Every finding on record at Ohio Living Quaker Heights

Based on record review, staff interview, policy review, Emergency Medical Services (EMS) report, police report, online guidelines from American Heart Association (AHA) and review of staff witness statements, the facility failed to assess a resident for a pulse or vital signs and failed to immediately start Cardio-Pulmonary Resuscitation (CPR) for a resident who was a full code. This resulted in serious life-threatening harm and/or death on [DATE] when Resident #60 was found unresponsive. The facility staff did not check Resident #60 for a pulse and did not obtain vital signs. CPR was not started by facility staff. This affected one (Resident #60) of three residents reviewed for Full Code status and Change of Condition. The facility census was 58.On [DATE] at 12:47 P.M., the Administrator and Director of Nursing (DON) were notified that Immediate Jeopardy began on [DATE] at 12:22 A.M. when Agency Certified Nursing Assistant (CNA) #141 discovered Resident #60 in his room unresponsive and without pulse. CNA #141 summoned the nursing staff. Agency Registered Nurse (RN) #142 arrived at Resident #60's room on [DATE] at 12:25 A.M. and then exited the room [ROOM NUMBER] seconds later without assessing the resident, taking any vital signs, and without initiating CPR immediately. EMS arrived on [DATE] at 12:35 A.M and started CPR. Resident #60 was pronounced dead at the hospital on [DATE] at 1:37 A.M. The Immediate Jeopardy was removed on [DATE] when the facility implemented the following corrective actions:On [DATE] at 10:30 A.M., the DON and Division Manager of Quality and Compliance (DMQC) #150 completed a retrospective review of the previous six months to identify any additional residents that experienced cardiac arrest or required CPR. No additional events were identified. The review was completed on [DATE] at 3:50 P.M.On [DATE] at 1:39 P.M., the DON notified the staffing agency leadership and the incident was discussed. All three CNAs (#141, #143 and #144) and Agency RN #142 were labeled as Do Not Return. On [DATE], the staffing agency leadership was able to obtain a witness statement from Agency RN #142, and it was sent to the facility. On [DATE] at 3:00 P.M., the DON, Assistant Director of Nursing (ADON) #74, Minimum Data Set (MDS) Licensed Practical Nurse (LPN) #120 and RN Staff Educator #138 reviewed the Emergency Response Procedures, Code Response Expectations, Emergency Response to Medical Emergencies Policy and Change in Condition policy. No changes were made. On [DATE] at 3:00 P.M. and on [DATE] at 6:50 P.M., the DON, ADON #74, and LPN #120 completed facility wide mock codes to evaluate staff response, communication, role delegation and adherence to basic life support (BLS) expectations. All staff at each mock code responded appropriately.On [DATE] at 3:45 P.M., staff education was initiated with all licensed nurses by RN Staff Educator #138 and LPN #120 on the recognition of cardiac arrest, location of crash carts, verification of code status, immediate activation of EMS, initiation of CPR for full code residents without delaying chest compressions while awaiting EMS and the facility's expectations regarding emergency response and teamwork. New hires would receive this education during their orientation with RN Staff Educator #138. All agency staff would receive this education prior to the beginning of their shifts. Agency training was provided by the agency binder with a signature sheet that verified that the agency staff member reviewed and understood the information in the binder. The education was completed on [DATE] at 12:10 P.M. for all licensed nurses employed by the facility. Agency education and new hire education remained ongoing. On [DATE] at 10:36 A.M., the DON created an SRI for an allegation of neglect/mistreatment. The SRI was completed on [DATE] at 11:04 A.M. and due to the facility's findings, the agency nurse delayed resuscitative measures, and the allegation of neglect was substantiated. On [DATE] at 3:45 P.M., Cardiac/respiratory arrest audits were initiated by the DON and ADON #74 to check to see if any resident with a Full Code Status coded, required CPR, and staff initiated CPR appropriately. This will be done five times weekly for two weeks then weekly for 90 days, then monthly for three months. The findings will be reported by the administrator to the QAPI committee.On [DATE] at 8:30 A.M., portable two-way radios were purchased and placed on the units by the DON. On [DATE] at 8:30 A.M., the DON, ADON #74, LPN #120 and RN Staff Educator #138 began education on where to find the two-way radios, where the chargers were located, the channel to be on, how to operate all functions of the two-way radios, no resident information was to be given out over the radios, use in urgent situations and only give a location to send help and hand-off at the radio and the end of the shift. Training for new hires would be provided during orientation with RN Staff Educator #138 and training for agency staff would be provided in the agency binders with the agency staff members signing that they had reviewed and understood the information in the binder.On [DATE] at 4:00 P.M., all CNAs were educated by ADON #74 on the steps to take if they find a resident unresponsive. The education was completed on [DATE] at 12:00 P.M. Beginning [DATE] at 5:00 P.M., agency staff received this education by the CNA agency binder, and their signature indicated that they reviewed and understood the information in the binder. All new hires would receive the training during their orientation by RN Staff Educator #138.On [DATE] at 4:30 P.M., Agency RN #142 was reported to the Board of Nursing by the DON. On [DATE] at 8:30 A.M., ADON #74 and LPN #120 completed an audit of all current code statuses to verify physician orders and accessibility of code status information. The audit was completed on [DATE] at 1:15 P.M. There were no additional concerns identified. On [DATE] at 3:30 P.M., an ad hoc Quality Assurance Performance Improvement (QAPI) meeting was held to review the incident that occurred on [DATE] which involved Resident #60 passing away and the nurse on duty not providing CPR. The investigation was reviewed and it was determined that the nurse did not follow her responsibilities of assuring the resident received necessary life sustaining interventions. The plan of correction was reviewed. The DON, the Administrator, DMQC #150, Staff Educator #138 and Physician #160 were in attendance.On [DATE], all emergency response events will be reviewed through the facility's QAPI process to identify trends and implement additional corrective actions as indicated.On [DATE] at 6:00 P.M., the DON initiated checks at the beginning of each shift by nursing leadership to ensure the agency nurses and CNAs had reviewed and expressed understanding of the information by signing the signature sheet. The audits will be completed daily for 60 days and then weekly for 90 days. The audit findings would be taken to the QAPI meeting by the Administrator to review. On [DATE], the DON implemented a new process to check all agency nurse's CPR status prior to working in the facility. The CPR status check is completed through the staffing agency's portal. Staff Educator #138 will monitor the facility's nursing staff for current CPR certifications. The facility does not require CNAs to be CPR certified. Beginning in [DATE], mock code drills will be completed monthly for three months and then quarterly thereafter by the DON, ADON #74 or RN Staff Educator #138. The findings would be taken to the QAPI meeting by the Administrator to review.Although the Immediate Jeopardy was removed, 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 action plan and monitoring to ensure on-going compliance.Findings include: Review of the medical record for Resident #60 revealed an admission date of [DATE]. Diagnoses included multiple fractured ribs on the left side, acute respiratory failure with hypoxia, acute respiratory failure with hypercapnia, type two diabetes mellitus with diabetic peripheral angiopathy, congestive heart failure (CHF), peripheral vascular disease (PVD), osteoarthritis left knee, and atherosclerotic heart disease of native coronary artery. Review of the code status dated [DATE] revealed Resident #60 was a full code. Review of the admission Minimum Data Set (MDS) assessment, dated [DATE], revealed Resident #60 was cognitively intact, was independent for eating and oral hygiene and required maximal assistance from staff from other activities of daily living (ADL). Review of the care plan dated [DATE], revealed Resident #60 wished to be a full code. Interventions included confirming the desired code status at least quarterly in care conferences and as needed, start CPR and call EMS for transport to the hospital if needed, maintain informed consent on the medical record, and notify the physician and family of the resident's condition.Review of the facility's timeline of events recorded from their closed-circuit television (CCTV) monitoring system revealed Agency CNA #141 entered Resident #60's room to do rounds on [DATE] at 12:22 A.M. Agency CNA #141 turned on the light and ten seconds later came out of the room to look for the nurse. Agency CNA #141 left the unit to get Agency CNA #144 who was working on another unit at 12:23 A.M. Agency CNA #141 and Agency CNA #144 entered Resident #60's room together at 12:24 A.M. and Agency RN #142 entered the room at 12:25 A.M. Agency RN #142 left the room approximately 10 seconds later and went to the nursing station to make a call. Agency CNA #141 and Agency CNA #144 exited the room directly after RN #142. Agency CNA #144 sat down next to the nursing station and started looking at her personal mobile phone and Agency CNA #141 stood near the nursing station. Agency RN #142 hung up the phone at 12:28 A.M. and went around the corner to get Agency CNA #143. Agency CNA #143 came to the hall in front of Resident #60's room and Agency CNAs #141, #143 and #144 stood at Resident #60's doorway at 12:29 A.M. Agency RN #142 pointed at the CNAs and then left the unit at 12:29 A.M. Police Officer #149 arrived at the facility at 12:32 A.M. and Agency RN #142 remained off the unit. Agency CNAs #141, #143 and #144 took Police Officer #149 to Resident #60's room. Police Officer #149 left the room at 12:33 A.M. and went to the entry door. EMS arrived at Resident #60's room at 12:35 A.M. and EMS left with Resident #60 at 1:02 A.M.Review of the 911 audio record dated [DATE] at 12:25 A.M., revealed the dispatcher asked what happened. Agency RN #142 stated she was just informed of an unresponsive patient and Agency RN #142 stated she thought he was deceased and couldn't provide an age. When the dispatcher asked a follow-up question about the resident being unresponsive, she asked if the facility was doing CPR and Agency RN #142 stated she had to check and see if the resident was a do not resuscitate (DNR) but then stated 911 needed to get there immediately.Review of the Computer Aided Dispatch (CAD) log dated [DATE], revealed a 911 call was received at 12:25 A.M. regarding a cardiac arrest at the facility. The caller (Agency RN #142) advised they had an unresponsive male and when asked for clarification, the caller advised she thought he had died.Review of the EMS report dated [DATE], revealed a 911 call was received at 12:25 A.M. for cardiac arrest and EMS arrived at the patient's room at 12:34 A.M. EMS arrived on the scene and found Resident #60 unresponsive, pulseless and apneic (no respirations). The nursing facility staff did not start CPR, and the staff did not know the approximate down time. EMS started CPR and completed Advanced Cardiovascular Life Support (ACLS) protocols during transport to the hospital. Review of the police report dated [DATE] at 12:27 A.M., revealed Police Officer #149 responded to the facility for an unresponsive male. When Police Officer #149 arrived, there were four CNAs standing in the room of Resident #60 and completely clueless of what to do. Police Officer #149 asked for information on Resident #60 and if there was a nurse on site and all individuals said no. Police Officer #149 noted he asked simple questions of how long Resident #60 had been unresponsive, and all parties said they had no idea. Police Officer #149 checked for a pulse on Resident #60, and he was still warm to the touch with no pulse. At that time, Police Officer #149 saw the lights to the squad and asked the personnel to let them in. Again, the staff was not reactive and the patient needed CPR. Police Officer #149 let EMS personnel in, and they initiated CPR on Resident #60. CPR was conducted on Resident #60, and a pulse was received and Resident #60 was prepared for transport. Police Officer #149 spoke to staff after the incident and all parties advised they were not CPR certified and had no way to communicate with the other wings or nurses other than by telephone. The staff stated they were all agency workers and did not even have key fobs to access doors or two-way radios. This information was relayed to the fire command staff. Review of the progress note for Resident #60 dated [DATE] at 12:28 A.M. and authored by Agency RN #142, revealed the resident was found unresponsive by the assigned CNA. Resident #60 received CPR and was transported to the hospital for further treatment. The hospital called to report Resident #60 passed away while receiving treatment in the hospital. The family, primary care physician and DON were notified.Review of the hospital records for Resident #60 dated [DATE] revealed the resident presented with apparent cardiac arrest at 1:27 A.M. Resident #60 was brought to the hospital by EMS. Resident #60 was from a nursing facility and was getting rehabilitation for broken ribs. Resident #60 was found unresponsive by the nursing facility staff, and they did not get a pulse, but they contacted EMS. No CPR was performed by the nursing facility for over ten minutes. EMS found Resident #60 in asystole (heart monitor rhythm indicating no electrical activity and no pulse), and CPR and ACLS protocols were initiated at that time. Resident #60 was given four rounds of epinephrine (tightens blood vessels to raise blood pressure and stimulates the heart to improve blood flow to the brain and heart) and did have a pulse for a short period of time to get him transported to the parking lot but then EMS quickly lost it. EMS did not get a pulse back and Resident #60 had seven rounds of epinephrine prior to arrival. Resident #60 was intubated (having a flexible plastic tube inserted through the mouth or nose and down into the windpipe [trachea]) in the field), and an intraosseous (IO) (a medical access tube placed directly into the bone marrow cavity to quickly deliver fluids, medications, or blood when standard veins cannot be found) line was established in the field to the left humerus (lower leg bone). Resident #60 was given several more rounds of epinephrine at the emergency room (ER) as well as sodium bicarbonate (medication used for specific targeted situations like severe hyperkalemia, tricyclic antidepressant [TCA] overdose, or preexisting severe metabolic acidosis) and Resident #60 had an agonal type rhythm (a slow, bizarre electrical activity on the heart monitor) noted on the monitor with pulse checks, but no pulse was able to be obtained. Resident #60 had a bedside ultrasound that did not show any significant cardiac activity. Resident #60 was pronounced deceased at 1:37 A.M.Review of the death certificate for Resident #60 dated [DATE], revealed the resident was pronounced dead on [DATE] at 1:37 A.M. The immediate cause of death was listed as cardiac arrest with an underlying cause being multiple rib fractures. The manner of death was listed as natural. The death certificate was certified by Physician #160 on [DATE].Review of an undated witness statement from Agency RN #141 and recorded by the DON, revealed the DON reached out to Agency CNA #141 via phone to ask questions about events that occurred on night shift on [DATE] when Resident #60 was found unresponsive. Agency CNA #141 stated that she went into Resident #60's room on her standard rounds and found him responsive. Agency CNA #141 stated she went to the nurses' station to find the nurse, but she was not there so she ran to grab Agency CNA #144 who was working on another unit. Agency CNA #141 stated she called Agency RN #142 when she was going to get Agency CNA #144. Agency CNA #141 stated she and Agency CNA #144 went into Resident #60's room and Resident #60 was not breathing or responding. Agency CNA #141 stated that Agency RN #142 came to the room and then came back out of the room a few minutes later and went to the nurses' station to call 911. Agency CNA #141 stated that Agency RN #142 went to grab a third CNA a few minutes later and all three CNAs were standing outside of Resident #60's room. Agency RN #142 asked who could help perform CPR and all three CNAs stated they were not certified.Review of the witness statement from Agency RN #142 dated [DATE] and recorded by the DON, revealed the DON reached out to Agency RN #142 via phone to ask questions about events that occurred on night shift on [DATE] when Resident #60 was found unresponsive. Agency RN #142 stated that Agency CNA #141 found Resident #60 unresponsive and called her to the room. Agency RN #142 arrived at Resident #60's room from the back of the unit and Agency CNAs #141 and #144 were in the doorway of Resident #60's room. Agency RN #142 stated that upon her assessment, she recognized Resident #60 did not have a pulse and she went to the nurses' station to call 911 and check his code status. Agency RN #142 stated that she asked Agency CNAs #141 and #144 if they could start CPR and they told her they were not CPR certified. Agency RN #142 then went to the back of the unit to grab CNA #143 and asked him if he was CPR certified and he said no. Agency RN #142 stated that she needed to go to the other units in the building to look for another nurse to perform CPR with her and to find a crash cart. The DON asked why she did not stay with the resident, start chest compressions and send one of the three CNAs standing there to go look for another nurse and to grab the crash cart and Agency RN #142 stated that she went because she knew where things where and was not sure if they did. The DON asked why Agency RN #142 did not start chest compressions and Agency RN #142 stated she was not sure if Resident #60 may have still had a thready pulse and he was still warm. Agency RN #142 stated that she put in her note that Resident #60 was unresponsive, and never said he was pulseless.Review of the facility's self-reported incident (SRI) was created on [DATE] at 10:36 P.M. for an allegation of abuse/neglect/mistreatment discovered on [DATE]. An internal investigation was ongoing regarding the actions of Agency RN #142 in response to a resident who was found unresponsive in the early hours of [DATE]. During the investigation, conflicting information was obtained from Agency RN #142 regarding the events surrounding the incident. On [DATE], Agency RN #142 was contacted as part of the facility's follow-up investigation on the new information. During that conversation, Agency RN #142 stated that CPR was not initiated while waiting for EMS to arrive because Agency RN #142 was unsure whether Resident #60 had a pulse and she believed she may have felt a weak, thready carotid pulse. When EMS arrived at the facility, they initiated CPR and were able to resuscitate Resident #60 and transfer the resident to the hospital. On [DATE], Agency RN #142 was contacted again and requested to provide a written statement. Agency RN #142 refused to provide a written statement and stated that she never said she was unsure if he had a pulse or not, which conflicted with the information documented during the previous follow-up conversation. The SRI was substantiated as neglect/mistreatment was verified by evidence. Review of Agency RN #142's witness statement dated [DATE] at 11:04 P.M., revealed Agency RN #142 received a call on her phone from Agency CNA #141. Agency CNA #141 informed Agency RN #142 that she heard audible noises coming from inside Resident #60's room. Agency CNA #141 entered the room to check on Resident #60 and found him unresponsive. Following the phone contact, Agency RN #142 responded immediately and arrived at Resident #60's room. When Agency RN #142 entered the room, Agency RN #142 found Resident #60 unresponsive and observed very shallow respirations. Agency RN #142 also observed his supplemental oxygen cannula was hanging off his face and was out of his nose. Based on Agency RN #142's nursing assessment at that time, Agency RN #142 believed Resident #60 was still exhibiting signs of life and required immediate emergency medical intervention. Agency RN #142 did not believe the resident was pulseless at the time of the assessment. Agency RN #142 immediately contacted EMS and obtained advanced medical assistance as quickly as possible and simultaneously obtained the resident's code status. While EMS was in route, Agency RN #142 notified available staff and directed them to lower the head of the bed and place the bed flat in preparation for the possibility that CPR could become necessary. Agency RN #142 instructed staff to prepare for an emergency response. The staff members present stated they were not CPR certified. Agency RN #142 had to temporarily leave the immediate area to secure qualified staff and emergency equipment because Resident #60's room and the unit lacked a facility wide emergency alert system to instantly summons qualified clinical assistance, and crash carts were not visible or readily identifiable on the unit. Agency RN #142 personally left the unit because she was familiar with the wider facility layout, knew the nurses on the other units and knew the access codes between the units. Based on Agency RN #142's familiarity with the building, she believed that she could obtain necessary resources more quickly than by directing non staff members who were unfamiliar with the facility to do so. At every point during the event, Agency RN #142's actions were guided by her clinical assessment that Resident #60 required the fastest possible emergency response and rapid access to advanced medical care. EMS arrived shortly thereafter and assumed care of Resident #60. Agency RN #142's subsequent electronic nursing documentation that stated CPR was initiated was to log that CPR occurred during the course of the overall emergency response and it was not intended to indicate that CPR was active or necessary at the exact moment of Agency RN #142's initial bedside assessment. Agency RN #142 did not recall the exact verbatim phrasing during the EMS call due to the high acuity nature of the emergency and Agency RN #142's focus was entirely on communicating clinical urgency to secure rapid EMS response.During an interview on [DATE] at 11:25 A.M., Paramedic #151 reported the call initially came in on [DATE] and the caller reported the facility had an unresponsive resident, and the caller thought the resident had passed away. Paramedic #151 stated they were dispatched to the facility on [DATE] at 12:27 A.M. and EMS arrived at approximately 12:32 A.M. Paramedic #151 reported that the police were on scene at the facility upon arrival of EMS. Paramedic #151 stated that EMS arrived at Resident #60's room and there were three employees standing around with Resident #60 being situated along the back wall of his room but there were no staff touching Resident #60 or performing CPR on Resident #60. Paramedic #151 stated Resident #60 was blue in color, unresponsive and had no signs of life. Paramedic #151 reported Resident #60 was lying flat on his back in bed. Paramedic #151 reported Resident #60 was cool to the touch but was not stiff. Paramedic #151 stated he started CPR and there were no signs that the facility had attempted CPR prior to EMS arrival as Paramedic #151 cracked Resident #60's ribs. Paramedic #151 reported he rotated chest compressions with Police Officer #149 while Paramedic #152 did ventilations. Paramedic #151 stated that there were four to five nursing facility employees present and he asked if anyone was CPR certified to help EMS with chest compressions and all the nursing facility employees said no. Paramedic #151 reported that none of the staff indicated that they were a nurse or that there were nurses present at the building. Paramedic #151 reported EMS got Resident #60's pulse back and EMS initiated transport to the hospital at approximately 1:08 A.M. Paramedic #151 stated EMS lost Resident #60's pulse in route to the hospital approximately five minutes into transport. Paramedic #151 stated EMS arrived at the hospital approximately 15 to 20 minutes later and Resident #60 was without a pulse upon arrival at the hospital. Paramedic #151 stated that Resident #60 was taken into a trauma bay and the hospital worked on him for approximately ten minutes before they called time of death. During an interview on [DATE] at 11:34 P.M., Paramedic #152 reported EMS was dispatched to the facility on [DATE] and upon arrival, there were three staff members just standing along the back wall of Resident #60's room and no one was performing CPR. Paramedic #152 stated Resident #60 was lying on his back in bed and his face was blue. Paramedic #152 stated that EMS started CPR as they asked for any information on Resident #60 and no one could give them Resident #60's age. Paramedic #152 reported the staff were asked if they were CPR certified to assist with doing chest compressions and all the staff stated that they were not certified to perform CPR. Paramedic #152 stated EMS was able to get a pulse back but became pulseless again as they transported Resident #60 to the hospital. Paramedic #152 stated the facility staff indicated Resident #60 was a full code and there were no signs that CPR was started prior to EMS arrival at the facility. During an interview via telephone on [DATE] at 2:00 P.M., Agency Licensed Practical Nurse (LPN) #146 stated she worked at the facility on [DATE] when Resident #60 was found unresponsive without respirations. Agency LPN #146 stated she was not informed of the situation until after EMS arrived and had initiated CPR on Resident #60. During an interview via telephone on [DATE] at 2:37 P.M., Agency RN #142 stated Agency CNA #141 heard Resident #60 making noises in his room and she went into the resident's room to check on him and found him unresponsive. Agency RN #142 stated Agency CNA #141 called Agency RN #142 to the resident's room and Agency RN #142 went to Resident #60's room and found him with his oxygen nasal canula hanging out of his nose. Agency RN #142 stated she observed Resident #60 take one shallow breath and she immediately left Resident #60's room to get his code status and to call EMS. Agency RN #142 stated she left the unit after she called EMS to round up resources including another nurse and a crash cart. Agency RN #142 stated she was not sure where the crash carts were located in the facility. Agency RN #142 reported she walked past a nurse while she was looking for resources, but the nurse was busy with a colostomy so she did not even tell the nurse about the situation because she thought explaining it to her would take forever. Agency RN #142 stated she found another nurse and took her back to the unit, but EMS had already arrived at the facility by the time she got back to the unit. Agency RN #142 verified she never took Resident #60's pulse or vitals. Agency RN #142 reported she instructed the CNAs on the unit to lay Resident #60's bed flat prior to her leaving the unit to gather resources. Agency RN #142 stated she asked the CNAs if they were CPR certified and they stated no. Agency RN #142 denied EMS ever asking if she was CPR certified. Agency RN #142 verified no staff performed CPR on Resident #60 from the time he was found by Agency CNA #141 until EMS arrived at the facility and that no pulse or vitals were taken during that time. During an interview via telephone on [DATE] at 2:48 P.M., Agency CNA #143 stated he worked at the facility on [DATE] when Resident #60 was found unresponsive by Agency CNA #141. Agency CNA #143 stated he followed Agency RN #142 to Resident #60's room around 12:00 A.M. and a couple of other CNAs were standing outside of Resident #60's room and everyone was trying to find out what was going on. Agency CNA #143 reported he stepped by Resident #60's door and saw Resident #60 lying in bed, but he could not give any additional details. Agency CNA #143 stated that he did not remember anyone going in Resident #60's room and he did not really pay attention to what Resident #60 looked like in the room. Agency CNA #143 stated the police arrived and spoke to Agency RN #142 and EMS arrived and initiated CPR. During an interview via telephone on [DATE] at 2:58 P.M., Agency CNA #144 stated she went into Resident #60's room because she heard moaning noises coming from the resident's room during rounds. Agency CNA #144 stated Agency CNA #141 found Resident #60 unresponsive and he was not breathing. Agency CNA #144 stated Agency CNA #141 called the nurse and went to find her. Agency CNA #144 stated Agency CNA #141 thought Resident #60 was deceased and Agency CNA #141 called her to the resident's room to see if Resident #60 was deceased . Agency CNA #144 stated she went in Resident #60's room and reported that Resident #60 appeared deceased , was not breathing, was warm to the touch and pale. Agency CNA #144 stated Agency RN #142 came to the room, looked at Resident #60 and then immediately left the room and called EMS. Agency CNA #144 stated Agency RN #142 never touched Resident #60 or took his vitals during the entire incident and never did CPR on the resident. Agency CNA #144 stated the police arrived at the facility first and Police Officer #149 reported Resident #60 had no pulse and that was the first time that Resident #60's pulse was taken during the incident. Agency CNA #144 reported Police Officer #149 asked Agency RN #142 what Resident #60's code status was and Agency RN #142 stated she didn't even think of that. Agency CNA #144 reported Agency RN #142 got on the computer and found out that Resident #60 was a full code, but EMS had arrived and started CPR by that time. Agency CNA #144 stated EMS asked the Police Officer #149 to help do chest compressions on Resident #60. Agency CNA #144 stated that EMS asked if anyone could help do CPR and Agency CNA #144 reported all the CNAs reported they were not certified to do CPR. Agency CNA #144 reported that Agency RN #142 told her that no one could help because the other nurse was busy doing a colostomy bag and Agency CNA #144 stated she did not understand why Agency RN #142 did not have the other two nurses at the facility help. Agency CNA #144 also reported that no one ever called a Code Blue or the facility's code for an unresponsive resident in need of CPR. Agency CNA #144 stated the facility did not have any way to communicate emergencies and the nurse never asked her or the other CNAs to do any tasks such as find the crash cart, get help or call EMS. Agency CNA #144 reported Resident #60 was without respirations for 10 to 15 minutes from the time Agency CNA #141 found Resident #60 unresponsive to the time EMS arrived at the facility and initiated CPR. During an interview via telephone on [DATE] at 3:19 P.M., Agency CNA #141 stated she was doing her rounds around midnight, and she thought she heard Resident #60 cough in his room. Agency CNA #141 stated she went into the resident's room, called out for the resident and rubbed the resident's legs. Agency CNA #141 stated that Resident #60 did not respond and she yelled for help. Agency CNA #141 stated she ran to another unit and told Agency CNA #144 to come help because Resident #60 was unresponsive. Agency CNA #141 stated Agency CNA #144 asked where the nurse was, and she called Agency RN #142. Agency CNA #141 could not recall if any nursing staff checked Resident #60's pulse or vitals. Agency CNA #141 stated Agency RN #142 arrived at Resident #60's room,[TRUNCATED]

Based on staff interview and record review, the facility failed to ensure residents received showers per their preference. This affected one (#46) out of three residents reviewed for activities of daily living. The facility census was 58.Findings include:Review of the medical record for Resident #46's revealed an admission date of 06/02/26. Diagnoses included encephalopathy, dementia unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety, altered mental status, thrombocytopenia, hypertension, and benign prostatic hyperplasia without lower urinary tract symptoms. Review of Resident #46's progress notes from 06/02/26 to 07/20/26, revealed Resident #46 did not refuse any showers documented in the chart. Review of Resident #46's shower sheets from 06/02/26 to 07/20/26, revealed Resident #46 received a shower on 06/12/26, 06/19/26, 07/10/26, and 07/14/26. Review of the admission Minimum Data Set (MDS) assessment for Resident #46 dated 06/08/26, revealed the resident was severely cognitively impaired and required moderate assistance with, showering. Review of the activities of daily living (ADL) care plan for Resident #46 dated 06/13/26, revealed the resident had an ADL self-care performance deficit related to encephalopathy and dementia. The resident required one to two staff assistance with bathing and showering and to provide a sponge bath when a full bath or shower could not be tolerated. Interview on 07/21/26 at 10:48 A.M. the Director of Nursing (DON) verified Resident #46 had no documented showers from 06/02/26 to 06/11/26, from 06/13/26 to 06/18/26, from 06/20/26 to 07/09/26 and from 07/15/26 to 07/30/26. The DON confirmed Resident #46 was scheduled to receive showers two times per week at the facility. Review of the facility's resident centered care bathing choice policy dated 01/26/26 revealed residents are informed that they would be offered bathing twice a week during the admission process. Residents are asked if they have a different preference for bathing. This deficiency represents non-compliance investigated under Complaint Number 3073748.

Based on record review and interview, the facility failed to implement appropriate fall interventions and the facility failed to ensure a resident's fall intervention was in place. This affected one (#31) resident out of three residents reviewed for falls. The facility census was 58.Findings include:Review of medical record for Resident #31's revealed an admission date of 09/01/21. Diagnoses included Alzheimer's disease, iron deficiency anemia, age-related physical debility, muscle weakness, other abnormalities of gait and mobility, and hypertension.Review of a physician order for Resident #31 dated 01/23/26, revealed staff were to ensure the resident was wearing non-slip socks or shoes while ambulating. Review of the quarterly Minimum Data Set (MDS) assessment for Resident #31 dated 07/06/26, revealed the resident to be severely cognitively impaired, required supervision with eating and rolling left and right. Resident #31 required moderate assistance with sitting to lying, lying to sitting, sitting to standing, chair transfers, toilet transfers, tub transfers and walking ten feet and maximal assistance with oral hygiene, showering, upper body dressing, and personal hygiene. Resident #31 was dependent with toileting, lower body dressing, and putting on and taking off footwear and Resident #31 had one fall with no injury on the MDS. Review of the fall risk assessment for Resident #31 dated dated 02/23/26, revealed Resident 31 was at high risk for falls. Review of the progress note for Resident #31 dated 03/27/26 at 4:13 P.M., revealed the resident was lowered to the floor by staff. Resident #31 had been changed and helped to bed by staff. At that point, Resident #31's shoes were taken off and socks were only worn. Resident #31's bed was low but not in the lowest position. Resident #31 got out of bed and the staff member was helping Resident #31 back into the bed. Resident #31 slipped and was lowered to the floor. The physician, Director of Nursing (DON) and power of attorney (POA) were notified. A new order was given to ensure Resident #31 was wearing non-skid socks at all times. Resident #31 was uncooperative with vitals. Range of motion was within normal limits and Resident #31 showed no signs of pain. No injuries were noted. Review of the fall investigative summary for Resident #31 dated 03/27/26 at 4:13 P.M., revealed the Certified Nursing Assistant (CNA) removed Resident #31's shoes and the resident only had her socks on when she got out of bed by herself. The CNA saw Resident #31 and went back into her room and began assisting her back to bed when Resident #31 slipped and the CNA had to lower her to the floor. The immediate intervention was a new order to ensure the resident was wearing non-skid socks at all times when not wearing shoes. Review of the fall care plan for Resident #31 dated 04/14/26, revealed the resident was at risk for falls related to previous falls, risk factors determined on the fall risk assessment, disease process and conditions, functional problems, and medication use. Interventions included non-skid socks at all times, non-skid socks during overnight hours and ensure the resident wore non-skid socks or shoes when ambulating. Review of the progress note for Resident #31 dated 07/06/26 at 4:14 P.M., revealed the nurse heard a loud thud at around 4:00 P.M. Resident #31 was found in the hallway near the dining room. Resident #31 had a hematoma noted on the right forehead. Resident #31's left hand had a large gash on the lateral pinky or fifth finger. Resident #31 was at her cognitive baseline. Resident #31 was uncooperative with care. Resident #31's hand was cleansed and was wrapped. Resident #31 removed treatment two times. Ice was applied to the right forehead. The physician, DON and POA were made aware. Review of the fall investigative summary for Resident #31 dated 07/05/26 at 4:00 P.M., revealed the resident was exiting a room at the end of the hallway when she stumbled and fell to the floor. Resident #31 hit her head. Resident #31 was assessed by staff who noted a hematoma developing to the right side of her forehead and a laceration to the fifth finger on the left hand. The injuries were tended to and the resident was placed on neurological (neuro) checks as she was at cognitive baseline subsequent to the fall. Resident #31 was assisted off the floor by staff and taken to a nearby chair in the common area for further evaluation and monitoring. Resident #31's most recent Brief interview for Mental Status (BIMS) was unable to be completed due to her cognition. Resident #31 had socks on at the time of the fall, and she was at risk for falls due to vascular dementia, age related physical debility and hypertension. The immediate intervention was to ensure the resident was wearing proper footwear while ambulating. Review of the fall investigative summary for Resident #31 dated 07/10/26 at 6:30 P.M., revealed the resident was ambulating in the common area when she cried out after falling to the floor. Resident #31 attempted to sit on the arm of a nearby chair. Resident #31 was found on the floor in the supine position and attempted to get back to her feet independently. Staff intervened and assessed Resident #31 and no new injuries were noted. Resident #31's range of motion and vitals were within normal limits. Resident #31 was assisted back to her feet and began ambulating again without difficulty. Resident #31's most recent BIMS was unable to be completed due to cognitive functioning secondary to dementia. Resident #31 was at risk for falls due to fall history, dementia and hypertension. Immediate interventions included resident education, and reinforcement on safe sitting. Follow up interventions included frequent checks and monitoring.Review of the progress note for Resident #31 dated 07/10/26 at 7:12 P.M., revealed the staff heard a thud during shift change and Resident #31 was calling out upon entering the common area. Resident #31 was observed on her back beside a tipped over recliner. Resident #31 appeared alert and was moving all extremities. Passive range of motion was tolerated well with no signs of shortening or rotation of extremities. Resident #31 was assisted from the floor easily with assistance of two staff members. Resident #31 immediately resumed ambulating with staff monitoring for her safety. Resident #31 was observed attempting to sit on the arm rest of another recliner and staff were able to intervene to prevent a second fall.Review of the fall risk assessment for Resident #31 dated 07/10/26, revealed the resident was at high risk for falls.Observation of Resident #31 on 07/20/26 at 8:39 A.M., revealed the resident was lying in bed. Resident #31 appeared clean and dressed appropriately and was not able to be interviewed due to cognition.Interview on 07/21/26 at 10:37 A.M., the DON verified Resident #31 fell at the facility on 03/27/26 and the resident's fall intervention was to wear non-skid socks at all times when not wearing shoes. The DON confirmed Resident #31 fell on [DATE] while ambulating with regular socks in place. The DON verified Resident #31's fall intervention of non-skid socks were not in place at the time of Resident #31's 07/05/26 fall. The DON also verified education was provided on safe sitting after Resident #31's fall on 07/10/26 despite Resident #31 being severely cognitively impaired with a diagnosis of dementia. Review of the facility's fall prevention and management policy dated 01/28/25, revealed fall risk screening will be completed upon admission and quarterly. Interventions will be put in place based on risk factors. At the time of the fall, the facility will implement an immediate intervention. The interdisciplinary team will conduct a daily fall meeting to determine the best long term fall interventions for the resident.This deficiency represents non-compliance investigated under Complaint Number 3075526.

Based on observation, interview and record review, the facility failed to ensure a resident's medical record was accurate and free from falsified information. This affected one (#60) of the three residents reviewed for accuracy of records. The facility census was 58Findings include: Review of medical record for Resident #60 revealed an admission date of 06/30/26. Diagnoses included multiple fractures of ribs left side, fall on or from other stairs and steps, acute respiratory failure with hypoxia, acute respiratory failure with hypercapnia, type two diabetes mellitus with diabetic peripheral angiopathy, congestive heart failure (CHF), peripheral vascular disease (PVD), unilateral primary osteoarthritis left knee, and atherosclerotic heart disease of native coronary artery without angina pectoris. Review of the admission Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #60 was cognitively intact. Review of the vital signs documentation dated 07/11/26, revealed Agency Registered Nurse (RN) #142 entered a pulse of 66 beats per minute and a blood pressure of 119 millimeters of mercury (mmHg) over 70 mmHg on 07/11/26 at 7:32 P.M. and Agency RN #142 entered a pulse of 66 beats per minute, a blood pressure of 119 mmHg over 70 mmHg and respirations of 18 breaths per minute on 07/11/26 at 7:32 P.M. Review of the facility's security footage from 07/11/26 from 6:50 P.M. to 12:22 A.M. on 07/21/26 at 11:20 A.M. with the Director of Nursing (DON), revealed Agency RN #142 came on shift on 07/11/26 at 6:55 A.M. The Certified Nursing Assistant (CNA) working on the unit was observed to enter Resident #60's room on 07/11/26 at 7:05 P.M. but there were no signs that the CNA took Resident #60's vitals as she did not have the facility's vital sign machine with her. Agency RN #142 was observed taking medication into Resident #60's room on 07/11/26 at 7:36 A.M. Agency RN #142 was in Resident #60's room for approximately 30 seconds prior to leaving the room and the video footage showed no evidence that Agency RN #142 took Resident #60's vitals at that time as Agency RN #142 did not have the vital sign machine with her. Further review of the video footage revealed Agency RN #142 went into Resident #60's room again on 07/11/26 at 8:50 P.M. for several seconds but there was no evidence that Resident #60's vitals were taken at that time as Agency RN #142 did not take the vital sign machine with her in the room. Agency RN #142 did not make any additional visits to Resident #60's room on 07/11/26 from 6:50 P.M. to 07/12/26 at 12:25 A.M. During an interview on 07/21/26 at 11:20 A.M., the DON verified none of the facility staff present on 07/11/26 from 6:55 A.M. to 07/12/26 at 1:02 A.M. took Resident #60's vitals despite Agency RN #142 entering a pulse of 66 beats per minute and a blood pressure of 119 mmHg over 70 mmHg on 07/11/26 at 7:32 P.M. and Agency RN #142 entering a pulse of 66 beats per minute, a blood pressure mmHg of 119 over 70 mmHg and respirations of 18 breaths per minute on 07/11/26 at 7:32 P.M. in Resident #60's medical record. During an interview via telephone on 07/22/26 at 8:40 A.M., Agency RN #142 verified she did not take any vital signs on Resident #60 her entire shift despite Agency RN #142 entering a pulse of 66 beats per minute and a blood pressure of 119 mmHg over 70 mmHg on 07/11/26 at 7:32 P.M. and Agency RN #142 entering a pulse of 66 beats per minute, a blood pressure of 119 mmHg over 70 mmHg and respirations of 18 breaths per minute on 07/11/26 at 7:32 P.M. in Resident #60's medical record. Agency RN #142 stated Unofficially off the record, if she didn't have machinery, she did not like to palpate a pulse and during her entire nursing career,, she always got a false pulse because she felt her pulse, but she could see a pulse.

Based on interview and record review, the facility failed to implement and follow it's abuse policy. This affected one (Resident #1), out of nine residents reviewed for abuse. The facility census was 58 at the time of survey. Findings include:Review of the medical record revealed Resident #1 was admitted to the facility on [DATE]. Diagnoses included displaced fracture of upper end of left humerus, pain due to internal orthopedic prosthetic devices, unsteadiness on feet, muscle weakness, age-related osteoporosis, hypertensive heart disease, peripheral vascular disease, and nutritional anemia. Review of the most recent Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed the resident had moderately impaired cognition with a Brief Interview of Mental Status Score (BIMS) of seven out of 15, had no behaviors, did not reject care, and did not wander. Resident#1 is documented to be frequently incontinent.Interview with Director of Nursing (DON) on 04/01/2026 at 12:45 P.M. revealed on 03/22/2026 Resident #1 complained of a broken arm and pain after care provided by former employee, Certified Nursing Assistants (CNA) #106. CNA #106 reported the complaint to an agency nurse working in the facility, who then directed CNA #106 to call DON and report the complaint. An assessment with no findings was performed by the agency nurse on 03/22/2026. CNA #106 failed to report the complaint to DON or any other appropriate staff member.On 03/23/2026 Registered Nurse (RN) #108 was notified at evening shift change (approximately 7:00 P.M.) that Resident #1 was complaining of pain in her left arm and reported that she was in a fight with a CNA. RN #108 immediately assessed Resident #1 and found bruising and swelling to left arm. DON was immediately notified. RN #108 notified the physician and Resident #1 was sent out to the local emergency department (ED) for further evaluation. Resident #1 was found to have a fracture to the left forearm and orthopedic evaluation recommended nonsurgical management and placemen of a sling.The facility filed an SRI (self-Reported Incident) on 03/23/2026. CNA #106 was suspended following investigation of the incident and employment was subsequently terminated for failing to report the incident. All staff were re-educated on the facility abuse policy on 03/24/2026. Local police were notified of the incident and declined to file a report after interview and investigation.Interview with DON on 04/02/2026 at 12:45 P.M. confirmed that CNA #106 failed to follow the facility abuse policy by failing to report the incident to facility staff.Facility policy titled Abuse, Neglect, Misappropriation and Crime Reporting, dated 08/14/1999, states All allegations of abuse, neglect, and misappropriation will be reported immediately and will be investigated and All staff members are trained to report abuse, including resident-to resident abuse, immediately (means as soon as they have knowledge of the abuse/allegation) to the staff nurse, supervisor in charge, Unit Manage, Director of Nursing or Administrator.This deficiency represents non-compliance investigated under Complaint Number 2968199.

Based on interview and record review, the facility failed to report allegations of abuse in a timely manner. This affected one (Resident #1) out of nine residents reviewed for abuse. The facility census was 58 at the time of survey.Findings include:Review of the medical record revealed Resident #1 was admitted to the facility on [DATE]. Diagnoses included displaced fracture of upper end of left humerus, pain due to internal orthopedic prosthetic devices, unsteadiness on feet, muscle weakness, age-related osteoporosis, hypertensive heart disease, peripheral vascular disease, and nutritional anemia. Review of the most recent Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed the resident had moderately impaired cognition with a Brief Interview of Mental Status Score (BIMS) of seven out of 15, had no behaviors, did not reject care, and did not wander. Resident#1 is documented to be frequently incontinent.Interview with Director of Nursing (DON) on 04/01/2026 at 12:45 P.M. revealed on 03/22/2026 Resident #1 complained of a broken arm and pain after care provided by former employee, Certified Nursing Assistants (CNA) #106. CNA #106 reported the complaint to an agency nurse working in the facility, who then directed CNA #106 to call DON and report the complaint. An assessment with no findings was performed by the agency nurse on 03/22/2026. CNA #106 failed to report the complaint to DON or any other appropriate staff member.On 03/23/2026 Registered Nurse (RN) #108 was notified at evening shift change (approximately 7:00 P.M.) that Resident #1 was complaining of pain in her left arm and reported that she was in a fight with a CNA. RN #108 immediately assessed Resident #1 and found bruising and swelling to left arm. DON was immediately notified. RN #108 notified the physician and Resident #1 was sent out to the local emergency department (ED) for further evaluation. Resident #1 was found to have a fracture to the left forearm and orthopedic evaluation recommended nonsurgical management and placemen of a sling.The facility filed an SRI (self-Reported Incident) on 03/23/2026. CNA #106 was suspended following investigation of the incident and employment was subsequently terminated for failing to report the incident. All staff were re-educated on the facility abuse policy on 03/24/2026. Local police were notified of the incident and declined to file a report after interview and investigation.Interview with DON on 04/02/2026 at 12:45 P.M. confirmed that CNA #106 failed to report the incident to facility staff.Facility policy titled Abuse, Neglect, Misappropriation and Crime Reporting, dated 08/14/1999, states All allegations of abuse, neglect, and misappropriation will be reported immediately and will be investigated and All staff members are trained to report abuse, including resident-to resident abuse, immediately (means as soon as they have knowledge of the abuse/allegation) to the staff nurse, supervisor in charge, Unit Manage, Director of Nursing or Administrator.This deficiency represents non-compliance investigated under Complaint Number 2968199.

Based on observation and interview, the facility failed to maintain call lights within reach of residents. This affected two (Residents #4 and #9). The facility census was 58 at the time of survey.Findings include:1.Review of the medical record revealed Resident #4 was admitted to the facility on [DATE]. Diagnoses included hemiplegia and hemiparesis following cerebral infarction, aphasia, muscle weakness, chronic respiratory failure with hypoxia, chronic obstructive pulmonary disease, and Type II Diabetes Mellitus.Review of the most recent Minimum Data Set (MDS) 3.0 assessment dated [DATE], revealed the resident had mildly impaired cognition, had no behaviors, did not reject care, and did not wander. Resident #4 was always incontinent of bowel and bladder.Resident #4 was a two-person physical assist, and was dependent for all activities of daily living (ADL).Review of Resident #4's care plan, dated 01/25/2026 revealed resident has ADL self-care deficit, he is dependent on staff for all ADL's with intervention including Keep call light in reach at all times.Observation on 04/01/2026 at 9:20 A.M. revealed that Resident #4's call light was sitting on a nightstand to the side of the bed, out of reach of the resident.Interview with Nurse Educator #102 on 04/01/2026 at 9:24 A.M. confirmed that Resident #4's call light was placed out of reach and Resident #4 was dependent for all care.2.Review of the medical record revealed Resident #9 was admitted to the facility on [DATE]. Diagnoses included Type II Diabetes Mellitus, vascular dementia, essential hypertension, hyperlipidemia, chronic kidney disease, and celiac disease.Review of the most recent Minimum Data Set (MDS) 3.0 assessment dated [DATE], revealed the resident had severely impaired cognition with a Brief Interview Status (BIMS) of three out of 15, had no behaviors, did not reject care, and did not wander. Resident #9 was frequently incontinent of bowel and bladder.Resident #9 was a one-person physical assist, required partial/moderate assistance for bed mobility, transfers, dressing, toileting, personal hygiene, eating, and locomotion.Observation on 04/01/2026 at 9:58 A.M. revealed that Resident #9's call light was wrapped tightly around a lower side bar on the residents bed unable to be accessed by the resident.Interview on 04/01/2026 at 10:26 A.M. with LPN #105 confirmed that Resident #9's call light was not accessible to the resident.Facility policy titled Responding to Call Lights dated 01/20/2026 states The signal cord or device must be easily accessible to the resident at all times.This deficiency represents non-compliance investigated under Complaint Number 2665706.

Based on observation and interview, the facility failed to ensure infection control policies and procedures were followed. This affected Residents #5 and #8. The facility census was 58 at the time of survey.Findings include:1.Review of the medical record revealed Resident #5 was admitted to the facility on [DATE]. Diagnoses included Lennox-Gastaut syndrome (intractable with status epilepticus), non-ST elevation myocardial infarction, acute respiratory failure with hypoxia, dysphagia, and acute kidney failure. Review of the most recent Minimum Data Set (MDS) 3.0 assessment dated [DATE], revealed the resident had moderately impaired cognition with a Brief Interview od Mental Status (BIMS) of 10 out of 15, had no behaviors, did not reject care, and did not wander. Resident #5 had a urinary catheter and was frequently incontinent of bowel.Resident #5 was a two-person physical assist, was dependent for all Activities of Daily Living (ADL's) and received tube feeds for nutrition.Review of the care plan dated 03/11/2026 revealed for Resident #5 Enhanced Barrier Precautions will be maintained per facility/organization policy.Observation on 03/31/2026 at 9:15 A.M. and 04/01/2026 at 7:03 A.M. revealed Resident #5 sitting in common area receiving tube feeds/flushes with the nurse not wearing any personal protective equipment (PPE).Interview with the Director of Nursing (DON) on 04/02/2026 at 7:55 A.M. confirmed tube feeds, flushes and medication administration through Gastrostomy (G)-tube occur regularly for Resident #5 in the common area and the nurses do not wear PPE during care.Enhanced Barrier Precautions signage placed on Resident #5's door states Providers and staff must .Wear gloves and a gown for the following high-contact resident care activities .Device care or use: central line, urinary catheter, feeding tube, tracheostomy.2.Review of the medical record revealed Resident #8 was admitted to the facility on [DATE]. Diagnoses included vascular dementia, anxiety disorder, major depressive disorder, and weakness.Review of the most recent Minimum Data Set (MDS) 3.0 assessment dated [DATE], revealed the resident had severely impaired cognition, had no behaviors, did not reject care, and did not wander. Resident #8 was always incontinent of bowel and bladder.Observation of incontinence care on 04/01/2026 at 9:37 A.M. revealed that CNA #103 did not change gloves after care and picked up Resident #8's call light off of the floor with her still gloved hand and handed it to the resident who promptly put the call light in her mouth.Interview with CNA #103 on 04/01/2026 at 9:50 A.M. confirmed that she did not change or remove her gloves and perform hand hygiene prior to handing Resident #8 her call light. It was further confirmed the call light was picked up off the floor and handed to the resident without being cleaned.Interview with DON on 04/02/2026 confirmed hand hygiene should have been performed and the call light should have been cleaned prior to providing it to resident.

Based on medical record review, observation, staff interview, physician interview, review of pharmacy delivery sheets, review of Controlled Drug Receipt/Records, and review of the facility policy, the facility failed to notify the physician when residents were not administered medications as ordered by the physician. This affected one (#75) out of the three residents reviewed for notification. The facility census was 61. Findings include: Review of the medical record for Resident #75 revealed the resident was admitted to the facility on [DATE], discharged on 08/12/25 and never returned. Diagnoses included dementia, anxiety disorder, hypo-osmolality and hyponatremia, major depressive disorder, diabetes mellitus (DM), atrial fibrillation, hypercholesterolemia, peripheral vascular disease, gastro-esophageal reflux disease, and hypothyroidism. Review of the Minimum Data Set (MDS) assessment for Resident #75, dated 08/12/25, revealed the resident was cognitively impaired and was dependent on staff for medication administration.Review of physician orders for Resident #75 dated 07/08/25 and discontinued on 08/12/25, revealed the resident was ordered Diltiazem (used to treat high blood pressure and heart rhythm disorders) extended release (ER) 180 milligrams (mg) daily in the morning, Sotalol (used to treat abnormal heart rhythms) 80 mg one half tablet (40 mg) twice daily and oxycodone (narcotic pain reliever) five mg every six hours as needed (PRN) for pain. Physician orders dated 07/19/25 and discontinued on 08/12/25, revealed the resident was ordered to receive isosorbide mononitrate (vasodilator used to treat heart conditions) ER 30 mg every morning. Physician orders dated 07/26/25 and discontinued on 08/02/25, revealed the resident was ordered metformin 500 mg daily. Review of the July 2025 medication administration record (MAR) for Resident #75 revealed the following: a) From 07/22/25 through 07/31/25, it was documented that the resident received diltiazem 180 mg daily, except for 07/28/25 (blank entry). b) From 07/24/25 through 07/31/25, it was documented that the resident received sotalol 80 mg twice daily, except for the morning dose of 07/28/25 (blank entry). c) From 07/19/25 through 07/29/25, it was documented the resident received isosorbide 30 mg daily, except for 07/28/25 (blank entry). a) On 07/26/25, 07/27/25, 07/28/25 (blank entry) and 07/29/25, the resident did not receive metformin 500 mg due to the medication being unavailable/new order. e) On the morning of 07/28/25, Lasix (anti-diuretic) 40 mg, Eliquis (anti-coagulant), Lantus (insulin) 20 units, cholecalciferol (vitamin D-3) (supplement), and lidocaine patch (pain reliever) were blank which indicated the resident was not administered the medications. There was also no documented blood sugar check (accuchecks) completed on 07/28/25 in the morning. Review of the August 2025 MAR for Resident #75 revealed the following: a) From 08/01/25 through 08/06/25, it was documented that the resident received diltiazem 180 mg daily. The MAR indicated the resident did not receive diltiazem 180 mg on 08/07/25, 08/10/25 (blank entry), 08/11/25 and 08/12/25, due to the medication not being available. b) From 08/01/25 through 08/04/25, it was documented that the resident received sotalol 80 mg twice daily. c) On 08/03/25 and 08/12/24, the MAR indicated the resident did not receive isosorbide due to medication no being available. d) From 08/09/25 through 08/11/25, the MAR was blank for oxycodone five mg, which indicated no medications were administered. Review of a progress note for Resident #75 dated 08/12/25 at 9:59 A.M., revealed the resident presented with an altered mental status (AMS) along with abnormal vital signs. The resident's pulse fluctuated between 29 and 40 beats per minute (normal 60-80), blood pressure was 130 over 97 milliliters of mercury (mmHg), oxygen saturation was 95 percent (%), and her body temperature was 97.9 Fahrenheit (F). Resident #75 was diaphoretic, complained of numbness in her right arm and hand along with three episodes of emesis. The resident was transferred to the hospital via squad. Review of the Prescription Order Status (a printed form by the facility showing the medications ordered and delivered) for Resident #75 on 10/07/25 at 2:00 P.M., revealed the resident had the following medications delivered to the facility: On 07/08/25, a quantity of 14 diltiazem 180 ER, a quantity of 14 sotalol 80 mg and a quantity of nine oxycodone five mg were delivered to the facility. On 07/14/25, a quantity of 28 oxycodone five mg were delivered. On 07/29/25, a quantity of 14 isosorbide 30 mg ER were delivered. On 08/04/25 a quantity of 14 sotalol were delivered. On 08/06/25, a quantity of 14 Diltiazem 180 mg ER were delivered and on 08/12/25, a quantity of 14 isosorbide tablets were delivered on 08/12/25. Review of a Controlled Drug Receipt/Record (Narcotic sheet) for Resident #75 75 on 10/07/25 at 2:10 P.M., revealed the facility received 28 oxycodone five mg tablets on 07/14/25. The resident was administered oxycodone on a regular basis from 07/16/25 through 08/08/25 when the card was empty. There were no additional oxycodone five mg received for Resident #75 after 08/08/25. Interview on 10/07/25 at 3:44 P.M. with the Director of Nursing (DON) confirmed the facility received 14 Diltiazem 180 mg for Resident #75 on 07/08/25, and 14 more 08/06/25. The DON verified Resident #75 was ordered to receive diltiazem 180 mg daily from 07/08/25 through 08/12/25. The DON verified the resident's MAR indicated the resident received diltiazem 180 mg from 07/22/25 through 08/06/25, despite the facility not having the medications in the facility and stated she could not explain the discrepancy. The DON also verified Resident #75 did not receive diltiazem 180 mg on 08/07/25, 08/10/25, and 08/11/25 due to the MAR indicating the medication was not available. The DON also verified the facility received 14 sotalol 80 mg for Resident #75 on 07/08/25 and 14 more on 08/04/25. The DON verified Resident #75 was ordered to receive sotalol 80 mg one half tablet twice daily from 07/08/25 through 08/12/25. The DON stated the 14 sotalol 80 mg received on 07/08/25 would have finished on 07/23/25. The DON verified the resident's MAR indicated the resident received sotalol 80 one half tablet twice daily from 07/24/25 through 08/04/25, despite the facility not having the sotalol in the facility and stated she could not explain the discrepancy. The DON also verified the facility received 14 isosorbide 30mg for Resident #75 on 07/29/25 and 14 more on 08/12/25. The DON verified Resident #75 was ordered to receive isosorbide ER 30 mg daily from 07/19/25 through 08/12/25. The DON verified the resident's MAR indicated the resident received isosorbide 30 mg from 07/19/25 through 07/29/25, despite the facility not having the medications in the facility and stated she could not explain the discrepancy. The DON also verified the facility received eight oxycodone five mg for Resident #75 on 07/08/25 and 28 more on 07/14/25. The DON verified Resident #75 received oxycodone regularly from 07/09/25 through 08/08/25 The DON verified the oxycodone five mg was not available for resident from 08/09/25 through 08/12/25. The DON stated a nurse requested a refill on 08/11/25 at 12:26 P.M. and the order was never filled. The DON stated she checked the facility's emergency supply box (e-box) list, and it did not reveal any indications of the nursing staff removing diltiazem, isosorbide mononitrate, sotalol, or oxycodone for Resident #75. The DON verified there was no documented evidence that the physician was notified of Resident #75 medication discrepancies. The DON stated it was the expectation for the nursing staff to contact the physician for any missed medications.Interview on 10/07/25 at 10:49 A.M. with PCP #500 stated he was never notified of the medication discrepancies for Resident #75. PCP #500 stated he was concerned about the medication discrepancies because Resident #75 was discharged to the hospital on [DATE] for heart related issues. Interview on 10/07/25 at 11:31 A.M. with Licensed Practical Nurse (LPN) #181 who stated she does not notify the physician if a resident missed medications. LPN #181 stated she would only notify the physician if the medication was an important medication but could not give an example of what an important medication was.Review of a text message exchange between Primary Care Physician (PCP) #500 and 100-200 hall nurse on 10/07/25 at 10:40 A.M. revealed the 100-200 hall nurse sent a text message to PCP #500 on 08/11/25 at 12:26 P.M. and reported Resident #75 needed a new script for PRN Oxycodone. At 4:09 P.M. the 100-200 hall nurse sent a text message to PCP #500 and noted Resident #75 had several episodes of diarrhea and wanted to give the resident Imodium. PCP #500 responded with an order for Imodium four mg three times a day prn. The message did not include anything about the oxycodone refill. Review of the facility policy titled Notification of Change dated 09/14/23 confirmed notifications of changes will be completed and documented. An immediate notification of the resident's physician will be completed for a need to alter treatments.

Based on medical record review, the facility staff interview, and facility policy review the facility failed to provide resident with showers. This affected one (#75) out of the three residents reviewed for showers. The facility census was 61.Findings include:Review of the medical record for Resident #75 revealed she was admitted to the facility on [DATE]. Resident #75 was discharged to the hospital on [DATE] and never returned. Diagnoses included anxiety disorder, hypo-osmolality and hyponatremia, major depressive disorder, diabetes mellitus (DM), atrial fibrillation, hypercholesterolemia, peripheral vascular disease, gastro-esophageal reflux disease, and hypothyroidism. Review of the July 2025 shower/bathing sheets for Resident #75, revealed the resident was documented as only receiving a shower on 07/14/25 and 07/24/25. Resident #75 had no documented showers for August 2025. Review of the Minimum Data Set (MDS) assessment for Resident #75, dated 08/12/25, revealed her cognitive status was not assessed and the resident was dependent on staff for personal hygiene and bathing/showers. Interview with the Director of Nursing (DON) on 10/07/25 at 3:44 P.M. who stated the residents were assigned two shower/bathing days a week and more if needed or requested. The DON verified Resident #75 only received a shower on 07/14/25 and 07/24/25, and there was no documented evidence Resident #75 received any showers/bathing in August 2025. Review of the facility policy titled Bathing dated 02/04/24 revealed the purpose of the bathing policy was to ensure residents receive bathing and given choices if desired. Further review of the policy revealed the residents were scheduled for bathing two times per week.This deficiency represents non-compliance investigated under Complaint Number 2625070.

Based on medical record review, observation, staff interview, physician interview, review of pharmacy delivery sheets, review of Controlled Drug Receipt/Records, and review of the facility policy, the facility failed to ensure residents were free of significant medication errors. This affected one (#75) of the three residents reviewed for medications. The census was 57. Findings include: Review of the medical record for Resident #75 revealed the resident was admitted to the facility on [DATE], discharged on 08/12/25 and never returned. Diagnoses included dementia, anxiety disorder, hypo-osmolality and hyponatremia, major depressive disorder, diabetes mellitus (DM), atrial fibrillation, hypercholesterolemia, peripheral vascular disease, gastro-esophageal reflux disease, and hypothyroidism. Review of the Minimum Data Set (MDS) assessment for Resident #75, dated 08/12/25, revealed the resident was cognitively impaired and was dependent on staff for medication administration.Review of physician orders for Resident #75 dated 07/08/25 and discontinued on 08/12/25, revealed the resident was ordered Diltiazem (used to treat high blood pressure and heart rhythm disorders) extended release (ER) 180 milligrams (mg) daily in the morning, Sotalol (used to treat abnormal heart rhythms) 80 mg one half tablet (40 mg) twice daily and oxycodone (narcotic pain reliever) five mg every six hours as needed (PRN) for pain. Physician orders dated 07/19/25 and discontinued on 08/12/25, revealed the resident was ordered to receive isosorbide mononitrate (vasodilator used to treat heart conditions) ER 30 mg every morning. Physician orders dated 07/26/25 and discontinued on 08/02/25, revealed the resident was ordered metformin 500 mg daily. Review of the progress notes for Resident #75 from 07/22/25 through 08/11/25, revealed no documentation of the physician being notified of the medication discrepancies. Review of the July 2025 medication administration record (MAR) for Resident #75 revealed the following: a) From 07/22/25 through 07/31/25, it was documented that the resident received diltiazem 180 mg daily, except for 07/28/25 (blank entry). b) From 07/24/25 through 07/31/25, it was documented that the resident received sotalol 80 mg twice daily, except for the morning dose of 07/28/25 (blank entry). c) From 07/19/25 through 07/29/25, it was documented the resident received isosorbide 30 mg daily, except for 07/28/25 (blank entry). d) On 07/26/25, 07/27/25, 07/28/25 (blank entry) and 07/29/25, the resident did not receive metformin 500 mg due to the medication being unavailable/new order. e) On the morning of 07/28/25, Lasix (anti-diuretic) 40 mg, Eliquis (anti-coagulant), Lantus (insulin) 20 units, cholecalciferol (vitamin D-3) (supplement), and lidocaine patch (pain reliever) were blank which indicated the resident was not administered the medications. There was also no documented blood sugar check (accuchecks) completed on 07/28/25 in the morning. Review of the August 2025 MAR for Resident #75 revealed the following: a) From 08/01/25 through 08/06/25, it was documented that the resident received diltiazem 180 mg daily. The MAR indicated the resident did not receive diltiazem 180 mg on 08/07/25, 08/10/25 (blank entry), 08/11/25 and 08/12/25, due to the medication not being available. b) From 08/01/25 through 08/04/25, it was documented that the resident received sotalol 80 mg twice daily. c) On 08/03/25 and 08/12/24, the MAR indicated the resident did not receive isosorbide due to medication no being available. d) from 08/09/25 through 08/11/25, the MAR was blank for oxycodone five mg, which indicated no medications were administered. Review of a progress note for Resident #75 dated 08/12/25 at 9:59 A.M., revealed the resident presented with an altered mental status (AMS) along with abnormal vital signs. The resident's pulse fluctuated between 29 and 40 beats per minute (normal 60-80), blood pressure was 130 over 97 milliliters of mercury (mmHg), oxygen saturation was 95 percent (%), and her body temperature was 97.9 Fahrenheit (F). Resident #75 was diaphoretic, complained of numbness in her right arm and hand along with three episodes of emesis. The resident was transferred to the hospital via squad. Review of the Prescription Order Status (a printed form by the facility showing the medications ordered and delivered) for Resident #75 on 10/07/25 at 2:00 P.M., revealed the resident had the following medications delivered to the facility: On 07/08/25, a quantity of 14 diltiazem 180 ER, a quantity of 14 sotalol 80 mg and a quantity of nine oxycodone five mg were delivered to the facility. On 07/14/25, a quantity of 28 oxycodone five mg were delivered. On 07/29/25, a quantity of 14 isosorbide 30 mg ER were delivered. On 08/04/25 a quantity of 14 sotalol were delivered. On 08/06/25, a quantity of 14 Diltiazem 180 mg ER were delivered and on 08/12/25, a quantity of 14 isosorbide tablets were delivered on 08/12/25. Review of a Controlled Drug Receipt/Record (Narcotic sheet) for Resident #75 75 on 10/07/25 at 2:10 P.M., revealed the facility received 28 oxycodone five mg tablets on 07/14/25. The resident was administered oxycodone on a regular basis from 07/16/25 through 08/08/25 when the card was empty. There were no additional oxycodone five mg received for Resident #75 after 08/08/25. Interview on 10/07/25 at 3:44 P.M. with the Director of Nursing (DON) confirmed the facility received 14 Diltiazem 180 mg for Resident #75 on 07/08/25, and 14 more 08/06/25. The DON verified Resident #75 was ordered to receive diltiazem 180 mg daily from 07/08/25 through 08/12/25. The DON verified the resident's MAR indicated the resident received diltiazem 180 mg from 07/22/25 through 08/06/25, despite the facility not having the medications in the facility and stated she could not explain the discrepancy. The DON also verified Resident #75 did not receive diltiazem 180 mg on 08/07/25, 08/10/25, and 08/11/25 due to the MAR indicating the medication was not available. The DON also verified the facility received 14 sotalol 80 mg for Resident #75 on 07/08/25 and 14 more on 08/04/25. The DON verified Resident #75 was ordered to receive sotalol 80 mg one half tablet twice daily from 07/08/25 through 08/12/25. The DON stated the 14 sotalol 80 mg received on 07/08/25 would have finished on 07/23/25. The DON verified the resident's MAR indicated the resident received sotalol 80 one half tablet twice daily from 07/24/25 through 08/04/25, despite the facility not having the sotalol in the facility and stated she could not explain the discrepancy. The DON also verified the facility received 14 isosorbide 30mg for Resident #75 on 07/29/25 and 14 more on 08/12/25. The DON verified Resident #75 was ordered to receive isosorbide ER 30 mg daily from 07/19/25 through 08/12/25. The DON verified the resident's MAR indicated the resident received isosorbide 30 mg from 07/19/25 through 07/29/25, despite the facility not having the medications in the facility and stated she could not explain the discrepancy. The DON also verified the facility received eight oxycodone five mg for Resident #75 on 07/08/25 and 28 more on 07/14/25. The DON verified Resident #75 received oxycodone regularly from 07/09/25 through 08/08/25 The DON verified the oxycodone five mg was not available for resident from 08/09/25 through 08/12/25. The DON stated a nurse requested a refill on 08/11/25 at 12:26 P.M. and the order was never filled. The DON stated she checked the facility's emergency supply box (e-box) list, and it did not reveal any indications of the nursing staff removing diltiazem, isosorbide mononitrate, sotalol, or oxycodone for Resident #75. Interview on 10/07/25 at 10:49 A.M. with PCP #500 stated he was never notified of the medication discrepancies for Resident #75. PCP #500 stated he was concerned about the medication discrepancies because Resident #75 was discharged to the hospital on [DATE] for heart related issues. Review of a text message exchange between Primary Care Physician (PCP) #500 and 100-200 hall nurse on 10/07/25 at 10:40 A.M. revealed the 100-200 hall nurse sent a text message to PCP #500 on 08/11/25 at 12:26 P.M. and reported Resident #75 needed a new script for PRN Oxycodone. At 4:09 P.M. the 100-200 hall nurse sent a text message to PCP #500 and noted Resident #75 had several episodes of diarrhea and wanted to give the resident Imodium. PCP #500 responded with an order for Imodium four mg three times a day prn. The message did not include anything about the oxycodone refill. Review of the undated facility policy titled Medication Administration, revealed all medications would be administered in an organized, accurate and safe manner, accordance with manufacturers specifications, and good nursing principles and practices. If a regularly scheduled medication was withheld, refused or given at other than the scheduled time, the nurse shall document in the MAR and enter an explanatory note in the record.

Based on record review, observation and interview, the facility failed to store foods in accordance with professional standards for food service safety. This had the potential to affect 56 residents who received food from the kitchen. The facility census was 56. Findings include: Observation of the Kitchen on 10/31/23 form 8:35 A.M. to 9:05 A.M. revealed the following: 1. In the reach in refrigerator: a. a large bag of lettuce appearing brown and watery dated 10/26/23. b. a bag of hot dogs and ham dated 10/26/23. c. a bag of apparent cheese with no date or label. d. open container whole milk with no date 2. In the milk cooler: a. a four by six inch spillage of milk on the bottom of the cooler with milk cartons stored above. 3. In dry storage and prep area: a. the meal slicer blade had brown colored debris and was uncovered. b. a package of spaghetti opened and unsealed on the storage shelf. 3. In the main kitchen area: a. on a shelf under the food preparation table, there was an aerosol can of a cleaning chemical stored with bags of foods. b. an opened bag of gravy mix with no open date. 4. In the mop and chemical storage room: a. soiled towels and soiled cleaning cloths were on the floor, measuring two by three feet wide. During interview on 10/31/23 at 9:05 A.M., Diet Manager, (DM) #57 verified the above observations. DM #57 verified foods should be labeled and dated, equipment cleaned and covered, soiled cleaning cloths stored off the floor, and chemicals should not be stored near food preparation areas. Review of the facility policy titled Food Storage: Dry Goods, dated September 2017, revealed all packaged food items will be properly sealed. Toxic material will not be stored with food. All items will be stored at least six inches above the floor. Review of the facility policy titled Food Storage: Cold Food, dated April 2018, revealed all foods will be labeled and dated, and arranged to prevent cross contamination.

Based on record review and interview, the facility failed to have clear documentation of advanced directives in the electronic medical record. This affected four (Residents #9, #10,#13 and #25) of five residents reviewed for advanced directives. The facility census was 56. Findings include: 1. Review of the medical record for Resident #9 revealed an admitted [DATE]. Review of Resident #9's medical records revealed a DNR order form signed by physician on 03/15/21 for an order of Do Not Resuscitate Comfort Care Arrest, (DNR- CCA). There was also a physician order for a code status of Do Not Resuscitate Comfort Care, (DNRCC) dated 08/29/23. 2. Review of the medical record for Resident #10 revealed an admitted [DATE]. Review of Resident's #10 medical records revealed Resident #10 had a physician order for a code status of Do Not Resuscitate Comfort Care Arrest, (DNRCC-A) dated 10/12/21 and a non-dated DNR order form with the words FULL CODE written in large back letters across the form. 30802 3. Review of the medical record for Resident #13 revealed an admitted [DATE]. Review of the electronic record revealed an order for DNRCC, but there was no copy of a signed advanced directive in the electronic record. There was no paper record for the resident. 4. Review of the medical record for Resident #25 revealed and admitted [DATE]. Review of the electronic record revealed a physician order for DNRCC, but there was no advanced directives form on the electronic record. There was no paper record for the resident. During interview on 11/02/23 at 2:45 P.M., Nurse #10 verified the conflicting information as noted above. She stated the copy of the signed advanced directives was kept in a binder at the nurses station with all the others. It was not scanned into the resident's electronic record and the residents did not have a paper record.

Based on record review and interview, the facility failed to initiate and update care plans for residents. This affected three (Residents #5, #354 and #48) of 21 residents whose care plans were reviewed The facility census was 56. Findings include: 1. Review of the medical record for Resident #5 revealed an admitted [DATE] and diagnoses including malignant pancreatic cancer, dysphagia, Alzheimer's disease, and depression. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #35 had moderately impaired cognition. Resident #5 had an advanced dysphagia diet ordered on 10/10/23 with no new texture change orders since 10/10/23. Review of social service progress notes dated 11/01/23 as late entry of 10/18/23 at 11:56 A.M. documented Resident #5's dentures had been broken. Review of Resident #5's plan of care had been updated with new problems, goals and interventions on 09/17/23. There were no interventions to address Resident #5 had broken dentures as of 10/18/23. Review of the progress notes documented by Registered Dietitian (RD) #16 dated 10/31/23 revealed no revised assessment, or plan care interventions addressing Resident #5's broken dentures. Observation on 10/31/23 at 12:21 P.M lunch meal Resident #35 received chopped lettuce. During interview at this time, Resident #5 stated she could not eat the chopped lettuce due to her lower dentures being broken for a couple of weeks. During observation on 11/01/23 at 8:18 A.M., Resident #5 did not eat the omelet served at breakfast meal. During interview at this time, Resident #35 stated she could not eat the omelet served at breakfast without her lower dentures. During interview on 11/02/23 at 3:00 P.M., the Director of Nursing, (DON) verified there was no new problem areas, goals or interventions to Resident #5's plan of care when her dentures were discovered broken on 10/18/23. 2. Review of the medical record for Resident #354 revealed an admitted [DATE] and diagnoses including diabetes, metabolic encephalopathy, and cognitive communication deficit and cerebrovascular disease. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #354 had severely impaired cognition. The skin risk assessment dated [DATE] revealed the resident was at risk for skin breakdown. Review of the initial plan of care date 08/01/23 and care plans through 11/02/23 revealed no skin problems, goals or interventions for the identified risk of skin breakdown. During interview on 11/02/23 at 3:00 P.M., the Director of Nursing, (DON) verified Resident #354 did not have a care plan area for risk of skin breakdown from date of admission of 07/31/23 to 11/03/23, when the care plan was updated. 47988 3. Review of Resident #48's medical record revealed an admission to the facility on [DATE], with diagnoses including pressure ulcer of sacral region stage four, pressure ulcer of right and left heel, muscle weakness, bacteremia, lymphedema, metabolic encephalopathy, hydrocele, retention of urine, type two diabetes mellitus, obstructive pulmonary disease, and morbid obesity. Review of Resident #48's quarterly Minimum Data Set (MDS) assessment, dated 09/13/23, documented the resident was severely cognitively impaired. Resident #48 was dependent for toilet hygiene, an indwelling urinary catheter was present and was frequently incontinent of bowel. Review of Resident #48's physician orders revealed an order dated 06/07/23 for an indwelling urinary catheter for diagnosis of bilateral hydrocele, change bag every 30 days and as needed and to change the catheter securement device every seven days. Review of Resident #48 comprehensive plan of care dated 06/13/23, revealed no information related to Resident #48 having a urinary catheter or for the care of a urinary catheter. During an interview on 11/06/23 at 3:15 P.M., the Director of Nursing verified there was no plan of care developed to address Resident #48's indwelling urinary catheter. Review of the facility policy titled Comprehensive Person-Centered Care Planning, dated 09/14/23, revealed the plan of care is centered on the residents needs including measurable objectives and time frames and must be re-evaluated with each comprehensive assessment and significant change assessment.

Based on record review and interview, the facility failed to complete a comprehensive assessment after a significant change in condition for one (Resident #354) of three residents sampled. The facility census was 56. Findings include: Review of the medical record of Resident #354 revealed an admitted [DATE] and diagnosis of diabetes, metabolic encephalopathy, and cognitive communication deficit and cerebrovascular disease. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #354 had severely impaired cognition. Review of Resident #354 physician orders revealed the resident received hospice services starting 08/23/23. Review of significant change MDS dated [DATE] revealed Resident #354 was clinically assessed due to a change in status for starting hospice services. During interview on 11/02/23 at 3:00 P.M. the Director of Nursing, (DON) verified Resident #354 changed to hospice services on 08/23/23 and did not receive a significant change comprehensive assessment until 10/26/23. The DON verified the significant change MDS was late and should have been completed 14 days after the start of hospice services.

Based on record review, interview, and policy review, the facility failed to refer a resident with a serious mental disorder and dementia to the appropriate State-designated authority for a Preadmission and Resident Review (PASRR) Level II assessment/determination. This affected one (Resident #34) of one resident reviewed for PASRR. The facility census was 56. Findings include: Review of the medical record for Resident #34 revealed an admitted [DATE]. Review of Resident #34's PASRR from a previous healthcare facility, dated 03/05/21, indicated the resident had no indications of serious mental illness, therefore, a PASRR Level II review was not warranted/completed. Resident #34 was admitted to the current facility with diagnoses is of adjustment disorder with mixed anxiety and depressed mood, unspecified dementia, mood disorder due to known physiological condition, and nonpsychotic mental disorder. No updated PASRR was completed upon admission with diagnoses to indicate mental health disorders were present. During interview 11/01/23 2:58 P.M., the Director of Nursing and Staff #16 verified that an updated or new PASRR should have been completed upon admission with diagnosis of mental health disorders and dementia. It was verified the current PASRR, dated 03/05/21, indicated that Resident #34 did not have any mental health disorders or dementia, which was an inaccurate representation of Resident #34 current medical diagnosis. Because of the inaccuracy, Resident #34 was not referred to the appropriate State-designated authority for a Level II resident review. Review of the facility policy titled Preadmission Screening and Annual Resident Review, dated 09/14/23, stated to refer all levels II residents and all residents with newly evident or possible serious mental disorder, intellectual disability, or a related condition for level II resident review.

Based on record review, observation and interview, the facility failed to prepare food in a form designed to meet the resident's individual needs. This affected three (Residents #4, #5 and #354) of three residents sampled. The facility census was 56. Findings include: 1. Review of the medical record of Resident #4 revealed an admitted [DATE] and diagnoses including dementia, diabetes, dysphagia, and chronic obstructive pulmonary disease. Resident #4 received hospice services starting 08/01/23. Resident #4's diet order included an advanced dysphagia diet, an eight-ounce supplement three times a day and four-ounce supplement with lunch due to malnutrition risk. Review of the nutritional plan of care dated 07/03/23, completed by Registered Dietitian, (RD) #64, revealed Resident #4 omitted food groups and was to be served fortified oatmeal at breakfast and supper. Review of Resident #4 meal ticket dated 11/06/23 revealed the resident was to receive six ounces of fortified oatmeal at breakfast and supper meals. The meals consisted of fortified cereal and beverages. Review of the fortified cereal recipe revealed the cereal preparation required six ounces of oatmeal, nine tablespoons whole milk, three quarters teaspoon powdered milk, three eighths teaspoons sugar, and 0.01 pound of butter. During observation on 11/01/23 at 8:01 A.M., during the breakfast tray line service, Diet Manager (DM) #57 was instructing Diet Aide (DA) #63 in how to prepare the fortified cereal. There was no recipe available. During interview on 11/01/23 at 8:33 A.M., DA #63 verified the meal ticket of Resident #4 listed fortified cereal at the breakfast meal as the main entree. DA #63 verified he was instructed by DM #57 during tray line in how to prepare Resident #4's fortified cereal. DA #63 verified he did not prepare the fortified cereal with a recipe, using the ingredients and portions listed in the recipe. To six ounces of prepared oatmeal, DA #63 stated he added unknown amounts of butter, sugar, and milk. The powered milk and the ingredients portions were not followed as listed on the fortified recipe. During interview on 11/01/23 at 8:35 A.M., DM #57 verified the fortified cereal recipe was not available to DA #63 on 11/01/23 to prepare Resident #4's fortified cereal. DM #57 verified the recipe needed to be available and followed to ensure the resident received the nutritional value as planned by RD #64. DM #57 verified Resident #4 did not receive the recipe specified fortified cereal as listed on the meal ticket. 2. Review of the medical record of Resident #5 revealed an admitted [DATE] and diagnoses including malignant pancreatic cancer, dysphagia, Alzheimer's disease, and depression. Record review revealed Resident #5's diet order included advanced dysphagia diet, and four ounces of a supplement once a day for adequate protein and energy intake. Review of the meal ticket of Resident #5 dated 11/06/23 revealed the resident was to receive four ounces of supplement on the lunch meal tray service. Observation on 10/31/23 at 12:21 P.M. of Resident #5 lunch meal tray revealed no four-ounce supplement was on the meal tray. During interview at this time, Resident #5 stated she was to receive a supplement on the lunch meal tray, she liked the supplement, as she could not eat some of the foods. During interview on 10/31/23 at 12:22 P.M., Licensed Practical Nurse, (LPN) #32 verified Resident #5 did not receive the four ounces of supplement on the meal tray form the kitchen meal service. 3. Review of the medical record of Resident #354 revealed an admitted [DATE] and diagnosis of diabetes, metabolic encephalopathy, and cognitive communication deficit and cerebrovascular disease. Review of the diet orders for Resident #354 revealed puree diet, and a supplement eight ounces twice a day to aide in blood sugar management. Review of Resident #354 meal ticket 11/02/23 revealed a notation of no juice at the breakfast meal. Review of the Registered Dietitian, (RD) #64 progress notes dated 11/01/23 revealed Resident #354 family representative discouraged juice due to the diagnosis of diabetes. The resident did not receive juice while at home to assist in blood sugar control. The family preferred other beverages be offered and lastly if the resident persisted, the juice to be offered in moderation. During observation on 11/02/23 at 8:30 A.M. in the main dining room, Resident #354 received eight ounces of juice from Activity Assistant (AA) #5. Resident #354 was not observed to ask for the juice. The breakfast meal ticket was printed in bold no juice. During interview on 11/02/23 at 8:32 A.M., AA #5 verified Resident #354's breakfast meal ticket had listed in bold, no juice. AA #5 stated Resident #354 cannot verbally ask for juice, type or how much, so she served him cranberry juice in the water glass size at the breakfast meal. She stated she did not know why no juice was listed on the meal ticket and had not confirmed with nurses or the RD #64 as to why no juice was listed on the meal ticket. AA #5 verified she did not know his medical or swallowing diagnosis.

Based on record review and interview, the facility failed to ensure the Ombudsman was notified when residents were discharged to the hospital. This affected one (Resident #33) of two residents reviewed for discharges. The facility census was 56. Findings include: Review of the medical record for Resident #36 revealed an admission 04/09/20. Review of the medical record for Resident #33, revealed the resident was sent to the hospital and admitted on [DATE]. There was no documentation the Ombudsman was notified of the resident's transfer to the hospital. During an interview on 11/06/23 at 11:00 A.M., Social Service Designee, (SSD) #16 stated notification to the Ombudsman had not been completed for Resident #33 or any other residents who had discharged between November 2022 and October 2023.

Based on record review and staff interview, the facility failed to ensure all Minimum Data Set (MDS) assessments were transmitted within 14 days after being completed. This affected two (Residents #19 and #46) of two residents reviewed for MDS assessments. The facility census was 56. Findings include: 1. Review of the record for Resident #19 revealed an admitted [DATE]. He had a quarterly Minimum Data Set (MDS) assessment dated [DATE]. This assessment stated production accepted but did not say it was completed. 2. Review of the record for Resident #46 revealed and admitted [DATE]. He had a quarterly Minimum Data Set (MDS) assessment dated [DATE]. The assessment stated production accepted but did not say completed. During interview on 11/06/23 at 2:57 PM, the administrator verified the above assessments were not submitted.

Based on medical record review, staff interview, review of the local hospital record, review of the manufacturers recommendations, and policy review the facility failed to ensure residents received appropriate supervision during mechanical lift transfers from the bed to the wheelchair. This resulted in Actual Harm when State tested Nursing Assistant (STNA) #39 failed to ensure there were two staff members present for the transfer using the mechanical lift when the lift tipped over resulting in Resident #63 descending from the lift, landing awkwardly onto the bed on his left side, the lift bar hit him in his head and subsequently suffered an abrasion above the right eye and a left femoral neck fracture. This affected one resident (#63) of three residents reviewed for mechanical lift transfers. The facility census was 64. Findings include: Review of the medical record revealed Resident #63 was admitted to the facility on [DATE]. Diagnoses included [CONDITION(S)] disease, [CONDITION(S)] (CHF), chronic kidney disease (CKD), [CONDITION(S)], diabetes mellitus, hypertension, and major depressive disorder Review of the admission plan of care dated 07/22/21 revealed Resident #63 required maximum assistance for transferring. Interventions included consulting physical therapy. Review of the admission Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had intact cognition. Review of the physician orders dated 07/22/21 revealed to ask the resident and assess for pain every shift. Review of the medication administration records (MAR) dated July 2021 and August 2021 revealed the resident was not in any pain, except on 08/13/21. Review of the MAR dated August 2021 revealed the resident was given a one-time dose of Tylenol ([MEDICATION(S)] pain medication) 650mg on 08/13/21 at 10:00 A.M. Review of the nursing note dated 08/13/21 at 10:13 A.M. revealed the resident was lethargic that morning, stating he was hurting all over today, and while attempting to transfer resident with the Hoyer lift (mechanical lift) to the wheelchair this morning the resident hit his head. A small abrasion was noted to the right eyebrow area, vital signs were obtained. The daughter, the doctor, and the Director of Nursing (DON) were notified. Review of the Physical Therapy (PT) note dated 08/13/21 at 11:51 A.M. revealed the physical therapy assistant (PTA) #38 began working with the resident in bed mobility with maximum assistance. The resident was unable to continue with participation due to increased acute pain in the left hip. The Resident #63 stated he fell earlier in the morning landing on his left hip. The nursing staff was notified and informed of the acute change in the resident status. Review of the Occupational Therapy (OT) note dated 08/13/21 at 2:20 P.M. revealed the Certified Occupational Therapy Assistant (COTA) #37 started working with the resident and he was laying supine in bed with his head elevated. The COTA #37 attempted to work with the Resident #63 in the morning on activities of daily living (ADL) and self-care, however, was unable to complete this due to the resident complained of pain in the left hip. The Resident #63 had not rated his pain. The nursing staff was notified. Review of the nursing notes dated 08/13/21 at 10:17 P.M. revealed the resident was having a change in condition involving change in complexion and lower blood pressures. The LPN #10 obtained new orders for [MEDICATION(S)] (a medication to support blood pressure) and fluids via clysis (a [MEDICATION(S)] injection to replace fluids). The LPN #10 stated the interventions were unsuccessful, and the doctor ordered to send the Resident #63 to the hospital for evaluation and treatment. Resident #63 was then transported to a local hospital. Interview on 08/20/21 at 3:58 P.M., the STNA #39 revealed he took care of the Resident #63 on 08/13/21 during the day shift. The STNA #39 stated around 10:00 A.M. he went to assist the resident out of the bed. The STNA #39 used a mechanical lift to assist the resident out of the bed into his wheelchair. The STNA #39 revealed he was the only person in the room when he used the mechanical lift. The STNA #39 stated he hooked the resident into the lift and began lifting him up off the bed. A few moments later, the STNA #39 stated the mechanical lift began to tip over. The STNA #39 stated he guided the Resident #63 onto the bed where the resident landed awkwardly, and the metal bar hit the resident's head above the right eye. The STNA #39 stated he knew better than to use a mechanical lift by himself. The staff he was working with was in another resident room at the time and he decided not to wait for assistance. He stated the resident had some discomfort while being changed during the day on 08/13/21 after the fall from the mechanical lift and he reported the discomfort to the Licensed Practical Nurse (LPN) #10. Interview on 08/23/21 at 1:10 P.M., the LPN #10 revealed the STNA #39 told her about the resident being hit in the head with the bar of the mechanical lift. The LPN #10 went to the resident room and assessed him after being notified he was hit in the head with the mechanical lift bar. The LPN #10 provided first aid to the abrasion above the right eye and further assessed the resident. This included obtaining vital signs (which were normal), completing hand grasps, and checking for pupil reactions. The LPN #10 further stated she could not remember if anyone had reported the pain or discomfort to her, however she remembered talking with therapy just could not recall the conversation. She denied any knowledge the Resident #63 had fallen from the mechanical lift. Interview on 08/23/21 at 2:00 P.M., the Director of Nursing (DON) revealed she was told the Resident #63 was bonked in the head with the mechanical lift bar. The DON was aware the doctor was called, and the family was notified as well. The DON denied any knowledge of the Resident #63 was dropped from the mechanical lift to the bed. The DON was unable to provide an investigation regarding Resident #63 getting bonked in the head with the mechanical lift. She also reviewed the hospital record and felt the left hip fracture was old due to no soft tissue swelling. Interview on 08/23/21 at 3:05 P.M., the Nurse Practitioner (NP) #42 revealed the hospital documentation for Resident #63 stated there was a fracture of the left hip. It was unclear to the NP #42 if the fracture was old or new based on the wording of the documentation. The NP #42 added there could be an acute fracture of any area without soft tissue swelling. Review of the hospital documentation for Resident #63 dated 08/13/21 at 8:27 P.M. revealed a left femoral neck fracture. Review of the doctor's notes from 08/14/21 at 5:19 P.M. revealed the hospital was having a difficult time putting together a timeline of events. There was no reported fall. The hospital doctor revealed the left hip area had no swelling or bruising noted at this time. Review of the Vanderlift 2 Operating Manual Revised March 2019 revealed patients must be assessed by the facility's professional nursing or professional rehabilitation staff to determine which patients are suitable for transfer with the VANDER-LIFT II (Trademark) B450, which VANDER-LIFT II (Trademark) transfer technique to use, which size sling is appropriate, and the number of staff members necessary to transfer each patient. Review of the facility policy titled Transfer with mechanical lift-long term care dated 11/20/20, revealed staff is expected to use two employees while operating mechanical lifts to stabilize and secure the resident. This deficiency substantiates Complaint Number OH 039.

Based on review of facility policy for abuse, review of Self-Reported Incidents, (SRI), interviews and written statements, the facility failed to keep one resident free from abuse when that resident was frightened and verbally abused by a State tested Nursing Assistant during the night shift. This resulted in emotional harm to Resident #4 who reported the next day she was afraid of the STNA and visible appear shaking when discussing the incident. This affected one of four residents reviewed for abuse. The census was 85. Findings include: Review of Resident #4's medical record indicated the resident was admitted to the facility on [DATE] and had [DIAGNOSES REDACTED]. The resident's Minimum Data Set (MDS) assessment dated [DATE] indicated the resident was cognitively intact but had periods of confusion due to a closed head injury. Review of a self reported incident (SRI), dated 10/27/12, indicated there was an allegation of physical, emotional and verbal abuse by STNA #3 during the night shift (6:00 P.M. to 6:00 A.M.) on 10/26/12 into the morning of 10/27/12. The SRI investigation stated Resident #4 reported on 10/26/12 that STNA #3 was rough with her during a transition to a different room. Resident #4 stated she was afraid of STNA #3 and she was rude and aggressive with her. Resident #4 was interviewed by the facility on 10/27/12 and stated STNA #3 jerked her blanket from her hands and she was hateful. During a second interview by the facility on 10/29/12, Resident #4 stated she was fearful of STNA #3 due to her tone of voice, which she described as rude, hateful, scary, mean and nasty. The investigation further stated the resident was shaking the next day when the staff interviewed her about the event. On 11/27/12 at 11:00 A.M. and on 11/29/12 at 3:40 P.M. interviews were attempted with Resident #4 and the resident was not able to answer questions about the incident. When interviewed on 11/30/12 at 8:50 A.M. the Executive Director stated the allegation of verbal abuse towards Resident #4 had been substantiated and STNA #3 had been terminated due to verbal abuse towards Resident #4.