and 12:10 P.M. revealed Resident #30 was in bed with a flat pillow under her right side which slightly tilted her to her left side. Her upper body was tilted but her buttocks were still resting on the mattress. Interview with Certified Nurse Practitioner (CNP) #104 on 04/01/24 at 8:15 A.M. revealed Resident #30 should have her Prevalon boots on in bed. She stated that the resident did have pain with movement but staff should attempt to turn the resident, so she is off of her bottom. Interview with Nursing Assistant #122 on 04/01/24 at 3:05 P.M. revealed Resident #30 would wear the Prevalon boots when applied by staff. Review of the March 2024 Treatment Administration Record (TAR) for Resident #30 revealed a treatment to the right heel of paint with betadine every day was completed through 03/06/24. There was no evidence of treatment to the area from 03/06/24 until 03/26/24. In addition, Prevalon boots at all times, off load heels while in bed, and turn and reposition as tolerated were not documented as completed on 03/07/24, 03/12/24, 03/13/24, 03/14/24, 03/15/24, and 03/18/24. Review of the wound care notes by the wound nurse practitioner dated 03/27/24 revealed the resident's left heel was healed. The pressure ulcer on the coccyx was noted to be Stage IV, measuring 7 cm by 6 cm by 0.8 cm deep (smaller in size). The left posterior thigh was 1.4 cm by 1.4 cm by 1.1 cm deep (smaller in size). The right heel was unstageable (3.2 cm by 2.2 cm by 0.1 cm) smaller in size. The right lateral lower leg was an unstageable pressure ulcer and measured 13 cm by 1.2 cm by 0.2 cm (larger in size since last readmission 10/09/23). Interview with ADON #128 on 04/03/24 at 8:25 A.M. and 8:50 A.M. confirmed there was no evidence Resident #30 had refused any treatment related to pressure ulcers. She confirmed the TAR lacked documentation that treatments were completed as ordered. She confirmed the pressure ulcer on the right heel developed in the facility and did not have treatment provided to it from 03/06/24 until 03/26/24. She stated the resident's pressure ulcers on the right heel and right lower leg were noted as declined on the pressure ulcer grid provided to the surveyors as the areas had gotten larger. She stated the pillows used by the facility were not thick enough to use for turning/repositioning to be able to alleviate pressure off of the residents' buttocks/backside. 3. Review of the medical record for Resident #41 revealed an admitted [DATE] with diagnoses including Parkinson's disease and chronic pain syndrome. Review of an admission nursing assessment dated [DATE] revealed a skin assessment which indicated a pressure ulcer on the coccyx. There was no size, description, or staging of the area. No pressure ulcers were noted to the heels. The assessment indicated the resident was at high risk for skin breakdown. The assessment indicated that friction and shear was a problem (sliding against sheets), and that heel elevation would be implemented. The resident had physician's orders on 01/20/24 to off-load heels while in bed as tolerated and turn and reposition as tolerated and as needed. Review of the wound nurse practitioner (WNP) notes on 01/24/24 revealed Resident #41 had a Stage III pressure ulcer on the coccyx with yellow slough measuring 3.7 centimeters (cm) long by 3.5 cm wide by 0.1 cm deep. The note indicated there was 90% granulation and 10 % slough. (Slough is non-viable yellow, tan, gray, green or brown tissue; usually moist, can be soft, stringy and mucinous in texture. Slough may be adherent to the base of the wound or present in clumps throughout the wound bed). The note stated to keep pressure off ulceration and avoid friction and shearing. An MDS assessment completed 01/25/24 documented the resident had a BIMS score of 13, indicating intact cognition. The assessment revealed the resident was dependent upon staff for toileting, showering, dressing, hygiene, rolling in bed, and transfers. The MDS indicated the resident had one Stage III pressure ulcer on admission. Review of the plan of care for Resident #41 dated 01/25/24 revealed an activities of daily living/mobility/functional ability performance deficit. Interventions included transfer with assist of two, provide total assist with bed mobility, provide total assist with transfer, and incontinence care after each episode. The plan of care on 01/18/24 revealed the resident had an unstageable pressure ulcer to the coccyx and to provide treatments as ordered. The plan of care on 02/04/24 revealed the resident had a potential for alteration in skin integrity related to history of skin breakdown, immobility, and incontinence. The goal was not to develop further skin breakdown. The interventions included pressure redistribution mattress to bed, turn and reposition as needed using lift pad to minimize friction and shear, and educate resident as to causes of skin breakdown including frequent positioning. (The interventions did not include Prevalon boots or floating heels). The plan of care on 03/19/24 revealed the resident had an alteration in skin integrity of self-inflicted friction blister on right heel. The interventions included treatments per order. (The plan of care also did not include the use of Prevalon boots or floating heels). Review of the medical record revealed on 02/08/24 Resident #41 went to the outside wound clinic. An unstageable pressure ulcer to the coccyx was noted measuring 4.5 cm long by 3 cm wide by 0.1 cm deep with purulent exudate. Recommendations from the wound clinic included Prevalon heel boots daily and turn every two hours. On 02/19/24 the resident returned to the outside wound clinic. An unstageable pressure ulcer to the coccyx was noted measuring 4.5 cm long by 4 cm wide by 0.1 cm deep with slough noted. Recommendations included Prevalon heel boots daily and turn every two hours. On 02/28/24 the WNP notes indicated the pressure ulcer on the coccyx was a Stage III with yellow, soft, black slough measuring 4 cm long by 2.5 cm wide by 0.1 cm deep. The note indicated the wound now had 90 % slough and 10 % granulation. The resident was hospitalized from 03/02/24 to 03/09/24. A late entry nurse's progress note, dated 03/13/24 revealed as of 03/09/24 the pressure ulcer on the coccyx measured 3.5 cm long by 2.5 cm wide. No depth was documented. 100% slough/necrosis noted. A treatment to the area started on 03/10/24 of applying small amount of iodosorb ointment to wound bed, cover with gauze, secure with Allevyn once daily. The treatment was not documented as done on 03/11/24, 03/13/24, and 03/19/24. A physician's order was written on 03/06/24 for Prevalon boots at all times in bed as tolerated. Review of the record revealed on 03/17/24 physician's orders for turn and reposition as tolerated and as needed-use lift pad to minimize friction and shear, and off load heels while in bed as tolerated were obtained post hospitalization . Record review revealed on 03/18/24 at 11:11 A.M. nurses progress notes indicated the resident was rubbing his foot back and forth on the bed. The resident stated, that is how I scratch my foot. Fluid filled blister on right heel measuring 2 cm by 1.5 cm by 0.1 cm deep. On 03/18/24 an additional order was written to encourage to wear Prevalon boots while in bed (even though already ordered previously on 03/06/24). Review of the treatment administration record for March 2024 revealed that the Prevalon boots were not documented as applied on 03/12/24, 03/13/24, 03/14/24, and 03/15/24 (the days leading up to the development of the blister on the right heel). In addition, offloading of the heels was not documented as done on 03/12/24, 03/13/24, 03/14/24, and 03/15/24 and turning/repositioning was not documented as done on 03/12/24, 03/13/24, 03/14/24, and 03/15/24. There was no evidence of refusals. On 03/19/24 a treatment was started for an area to the right heel noted as a self-inflicted friction blister. The area was to be cleansed with wound cleanser, pat dry, apply puracol to area and cover with foam every day. Review of wound practitioner notes on 03/20/24 revealed Resident #41 had a new friction blister that opened from the resident repeatedly rubbing his heel against the bed measuring 2.5 cm by 1.3 cm by 0.1 cm with pink granulation. The resident's Stage III pressure ulcer to the coccyx measured 3 cm by 3 cm by 0.3 cm deep. The area was noted with 10% granulation and 90% slough. Review of notes from the outside wound clinic on 03/29/24 revealed Resident #41 had a Stage III pressure ulcer on the coccyx measuring 3 cm by 2.3 cm by 0.6 cm deep with slough. The resident was noted to have a pressure injury on the right heel measuring 2.1 cm by 2.0 cm by 0.2 cm deep. It was noted as a stage two pressure ulcer. Record review revealed the pressure ulcer to the resident's right heel was not properly identified by the facility as being a pressure ulcer and was not listed on their pressure ulcer log provided to the surveyors. Interview with Resident #41 on 03/26/24 at 1:22 P.M. revealed the treatments for his pressure ulcer were to be done daily but were not always done daily. He stated the staff did not turn him every two hours. He stated the facility was understaffed. He stated he sits up in his wheelchair until he becomes uncomfortable and then staff assist him to bed. The resident was observed in the wheelchair at the time of this interview. Interview with Certified Nurse Practitioner (CNP) #104 on 04/01/24 at 8:15 A.M. revealed Resident #41 never should have developed the friction area on his right heel if he had the Prevalon boots on or if his heels were elevated as ordered. CNP #104 confirmed she had no knowledge of the resident refusing to wear the Prevalon boots or float heels. Interview with Resident #41 on 04/01/24 at 9:55 A.M. revealed he had not refused his Prevalon boots recently as they benefit him. Interview with Assistant Director of Nursing (ADON) #128 on 04/01/24 at 10:25 A.M. confirmed the pressure ulcer to the resident's coccyx had declined in the percentage of granulation tissue to slough from 01/24/24 to 02/28/24. ADON #128 confirmed the lack of documentation on the March 2024 treatment administration to indicate treatments were done as ordered and Prevalon boots were applied as ordered. She stated the resident refused to wear them but confirmed there was no documentation of this. She confirmed the plan of care was silent to the need for Prevalon boots or floating heels or refusal of care. She stated that, although the physician's orders and plan of care indicated to turn and reposition as needed, residents, including Resident #41 should be turned every two hours. ADON #128 confirmed the pressure ulcer on Resident #41's coccyx was not measured until 01/24/24. She confirmed it should have been assessed and measured on admission. Observations on 03/26/24 at 3:47 P.M. revealed Resident #41 was still sitting up in the wheelchair. Observations on 03/27/24 at 7:35 A.M. and 9:35 A.M. revealed the resident was in bed on his back (no positioning pillows noted in the bed). At 11:18 A.M. and 1:50 P.M. the resident was observed up in the wheelchair. (All observations identified the resident had pressure to the ulcer on the coccyx). Observations on 03/27/24 at 2:00 P.M. of the treatments to the coccyx and right heel revealed an open area to the right heel measuring 1.8 cm by 0.8 cm by 0.1 cm deep. The resident complained of pain to the right heel during the treatment. The pressure ulcer on the sacrum measured 2.5 cm by 1.5 cm by 0.2 cm and contained yellow slough. The wound was described by the wound nurse practitioner as 75% slough and 25% red tissue. The skin around the ulcer was very red. The treatments were completed by the wound nurse practitioner and Assistant Director of Nursing #128. During the treatments, the wound nurse practitioner explained to the resident how important it was to stay off of his bottom for healing of the wound (even though the resident was dependent upon staff for transfers and repositioning). Upon completion of the treatments, the resident was left in bed on his right side with his heels resting on the mattress and without any Prevalon boots as ordered. Observation on 03/28/24 at 8:28 A.M. revealed the resident was sitting on the edge of the bed eating breakfast. At 10:40 A.M. and 12:08 P.M. the resident was up in the wheelchair (all observations revealed the resident had pressure to the ulcer on the coccyx). Review of the facility policy titled Pressure Ulcer Prevention Protocols/Risk Assessment, dated 11/30/23 revealed resident's level of risk for pressure ulcer development would initially be determined at the time of admission or readmission taking into consideration the nature of risk to include underlying causes. Residents were considered high risk when admitted with a pressure ulcer. Pressure ulcer preventative/supportive precautions would be implemented. This deficiency represents non-compliance investigated under Master Complaint Number OH00152295 and Complaint Number OH00151794.

Based on medical record review, staff interview, resident interview, and policy review, the facility failed to ensure a resident received services and assistance to maintain bladder continence and failed to ensure a resident received appropriate treatment and services to treat urinary tract infections. This affected two of 36 residents reviewed for quality of care (#25 and #29). The facility census was 66. Actual Harm occurred on 05/03/23 when Resident #25, who had been always continent of bladder as assessed to be frequently incontinent of bladder. The resident reported the increased incontinence was a result of having to wait on staff to assist him to use the urinal resulting in accidents/incidents of urinary incontinence. Actual Harm occurred on 12/08/23 to Resident #29 when she required re-hospitalization and admission for seven days for treatment of sepsis and bacteremia secondary to UTI requiring intravenous antibiotic administration and infectious diseases consult due to the facility's failure to administer intravenous antibiotics as ordered and obtain urine samples for analysis including culture and sensitivity. The facility continuously failed to follow physician orders related to the infectious disease consult as the consult was never completed even after Resident #29's physician continued to order the infectious disease consult on orders dated 12/11/23, 01/22/24, and 01/23/24. Findings include: 1. Review of the medical record for Resident #25 revealed an admitted [DATE] and diagnoses including peripheral vascular disease, chronic obstructive pulmonary disease, history of traumatic brain injury, and limited mobility. Review of an annual Minimum Data Set (MDS) assessment completed 03/26/23 revealed the resident was always continent of bladder. Review of a MDS assessment completed 05/03/23 revealed the resident was now frequently incontinent of bladder. There was no other screening assessment completed for the resident's bladder function until the 03/19/24 restorative screening was completed. Review of the plan of care for Resident #25 revealed on 12/17/23 an Activities of Daily Living/mobility deficit was noted. The goal was to maintain the current level of function in transfer, including toilet transfer. Interventions included: mechanical lift transfer with two assist; total dependence in toilet use (toilet transfer and toilet hygiene), and re-assess quarterly and as needed. On 02/16/24 an MDS assessment indicated the resident had a brief interview for mental status (BIMS) score of 15, indicating intact cognition. It further indicated the resident was dependent upon staff for toileting and was frequently incontinent of bladder. There was no evidence of an evaluation of the decline in Resident #25's urinary continence. Review of bladder documentation from 03/21/24 to 04/03/24 revealed the resident was documented to be incontinent on 03/27/24, 03/30/24, 04/01/24, and 04/02/24. The resident was continent on the other days. (Per interview with the Director of Nursing on 04/03/24 at 4:00 P.M., the bladder documentation is only available in the computer for 30 days prior). There was no evidence the facility identified Resident #25's bladder incontinence was identified by the facility. There was no evidence the facility had developed and implemented a plan to restore Resident #25's bladder to normal function. The facility provided a Restorative Screening assessment dated [DATE] for Resident #25. It indicated the resident required the use of a Hoyer (mechanical) lift for transfer. It stated the resident was always incontinent of bladder. It stated that a trial of a toileting program had not been attempted in the facility. The section on incontinence pattern was blank. The section on appropriate interventions based on assessment was blank. The reason for not starting a toileting program was blank. The facility also provided a physician progress note 02/08/24 that stated the resident had mild neurogenic bowel and bladder. On 04/01/24 the resident's plan of care included the resident had bladder incontinence. The interventions included check resident if he/she is continent, offer to assist with toileting, and if incontinent, provide incontinence care. Interview with Resident #25 on 03/27/24 at 10:33 A.M. revealed he can use a urinal to urinate. However, he likes to use it in bed and not while up in his wheelchair. He stated that he required the use of a Hoyer (mechanical) lift and two staff assistance to transfer to bed. He stated that there was usually only one aide working on each hall. Therefore, the aide had to go and find help when he wanted to be transferred to bed to use the urinal, and this takes a long time because the staff on the other halls were busy. He stated he has accidents and is incontinent of urine waiting on the staff to assist him to use the urinal. He stated the resident care at the facility had deteriorated. He stated the nursing assistants were stressed out and say they had a lot of work to do and then they quit. He stated the Director of Nursing told him they could not have any more nursing assistants until the census went up. (There were 21 residents residing on the hallway where Resident #25 lived). Interview with Nursing Assistants (#117, #118, #122, and #127) on 03/28/24 between 11:00 P.M. and 11:55 P.M. and on 04/01/24 at 3:05 P.M. revealed there was one nursing assistant per hallway on the 7:00 P.M. to 7:00 A.M. shift. Staff stated there were not enough staff to answer call lights timely. Staff stated if a resident required two staff for transfer, they had to go find someone on another hall to help and had to wait until that staff was not busy. Staff stated residents were neglected as staff were not able to provide the care needed including toileting assistance/incontinence care. Staff stated residents sometimes had to wait a long time to use the bathroom. Interview with Nursing Assistant #125 on 04/03/24 at 9:20 A.M. confirmed Resident #25 used a urinal. Nursing Assistant #125 stated the resident usually lays down to use the urinal and the bed pan with staff assistance. Nursing Assistant #125 confirmed the resident was incontinent at times but he/she did not know why. Interview with Director of Nursing (DON) #147 on 04/03/24 at 4:00 P.M. confirmed there had been no evaluation to determine why Resident #25 had declined in bladder continence. She confirmed the restorative screening assessment (dated 03/29/24) was not fully completed. The DON verified there was no evidence the facility identified Resident #25's bladder incontinence and there was no evidence the facility had developed and implemented a plan to restore Resident #25's bladder to normal function. Interview with Certified Nurse Practitioner (CNP) #104 on 04/04/24 at 10:45 A.M. revealed Resident #25 did have some urinary retention, but this did not explain a decline in continence. On 04/04/24 Assistant Administrator #137 provided information which indicated the facility did not have any residents on a restorative toileting program. Review of the facility policy titled Continence Programs, dated 06/08/22 revealed the purpose of continence programs included maintaining or improving bladder and/or bowel functioning. It stated: 1) residents who may be appropriate for a bladder and/or bowel program must fall into one of three different categories upon assessment: 2) all current residents who develop a continence problem in bladder and/or bowel, when there was no evidence of incontinence concerns when the initial MDS and quarterly reassessments were performed previously. 3) A resident who develops a continence problem which may be infrequent and warrants further investigation. Continence programs are designed for residents that are cognitively and physically able to participate in toileting activities. The policy stated an assessment should be completed and the types of continence programs were listed in the policy. 2. Review of the medical record for Resident #29 revealed an admitted [DATE] with diagnoses including diabetes and acute kidney failure. A Minimum Data Set (MDS) assessment completed 11/21/23 documented a BIMS score of 12, indicating moderately impaired cognition. It indicated the resident was dependent upon staff for dressing, bathing, and toileting. The resident was admitted to the facility from the hospital after being treated for sepsis shock and urinary tract infection. Upon admission on 11/15/23 the resident had a physician's order for Meropenem (an antibiotic to treat infections) 1 gram by intravenous every eight hours until 11/23/23. Hospital records indicated the resident got the last dose at the hospital on 11/15/23 at 11:50 A.M. The resident arrived at the facility at 7:50 P.M. Review of the medication administration record (MAR) for November 2023 revealed the facility set up the medication to start on 11/16/23 and to give at 12:00 A.M., 8:00 A.M., and 4:00 P.M. However, review of the MAR for November 2023 revealed the medication was not given at all on 11/16/23 and did not start until 12:00 A.M. on 11/17/23. Review of a physician's progress note on 11/20/23 revealed the resident had a temperature of 100.5 and was having increasing confusion. She did miss a dose of her IV antibiotics for her urinary tract infection. She missed that on 11/16/23. The patient would have her antibiotic extended for one dose as she did miss one dose on 11/16/23. Review of the MAR for November 2023 revealed the resident did get one additional dose on 11/24/23 (the resident received one additional dose even though she had actually missed three doses). Record review revealed a physician's order on 11/27/23 for a urinalysis by straight catheterization with culture if indicated. The urine specimen was collected on 11/28/23. The urine culture indicated gross contamination and suggested repeat if UTI still suspected. There was no evidence the urine culture was repeated. There was a physician's order for a urinalysis for culture and sensitivity on 11/30/23. However, there was no evidence that the urinalysis for culture and sensitivity was completed. Review of a physician's progress note on 12/04/23 revealed the resident recently had a UTI and was in the hospital. She also had some pneumonia and was treated with the antibiotic, Azithromycin. This morning her temperature was 101 and over the weekend it was 103. She reports chills and flank pain. The plan was to send the resident to the emergency room . The resident was admitted and remained in the hospital until 12/10/23. Review of hospital records dated 12/08/23 revealed the resident was admitted with sepsis and bacteremia secondary to UTI. Urine culture growing ESBL-E-coli. Infectious disease consulted and plan for Ertapenem (antibiotic) at discharge for 14 days. Resident #29 returned to the facility on [DATE] at 5:18 P.M. The resident had a physician's order for Ertapenem 1 gram intravenous every 24 hours for 14 doses. It was set up to start on 12/11/23. However, review of the December 2023 MAR revealed it was documented as not available on 12/11/23. The resident received the dose on 12/12/23. However, the dose was not documented as given on 12/13/23 as the resident went out to the hospital and returned on the same day. The resident received 12 additional doses from 12/14/23 to 12/25/23 for a total of 13 doses. A physician's progress note dated 12/11/23 stated to make sure the resident had a follow up with infectious disease. A physician's order dated 12/11/23 stated to follow up with infectious disease physician in two to four weeks. There was no evidence this was done. A physician's order on 01/22/24 revealed to follow up with infectious disease in one week. A physician's progress note dated 01/23/24 revealed to refer to infectious disease due to elevated white count. There was no evidence this was done. Interview with Clinical Services Manager (CSM) #102 on 04/03/24 at 10:00 A.M. confirmed Resident #29 did not receive the ordered antibiotic on 11/16/23. She stated the resident should have received the three doses on 11/16/23 and she did not know why she didn't. She confirmed the urine test ordered 11/30/23 was not completed as ordered. She confirmed the antibiotics ordered to start on 12/11/23 should have been given on 12/11/23. She confirmed there was no evidence the resident was seen by the infectious disease physician as ordered. Interview with Certified Nurse Practitioner (CNP) #104 on 04/04/24 at 10:45 A.M. confirmed that not receiving all of the doses of IV antibiotic as ordered could have contributed to the resident having to be re-hospitalized [DATE]. This deficiency represents non-compliance investigated under Master Complaint Number OH00152295 and Complaint Number OH00151794.

Based on closed record review, review of a facility self-reported incident (SRI) investigation and interview the facility failed to implement an effective and timely pain management program, including the administration of the opioid medication, [MEDICATION(S)] at the correct dose and frequency as ordered for Resident #64 who had a terminal diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Actual Harm occurred on [DATE] at 1:20 P.M. when a verbal order for [MEDICATION(S)] Concentrate solution 100 milligrams (mg) per five milliliter (ml) administer one ml (20 mg) every four hours (routine) scheduled and one ml every hour as needed for pain or shortness of breath (SOB) was not implemented for Resident #64 related to end of life care. On [DATE] at 6:09 P.M. the same order was obtained in writing from the oncologist and also not implemented. Neither order was transcribed onto the medication administration record for the resident which resulted in the resident experiencing unnecessary and unmanaged pain at the end of his life. The resident did not receive any [MEDICATION(S)] pain medication from [DATE] at 9:00 P.M. until [DATE] at 8:30 A.M. On [DATE] at 10:51 A.M. the Hospice physician faxed a prescription for the resident to receive [MEDICATION(S)] 20 mg per ml administer one ml every four hours scheduled and one ml every hour as needed for pain and dyspnea (SOB). The Director of Nursing (DON) wrote this order [MEDICATION(S)] concentrate 100 mg per five ml and 20 mg per ml solution administer one ml scheduled every four hours and as needed orally on [DATE] at 11:15 A.M. However, the order was not transcribed on the MAR until [DATE] at 10:00 P.M. and was transcribed inaccurately to read [MEDICATION(S)] Sulfate 200 mg/ml give 0.5 ml every four hours scheduled. The resident expired on [DATE] at 1:05 A.M. This affected one resident (#64) of three residents reviewed for pain management. Findings Include: Review of Resident #64's closed medical record revealed the resident was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The resident expired with hospice services at the facility on [DATE]. Review of Resident #64's admission history and physical and physician's progress notes, dated [DATE] and [DATE] revealed the resident had metastatic disease, consistent in the liver and ascites. The resident was seen by oncology and it was explained to him that his cancer was rather extensive and no treatment would be administered as the cancer was likely terminal. The resident was admitted the facility for further treatment and support. The plan included pain control, new mattress for pain control, discontinue therapy, family support and hospice. Review of Resident #64's pain assessment, dated [DATE] revealed the resident's highest level of pain was 10 and lowest was zero. The pattern of pain was unable to be determined and the resident rarely had pain over the last five days. The pain could occur at any time throughout the day. The location of the pain was blank. The description (aching, throbbing, stabbing, stiff, sore, tightness, pressure, hurts all over, cramping, gnawing, tingling, shooting, burning, pin/needle, and numbness) of the pain were all answered no. The resident had no exacerbating factors and was unable to determine the relieving factors. The pain had no functional/psychological impact. The assessment revealed the resident had no prescription or over the counter pain medication. The non pharmological interventions were all marked not applicable. There was no evidence another pain assessment was completed after new orders were written on [DATE] for pain medications. Review of Resident #64's abdominal pain plan of care, initiated on [DATE] revealed the resident had abdominal pain as evidence by verbalization related to liver mass, suspected colon cancer and recent history of [CONDITION(S)] and abdominal distention. Interventions included to administer medication per order, reposition, non-pharmological interventions and notify physician. Review of Resident #64's physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The resident was admitted to hospice with unknown primary cancer. The resident had an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #64's admission Minimum Data Set (MDS) 3.0 assessment, dated [DATE] revealed the resident's cognition was intact with a Brief Interview for Mental Status (BIMS) score of 13. The assessment revealed the resident required extensive assistance from one staff for bed mobility, dressing, toileting and hygiene and extensive assistance from two staff for transfers. The assessment revealed the resident was on a pain medication regimen and received as needed pain medications but did not receive any non-medication interventions for pain. The resident had pain in the last five days that happened occasionally but did not affect his sleep or day to day activities with the worst pain being a seven. The resident did not require a pain assessment to be conducted thus the remaining pain section of the MDS was not completed which included indicators for pain and frequency. On [DATE] the oncologist gave verbal orders to administer [MEDICATION(S)] and [MEDICATION(S)] at the same time for pain management of hospice patient. On [DATE] at 1:20 P.M. the oncologist gave verbal orders to discontinue all medications except for [MEDICATION(S)], [MEDICATION(S)], [MEDICATION(S)] and [MEDICATION(S)]. A verbal order for [MEDICATION(S)] to be administered routinely every four hours was noted at that time. However, the order was not initiated at that time. Review of the oncologist script, dated [DATE] at 6:09 P.M. revealed [MEDICATION(S)] Concentrate 100 mg/5ml (20 mg/ml) solution administer one ml every four hours scheduled and one ml every 30 minutes as needed for pain or shortness of breath. Review of Resident #64 MAR revealed no evidence the above order was initiated or transcribed on the MAR at that time. On [DATE] at 10:51 A.M. the hospice physician faxed a prescription for [MEDICATION(S)] 20 mg per ml administer one ml every four hours scheduled and one ml every hour as needed for pain and dyspnea. On [DATE] the DON wrote a telephone order at 11:15 A.M. for [MEDICATION(S)] concentrate 100 mg per five ml (20 mg per ml) solution administer one ml scheduled every four hours and as needed orally. However, the [MEDICATION(S)] orders from [DATE] were not transcribed to the MAR until [DATE] at 10:00 P.M. The order written on the MAR was for [MEDICATION(S)] Sulfate 200 mg/ml give 0.5 ml every four hours scheduled. This inaccurately reflected a 100 mg dose instead of the ordered 20 mg dosage. On [DATE] at 2:54 P.M. the oncologist wrote an additional as needed order for [MEDICATION(S)] 0.5 to one ml (10 to 20 mg) every 30 minutes for pain and shortness of breath due to terminal hospice. The above order was not transcribed on the MAR. Review of Resident #64 MAR for [DATE] revealed there were only two [MEDICATION(S)] orders documented. One order, written from [DATE] to [DATE] was for [MEDICATION(S)] Sulfate oral concentration 200 mg/ml administer 0.5 ml every 30 minutes as needed for pain or dyspnea. The second order, written on [DATE] at 10:00 P.M. was for [MEDICATION(S)] sulfate concentration 200 mg/ml give 0.5 ml every four hours scheduled. Neither of these written orders were accurate to match the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] Review of Resident #64's controlled substance record revealed the sheet was for [MEDICATION(S)] Sulfate 20 mg/ml. On [DATE] staff signed out and administered one dose of [MEDICATION(S)] 20 mg (one ml). All of the remaining doses administered dated [DATE] to [DATE] revealed the resident received 0.5 ml/10 mg for each administered dose. From [DATE] through [DATE] the resident should have received 20 mg every four hours scheduled and 20 mg as needed (prn). Further review of the controlled substance records from [DATE] to [DATE] revealed on [DATE] the resident received 0.5 ml (10 mg) of [MEDICATION(S)] at 4:30 A.M., 8:45 A.M., 9:45 A.M., 10:30 A.M., 1:40 P.M., 2:47 P.M., 6:45 P.M., 9:00 P.M. In addition to receiving the incorrect dose of 10 mg after the new orders were obtained on this date, no doses were administered after [DATE] at 9:00 P.M. until [DATE] at 8:30 A.M. even though the order was to administer [MEDICATION(S)] 20 mg every four hours routinely (in addition to the prn order). The resident was medicated on [DATE] with 0.5 ml (10 mg) at 10:30 A.M., 12:30 P.M., 2:15 P.M., 4:00 P.M., 5:30 P.M., 6:30 P.M., 7:00 P.M., 8:00 P.M., 8:30 P.M., 9:00 P.M., 9:30 P.M., 10:00 P.M., 11:30 P.M. and on [DATE] at 12:00 A.M. The order for these doses should have been 20 mg doses. Review of the Resident #64's nursing progress notes revealed a note dated [DATE] at 9:16 P.M. and authored by LPN #301. LPN #301 documented Resident #64's skin color was yellow and the resident was refusing meals and drinks. The resident was having difficulty swallowing and was resting in his room with his eyes closed all shift (the nurse had worked from 7 AM to 7 PM on this date). Respirations increased and louder. Moaning and groaning out. As needed [MEDICATION(S)] and [MEDICATION(S)] given and effective. Hospice notified of condition change with new orders given. (The [MEDICATION(S)] was increased to 20 mg and scheduled to be given every four hours scheduled and every hour as needed/prn). The next note, dated [DATE] at 8:47 A.M. and authored by LPN #102 (this nurse was scheduled to work from [DATE] at 7:00 P.M. until [DATE] at 7:00 A.M.) included a respiratory assessment for Resident #64 but did not assess or include any documentation regarding the resident's pain at that time. On [DATE] at 11:22 A.M. the DON faxed [MEDICATION(S)] orders to pharmacy and the family was at the resident's bedside. There was no evidence a pain assessment was completed for the resident on [DATE]. Review of the Resident #64's nursing progress notes revealed the resident expired on [DATE] at 1:05 A.M. with his son at the bedside. Review of the a facility self reported incident (SRI), tracking number 9, dated [DATE] revealed Resident #64's family reported the resident was awake in pain due to Licensed Practical Nurse (LPN) #102 not assessing the resident or administering pain medication on the 7:00 P.M. to 7:00 A.M., shift on [DATE] into [DATE]. There was no evidence the facility had identified any medication error(s) regarding the resident's pain medication, [MEDICATION(S)] which was ordered to be given every four hours scheduled beginning on [DATE]. Further review of the facility investigation revealed the following witness statements: On [DATE] (time not provided), LPN #301 was interviewed by Human Resource (HR) #128. LPN #301 reported on Thursday ([DATE]) she was giving report to LPN #102 that Resident #64 was declining and she had to administer [MEDICATION(S)] several times that day. When she came back to work on day shift ([DATE]) and got report from LPN #102, the LPN reported he did not give the resident any [MEDICATION(S)] overnight and had not checked on him; the resident's family stated the resident did not need anything and he had been sleeping since 9:00 P.M. When LPN #301 asked LPN #102 how many times he had checked on the resident, the LPN then responded twice, once at 9:00 P.M. and then at 6:00 A.M. LPN #301 reported she had notified hospice and requested more pain medication because the resident was moaning, unresponsive and making gurgling sounds. The LPN reported she had to administer more medication and stated she could not get the resident calmed down or comfortable the remainder of the day (on [DATE]). She stated she knew LPN #102 was supposed to work that hall again that night and asked for someone else to be assigned to the hall for the fear the resident not being administered pain medication needed. On [DATE] at 2:20 P.M. the Director of Nursing (DON) interviewed Resident #64's daughter. The daughter had voiced concerns that on [DATE] her father was medicated (for pain) around 9:00 P.M. but then was not seen by LPN #102 until 6:00 A.M. The daughter reported the resident had slept throughout the night but had awoken in pain moaning and groaning with a protrusion to his abdomen. The resident's son had recorded the moaning on his cell phone and sent it to a friend who was a nurse to ask if it was normal. When the dayshift nurse (LPN #301) arrived around 7:00 A.M., she began medicating the resident regularly in an attempt to get the resident's pain back into control. The daughter was concerned the pain should have been managed throughout the night so it would not be out of control and difficult to get back a head of. She had expressed her father was in the facility to keep his pain under control and LPN #102 neglected to do that. On [DATE] at 3:00 P.M. LPN #102 was interviewed by the Administrator. The LPN reported the night of [DATE] he had gone down the 300 halls around 10:00 P.M. He stated he had checked on Resident #64 and spoke to the son. The son sated the resident did not need any medication at that time and he was resting fine and did not need anything. At approximately 5:30 A.M., the LPN stated he had checked on Resident #64 and the resident was sleeping. The LPN reported he did not check out any medication the evening for his entire shift for Resident #64. LPN #102 reported he did see the resident's daughter that evening during shift change but did not speak to her at all and at no time did she request pain medication for her father. The LPN also reported he was not in the room at any time during the night in which the resident's family was not present. On [DATE] at 7:15 A.M. LPN #301 was interviewed by the Administrator and reported both the son and daughter of Resident #64 were angry and had spoken to her about the resident not getting pain medication on the 7:00 P.M. to 7:00 A.M. shift on [DATE] and [DATE]. The family had audio recorded the resident's pain. On [DATE] at 7:26 A.M. interview with LPN #102 revealed he had worked nightshift on [DATE] and was responsible for Resident #64's care. The LPN reported he started his shift around 7:00 P.M. and the family had requested pain medication for the resident. The LPN revealed [MEDICATION(S)] was administered around 9:00 P.M. At around 10:00 P.M. he had asked Resident #64's son if the resident needed anything for pain. The son declined and reported to let the resident sleep. The LPN revealed the resident was not in distress and slept throughout the night. He stated he had checked on the resident three times during his shift and indicated if the family would need anything they would usually come to the nurse's station or use the call light and they never did that night. On [DATE] at 10:35 A.M. interview with Resident #64's son (#302) revealed he was not the son who was present on the night of [DATE], however the family did have concerns regarding their father's pain medication that night. The resident did not receive his pain medication as ordered and had awoken in pain. On [DATE] at 10:58 A.M. interview with Resident #64's son (#303) revealed he was the son who was present the night of [DATE]. Son #303 reported his father was medicated around 9:00 P.M. and was not medicated the rest of the night. Son #303 revealed he had fallen asleep around 11:00 P.M. and was woke by his father's grunting in pain around 6:,d+[DATE]:00 A.M. The son indicated he thought his father was supposed to be medicated throughout the night but he was not aware of staff checking or medicating his father after 9:00 P.M. He stated he had recorded his father groaning and grunting out in pain that morning and throughout the day the family recorded his pain and it wasn't until that evening before his father was comfortable. On [DATE] at 12:23 P.M. interview with the DON verified there were discrepancies in the orders for the resident's [MEDICATION(S)] as transcribed above (200 mg/ml give 0.5 mg which would be a 100 mg dose) and orders for 100 mg/5ml one ml (a 20 mg dose) every four hours scheduled and one ml every one hour and then every 30 minutes as needed for pain or shortness of breath. The DON verified the new order received for the [MEDICATION(S)] on [DATE] at 1:20 P.M. to increase the frequency to every four hours routinely and as needed every hour was not transcribed onto the MAR and the resident did not receive the [MEDICATION(S)] as per the routine order or at the correct dose of 20 mg as the controlled substance record reflected 10 mg doses were signed out and administered. The DON also verified she had taken another new order as well on [DATE] at 11:15 A.M. for the 20 mg every four hours and every 30 minutes as needed which was also not transcribed onto the MAR until 10:00 P.M. that night and when it was transcribed on the MAR it was written incorrectly for 100 mg. The DON confirmed the above findings/discrepancies and errors were not identified during the SRI investigation. This deficiency substantiates Complaint Number OH 364.

Based on closed record review, interview, police report review, emergency room record review, interview and policy review the facility failed to ensure timely physician notification related to a resident's condition change. This affected one resident (#42) of three residents reviewed for transfer/discharge. Actual harm occurred on 04/03/21 when the facility failed to timely notify Resident #42's physician regarding increased pain and the resident/resident representative's request to be evaluated in the emergency room resulting in the resident being required to sign out against medical advice in order to receive medical care. The resident was admitted to the hospital with [CONDITION(S)], urinary tract infection (UTI), ureterolithiasis (kidney stones), pleural effusion and hydronephrosis (dilation of the renal pelvis as a result of obstruction to urine flow downstream). Findings include: Review of Resident #42's closed medical record revealed an admitted [DATE], after a hospital stay (from 03/03/21 to 03/11/21) in which the resident had an exploratory laparotomy (a general surgical procedure where the abdomen is opened and the abdominal organs are examined for disease or injury), left colectomy (surgical procedure to remove all or part of the colon) left ureterolysis (surgical procedure aimed at exposing the ureter in order to free it from external pressure or adhesions or to avoid injury to it during pelvic surgery), lymphadenectomy (removal of lymph nodes), [MEDICATION(S)] [CONDITION(S)] (performed in the middle section of the colon), insertion of bilateral [CONDITION(S)] stents (to keep the ureters open), cholecystectomy (gall bladder removal) and liver resection. The resident also had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] .M. and one tablet every 6 hours as needed for post surgical pain and Tylenol 650 mg take 2 tablets every six hours as needed for pain and a pain evaluation daily on each shift Review of the admission Minimum Data Set (MDS) 3.0 assessment, dated 03/18/21 revealed the resident had intact cognition and required extensive assistance of two staff members with bed mobility, transfers and toilet use. The resident also required extensive assistance of one staff member with dressing and personal hygiene. The resident was continent of bladder and had a [CONDITION(S)]. The resident received as needed pain medication and admitted to frequent pain that often affected the resident's ability to sleep. Review of the plan of care for pain (abdomen) evidenced by verbalization related to colon cancer with mets to liver and recent surgical procedure, initiated 03/26/21 revealed interventions including to administer pain medications as ordered, notify the physician if pain frequency/intensity was worsening or if current [MEDICATION(S)] regimen has become ineffective. Review of the controlled substance record for the [MEDICATION(S)] 50 mg medication revealed the resident received [MEDICATION(S)] on 04/03/21 at 2:30 A.M., 04/03/21 at 8:20 A.M. and again on 04/03/21 at 10:30 A.M. Review of the Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] .M. for pain rated an eight on a scale of one to ten (8/10), and again at 10:30 A.M. for pain rated an 8/10. Post pain numerical evaluations noted on the MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the nursing progress note, authored by Licensed Practical Nurse (LPN) #52 on 04/03/21 at 10:40 A.M. revealed the resident's girlfriend/significant other (SO) called in and wanted to know why the nurse (Licensed Practical Nurse #52) wasn't taking care of the resident. The nurse stated she did not know what the SO was talking about. The SO stated the resident was in pain and the nurse was not doing anything about it. The nurse explained to her the resident did not express pain when she was in the room. The SO said she was just going to take the resident to the emergency room . LPN #52 explained she would evaluate the resident and if he needed to go (to ER), she would send him. When the LPN approached the resident he stated he was in pain and asked for a nurse. The LPN told him he did not express pain when she was in there this morning. The resident stated she was not in there and the LPN explained she gave him his medications that morning and tucked him back into bed. The LPN showed the resident the cup that had the [MEDICATION(S)] (laxative) medication in it. The LPN got the resident prn (as needed) medication and explained he was given one at 8 A.M. as well. The resident stated he would try it. Review of the nurse's progress notes, authored by LPN #52 on 04/03/21 at 11:40 A.M. revealed the resident stated his pain was now a three out of 10 on a numeric pain scale. The PRN medication was noted to be effective. Further review of the nurse's progress note, authored by LPN #52 on 04/03/21 at 7:50 P.M. revealed LPN #52 received another call from the resident's SO stating she was coming to pick up the resident and take him to the emergency room (ER) because the resident was not being taken care of. LPN #52 explained to the SO the resident had not put on his call light nor had he told the nurse or other staff he was in pain or needed anything. The nurse explained to the SO an hour after the resident received pain medication he rated his pain a 3/10 on a pain scale so the medication was effective. The resident's SO continued to repeat over and over that she was taking the resident to the emergency room . LPN #52 explained to the SO it would be considered leaving against medical advice (AMA). The SO stated that was fine. LPN #52 approached the resident and asked why he never stated he was in pain again. The resident stated, per LPN #52, it takes five minutes for anyone to come. LPN #52 documented she explained he hadn't said anything to anyone which made it difficult to help him. LPN #52 documented the resident completely read and signed the AMA papers. An STNA (not identified) helped the resident pack his belongings and his SO arrived to pick the resident up. A message was left for the physician to return the call and the Administrator was notified. Review of the Release for Discharge Against Medical Advice form revealed the resident acknowledged he had been advised by his attending physician and the facility that it was inadvisable for him to leave the facility at this time. Having been advised of, and understanding, the possible consequences of leaving the facility against medical advice and without a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The form was signed by the resident on 04/03/21 at 7:00 P.M. Review of the police report dated 04/03/21 at 7:37 P.M. revealed the resident's SO called and said she was en-route to get the resident who was having severe pain and the staff advised they would not allow her to transport to the hospital. The staff had set all of the resident's stuff outside of the facility. At 7:55 P.M. the police were notified the SO had the resident and they (the police) said they would escort her to the hospital. The police report was closed at 8:34 P.M. Review of the emergency room (ER) documentation, dated 04/03/21 revealed the resident presented to the ER for evaluation of left lower quadrant abdominal pain. The resident was staying at the nursing home for rehabilitation (rehab) following a partial colectomy with ostomy for neoplastic process near the beginning of the month. The patient stated he began experiencing left lower quadrant abdominal pain earlier in the day, the patient's SO indicated she believed the resident was not getting the appropriate care at the rehab facility, they would not call a squad to have him brought to the hospital, so she went to the facility, got him and brought him to the ER for evaluation. The patient does indicate he had some difficulty with urination, he feels he had to go but could not have a complete void. The patient additionally stated he may have some cardiac history, however he was unable to elaborate. The patient denied having any type of renal issues, had prescription medications but was unsure what he takes. The patient denied any concerns at this time. Review of systems revealed the resident had left lower quadrant abdominal pain with no vomiting or diarrhea and difficulty urinating. The resident's lungs had expiratory wheezes and his abdomen was soft with tenderness to palpation at the left lower quadrant below the resident's ostomy, the ostomy site was intact with appropriate output. The resident was alert, answering questions appropriately with no focal defects. The resident was admitted to the hospital with [CONDITION(S)], UTI, ureterolithiasis (kidney stones), pleural effusion and hydronephrosis (dilation of the renal pelvis as a result of obstruction to urine flow downstream). On 04/21/21 at 11:45 A.M. interview with Physician #83 revealed he was the resident's physician and the facility medical director. The physician verified no one from the facility contacted him regarding the resident until after the resident left the facility AMA. Physician #83 stated his expectation would be for the facility to honor the resident or resident representative's request to be transferred to the hospital regardless if the staff felt the resident didn't need to be transferred as this was his right. Further interview revealed the physician expected to be notified if a resident's current pain regimen was ineffective for further orders or intervention. On 04/21/21 at 2:28 P.M. interview with LPN #52 revealed she was the nurse providing care to Resident #42 the day he signed out AMA but this was the first time she had cared for the resident. LPN #52 stated she received in report that morning that Resident #42 had vomiting the night before but received medication that helped. Further interview revealed the resident also had pain medication but then complained of itching but had no there issues. LPN #52 shared she started toward the back of 300 hall that morning and Resident #42 was the second resident she gave medications to. The resident denied pain when he received his scheduled [MEDICATION(S)]. Around 10:00 A.M. the resident's SO called and said the resident was miserable, that no one was helping him. LPN #52 stated she looked at his chart and he had a PRN pain medication order. The resident had one at 8:00 A.M. and she got another one ready to take back to the resident. The LPN stated she thought the resident rated his pain an eight on a 0-10 pain scale. She said he was having a sharp pain to his lower abdomen. The LPN also stated the resident complained the pain felt like diverticulitis pain and he provided her with the name of a medication he used for diverticulitis. The LPN shared the resident provided her the name of the medication and she stated she tried to reach the physician but she was unable to make contact (however, this assessment and attempted communication was not documented in the medical record). The LPN stated the resident didn't have any other scheduled medications so she didn't see any reason to go into the resident's room. The resident's SO called around 7:00 P.M. to 7:30 P.M. asking why LPN #52 was not caring for the resident. LPN #52 informed the SO the resident had not reported pain to herself or the STNAs and his call light had not been going off. The SO asked the nurse if she was calling him a liar to which LPN #52 said no. The resident's SO said she was coming to the facility to pick up the resident and take him to the ER. LPN #52 stated she didn't feel the resident needed to go to the ER as he did not have an emergent need and informed the SO if Resident #42 left the premises, he would have to sign AMA papers since he was leaving against medical advice. The SO stated that was fine and she was coming to the facility to get the resident. LPN #52 shared she went back to Resident #42's room and asked him why he didn't tell her he was having pain and the resident told her he hadn't seen her all day and it took staff too long to come back to his room. LPN #52 stated she gave Resident #42 the AMA paper, he read and signed the document. LPN #52 stated she informed the STNA to pack the resident's belongings. The LPN stated it took the resident's SO about 30 minutes to arrive at the facility. During the interview with LPN #52, the LPN was asked how the resident leaving to go to the ER constituted leaving against medical advice when she was not able to contact the physician for direction and when she did not call the DON (for guidance), the LPN stated this was leaving AMA because he was leaving the premises even though he was leaving the facility to seek medical attention. The LPN did not feel the resident's condition was emergent and did not warrant an ER evaluation. LPN #52 denied offering to call an ambulance. LPN #52 stated she tried to reach the physician and left a message for him to return her call. LPN #52 stated she also called Administrator #80 and was informed to ensure Resident #42 completed the appropriate paperwork. LPN #52 stated two Registered Nurses (RN) #14 and RN #25 both were working and told her she made the correct decision by having the resident sign out AMA to be seen in the ER. On 04/21/21 at 312 P.M. interview with RN #25 revealed she had been employed at the facility for 22 months and had never been the nurse for Resident #42. RN #25 stated she really wasn't sure of the entire issue between LPN #52 and Resident #42 but knew the resident's SO had called multiple times that day. Once, the SO called and demanded to speak to LPN #52 and RN #25 told STNA #69 to go back and check on the resident while LPN #52 spoke to the resident's SO. The STNA said the resident was fine when she checked on him. The SO said she was coming to get the resident and LPN #52 tried to explain the resident had not reported pain to her and if the resident's left without a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . RN #25 stated the SO arrived to the facility, Resident #42 went out to the SO's car and the police arrived to the facility. RN #25 stated if the resident or resident representative requested to go to the ER for evaluation, it was the right of the resident to choose to be seen and the resident should not have to sign out AMA and should be assisted with transportation from the facility. The RN stated she did not intervene and tell LPN #52 to send the resident to the hospital because he was not her resident and she didn't want to step on anyone's toes. RN #25 stated she shared her concerns regarding the AMA discharge to management when she worked again later that week. On 04/21/21 at 3:40 P.M. interview with RN #14 revealed LPN #52 did not report to her she was having issues with Resident #42's SO because she would have told LPN #52 to send the resident to the hospital per the SO and resident's request. RN #14 stated it was the resident's right to be transported to the hospital and he should not have had to sign out AMA to receive medical care. On 04/21/21 at 5:05 P.M. interview with Administrator #80 revealed she was aware the resident was signing out AMA before he left the faciity on [DATE]. She stated LPN #52 called and said the resident wanted to go to the hospital and she didn't have an order from the physician so LPN #52 said the resident was leaving AMA. Administrator #80 stated she told LPN #52 to make sure the resident completed the appropriate paperwork. Administrator #80 denied knowing there were issues with the SO feeling the resident wasn't receiving adequate care and, with all things considered the Administrator stated she should have had the LPN call the DON or nursing supervisor but she didn't have all the details apparently. Further interview revealed she was unaware the police had come to the facility and escorted the resident to the hospital. Lastly, Administrator #80 stated when this occurred, it was her final week at the facility and she and Administrator #81 were both overlapping as the Administrator in the facility until she left at the end of the week. On 04/22/21 at 1:58 P.M. interview with Administrator #81 revealed he was the acting Administrator for about two weeks, beginning 04/01/21 and some of his time overlapped with Administrator #80. Administrator #81 stated he had heard about the incident through the morning meeting and felt the nurse should have handled the situation differently by sending the resident to the hospital for evaluation as the SO and resident requested. Administrator #81 stated LPN #52 felt the resident wasn't ill or needed to go to the ER but the expectation would have been for one of the RN's to complete an assessment and honor the resident's wishes to go to the ER and the facility should have arranged transportation. On 04/22/21 at 4:45 P.M. interview with STNA #69 revealed she was the STNA providing direct care to Resident #42 the evening he left AMA. She was directed by LPN #52 to pack his belongings, set them outside and not assist the resident in leaving the facility. STNA #69 stated the resident had been having pain a few days prior to the incident around his [CONDITION(S)]. The STNA stated she thought residents were able to be evaluated in the ER if they requested. On 04/26/21 at 9:15 A.M. interview with the Director of Nursing verified the resident should not have been discharged AMA and the facility should have assisted the resident with transport to the hospital for evaluation. The DON stated residents have the right to go to the ER for evaluation. The DON also verified the nurse should have notified the physician regarding the resident's complaints of pain and verified the resident received three [MEDICATION(S)] in an eight hour period which exceeded the order for one every six hours as needed and one tablet scheduled daily at 8:00 A.M. On 04/26/21 at 9:45 A.M. interview with Certified Nurse Practitioner (CNP) #84 revealed [MEDICATION(S)] 50 mg was ordered for the resident's post operative pain. The CNP verified the resident had extensive abdominal surgery and [MEDICATION(S)] may not have always been effective for pain management. The CNP stated if the resident continued to complain of pain after the scheduled [MEDICATION(S)], the physician should have been notified for additional directive especially before administering the resident's [MEDICATION(S)] within two hours of the scheduled dose. Review of the Discharge of Patient: Against Medical Advice Policy 12/2009 revealed the purpose was to describe the discharge process for a patient departing from the center against medical advice. Unless deemed incompetent in a court of law or by two attending physicians the patient has the right to make decisions about healthcare. Notify the regional director of operations and legal counsel as needed. Discuss with patient or legal representative the desire to leave the center AMA. Determine patients or legal representative's plan of care and document findings in the medical record. Evaluate the patient's physical condition and document findings if possible. Notify the Administrator, DON, and social services of patient's intent to discharge AMA. Inform the physician of the patient's intent to discharge against medical advice and physical condition. Note physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Assist the physician on fully explaining to the patient and, if necessary, the legal representative the risks of discharge AMA, Provide written and verbal education to the patient or legal representative if possible. Escort and assist patient to transport vehicle if needed. Review of the Change in Condition Policy, dated 11/2016 revealed the purpose was to provide guidance in the identification of clinical changes that may constitute a change in condition and require intervention and notifications. A facility must immediately inform the resident; consult with the resident's physician and notify, consistent with his or hers authority, the resident representative(s) when there is: a significant change in the resident's physical, mental or psychosocial status (that is, a deterioration in health, mental or psychosocial status in either life threatening conditions or clinical complications); a need to alter treatment significantly (that is, a need to discontinue or change an existing form of treatment due to adverse consequences, or to commence a new form of treatment; or a decision to transfer or discharge the resident from the facility. Immediate notification is recommended for any symptom, sign or apparent discomfort that is acute or sudden in onset and a marked change in relation to usual symptoms and signs, or is unrelieved by measures already prescribed. This deficiency substantiates Complaint Number OH 413.

Based on observations, resident and staff interview, medical record review, and review of the facility skin practice guide, the facility failed to provide care and treatment to prevent the development of an unstageable pressure ulcer on the sacrum for one resident (Resident #25) and failed to provide treatments as ordered for one resident with a pressure ulcer (Resident #38). Actual harm occurred when Resident #25, assessed as requiring extensive assistance for bed mobility, was not on a repositioning program and developed an avoidable, unstageable pressure ulcer to the sacrum. This affected two of two residents reviewed for pressure ulcers (Residents #25 and #38). The facility identified five residents with pressure ulcers. Findings include: 1. Review of the medical record for Resident #25 revealed an admission date of [DATE] with [DIAGNOSES REDACTED]. Review of a Braden pressure ulcer risk assessment completed 10/11/18 revealed the resident was identified as being at moderate risk for the development of pressure ulcers Review of the quarterly MDS assessment completed 12/06/18 indicated the resident was frequently incontinent of bladder, always incontinent of bowel, and did not walk. The MDS indicated the resident did not have any pressure ulcers. Review of the plan of care revised 11/23/18 revealed the resident was at risk for alteration in skin integrity related to the resident required extensive assistance for bed mobility, urinary incontinence, chronic [MEDICAL CONDITION], and [MEDICAL CONDITION]. The goal was to decrease/minimize skin breakdown risks. Interventions included encourage to reposition as needed. The plan of care did not specify how often staff should reposition the resident. The plan of care indicated to float heels as able, observe skin condition with activities of daily living care daily, and report abnormalities. Review of physician's orders [REDACTED]. Review of a significant change Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed a brief interview for mental status (BIMS) score of 13 indicating intact cognition. Resident #25 required extensive assistance from two staff for bed mobility and was totally dependent upon staff for transfers. The MDS indicated the resident had one unstageable pressure ulcer that was not present upon admission and was not on a turning/repositioning program. An unstageable pressure ulcer is defined as full-thickness skin and tissue loss in which the extent of tissue damage within the ulcer cannot be confirmed because the wound bed is obscured by slough or eschar. If the slough or eschar is removed, a Stage 3 or Stage 4 pressure ulcer will be revealed. Eschar is dead or devitalized tissue that is hard or soft in texture; usually black, brown, or tan in color, and may appear scab-like. Slough is non-viable yellow, tan, gray, green or brown tissue; usually moist, can be soft, stringy and mucinous in texture. Review of a progress note by Nurse Practitioner (NP) #125 on 01/14/19 at 12:56 revealed it was noted today during his care that Resident #25 had an area of discoloration and alteration in his skin. The note further stated the resident had a right hip open area with some bleeding, discoloration over ischemic right side that was non-blanching with intact skin over site, and coccyx and left inner buttock discolored with sloughing skin and open areas, non-blanching with some bleeding noted. The assessment indicated the resident had an unstageable coccyx pressure ulcer. The note stated the resident was unable to turn and position himself. The progress note indicated to check complete metabolic profile (CMP) and pre-[MEDICATION NAME] level and off-load pressure to right side and coccyx. Review of the treatment administration record for (MONTH) 2019 revealed weekly body audits were scheduled for the 7:00 P.M. to 7:00 A.M. shift. A weekly body audit was documented as completed on 01/05/19. There was no documentation to indicate any abnormalities. The next weekly body audit due on 01/12/19 was not documented as completed. Review of nurse's progress notes by RN #109 on 01/14/19 at 5:17 P.M. revealed Resident #25 was noted with pressure injuries to the right ischium and sacrum. The right ischium was noted to be a deep tissue injury measuring 4.0 centimeters (cm) long by 1.5 cm wide. The area presented as intact skin with deep maroon discoloration that was non-blanching. Treatment to cleanse with wound cleanser, pat dry, and apply skin prep twice daily. The sacrum was noted with an unstageable pressure injury measuring 10.0 cm long by 12.0 cm wide with unable to assess depth. The 10.0 cm long and 7.0 cm wide area is open with dark pink tissue present to 50% of wound bed, remaining 50% deep maroon discoloration. Area outside open portion of wound intact skin with pink discoloration that was nonblanching and firm. Moderate amount of serosanguinous drainage noted. No foul odor detected. Treatment to cleanse with wound cleanser, pat dry, apply skin prep to peri wound, apply [MEDICATION NAME] AG (an absorbent dressing) to open wound bed and cover with comfort foam. Change daily and as needed. Review of physician's orders [REDACTED]. Review of the treatment administration record for (MONTH) 2019 revealed between 01/14/19 and 01/29/19 the daily body audits were documented as completed three of the 15 days. In addition, the treatment to the right ischium scheduled for the 7:00 P.M. to 7:00 A.M. shift was documented as completed two of seven days between 01/14/19 and 01/22/19. Review of the plan of care dated 01/14/19 revealed the resident had a pressure ulcer to sacrum related to impaired mobility with frequent incontinence. The interventions included treatment per physician's orders [REDACTED]. (The plan was not specific to how often to be repositioned or what areas to avoid). Review of a progress note by NP #125 on 01/16/19 at 2:58 P.M. revealed a treatment was started to the coccyx two days ago and it had not improved per nursing. (The treatment to the coccyx was not documented as being completed on the treatment administration record on 01/15/19). Coccyx discolored with sloughing of skin. Foul odor. Refer to wound center for further evaluation and treatment. Start protein supplement twice daily. Review of physician's orders [REDACTED]. Review of a progress note by NP #125 on 01/22/19 at 1:26 P.M. revealed coccyx area was discolored with sloughing of skin, foul odor. Start Santyl dressing daily to area. Use Santyl only over slough and dark discolored area. Appointment pending to wound center. Off load pressure to right side and coccyx. Review of a nursing progress note by RN #111 on 01/22/19 at 3:08 P.M. revealed the right ischium deep tissue injury was healed. Area presented as intact skin with pale purple discoloration and blanching. Treatment discontinued. The sacral unstageable pressure injury measured 10.0 cm long by 9.0 cm wide with unable to assess depth. Area presents as greater than 75% adherent slough with area of dark brown eschar to lateral aspect of wound measuring 2.0 cm long by 3.0 cm wide. Remaining portion of wound bed dark pink tissue. Moderate amount of mix of serosanguinous and thin yellow drainage noted. No foul odor detected. Treatment to cleanse with wound cleanser, pat dry, apply skin prep to peri wound, apply nickel thick layer of Santyl to wound bed and cover with comfort foam dressing. Change daily and as needed. Review of the treatment administration record for (MONTH) 2019 revealed no evidence the treatment was completed on the sacral pressure ulcer on four of eight days between 01/22/19 and 01/29/19. A nursing progress note on 01/25/19 at 4:03 P.M. documented an appointment at the wound center was scheduled for 01/28/19. Review of the wound center referral notes from 01/28/19 revealed Resident #25 had an unstageable pressure ulcer of the sacral region. The wound on the coccyx was described as 10.5 cm long by 8.5 cm wide by 0.3 cm deep, open, unstageable, purulent exudate, no granulation present, large (67-100%) necrotic tissue (eschar and adherent slough). Recommendations included keep weight off area of wound at all times and increase protein intake. The next wound center appointment was for 02/04/19. Interview with Resident #25 on 01/28/19 at 2:46 P.M. revealed he had sores on his bottom. He stated he also has sores on his heels that started a few days ago. He stated the staff did not turn/reposition him every two hours like they were supposed to. Observations on 01/28/19 at 2:46 P.M. revealed Resident #25 was in bed on his back. The resident had a pillow under his legs, but his heels were touching the mattress. Interview with LPN #18 on 01/31/19 at 7:50 A.M. revealed there were only two nurses on duty for approximately 85 residents on four different hallways for the 7:00 P.M. to 7:00 A.M. shift on 01/30/19-01/31/19. She stated the nurses had to pick and choose the priority things to get done. She stated treatments and dressings did not always get done. Interview with RN #109 on 01/31/19 at 10:30 A.M. revealed the resident was unable to be seen at the wound center on 01/25/19 due to consent needed from family. Therefore, the resident was not evaluated at the wound center until 01/28/19 (12 days after the order for referral to wound center was obtained). RN #109 confirmed there was no evidence the daily body audits or skin treatments were completed as ordered. Review of the Medication Administration Record [REDACTED]. There was no evidence this was re-evaluated for a different type of protein supplement. Interview with RN #109 on 01/31/19 at 10:30 A.M. confirmed Resident #25's pressure ulcer on the sacrum developed in the facility and was not identified by staff until it was an unstageable pressure ulcer. He stated nursing assistants are to note any skin redness or impairment and report to the nurse. Interview with State tested Nursing Assistant (STNA) #101 on 01/31/19 at 10:50 A.M. revealed Resident #25 was cooperative with turning. She stated she turns him from left side to back to right side. She stated that, although his Kardex stated to encourage and/or assist to reposition frequently as needed, she turned him every two hours. She stated she was the only nursing assistant scheduled for the 400 hall on dayshift that day (for approximately 22 residents). She stated since the resident was a two person assist, she had to get an STNA from another hall to come and help her with his care. She stated the resident did not have any pressure ulcers on his heels. Interview with the Director of Nursing (DON) on 0/31/19 at 11:25 A.M. revealed on 01/11/19 at STNA had found a pink area on Resident #25's bottom and reported it to the nurse. She stated the nurse then put a comfort foam dressing on the area without a physician's orders [REDACTED]. Then on 01/14/19 she was notified he had an unstageable pressure ulcer. The DON further confirmed the pressure ulcer risk assessment identified the resident at moderate risk even after he developed a pressure ulcer and the policy stated a resident is automatically at high risk if they have a pressure ulcer. The DON confirmed the plan of care did not specify a frequency for repositioning of the resident. She stated he should be turned every two hours and should not be positioned on his back except to eat. Observations on 01/31/19 at 1:30 P.M. revealed Resident #25 had a 6.0 cm long by 8.0 cm wide open area to the sacral area which was covered with tan colored slough and small areas of dark eschar. There was a foul odor. The resident was also noted with a quarter sized tan/brown area on the left heel. STNA #101 stated this was a new area. Licensed Practical Nurse #102 stated the area was caused from his heel touching the mattress (pressure). The medical record contained no documentation of the area on the left heel. Review of the facility skin practice guide dated 01/2013 revealed a resident with a pressure ulcer was automatically considered high risk for pressure ulcers. Weekly skin evaluations for residents at risk for skin breakdown are completed by the nurse. It further stated daily skin evaluations were to be completed by a licensed nurse for any resident with a pressure ulcer. The guide stated the comprehensive care plan approaches for skin management are to be clear, specific, and individualized for the resident's needs. It stated to minimize direct pressure over vulnerable areas and actual pressure ulcers, reposition frequently, and elevate or float heels even if on specialty support surface. Increased protein intake is often emphasized in residents with non-healing wounds. 2. Medical record review revealed Resident #38 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The resident was hospitalized from [DATE] to 12/22/18 for uncontrolled pain. Review of Resident #38's admission skin assessment dated [DATE] revealed the resident had an 8.0 by 8.0 centimeter (cm) dark red, roughly circular shaped area on the coccyx. Further review revealed no evidence of a comprehensive assessment of the wound or staging of the wound. Review of Resident #38's orders dated 12/14/18 revealed to cleanse the coccyx area with wound cleanser, pat dry, and apply a comfort foam dressing every 3rd day and as needed. Interview on 01/30/19 at 2:10 P.M., with RN #111 verified there was not a comprehensive skin assessment completed on Resident #38's coccyx area on admission (12/14/18). RN #11 reported only the wound team was permitted to assess and stage pressure ulcers per the facility's policy. She confirmed the wound team did not assess the resident's coccyx wound due to the wound team only rounded on Tuesday's and the resident was admitted on a Friday and was sent out to the hospital on Monday for pain. Review of Resident #38's readmission skin assessment dated [DATE] revealed the resident had a pressure area to the bony prominence of the upper back measuring 7.0 cm by 5.0 cm, no depth and blanches. There was a pressure area to left buttocks measuring 1.2 cm by 3.1 cm by 0.1 cm. A partially filled blister to left heel, black spots noted through the clear fluid. The blister measured 2.0 cm by 3.1 cm. There was no evidence of skin alteration to the coccyx. Review of the wound team notes dated 12/24/18 and 12/25/18 revealed the resident was admitted with pressure injuries to the mid lumbar spine region, left upper buttocks, coccyx, and left heel. The pressure ulcer to the mid lumbar spine was Stage 2 (partial thickness loss of the dermis) open ulcer measuring 0.9 cm by 0.6 cm by 0.1 cm with redness and shearing surrounding the open area measuring 5.9 cm by 3.2 cm. Orders were received to cleanse the area with house wound cleanser, pat dry and apply comfort foam every 3rd day and as needed. The pressure ulcer to the coccyx was Stage 1(pressure related alteration of intact skin) non-blanching redness measuring 4.0 cm by 4.8 cm. Orders were received to cleanse the area with house wound cleanser pat dry and apply comfort foam every 3rd day and as needed. There was an unstageable pressure ulcer to the left upper buttocks measuring 3.6 cm by 1.4 cm with yellow slough to the wound bed covering the total wound bed. Orders were received to cleanse with house wound cleanser, pat dry, apply iodasorb to wound bed, cover with comfort foam every day and as needed. There was a deep tissue injury (purple or maroon area of discolored intact skin) to the left heel, fluid filled intact blister with dry purple center measuring 3.8 cm by 3.1 cm. Orders were received to cleanse wound with house wound cleanser, pat dry and apply skin prep every shift. Review of Resident #38's treatment administration records (TAR) dated (MONTH) 2019 revealed the treatments to the left heel were not completed on 01/04/19, 01/14/19, 01/21/19, 01/22/19, 01/26/19, and 01/27/19. Further review revealed staff had signed off they replaced the foam dressing on the [MEDICATION NAME] area on 01/24/19 and 01/27/19, however after observation of the dressing on 01/29/19, the dressing to the wound was dated 01/20/19. Staff had signed off on a treatment to the left buttocks from 01/26/19 to 01/28/19 that was discontinued/changed on 01/22/19. Interview on 01/28/19 at 10:21 A.M., with Resident #38 revealed staff were not changing the dressing to her pressure ulcers on her back, buttocks, and heel as ordered. She reported it had been over a week since they changed her dressings. Interview on 01/29/19 at 2:48 P.M., with Resident #38 revealed the dressing on her heel had fallen off this morning in the shower and the aide reported the dressing to the nurse, however no one had come in yet to put a new dressing on. Observation of Resident #38 on 01/29/19 at 4:45 P.M., with RN #109 and the DON revealed there was no dressing to the left heel or left upper buttocks. The dressing on the mid [MEDICATION NAME] pressure area was dated 01/20/19. These findings were verified with RN #109 and the DON during the observation. The resident had verbalized to the DON that staff were not changing her dressing and she was concerned. Interview on 01/29/19 at 5:23 P.M., with the DON confirmed the TAR indicated the [MEDICATION NAME] spine treatment was completed on the 01/24/19 and 01/27/19, however the dressing was dated 01/20/19. The DON verified staff were signing off on treatments to the left buttocks that had been discontinued (changed) on 01/22/19. In addition, staff were signing off they were performing the new treatment to the left buttocks. The DON confirmed there were six missed treatments to the left heel per the TAR. Review of the skin alteration policy dated 2013 revealed if a skin alteration was identified on admission, a designated member of the wound team evaluates the status of the wound (ideally within 24-hours of admission) and collaborates with the licensed nurse and physician to determine the type of alteration present. Treatments are to be documented on the TAR immediately after being performed. The facility did not have a pressure ulcer staging policy or procedure.

Based on observation, medical record review, policy review, and staff interview, the facility failed to ensure a resident was free from physical and verbal abuse. This affected one of three sampled residents of 89 total residents (Resident #52). Harm occurred when the facility failed to ensure Resident #52 was free from verbal and physical abuse which resulted in eight bruises to the resident's right upper arm and emotional distress as evidenced by the resident being visibly upset and crying for several hours. Findings include: Medical record review revealed Resident #52 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident required extensive assistance of two staff members for bed mobility and toilet use. Review of the Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED].M. for complaints of pain rated 8 out of 10. On 03/23/11 at 9:10 A.M., observation of Resident #52's right upper arm revealed four yellowish-green bruises approximately five centimeters (cm) in length (l) by one centimeter in width (w). The resident also had a circular, red bruise approximately two cm (l) by two cm (w) on her upper right arm. Review of the medical record revealed no documented skin conditions or bruises before 03/19/11. Review of the nurse's note dated 03/13/11 at 6:00 P.M. revealed Resident #52 had made statements that she was being abused by staff. Review of the medical record revealed no documented evidence the allegation of abuse was reported to the Administrator or investigated. Review of the daily staffing schedule dated 03/13/11 revealed State-tested Nurse Aide (STNA) #5 worked 3:00 P.M. until 11:00 P.M. on 03/13/11, 03/14/11, 03/16/11, 03/17/11, and 03/18/11. On 03/23/11 at 9:10 A.M., interview with Resident #52 stated on 03/18/11 at approximately 9:30 P.M., STNA #5 entered her room and was trying to move her over in bed. STNA #5 told the resident she did not want to move her because she was obese. The resident stated STNA #5 was unable to turn her, became angry, and hit her "as hard as she could" in the right arm. Resident #52 stated "she punched me so hard, if she would have hit me in the head, it would have knocked me out." Resident #52 told STNA #5 she was going to report the incident to the Administrator, and STNA #5 responded "If you do, I will make your life a living hell." STNA #5 left the resident's room, and the resident started to cry. Resident #52 stated she was still crying when the night shift STNA entered her room and reported the abuse to STNA #7. Review of STNA #5's written statement dated 03/21/11 revealed while assisting the resident to turn, the resident stated she was being hurt and was going to report it to the Administrator. STNA #5 told the resident "If you report me, I'll make your life a living hell." Review of the written statement revealed STNA #5 worked 3:00 P.M. until 11:00 P.M. on 03/18/11. Review of STNA #4's written statement dated 03/21/11 revealed upon entering the resident's room, the resident was screaming and told her to go away. STNA #4 informed STNA #7. Review of the written statement revealed STNA #4 worked 11:00 P.M. until 7:00 A.M. on 03/18/11. Review of STNA #7's written statement dated 03/21/11 revealed STNA #5 had reported that Resident #52 had been yelling off and on all evening. STNA #7 stated Resident #52 was screaming and yelling that she had been abused all evening and that STNA #5 was rough with her and punched her in the right arm above the elbow. Resident #52 was rubbing her arm. STNA #7 stated she reported the allegation of abuse to Licensed Practical Nurse (LPN) #3 around 11:30 P.M. Review of the written statement revealed STNA #7 worked 11:00 P.M. until 7:00 A.M. on 03/18/11. Review of Registered Nurse (RN) #2's written statement dated 03/19/11 revealed STNA #5 entered Resident #52's room around 9:30 P.M. and when she came out of the room, STNA#5 stated the resident said she had hurt her. Review of the facility investigation dated 03/19/11 revealed the resident had eight bruises to the right upper arm. The assessment revealed the following bruises and all areas were documented purple and reddish-brown in color: -Bruise #1 was located closest to the shoulder that measured 0.7 centimeters (cm) in length (l) by 0.3cm in width (w). -Bruise#2 was lateral to bruise #1 and measured 0.8(l) by 0.6 cm(w). -Bruise #3 was below bruise #2 and measured 1.2 cm(l) by 0.9 cm(w). -Bruise #4 was lateral to bruise #3 and measured 0.7cm (l) by 0.3cm (w). -Bruise #5 was located above bruise #4 and measured 0.3cm (l) by 0.2cm (w). -Bruise #6 was lateral to bruise #5 and measured 1.3cm(l) by 0.4cm(w). -Bruise #7 was above and lateral to bruise #6 and measured 0.9cm(l) by 0.4cm (w). -Bruise #8 was lateral to bruise #7 and measured 0.3cm(l) by 0.3cm(w). Review of the facility investigation revealed the administrator, the resident's family, and the physician were not notified of the physical and verbal abuse until 03/19/11 between 1:30 P.M. and 2:30 P.M. Review of the employee time detail sheet (dated 03/09/11 through 03/22/11) revealed the following: -On 03/13/11, STNA #5 worked from 3:06 P.M. until 11:11 P.M. -On 03/14/11, STNA #5 worked from 2:58 P.M. until 11:15 P.M. -On 03/16/11, STNA #5 worked from 2:54 P.M. until 11:13 P.M. -On 03/17/11, STNA #5 worked from 3:00 P.M. until 11:05 P.M. -On 03/18/11, STNA #5 worked from 3:00 P.M. until 11:13 P.M. Review of the social services progress notes revealed no documented resident assessment until 03/21/11. Review of the abuse, neglect and misappropriation of patient property prevention policy (dated 04/21/06) revealed any allegation of abuse must be immediately reported to the supervisor, the administrator, and the State survey and certification agency. The policy also stated the facility should identify and consider events such as behavioral changes, bruising of patients, and other trends that may signify abuse. All alleged violations were to be thoroughly investigated and must prevent further potential abuse. On 03/23/11 at 9:52 A.M., interview with the Director of Nursing (DON) verified Resident #52 was verbally and physically abused by STNA #5 at 9:30 P.M. on 03/18/11, and the abuse was not reported to her until 11:00 A.M. on 03/19/11. The DON verified the allegation of abuse on 03/13/11 was not reported or investigated. On 03/23/11 at 2:40 P.M., interview with the DON verified the facility failed to report and investigate the allegation of abuse immediately. On 03/23/11 at 2:51 P.M., interview with the DON verified STNA #5 continued to work in the facility for two hours after verbally and physically abusing Resident #52. This certification deficiency substantiates Complaint Number OH 110.